bluuebunny/crossref_metadata_2025 huggingface dataset:
Degloving Soft Tissue Injuries of the Extremity: Characterization, Categorization, Outcomes, and Management
Authors: Velazquez Christine , Whitaker Litton , Pestana Ivo A.
Published: January 2021

Background:

We aimed to identify degloving soft tissue injury (DSTI) patient characteristics, injury and reconstruction patterns, and factors affecting outcomes of DSTI injuries to propose a reconstructive protocol for these injuries.

Methods:

A retrospective analysis of consecutive patients with DSTIs of an extremity over a 22-year period has been done.

Results:

188 patients with 201 extremity DSTIs were included. Mean patient age was 37 years, with follow-up of 19.6 months. In total, 96% of injuries were related to motor vehicles or machinery, and 74.6% of DSTIs had injuries to structures deep to skin/subcutis. The avulsed tissue was utilized in reconstruction in 71.6% of cases and 86.8% of these experienced some loss of the used avulsed tissues. Of the total cases, 82% employed skin grafting in reconstruction. Dermal regeneration templates were used in 32% of patients. An estimated 86.5% of patients had negative pressure wound therapy utilized. Of the injured patients, 21% required flap reconstruction and 22% required some form of amputation. Age, body mass index, and tobacco use did not increase perioperative complications or amputation. DSTIs with injury to structures deep to skin/subcutis were associated with negative pressure wound therapy use (P = 0.02). DSTIs with underlying fractures required more procedures to reach reconstruction completion (P = 0.008), had more minor (P = 0.49) and major perioperative complications (P = 0.001), longer time to heal (P = 0.002), and increased need for amputation (P = 0.02).

Conclusions:

Factors affecting the reconstructive management and outcome of DSTIs include injury to structures deep to the skin/subcutis. We categorized DSTIs based on the level of injury and proposed a systematic approach to extremity DSTIs which may be utilized by plastic surgeons and other surgical services to manage these complex injuries.
Clostridium difficile Infection in the Plastic Surgery Population: Lessons from the ACS NSQIP Database
Authors: Karamanos Efstathios , Wang Howard , Shah Amita R.
Published: January 2021

Background:

Clostridium difficile–associated infections (CDI) have a significant impact on morbidity and mortality of hospitalized medical and surgical patients. There is a paucity of data regarding the incidence, impact, and modifiable risk factors in the plastic surgery population.

Methods:

The ACS NSQIP database was retrospectively queried for all cases performed by plastic surgeons during 2016. All plastic surgery cases, combined cases, demographics, and baseline clinical characteristics were extracted from the database. The study population was divided into 2 groups based on the development of CDI. Independent variables for development of CDI were identified.

Results:

During the study period, a total of 29,256 patients underwent a procedure by plastic surgery, with the most commonly performed procedures involving the breast (58%) and trunk (14%). Only 44 patients developed post-operative CDI (0.1%). Factors independently associated with development of CDI were wound classification at the end of the surgery, COPD, procedures involving the trunk, and surgery for reconstruction of pressure ulcers. Outpatient surgery was associated with decreased odds of developing CDI [AOR (95% CI):0.2 (0.1, 0.4), adj P < 0.001]. Staying overnight did not increase the odds of developing CDI; however, staying for >1 day in the hospital was associated with an increased risk of CDI development [AOR (95% CI): 1.03 (1.01, 1.13), adj P = 0.001]. Combined cases, ASA, body mass index, diabetes, and active smoking were not associated with CDI.

Conclusions:

CDI are rare in the plastic surgery population and are most associated with trunk/decubitus ulcer reconstructions, inpatient hospital stay, and contaminated wounds. The patients that usually fit in these categories have acutely or chronically infected wounds, which are often treated with systemic antibiotics. For patient with decubitus ulcers and other trunk reconstruction, the guidelines for pre and post-operative systemic antibiotic usage is not well defined. For patients who have had trunk reconstruction, development of evidence-based antibiotic stewardship guidelines may help these patients by limiting antibiotic usage and thereby reducing the incidence of CDI.
Distally-based Peroneus Brevis Turnover Muscle Flap in the Reconstruction of Soft Tissue Defects
Authors: Malahias Marco , Khalil Haitham , Abdalbary Sahar Ahmed , Abdelkader Rasha
Published: January 2021

Background:

Reconstruction of the distal 3rd of the lower leg requires either local or free flap coverage if tendons or bones are exposed. The distally based, pedicled peroneus brevis (PB) flap has been shown to be a valid option in the management of distal 3rd lower limb injuries. Herein, we present 21 cases treated with distally-based PB muscle flaps between May 2017 and September 2019. The defect location varied, and included defects over the lateral and medial malleolar areas, distal tibia (middle and distal 3rd junction, and the distal 3rd), and Achilles tendon area.

Methods:

The PB was dissected from the lateral fibula and intermuscular septa in a cephalic to caudal direction, to a point no lower than 7 cm proximal to the lateral malleolus tip. This preserved most distal vascular perforators to the muscle, and afforded sufficient mobilization to allow successful turn-over of the muscle, with transposition into the defect within 30 minutes of tourniquet time. A meshed skin graft completed the intervention.

Results:

The metalwork was removed in all chronic cases (10/21), as bone union had occurred. All flaps survived completely. One patient partially lost the skin graft; the wound was healed by secondary intention. No major complications occurred and no significant patient discomfort was noted. All wounds healed completely by 9 weeks of follow-up.

