Search

Indocyanine green (ICG) angiography for the intraoperative evaluation of tissue perfusion is commonly used in implant-based breast reconstruction (IBR). The assessment of ICG images depends on the surgeon's interpretation and is qualitative or semiqualitative in nature. To quantify ICG metrics, this study aimed to apply a novel assessment of fill-rate dynamics to predict wound-healing complications and provide pragmatic assessment tools in IBR. This was a retrospective cohort study of patients who underwent IBR with ICG using the photodynamic eye (PDE-Neo II) qualitative imaging system between April 2021 and September 2023. ICG recordings were reviewed to quantify the relative surface area and fluorescence intensity of visual perfusion deficits using ImageJ. The primary outcome was the incidence of wound-healing complications. t-tests and logistic regression were performed for statistical testing. A total of 112 patients (201 breasts) were included. The incidence of wound-healing complications was 12.9%. A higher relative surface area of ischemic regions was significantly associated with wound-healing complications (3.3% vs. 0.90%; p = 0.001). The rate of change in the surface area of ischemic regions was significantly associated with wound-healing complications (0.35% per second vs. 1.29% per second; p = 0.003%). On average, the duration of transient ischemic areas was significantly longer in breasts with wound-healing complications (46.0 s vs. 36.0 s, p = 0.01). A transient ischemic area of > 5% of the breast and/or failure to resolve transient ischemic areas after 60 s may predict wound-healing complications and inform surgical reconstructive decision-making in IBR. [ABSTRACT FROM AUTHOR]

Nurses are often suboptimally used in HIV care, due to misalignment of training and practice, workflow inefficiencies, and management challenges. We sought to understand nursing workforce capacity and support implementation of process improvement strategies to improve efficiency of HIV service delivery in Tanzania and Zambia. We conducted time and motion observations and task analyses at 16 facilities followed by process improvement workshops. On average, each nurse cared for 45 clients per day in Tanzania and 29 in Zambia. Administrative tasks and documentation occupied large proportions of nurse time. Self-reported competency was low at baseline and higher at follow-up for identifying and managing treatment failure and prescribing antiretroviral therapy. After workshops, facilities changed care processes, provided additional training and mentorship, and changed staffing and supervision. Efficiency outcomes were stable despite staffing increases. Collaborative approaches to use workforce data to engage providers in improvement strategies can support roll-out of nurse-managed HIV treatment. [ABSTRACT FROM AUTHOR]

Purpose: To compare the cost and outcomes of surgical and interventional radiology (IR) placement of totally implantable venous access devices (TIVADs) within a large regional health system to determine the service line with better outcomes and lower costs to the health system.Materials and Methods: A retrospective review of all chest port placements performed in the operating room (OR) and IR suite over 12 months was conducted at a large, integrated health system with 6 major hospitals. Secondary electronic health record and cost data were used to identify TIVAD placements, follow-up procedures indicating port malfunction, early adverse events (within 1 month after the surgery), late adverse events (2-12 months after the procedure), and health system cost of TIVAD placement and management.Results: For 799 total port placements included in this analysis, the rate of major adverse events was 1.3% and 1.9% for the IR and OR groups, respectively, during the early follow-up (P = .5655) and 4.9% and 2.8% for the IR and OR groups, respectively, during the late follow-up (P = .5437). Malfunction-related follow-up procedure rates were 1.8% and 2.6% for the IR and OR groups, respectively, during the early follow-up (P = .4787) and 12.4% and 10.5% for the IR and OR groups, respectively, during the late follow-up (P = .4354). The mean cost of port placement per patient was $4,509 and $5,247 for the IR and OR groups, respectively. The difference in per-patient cost of port placement was $1,170 greater for the OR group (P = .0074).Conclusions: The similar rates of adverse events and follow-up procedures and significant differences in insertion cost suggest that IR TIVAD placement may be more cost effective than surgical placement without affecting the quality. [ABSTRACT FROM AUTHOR]

Perinatal mental health conditions affect up to 20 % of pregnant or postpartum individuals, and nearly 15 % of pregnant individuals meet criteria for substance use disorder (SUD). All providers taking care of pregnant or postpartum individuals will encounter patients in these scenarios. Maternal Mortality Review Committees (MMRCs) have determined maternal mental health conditions, including SUD, to be the leading cause of preventable maternal death during pregnancy or in the first year postpartum. Lessons learned from MMRCs to prevent these deaths include the recommendation that screening and identification of mental health conditions need to be linked with evidence-based, patient-centered, and accessible treatments. Obstetricians and gynecologists, midwives, family medicine providers, and pediatricians, are in unique positions not only to screen and diagnose, but also to treat individuals with mental health concerns, including SUD, during pregnancy and postpartum. [ABSTRACT FROM AUTHOR]

