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The transcription factor and oncoprotein MYC is a potent driver of many human cancers and can regulate numerous biological activities that contribute to tumorigenesis. How a single transcription factor can regulate such a diverse set of biological programmes is central to the understanding of MYC function in cancer. In this Perspective, we highlight how multiple proteins that interact with MYC enable MYC to regulate several central control points of gene transcription. These include promoter binding, epigenetic modifications, initiation, elongation and post-transcriptional processes. Evidence shows that a combination of multiple protein interactions enables MYC to function as a potent oncoprotein, working together in a 'coalition model', as presented here. Moreover, as MYC depends on its protein interactome for function, we discuss recent research that emphasizes an unprecedented opportunity to target protein interactors to directly impede MYC oncogenesis.

Despite MYC dysregulation in most human cancers, strategies to target this potent oncogenic driver remain an urgent unmet need. Recent evidence shows the PP1 phosphatase and its regulatory subunit PNUTS control MYC phosphorylation, chromatin occupancy, and stability, however the molecular basis remains unclear. Here we demonstrate that MYC interacts directly with PNUTS through the MYC homology Box 0 (MB0), a highly conserved region recently shown to be important for MYC oncogenic activity. By NMR we identified a distinct peptide motif within MB0 that interacts with PNUTS residues 1-148, a functional unit, here termed PNUTS amino-terminal domain (PAD). Using NMR spectroscopy we determined the solution structure of PAD, and characterised its MYC-binding patch. Point mutations of residues at the MYC-PNUTS interface significantly weaken their interaction both in vitro and in vivo, leading to elevated MYC phosphorylation. These data demonstrate that the MB0 region of MYC directly interacts with the PAD of PNUTS, which provides new insight into the control mechanisms of MYC as a regulator of gene transcription and a pervasive cancer driver. Funding: Canadian Institutes of Health Research [FRN156167 to L.Z.P., FDN154328 to C.H.A., FDN143312 to D.W.A.]; Swedish Cancer Society [20 1276 PjF 01 H to M.S.]; Swedish Childhood Cancer Fund [PR2019-0143 project grant to M.S., TJ2018-0103 postdoc award to A.A.]; Swedish Research Council [2018-04390 to M.S., 2016-05369 to B.W.]; Princess Margaret Cancer Centre; Princess Margaret Cancer Foundation; Ontario Ministry of Health; the Structural Genomics Consortium is a registered charity [1097737] that receives funds from Bayer AG, Boehringer Ingelheim, Bristol Myers Squibb, Genentech, Genome Canada through Ontario Genomics Institute [OGI-196]; EU/EFPIA/OICR/McGill/KTH/Diamond Innovative Medicines Initiative 2 Joint Undertaking [EUbOPEN grant 875510]; Janssen, Merck KGaA (aka EMD in Canada and US); Pfizer; Takeda; NMR access at the ProLinC core facility was funded by Linköping University; the computations were performed on resources provided by the Swedish National Infrastructure for Computing (SNIC) at the National Supercomputer Centre (NSC) in Linköping; L.Z.P. and D.W.A. hold Tier 1 Canada Research Chairs in Molecular Oncology and Membrane Biogenesis, respectively. Funding for open access charge: Canadian Institutes of Health Research.

By identifying MYC protein-protein interactors, we aim to gain a deeper mechanistic understanding of MYC as a regulator of gene transcription and potent oncoprotein. This information can then be used to devise strategies for disrupting critical MYC protein-protein interactions to inhibit MYC-driven tumorigenesis. In this chapter, we discuss four techniques to identify and validate MYC-interacting partners. First, we highlight BioID, a powerful discovery method used to identify high-confidence proximal interactors in living cells. We also discuss bioinformatic prioritization strategies for the BioID-derived MYC-proximal complexes. Next, we discuss how protein interactions can be validated using techniques such as in vivo-in vitro pull-down assays and the proximity ligation assay (PLA). We conclude with an overview of biolayer interferometry (BLI), a quantitative method used to characterize direct interactions between two proteins in vitro. Overall, we highlight the principles of each assay and provide methodology necessary to conduct these experiments and adapt them to the study of interactors of additional proteins of interest.