Conclusion:

The PB turnover muscle flap is a versatile flap, ideally suited to manage up to moderately sized defects of the distal 3rd of the lower leg, with negligible postoperative morbidity.
Foot Web Space Transfer for Congenital Syndactyly
Authors: Tomioka Yoko Katsuragi , Narushima Mitsunaga , Yamashita Shuji , Ito Asuka , Okazaki Mutsumi
Published: January 2021

Syndactyly of the hand is commonly treated using local flaps with skin grafts; however, contractures and/or pigmentation pose a challenge, requiring repeated surgery. Here, we describe a case of a 1-year-old boy who underwent web transplantation for syndactyly. To the best of our knowledge, no “web for web” transplantations have been documented in pediatric literature. Because the patient had an “extra” web space, functional and aesthetic reconstruction was performed with careful preparation. The vascular pattern was assessed using high-resolution ultrasonography. The flap was harvested under a microscope, intravascular stenting was performed for secure anastomosis, and the adequacy of circulation in the flap was verified using the indocyanine green test. Each technique in the procedure used by us contributed to making the microsurgery safer. The present case suggests that “web for web” is a favorable treatment option for some cases, although these would be limited in number.
Computed Tomography Image Analysis in Abdominal Wall Reconstruction: A Systematic Review
Authors: Elfanagely Omar , Mellia Joseph A. , Othman Sammy , Basta Marten N. , Mauch Jaclyn T. , Fischer John P.
Published: January 2021

Background:

Ventral hernias are a complex and costly burden to the health care system. Although preoperative radiologic imaging is commonly performed, the plethora of anatomic features present and available in routine imaging are seldomly quantified and integrated into patient selection, preoperative risk stratification, and perioperative planning. We herein aimed to critically examine the current state of computed tomography feature application in predicting surgical outcomes.

Methods:

A systematic review was conducted in accordance with the Preferred Reporting Items for a Systematic Review and Meta-Analysis (PRISMA) checklist. PubMed, MEDLINE, and Embase databases were reviewed under search syntax “computed tomography imaging” and “abdominal hernia” for papers published between 2000 and 2020.

Results:

Of the initial 1922 studies, 12 papers met inclusion and exclusion criteria. The most frequently used radiologic features were hernia volume (n = 9), subcutaneous fat volume (n = 5), and defect size (n = 8). Outcomes included both complications and need for surgical intervention. Median area under the curve (AUC) and odds ratio were 0.68 (±0.16) and 1.12 (±0.39), respectively. The best predictive feature was hernia neck ratio > 2.5 (AUC 0.903).

Conclusions:

Computed tomography feature selection offers hernia surgeons an opportunity to identify, quantify, and integrate routinely available morphologic tissue features into preoperative decision-making. Despite being in its early stages, future surgeons and researchers will soon be able to integrate 3D volumetric analysis and complex machine learning and neural network models to improvement patient care.
The “Corset Repair” for Complex Hernia: A Proof-of-concept Report of an Innovative Approach
Authors: Byrnes Yasmeen M. , Othman Sammy , Elfanagely Omar , Card Elizabeth B. , Mellia Joseph A. , Llado-Farrulla Monica , Fischer John P.
Published: January 2021

Incisional hernias, especially those below the arcuate line, pose a unique challenge to reconstructive surgeons, as no consensus exists for repair strategy. An innovative approach is presented and illustrated. The “corset repair” involves placing an onlay mesh partially beneath released bilateral external obliques. A detailed technical review is provided to illustrate the benefits of this technique particularly in large defects and in hernia after abdominal flap harvest. Hernia recurrence and surgical site occurrence rates were reviewed and analyzed for a cohort of corset repair patients between December 2016 and January 2020. Twenty patients were included. All defects were successfully closed. Zero patients experienced hernia recurrence. Eight patients (40%) had a surgical site occurrence, of which 5 (63%) were either observed or managed non-operatively. Two of the surgical site occurrences were deep surgical site infections: 1 required surgical intervention for suspected mesh infection and the other did not. One patient (5%) developed hematoma 23 months post-operatively. The “corset repair” technique represents a modification to a classic technique for hernia repair. It is feasible and may be advantageous especially for large or challenging repairs below the arcuate line. It has promising results on early follow-up, and further research is needed to evaluate long-term efficacy.
Efficacy, Safety, and Durability of Response of Collagenase Clostridium Histolyticum-aaes for Treating Cellulite
Authors: Kaufman-Janette Joely A. , Bass Lawrence S. , Xiang Qinfang , McLane Michael P. , Kirby M. Todd , Vijayan Saji
Published: January 2021

Background:

Collagenase clostridium histolyticum-aaes (CCH) enzymatically releases fibrous septa that contribute to the skin dimpling characteristic of cellulite. Long-term safety/duration of efficacy (durability) results from an open-label extension (OLE) of a randomized, double-blind, placebo-controlled trial (RCT) evaluating CCH efficacy/safety for moderate-to-severe cellulite of the buttocks or posterolateral thighs in women was assessed. Efficacy/safety of CCH treatment/retreatment during OLE was also evaluated.