While previous scholars have connected Wilder’s works to “orthodox” existentialism, a close analysis of Camus’ The Myth of Sisyphus and Wilder’s The Skin of Our Teeth, both published in 1942, and of Wilder’s relationship to existentialist thought, reveals a more complicated correlation. Whereas Camus’ “orthodox” existentialism stems from the cynicism of post-World War I Europe, Wilder’s version, what we term “American existentialism,” differs in seeking meaning through a collective, progressive, and hopeful worldview. [ABSTRACT FROM AUTHOR]

Background and Objectives: There is a need for local anesthetics that provide consistent analgesia through 72 hours after surgery. This study evaluates the use of HTX-011 (bupivacaine and meloxicam in Biochronomerpolymer technology), an extended-release, dual-acting local anesthetic, in reducing both postoperative pain over 72 hours and postoperative opioid use when compared with bupivacaine hydrochloride (HCl) and saline placebo. Inclusion of low-dose meloxicam in HTX-011 is designed to reduce local inflammation caused by surgery, potentiating the analgesic effect of bupivacaine. Previously, significant synergy has been observed with bupivacaine and meloxicam with both given locally together.Methods: EPOCH 1 was a randomized, double-blind, placebo-controlled and active-controlled phase III study in subjects undergoing a primary unilateral, distal, first metatarsal bunionectomy in which subjects received either a single intraoperative dose of HTX-011, immediate-release bupivacaine HCl or saline placebo.Results: A total of 412 subjects were dosed. The results for the primary and all four key secondary endpoints were statistically significant in favor of HTX-011. HTX-011 demonstrated superior, sustained pain reduction through 72 hours, significantly reduced opioid consumption and resulted in significantly more opioid-free subjects compared with saline placebo and bupivacaine HCl. Safety was similar across groups with fewer opioid-related adverse events observed in the HTX-011 group.Conclusions: HTX-011 demonstrated significant reduction in postoperative pain through 72 hours with significant reduction in opioid consumption and a significant increase in the proportion of opioid-free subjects compared with saline placebo and the most widely used local anesthetic, bupivacaine HCl.Trial Registration Number: NCT03295721. [ABSTRACT FROM AUTHOR]

Danny Boyle's film Yesterday (2019) is a contemporary morality play in which the main character, Jack Malik, a failing singer-songwriter, is magically sent to a different possible world in which the Beatles never existed. Possessing his memory of the Beatles' catalogue in the new possible world, he is now in sole possession of an extremely valuable artifact. Recording and performing the songs of the Beatles and passing them off as his own, he becomes rich, famous, and deeply unhappy. Once he confesses his wrong-doing, however, he is redeemed and his life becomes wonderful. The presupposition that underlays the plot is that in claiming authorship of the songs of the Beatles in a world in which the Beatles never existed, he is acting immorally. But on what theoretical grounds can this intuitive judgment be justified? Can one plagiarize work for which there is no author in one's world? Saul Kripke, in Naming and Necessity, dubs terms that refer in all possible worlds to be "rigid designators" and considers the metaphysics necessary to support them. In this case, it is not reference but moral responsibility that is invariant under changes of possible world and so we must ask a similar question for "rigid obligators." We argue that a virtue ethics approach is the only way to support the foundational moral intuition. [ABSTRACT FROM AUTHOR]

While a growing number of research studies have reported the inter-observer variability in computed tomographic (CT) measurements, there are very few interventional studies performed. We aimed to assess whether a peer benchmarking intervention tool may have an influence on reducing interobserver variability in CT measurements and identify possible barriers to the intervention. In this retrospective study, 13 board-certified radiologists repeatedly reviewed 10 CT image sets of lung lesions and hepatic metastases during 3 noncontiguous time periods (T1, T2, T3). Each preselected case contained normal anatomy cephalad and caudal to the lesion of interest. Lesion size measurement under RECISTS 1.1 guidelines, choice of CT slice, and time spent on measurement were captured. Prior to their final measurements, the participants were exposed to the intervention designed to reduce the number of measurements deviating from the median. Chi-square test was performed to identify radiologist-dependent factors associated with the variability. The percent of deviating measurements during T1 and T2 were 20.0% and 23.1%, respectively. There was no statistically significant change in the number of deviating measurements upon the presentation of the intervention despite the decrease in percent from 23.1% to 17.7%. The identified barriers to the intervention include clinical disagreements among radiologists. Specifically, the inter-observer variability was associated with the controversy over the choice of CT image slice (P = 0.045) and selection of start-point, axis, and end-point (P = 0.011). Clinical disagreements rather than random errors were barriers to reducing interobserver variability in CT measurement among experienced radiologists. Future interventions could aim to resolve the disagreement in an interactive approach. [ABSTRACT FROM AUTHOR]