The essential eukaryotic chaperone Hsp90 regulates the form and function of diverse client proteins, many of which govern thermotolerance, virulence, and drug resistance in fungal species. However, use of Hsp90 inhibitors as antifungal therapeutics has been precluded by human host toxicities and suppression of immune responses. We recently described resorcylate aminopyrazoles (RAPs) as the first class of Hsp90 inhibitors capable of discriminating between fungal (Cryptococcus neoformans, Candida albicans) and human isoforms of Hsp90 in biochemical assays. Here, we report an iterative structure-property optimization toward RAPs capable of inhibiting C. neoformans growth in culture. In addition, we report the first X-ray crystal structures of C. neoformans Hsp90 nucleotide binding domain (NBD), as the apoprotein and in complexes with the non-species-selective Hsp90 inhibitor NVP-AUY922 and three RAPs revealing unique ligand-induced conformational rearrangements, which reaffirm the hypothesis that intrinsic differences in protein flexibility can confer selective inhibition of fungal versus human Hsp90 isoforms.

Objective:Meta-analyses report moderate effects across cognitive remediation (CR) trials in schizophrenia. However, individual responses are variable, with some participants showing no appreciable gain in cognitive performance. Furthermore, reasons for heterogeneous outcome are undetermined. We examine the extent to which CR outcome is attributable to near learning—direct gains in trained cognitive tasks—while also exploring factors influencing far transfer of gains during training to external cognitive measures.Method:Thirty-seven schizophrenia outpatients were classified as CR responders and non-responders according to change in MATRICS Consensus Cognitive Battery composite score following 20 sessions of computer-based training. Metrics of near learning during training, as well as baseline demographic, clinical, cognitive, and electroencephalographic (EEG) measures, were examined as predictors of responder status.Results:Significant post-training improvement in cognitive composite score (Cohen’s d = .41) was observed across the sample, with n = 21 and n = 16 classified as responders and non-responders, respectively. Near learning was evidenced by significant improvement on each training exercise with practice; however, learning did not directly predict responder status. Group-wise comparison of responders and non-responders identified two factors favoring responders: higher EEG individual alpha frequency (IAF) and lower antipsychotic dosing. Tested in moderation analyses, IAF interacted with learning to predict improvement in cognitive outcome.Conclusion:CR outcome in schizophrenia is not directly explained by learning during training and appears to depend on latent factors influencing far transfer of trained abilities. Further understanding of factors influencing transfer of learning is needed to optimize CR efficacy.

Objective : To study the responsiveness of peripheral blood mononuclear cells to lipopolysaccharide (LPS) after severe trauma and its regulatory mechanisms. Materials and Methods : The release of proinflammatory reacting cytokines (tumor necrosis factor-α, interleukin (IL)-1β, IL-6, IL-8, interferon (IFN)-γ) into whole blood from 12 patients on day 1, 5, 10, and 14 after severe trauma (Injury Severity Score, 39.3 ± 2.8 points) and 10 healthy volunteers was studied after stimulation with LPS, concanavalin A, phorbol myristate acetate (PMA), and the addition of recombinant IFN-γ. Main Results : Trauma caused a significant reduction of LPS and concanavalin A induced release of inflammation activating cytokines into whole blood, including IFN-γ. However, the diminished release of proinflammatory cytokines could be increased with recombinant IFN-γ or even attenuated after stimulation of peripheral blood mononuclear cells with the protein kinase C activator PMA. Conclusions : Trauma leads to reduced responsiveness of blood monocytes to LPS and a decreased secretion of proinflammatory reacting lymphokines. Because activation of the protein kinase C pathway with PMA or the addition of IFN-γ significantly increased cytokine response, endotoxin tolerance is not caused by inhibition of protein synthesis, but to disturbances in the signal transduction pathway and its regulating mediators.