Methods:

After RCT unblinding, women could enroll in OLE for assessment of long-term CCH durability (observation only, up to day 720) or CCH treatment/retreatment, the latter in women with moderate-to-severe buttock/posterolateral thigh cellulite [Clinician Reported Photonumeric Cellulite Severity Scale (CR-PCSS) and Patient Reported PCSS (PR-PCSS) scores of 3/4; Hexsel Cellulite Severity Scale score ≤13]. A treatment/retreatment course comprised 1 or 2 courses of 3 sessions (0.84-mg CCH injected at days 1, 22, and 43). CCH efficacy/safety was assessed at baseline, days 22, 43, 71, and quarterly at day 360.

Results:

Of the 259 OLE participants, 53 were observed for long-term CCH durability. For those who were ≥2-level composite responders during RCT (≥2-point CR-PCSS/PR-PCSS score improvements), CCH effect was durable (scores did not reach RCT baseline levels) in all women on days 180 (19/19), 360 (16/16), and 720 (7/7). Of the 200 women receiving CCH treatment/retreatment, more than 75% had ≥1-level improvement in patient and clinical assessments at day 71. The most common adverse events were injection-site bruising and pain.

Conclusions:

CCH treatment provided durable improvement in moderate-to-severe buttock/thigh cellulite and was generally well tolerated. Repeated CCH exposure did not increase adverse event risk or reduce efficacy.
Academics in the Pandemic: Early Impact of COVID-19 on Plastic Surgery Training Programs
Authors: Steele Thomas N. , Hemal Kshipra , Browne Donald T. , Balumuka Darius , Hansen Juliana E. , David Lisa R.
Published: January 2021

Background:

The COVID-19 global pandemic has impacted plastic surgery training in the United States, requiring unprecedented measures to prepare for potential surges in critically ill patients. This study investigates how plastic surgery programs responded to this crisis, as well as how successful these changes were, through a survey of program directors and of residents at academic training programs in the United States.

Methods:

Two separate anonymous online surveys were conducted via REDCap between April 16 and June 4, 2020. The first survey was distributed to program directors, and the second was distributed to plastic surgery residents. Resident responses were then subdivided for an analysis between geographic regions.

Results:

Of the 59 program director responses (43.7%), the majority of programs implemented a platoon approach for resident coverage. A minority did the same for attending coverage. In total, 92% transitioned to virtual didactics only. Plastic surgery residents covered alternative services at 25% of responding institutions, and an additional 68% had a plan in place for responding to personnel shortages. Overall, residents were satisfied with their program’s response in a variety of categories. When subdivided based on geographic region, respondents in the Northeast and Northwest were less satisfied with resident wellness, personal and loved ones’ safety, and program communication.

Conclusions:

With the possibility of a “second wave,” successful methods of academic programs adapting to the pandemic should be communicated to reduce the future impact. Increased frequency of communications between program directors and residents can improve mental health and wellness of the resident population.
The etiology of menopause: not just ovarian dysfunction but also a role for the central nervous system
Authors: Perlman Barry , Kulak David , Goldsmith Laura T. , Weiss Gerson
Published: January 2021

Background:

The hormonal changes which occur leading up to menopause have been described in multiple cross-sectional and longitudinal studies. Results from these studies document the occurrence of marked alterations in pituitary-hypothalamic function, along with the changes in the ovary, which play a role in the etiology of menopause. However, the role of pituitary-hypothalamic function in the menopausal transition (MT) has been generally overlooked.

Methods:

Literature searches were performed using PubMed, Scopus, and Medline, for articles with content related to menopause and the MT. The searches were restricted to English language observational studies and reviews of human studies and clinical trials.

Results:

During the MT, in addition to a reduction in the number of ovarian follicles, there is a marked reduction in the sensitivity of the central nervous system to both the positive and negative feedback effects of estrogen. These changes in sensitivity explain menstrual irregularities and systemic systems which are present in the time before the final menstrual period. Although the timing of menopause is difficult to predict, broad patterns in hormonal changes are seen, including a slow drop in inhibin B levels, followed by a monotropic rise in follicle-stimulating hormone during the late reproductive period. The MT is marked by irregular cycles with unpredictable luteinizing hormone levels and unpredictable ovulation. The levels of estrogen remain stable, or are even elevated through most of the MT, and levels of estrogen do not begin to decrease until late in the MT. The Stages of Reproductive Aging Workshop guidelines have improved the homogeneity of classifications in studies.

Conclusions:

On the basis of longitudinal hormone studies, it is clear that desensitization of the hypothalamic-pituitary-ovarian feedback loop plays an important role, in addition to a decrease in follicle number and insensitivity of remaining follicles to the positive feedback of estrogen, to trigger ovulation. Further studies in humans are needed to elucidate the mechanisms responsible for these perimenopausal changes if proper therapeutic modalities for the symptoms associated with menopause can be developed.
Reducing burnout among nurses: The role of high-involvement work practices and colleague support
Authors: Kilroy Steven , Bosak Janine , Chênevert Denis , Flood Patrick C. , Hill Kevin
Published: January 2021

Background

The impact of human resource practices on nurses’ well-being, the underlying mechanisms involved, and the contextual factors that enhance or impede their success are not fully clear.

Purpose

The aim of this article was to examine a moderated mediation model whereby high-involvement work practices are purported to reduce nurses’ burnout via psychological empowerment, and colleague support is expected to moderate the mediating role of psychological empowerment in the high-involvement work practices–burnout link.

Methodology/Approach

Structural equation modeling was employed on cross-sectional survey data collected from a large sample of nurses in Canada (N = 2,174).

Results

The findings revealed that psychological empowerment partially mediated the association between high-involvement work practices and burnout, whereas colleague support was directly associated with lower burnout rather than exerting a moderating effect.