Abstract Introduction Leadership and teaching skills are essential, but not often emphasized, components of medical training. As emergency care develops as a specialty in Uganda, two cadres of providers are being trained: physicians and non-physician clinicians (NPCs). Building formal leadership and educator training into these curricula is essential. Methods A week long continuing education (CE) course on leadership and teaching is described and evaluated for effectiveness using Kirkpatrick's framework for learner-centred outcomes. The emergency care trained NPCs participated in a week-long course consisting of lectures, role-playing, and small group discussions, as well as a personality self-assessment. The evaluation process consisted of: 1) an immediate post-course survey to measure learner satisfaction, 2) a retrospective, pre/post self-assessment with a Likert-type scoring tool to measure knowledge gains, and 3) a three-month follow up survey and structured interviews to measure knowledge retention and behaviour change in practice. Results All 15 NPCs participated in the evaluation process. Learner satisfaction was high with an average score of 9.3 (on a 1–10 scale) for course content, amount learned, and use of time. Participants reported gains in knowledge for each of the 24 competencies measured, with an average difference in pre- and post-course Likert scores of 1.11 (on a scale of 1–5). Lastly, all 15 participants shared detailed examples of using course content in practice three months after the course finished. The most frequently mentioned themes were "giving and receiving feedback," "delegating and assigning tasks," and "communication." Conclusion This course was a successful CE intervention in this setting as measured by Kirkpatrick's framework. The most frequently mentioned concepts used in practice point to the NPCs ability to take on leadership roles in this setting. Further research and evaluation methods should focus on the influence of culture and personalities on leadership education and translation into practice in an EM setting. [ABSTRACT FROM AUTHOR]

Copyright of Canadian Journal of Ophthalmology is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Summary Purpose Although abdominal-based flaps remain the first choice for autologous breast reconstruction, alternative donor sites are necessary when the abdomen is unavailable. Abdominal donor site suitability is determined, at times, according to deep inferior epigastric perforator (DIEP)-protocol computed tomographic angiography (CTA) results. CTA provides information about the pelvis/upper thigh that can be used to evaluate the suitability of other donor sites. This study aimed to examine the utility of DIEP-protocol CTA in the assessment of a lateral thigh perforator (LTP) flap. Furthermore, a small clinical LTP flap breast reconstruction series was presented. Methods The LTP flap anatomy was studied in 100 DIEP-protocol CT angiographies (200 thighs). Collected data included lateral circumflex femoral artery (LCFA) origin; number, type, and course of LTPs; pedicle characteristics; and reference point measurements. Relative relationships between reference point anatomy and perforator anatomy were analyzed. Results Perforators originated from the LCFA ascending branch (4.6 mm average diameter), averaging 2.6 perforators/thigh. The mean estimated pedicle length was 7.7 cm (±0.7 cm). Septocutaneous perforators were present in 97% (1.8 perforators/thigh). Musculocutaneous perforators were present in 64% (0.9 perforators/thigh). The mean distance between anterior superior iliac spine and perforator was 9.9 cm (±1.5 cm). Perforators were located 0.13 cm (±1.1 cm) below the pubic symphysis. Our LTP flap clinical series featured dissection in the supine position and primary donor site closure and highlighted the difficulty in flap design (six patients, nine LTP flaps). Conclusions LTPs are consistent, reliably present, and radiographically appear to be suitable for microsurgical transfer. DIEP-protocol CTA is an acceptable method for imaging the pertinent LTP anatomy. [ABSTRACT FROM AUTHOR]

Introduction Colorectal cancer (CRC) diagnosed before age 30 years is a fatal disease whose biology remains poorly understood. To understand its pathogenesis, we compared molecular and clinical data in surgically treated early-age onset and adult onset patients. Materials and Methods Clinical data and tumor tissue were collected retrospectively for 94 patients with early-age onset CRC (age ≤ 30 years) and compared to 275 adult CRC patients (age ≥ 50 years). Tumor morphology, microsatellite instability (MSI) and stability (MSS), KRAS and BRAF mutations, and mismatch repair (MMR) expression ( MSH2, MLH1, MSH6, PMS2 ) were assessed. Results Early-age CRC was distinguished from adult CRC by advanced stage presentation ( P < 0.001), frequent high grade cancers ( P < 0.001), and poor prognosis ( P < 0.001). MSI was associated with favorable survival and MMR loss in both groups. Compared to adults, MSI in early-onset CRC was more prevalent ( P < 0.01), not tightly linked to MLH1/PMS2 loss, and never associated with BRAFV600E mutations ( P < 0.01). MSS/ BRAFV600E genotype had poor prognosis and was more prevalent in early-age CRC (9% vs. 3%). Discussion Specific genetic subtypes are found at different frequencies in early-age onset and adult onset CRC. Complete absence of the indolent MSI/ BRAFV600E genotype and enrichment in the unfavorable MSS/ BRAFV600E genotype help explain the poor prognosis of early onset CRC. [ABSTRACT FROM AUTHOR]