Conclusion

The study identifies the universality of high-involvement work practices in alleviating nurses’ burnout and highlights the important role of psychological empowerment as an explanatory variable. In addition, colleague support is an important yet independent predictor of nurses’ burnout.

Practical Implications

This study identifies a strategy that can be adopted by hospital managers to help protect against nurse burnout while offering insights into the underlying process involved.
Treatment of Aggression in Adults with Autism Spectrum Disorder: A Review
Authors: Im David S.
Published: January 2021

Background

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by markedly impaired social interaction, impaired communication, and restricted/repetitive patterns of behavior, interests, and activities. In addition to challenges caused by core symptoms, maladaptive behaviors such as aggression can be associated with ASD and can further disrupt functioning and quality of life. For adults with ASD, these behaviors can portend adverse outcomes (e.g., harm to others or to the individual with ASD, hindering of employment opportunities, criminal justice system involvement). This article reviews the scientific literature to provide an update on evidence-based interventions for aggression in adults with ASD.

Method

A search of the electronic databases CINAHL, EMBASE, and PsycINFO was conducted using relevant search terms. After reviewing titles, abstracts, full-length articles, and reference lists, 70 articles were identified and reviewed.

Results

The strongest (controlled trial) evidence suggests beneficial effects of risperidone, propranolol, fluvoxamine, vigorous aerobic exercise, and dextromethorphan/quinidine for treating aggression in adults with ASD, with lower levels of evidence supporting behavioral interventions, multisensory environments, yokukansan, and other treatments.

Conclusions

Additional randomized, controlled trials using consistent methodology that adequately addresses sources of bias are needed to determine which treatments are reliably effective in addressing aggression in adults with ASD. In the meantime, considering efficacy and adverse effect/long-term risk profiles, a practical approach could start with functional assessment–informed behavioral interventions along with encouragement of regular, vigorous aerobic exercise to target aggression in adults with ASD, with pharmacotherapy employed if these interventions are unavailable or inadequate based on symptom acuity.
CONCOMITANT MUTATIONS IN INHERITED RETINAL DYSTROPHIES
Authors: Rodríguez-Muñoz Ana , García-Bohórquez Belén , Udaondo Patricia , Hervás-Ontiveros Ana , Salom David , Aller Elena , Jaijo Teresa , García-García Gema , Millán José
Published: January 2021

Purpose:

To highlight the challenge of correct reproductive and therapeutic counseling in complex pedigrees with different inherited retinal dystrophies (IRD).

Methods:

Two hundred eight patients diagnosed with nonsyndromic IRD underwent full ophthalmologic examination and molecular analysis using targeted next-generation sequencing.

Results:

Five families (4%) carried mutations in more than one gene that contribute to different IRD. Family fRPN-NB had a dominant mutation in SNRNP200, which was present in nine affected individuals and four unaffected, and a mutation in RP2 among 11 family members. Family fRPN-142 carried a mutation in RPGR that cosegregated with the disease in all affected individuals. In addition, the proband also harbored two disease-causing mutations in the genes BEST1 and SNRNP200. Family fRPN-169 beared compound heterozygous mutations in USH2A and a dominant mutation in RP1. Genetic testing of fRPN-194 determined compound heterozygous mutations in CNGA3 and a dominant mutation in PRPF8 only in the proband. Finally, fRPN-219 carried compound heterozygous mutations in the genes ABCA4 and TYR.

Conclusion:

These findings reinforce the complexity of IRD and underscore the need for the combination of high-throughput genetic testing and clinical characterization. Because of these features, the reproductive and therapeutic counseling for IRD must be approached with caution.
Incidence of and Risk Factors for Steroid Response After Cataract Surgery in Patients With and Without Glaucoma
Authors: Bojikian Karine D. , Nobrega Priscilla , Roldan Ashley , Forrest Samantha L. , Tsukikawa Mai , Chen Philip P.
Published: January 2021

Precis:

Steroid response after cataract surgery was more frequent in glaucoma patients than nonglaucoma patients. Longer axial length and more preoperative medications were risk factors for steroid response in glaucoma patients.

Purpose:

The aim was to evaluate incidence and risk factors for topical steroid response after uneventful cataract surgery in patients with and without glaucoma.

Setting:

Academic glaucoma clinics.

Design:

This was a retrospective review.

Participants:

Consecutive patients with and without glaucoma and no prior incisional glaucoma surgery undergoing cataract surgery between March 2007 and September 2016. All patients routinely received topical prednisolone acetate 1% postoperatively.

Methods:

Pertinent clinical information was recorded. Steroid response was defined as intraocular pressure >50% above the baseline intraocular pressure measurement, occurring at or after the second postoperative week.

Results:

We included 472 eyes of 472 nonglaucoma patients and 191 eyes of 191 glaucoma patients. Ten (2.1%) nonglaucoma eyes and 16 (8.4%) glaucoma eyes were diagnosed as steroid responders (relative risk=3.72; 95% confidence interval: 1.71-8.07; P<0.001). Logistic regression showed that for nonglaucoma, longer axial length (AL) and younger age were associated with a higher incidence of steroid response (P≤0.003), while for glaucoma patients, longer AL and more preoperative medications were associated with steroid response (P≤0.030). An AL ≥26 mm was associated with steroid response for both groups (P≤0.024).

Conclusion:

Although glaucoma patients were 3.72 times more likely to have steroid response after uneventful cataract surgery, the incidence of steroid response with prednisolone acetate 1% was relatively low after phacoemulsification in both nonglaucoma and glaucoma eyes. Steroid response was associated with longer AL in both groups and with more preoperative medications in glaucoma patients.
Prospective Evaluation of the First Mitomycin C Augmented Needle Revision in Patients With Failed Nonpenetrating Deep Sclerectomy
Authors: Gutiérrez-Ortiz Consuelo , Moreno-Salgueiro Agustín , Rodrigo-Rey Sara , González-Mesa Ana , Pérez-Rico Consuelo
Published: January 2021

Precis:

At 6 months the procedure achieved a 33.89% drop in intraocular pressure (IOP), had an overall success rate of 57.15%, and did not change the best-corrected visual acuity. Achieving <8 mm Hg of IOP the day after the procedure may be a prognostic success indicator.

Purpose:

The purpose of this study was to evaluate the first mitomycin C (MMC)-augmented needle revision in patients with failed nonpenetrating deep sclerectomy (NPDS) and factors associated with its success.

Materials and Methods:

This prospective, nonrandomized comparative trial included 21 consecutive patients (21 eyes) who underwent their first MMC needling revision of failed NPDS blebs. The success was defined as absolute if the IOP decreased >20% from the preoperative value without antiglaucoma treatment and as qualified if that level was achieved with antiglaucoma medications. Preoperative and postoperative factors were evaluated for an association with postoperative success using Kaplan-Meier analysis.

Results:

A significant reduction in mean IOP from preoperative levels was evident at the end of the follow-up. The overall surgical success rate was 57.15%. On the basis of Kaplan-Meier survival analysis, we found that patients whose IOP on the following day of the procedure was <8 mm Hg had a higher success rate than those whose 1-day postoperative IOP was higher. These patients had a percentage of success of 100%, 84.6%, and 76.9% at 1-, 3-, and 6-month postoperative follow-up, respectively.

Conclusion:

The IOP level on the first postoperative day could be considered a prognostic indicator of success in needling revision performed in failed NPDS.
Mistaken MIS-C: A Case Series of Bacterial Enteritis Mimicking MIS-C
Authors: Dworsky Zephyr D. , Roberts Jordan E. , Son Mary Beth F. , Tremoulet Adriana H. , Newburger Jane W. , Burns Jane C.
Published: January 2021

Multisystem inflammatory syndrome in children following severe acute respiratory syndrome coronavirus 2 infection is characterized by fever, elevated inflammatory markers, and multisystem organ involvement. Presentations are variable but often include gastrointestinal symptoms. We describe 5 children with fever and gastrointestinal symptoms initially concerning for multisystem inflammatory syndrome in children who were ultimately diagnosed with bacterial enteritis, highlighting the diagnostic challenges presented by the severe acute respiratory syndrome coronavirus 2 pandemic.
The role of albumin–bilirubin grade in determining the outcomes of patients with very early-stage hepatocellular carcinoma
Authors: Chang Chung-Yu , Wei Cheng-Yi , Chen Ping-Hsien , Hou Ming-Chih , Chao Yee , Chau Gar-Yang , Lee Rheun-Chuan , Huang Yi-Hsiang , Su Yu-Hui , Wu Jaw-Ching , Su Chien-Wei
Published: January 2021

Background:

Patients with hepatocellular carcinoma (HCC) and with a single tumor <2 cm in size are classified as having Barcelona Clinic Liver Cancer (BCLC) stage 0 HCC. We aimed to investigate the role of the albumin–bilirubin (ALBI) grade in predicting outcomes in patients with BCLC stage 0 HCC.

Methods:

We retrospectively enrolled patients with BCLC stage 0 HCC in Taipei Veterans General Hospital from 2007 to 2015. Prognostic factors were analyzed using a Cox proportional hazards model and propensity score matching (PSM) analysis.

Results:

There were 420 patients enrolled, including 207 with ALBI grade 1, and 213 with ALBI grade 2 or 3. After a median follow-up of 60.0 months (interquartile range, 37.2–84.6 months), 179 patients died. The cumulative 5-year overall survival (OS) rates were 80.6% in patients with ALBI grade 1 and 53.7% in those with ALBI grade 2 or 3, respectively (p < 0.001). Multivariate analysis showed that age >65 years, negative hepatitis B surface in serum, creatinine >1.0 mg/dL, platelet count ≤105/mm3, tumor size >1.5 cm, nonsurgical resection (SR) therapy, and higher ALBI grade were independent risk factors related to poor OS. Patients who underwent SR had a better OS and recurrence-free survival than those who received radiofrequency ablation, which was confirmed by a multivariate analysis and PSM analysis.

Conclusion:

The ALBI grade can determine OS for patients with BCLC stage 0 HCC. SR can also provide a better outcome than nonsurgical treatment.
The differences in nurses’ willingness to discuss palliative care with patients and their family members
Authors: Lin Yi-Hsuan , Lin Ming-Hwai , Chen Chun-Ku , Yang Che , Chuang Ya-Ting , Shyu Chuen-Huei , Lin Huei-Jin , Chen Hui-Fang , Yang Wan-Ling , Chen Ya-Jyun , Chen Tzeng-Ji , Hwang Shinn-Jang , Chang Hsiao-Ting
Published: January 2021

Background:

This study aimed to evaluate the differences in nurses’ willingness to discuss palliative care with terminally ill patients and their family members.

Methods:

The participants were randomly recruited from registered staff nurses ≥20 years of age who were responsible for clinical inpatient care in a tertiary hospital in northern Taiwan. A semi-structured questionnaire was administered to evaluate nurses’ experiences of discussing do-not-resuscitate (DNR) decisions and their willingness to discuss palliative care with terminal patients and their family members. The differences in nurses’ experiences regarding DNR and willingness to discuss palliative care with terminally ill patients and their family members were compared using the Chi-square test. Logistic regressions were used to analyze factors associated with nurses’ willingness to discuss palliative care with patients and their families.

Results:

More participants had experienced initiating discussions about DNR with patients’ families than with patients (72.2% vs 61.9%, p < 0.001). Unadjusted logistic regression analysis showed that the experiences of actively initiating DNR discussions with patients were a significant factor associated with palliative care discussion with patients (odds ratio [OR] = 2.91, 95% confidence interval [CI]: 1.09–7.79). On the other hand, the experiences of actively initiating DNR discussions with patients and with patients’ families were significant factors associated with palliative care discussion with patients’ families (OR = 3.84, 95% CI: 1.22–12.06 and OR = 3.60, 95% CI: 1.19–10.90, respectively). After adjusting for covariates, no significant factors were found to be independently associated with nurses’ willingness to discuss palliative care with patients and their family members.

Conclusion:

There are significant differences in nurses’ willingness to discuss palliative care with patients and their family members. Further research is needed to evaluate factors associated with nurses’ willingness to discuss palliative care with patients and their families to facilitate these discussions and protect patients’ autonomy.
Inflammatory Indurated Plaques With Central Ulceration
Authors: Baghchechi Mohsen , Moncrieff Andre E. , Jacob Sharon E.
Published: January 2021

Teledermatology is a term to describe the provision of dermatologic medical services through telecommunication technology. This is a case of inflammatory indurated plaques with central ulceration.
The Role of Organizational Slack in Buffering Financially Distressed Hospitals from Market Exits
Authors: Puro Neeraj , Borkowski Nancy , Feyereisen Scott , Hearld Larry , Carroll Nathaniel , Byrd James , Smith Dean , Ghiasi Akbar
Published: January 2021

EXECUTIVE SUMMARY

Financial distress is a persistent problem in U.S. hospitals, leading them to close at an alarming rate over the past two decades. Given the potential adverse effects of hospital closures on healthcare access and public health, interest is growing in understanding more about the financial health of U.S. hospitals. In this study, we set out to explore the extent to which relevant organizational and environmental factors potentially buffer financially distressed hospitals from closure, and even at the brink of closure, enable some to merge with other hospitals. We tested our hypotheses by first examining how factors such as slack resources, environmental munificence, and environmental complexity affect the likelihood of survival versus closing or merging with other organizations. We then tested how the same factors affect the likelihood of merging relative to closing for financially distressed hospitals that undergo one of these two events. We found that different types of slack resources and environmental forces impact different outcomes. In this article, we discuss the implications of our findings for hospital stakeholders.
COVID-19 Risk Management and Emotional Reactions to COVID-19 Among School Teachers in Denmark
Authors: Nabe-Nielsen Kirsten , Fuglsang Nina Vibe , Larsen Inge , Nilsson Charlotte Juul
Published: January 2021

Objectives:

We explored teachers’ emotional reactions to the COVID-19 pandemic, and the association between COVID-19 risk management and these emotional reactions.

Methods:

We used cross-sectional data from 2665 teachers working at public schools. Participants responded to a questionnaire in May 2020. The analyses were adjusted for sex, age, cohabitation, and region.

Results:

Knowledge about adequate test behavior and feeling secure regarding colleagues’ actions to hinder spread of virus were associated with less frequent emotional reactions. Lack of access to personal protective equipment and exposure to infected pupils, parents or colleagues were associated with more frequent emotional reactions.

Conclusion:

Similar to other groups of frontline employees, teachers experience negative emotional reactions to the COVID-19 pandemic. Gaining knowledge about teachers’ worries and fears during pandemics is an important first step enabling leaders and occupational health professionals to address these.
“This Is Me!” Perceptions of Older Adult Simulated Participants in an Aging and Injury Simulation Experience
Authors: Lee Deborah A. , Maxwell Cathy A. , Miller Sally
Published: January 2021

Background:

Older adults played the role of frail and prefrail geriatric trauma patients in a frailty-focused communication workshop for nurses. Although subjects played a role (acting) as simulated participants (SPs) for simulation, workshop content and role-play also applied to them personally. We aimed to explore the effect that learning frailty-focused content, scripts, and portrayal of prefrail and frail older adults has on older adult SPs.

Methods:

Qualitative focus group. Participants included older adults older than 70 years (N = 6).

Procedure:

Focus group questions pertained to (1) the SP experience, (2) thoughts and emotions throughout the SP experience, and (3) applicability of workshop content and SP experience to personal life. The focus group lasted 90 min, was digitally recorded, and transcribed verbatim. Authors independently coded transcripts to identify categories and supporting quotations. Categories and subcategories were condensed and modified through iterative discussions. Descriptive content analysis was utilized for data analysis.

Results:

Six categories and 2 subcategories emerged, including (1) inevitability of aging: not playing a role (sub: inevitability of death), (2) shifting perceptions: how aging impacts thought and actions, (3) time as a factor: getting information sooner, (4) changing behavior/safety: mental recalibration, (5) attitude as a determining factor (sub: loss of independence), and (6) sharing information with others.

Conclusion:

The study supports the use of frailty-focused communication with older adults to prompt contemplation of aging and frailty and eventual decline/death. Providing information earlier in the aging trajectory enables time for behavior change that can prevent and delay frailty and mitigate untoward outcomes (falls, hospitalizations).
Burnout and Anxiety Among Trauma Nursing Specialties in a Rural Level I Trauma Center
Authors: Cook Alan , Sigler Carly , Allen LaDonna , Peters Jo Ann , Guthrie Christiana , Marroquin Michele , Ndetan Harrison , Singh Karan P. , Murry Jason , Norwood Scott , Philley Julie V.
Published: January 2021

Background:

Burnout and anxiety compromise physical and mental well-being of nurses and jeopardize patient safety. Personal, professional, and workplace characteristics have been associated with burnout and anxiety across diverse practice settings, yet none in rural, community trauma centers. We sought to identify the severity and predictors of burnout and anxiety in the trauma nursing staff of a rural Level I trauma center.

Methods:

A convenience sample of trauma nurses from the emergency department (ED), intensive care unit (ICU), and trauma ward was voluntarily surveyed using a demographic questionnaire, the Maslach Burnout Inventory (MBI) subscales: depersonalization (DP), emotional exhaustion (EE), and reduced personal accomplishment, as well as the Generalized Anxiety Disorder seven-item (GAD-7) scale. Multivariable linear regression identified the significant predictors of burnout and anxiety.

Results:

Ninety-six nurses completed surveys (response rate: 83.5%). Married or divorced status, and ICU or trauma ward job assignments were associated with significantly lower adjusted DP scores. Thus, the model-predicted score for a single ED nurse was 15 versus a predicted score of 7 for a divorced ICU or trauma ward nurse, p < .001 for each group. The GAD-7 model demonstrated that race/ethnicity (Asian compared with White, coefficient: −5.06, p = .03), number of children (2 compared with 0, coefficient: −2.54, p = .02), and job tenure (5–10 years vs. <2, coefficient: −3.18, p = .01) were each associated with fewer GAD-7 points.

Conclusion:

Depersonalization and anxiety vary across the trauma nursing workforce based on identifiable personal and work-related risk factors. Group-specific, targeted interventions are needed to effectively reduce burnout and anxiety in trauma nursing staff.
Nurse-Driven Universal Concussion Screening: A Quality Improvement Initiative
Authors: Downie Katie , Cunningham Aaron , Jafri Mubeen
Published: January 2021

Background:

The purpose of this study was to provide an evaluation of a performance improvement initiative that operationalized universal concussion screening for all pediatric trauma admissions at a Level I pediatric trauma center. Mild traumatic brain injury may be difficult to identify in injured children. We implemented a screening tool to identify the risk for concussion after traumatic injury and to improve access to cognitive evaluation and intervention in children. Prior to implementation of our screening tool, children admitted without obvious head injury or those younger than 12 years were not being screened for concussion risk.

Methods:

We employed a nurse-driven screening tool, derived from the Centers for Disease Control and Prevention Acute Concussion Evaluation, on all pediatric trauma patients ages 0–17 years. The screening tool identifies symptoms of physical, cognitive, sleep, or emotional deficits and prompts a cognitive evaluation with concussion education. The tool was administered by nursing and tracked in the electronic medical record.

Results:

Key stakeholders were interviewed to identify workflow barriers and education gaps following implementation. Enhancements to the electronic medical record and refocused nursing education improved compliance from 41% in the first 12 months to 91% at 24 months post-implementation (p < .001). The increasing number of evaluations additionally resulted in overall more cognitive evaluations as an initial step in identifying and treating previously unrecognized traumatic brain injury.

Conclusions:

A pediatric concussion screening tool is simple to administer, applies to all developmental ages, and improves diagnostic capture of traumatic brain injury in pediatric trauma when administered by nurses with support through the electronic medical record.
Coronavirus disease 2019 and coagulopathy: other prothrombotic coagulation factors
Authors: Calderon-Lopez Maria-Teresa , Garcia-Leon Natalia , Gomez-Arevalillo Sergio , Martin-Serrano Purificacion , Matilla-Garcia Arturo
Published: January 2021

There is an increasing evidence supporting the existence of coagulopathy in coronavirus disease 2019 (COVID-19) patients. Most of reports are mainly focused on d-dimer. Our objective is to describe coagulation parameters in these patients that could be involved in a hypercoagulate state and to test platelet function to see if there are short closure times. We analyzed coagulation samples from 80 patients admitted with COVID-19 in our hospital. We also tested platelet function by closure times in a small subgroup of patients. Most of samples had increased d-dimer (96.2%) (median of d-dimer: 1158 ng/ml FEU), increased fibrinogen (75.2%) (median: 5.23 g/l), increased factor VIII (86%) (median: 264.8 U/dl), decreased protein S (22.5% of women, 62.5% of men) (median: 62.8 and 68.5 U/dl, respectively), decreased protein C (7.6%) (median: 100 U/dl), decreased factor XII (25.3%) (median: 90.3 U/dl) and decreased antithrombin activity (21%) (median: 86 U/dl). International normalized ratio was higher than normal in 24 patients (30%) (median: 1.13). The activated partial thromboplastin time ratio was below the normal range in nine patients (11.2%) and above normal in three (3.75%) (median: 0.93). The closure times were short in the 20% and 40% of samples of collagen and ADP and collagen and epinephrine, respectively. Twelve of the 80 patients (15%) had a thrombotic event and all had several abnormal coagulation parameters related with increased thrombotic risk. The results of this study support a hypercoagulability state in COVID-19 patients and it may help to explain the microvascular thrombosis caused by the inflammatory response.
Coronary artery calcium score and risk of cardiovascular events without established coronary artery disease: a systemic review and meta-analysis
Authors: Abuzaid Ahmed , Saad Marwan , Addoumieh Antoine , Ha Le Dung , Elbadawi Ayman , Mahmoud Ahmed N. , Elgendy Akram , Abdelaziz Hesham K. , Barakat Amr F. , Mentias Amgad , Adeola Oluwaseun , Elgendy Islam Y. , Qasim Atif , Budoff Matthew
Published: January 2021

Background

Coronary artery calcium (CAC) is an indicator of atherosclerosis, and the CAC score is a useful noninvasive assessment of coronary artery disease.

Objective

To compare the risk of cardiovascular outcomes in patients with CAC > 0 versus CAC = 0 in asymptomatic and symptomatic population in patients without an established diagnosis of coronary artery disease.

Methods

A systematic search of electronic databases was conducted until January 2018 for any cohort study reporting cardiovascular events in patients with CAC > 0 compared with absence of CAC.

Results

Forty-five studies were included with 192 080 asymptomatic 32 477 symptomatic patients. At mean follow-up of 11 years, CAC > 0 was associated with an increased risk of major adverse cardiovascular and cerebrovascular events (MACE) compared to a CAC = 0 in asymptomatic arm [pooled risk ratio (RR) 4.05, 95% confidence interval (CI) 2.91–5.63, P < 0.00001, I
2 = 80%] and symptomatic arm (pooled RR 6.06, 95% CI 4.23–8.68, P < 0.00001, I
2 = 69%). CAC > 0 was also associated with increased risk of all-cause mortality in symptomatic population (pooled RR 7.94, 95% CI 2.61-24.17, P < 0.00001, I
2 = 85%) and in asymptomatic population CAC > 0 was associated with higher all-cause mortality (pooled RR 3.23, 95% CI 2.12–4.93, P < 0.00001, I
2 = 94%). In symptomatic population, revascularization in CAC > 0 was higher (pooled RR 15, 95% CI 6.66–33.80, P < 0.00001, I
2 = 72) compared with CAC = 0. Additionally, CAC > 0 was associated with more revascularization in asymptomatic population (pooled RR 5.34, 95% CI 2.06–13.85, P = 0.0006, I
2 = 93). In subgroup analysis of asymptomatic population by gender, CAC > 0 was associated with higher MACE (RR 6.39, 95% CI 3.39–12.84, P < 0.00001).

Conclusion

Absence of CAC is associated with low risk of cardiovascular events compared with any CAC > 0 in both asymptomatic and symptomatic population without coronary artery disease.
Nutrition in the critically ill surgical patient
Authors: Puzio Thaddeus J. , Kozar Rosemary A.
Published: January 2021

Purpose of review

The aim of this study was to discuss recent findings related to providing adequate and well tolerated nutrition to the critically ill surgical patient.

Recent findings

The majority of nutritional studies in the critically ill have been performed on well nourished patients, but validated scoring systems can now identify high nutrition risk patients. Although it remains well accepted that early enteral nutrition with protein supplementation is key, mechanistic data suggest that hypocaloric feeding in septic patients may be beneficial. For critically ill patients unable to tolerate enteral nutrition, randomized pilot data demonstrate improved functional outcomes with early supplemental parenteral nutrition. Current guidelines also recommend early total parenteral nutrition in high nutrition risk patients with contraindications to enteral nutrition. When critically ill patients require low or moderate-dose vasopressors, enteral feeding appears well tolerated based on a large database study, while randomized prospective data showed worse outcomes in patients receiving high-dose vasopressors.

Current evidence suggests early enteral nutrition with protein supplementation in critically ill surgical patients with consideration of early parenteral nutrition in high nutrition risk patients unable to achieve nutrition goals enterally. Despite established guidelines for nutritional therapy, the paucity of data to support these recommendations illustrates the critical need for additional studies.
New imaging techniques in AKI
Authors: Selby Nicholas M. , Duranteau Jacques
Published: January 2021

Purpose of review

Acute kidney injury (AKI) is a common complication in critically ill patients. Understanding the pathophysiology of AKI is essential to guide patient management. Imaging techniques that inform the pathogenesis of AKI in critically ill patients are urgently needed, in both research and ultimately clinical settings. Renal contrast-enhanced ultrasonography (CEUS) and multiparametric MRI appear to be the most promising imaging techniques for exploring the pathophysiological mechanisms involved in AKI.

Recent findings

CEUS and MRI can be used to noninvasively and safely evaluate renal macrocirculation and microcirculation and oxygenation in critical ill patients. These techniques show that a decrease in renal blood flow, particularly cortical blood flow, may be observed in septic AKI and may contribute to its development. MRI may be a valuable method to quantify long-term renal damage after AKI that cannot currently be detected using standard clinical approaches.

CEUS and multiparametric renal MRI are promising imaging techniques but more evidence is needed to show how they can first be more widely used in a research setting to test key hypotheses about the pathophysiology and recovery of AKI, and then ultimately be adopted in clinical practice to guide patient management.