Norplant's long duration of action may result in users being less motivated than non-users to return for reproductive health care appointments. This study determined compliance with scheduled return appointments among adolescents using Norplant and those using other methods of contraception.We retrospectively reviewed the records of all teenagers (ageor = 18 years) who received Norplant between June 1991 and August 1993, as well as those of a comparison group of adolescents, matched for age and race, using other methods of contraception. Subjects receiving Norplant were given appointments for a two-week and an annual examination. Comparison subjects were given only an appointment for an annual examination. Norplant users not returning within 5 weeks or any subject not presenting within 12 months for an annual examination, were considered non-compliant.Eighty-eight adolescents received Norplant during the study period and the records of 85 were available for review. Only 48 of the 85 Norplant users returned for scheduled two-week check-up, while 18 of 43 subjects who had Norplant at least 12 months were compliant with annual examinations. The compliance rate with annual examinations among the 89 subjects not using Norplant was 38%, not dissimilar from that of the Norplant group.These data demonstrate that compliance with return appointments for reproductive health care among adolescent Norplant users is poor but not significantly worse than that of non-users of Norplant. Strategies promoting the benefits of return visits need to be improved for adolescents receiving contraception.Although the long-term protection from pregnancy conferred by Norplant use makes this a potentially effective method for adolescents, there are concerns that teenagers with implants will not be motivated to return for routine reproductive health examinations. To assess this possibility, compliance with scheduled return clinic appointments among 85 Norplant acceptors aged 18 years and younger and 89 age- and race-matched controls was compared through retrospective review of records at a community-based family planning clinic in North Carolina. Only 14 Norplant acceptors returned to have the insertion site examined within five weeks of insertion; another seven appeared for the initial examination after a reminder was mailed, yielding a 25% compliance rate. In terms of the annual examination, 18 of the 43 subjects who had used Norplant for at least 12 months and 34 of the 89 controls were compliant. There was no significant difference in this compliance rate between cases (41.9%) and users of other methods (38.2%). Among cases, the records showed that appointment compliance after Norplant insertion was not significantly lower than it had been among these women when they were using other methods. Only three Norplant acceptors discontinued the method, indicating a high degree of user satisfaction. Although these findings indicate that Norplant use does not increase the risk of poor compliance with reproductive health care, they indicate a need to convince teenagers of the benefits of such care, especially for the detection of sexually transmitted diseases.

This report describes one aspect of "Assessing the New Federalism," a multi-year research project, started by the Urban Institute in 1996, to analyze the devolution of responsibility for social programs from the federal government to the states. The project combines case studies in 13 diverse states with analyses of data drawn from a wide range of sources, including a new household survey--the National Survey of America's Families (NSAF). The NSAF, which contains nationally representative data from almost 45,000 families, was fielded in 1997 and 1999, and is planned for 2001 and again at subsequent two-year intervals. In this paper, we provide an overview of the NSAF's purpose; the sampling approach and methods; the questionnaire content, with particular emphasis on questions of interest to health policy researchers; health policy research planned by Urban Institute staff; and the timetable for public release of the NSAF data.

Congressional attempts to curtail spending growth in Medicare home health may affect Medicaid, given the number of Medicare enrollees who qualify for Medicaid-covered home care services. This DataWatch examines interactions between the Medicare and Medicaid home care programs using state-level expenditure data for 1995 and through case studies in five states: Connecticut, Louisiana, Minnesota, New Mexico, and New York.

Background : Excessive release of proinflammatory cytokines has been involved in pathogenesis of acute respiratory distress syndrome. Design : Since injured patients with chest trauma reveal a high risk for posttraumatic acute respiratory distress syndrome, local and systemic release of proinflammatory cytokines and their naturally occurring inhibitors were determined in the early posttraumatic period. Materials and Methods : Proinflammatory and anti-inflammatory mediators were measured in plasma and bronchoalveolar lavage fluid (BALF) from 16 patients with multiple injuries including severe chest injury (Injury Severity Score of 34.4 ± 2.3 points) and compared with healthy volunteers (n = 17). Results : Tumor necrosis factor-α was detectable neither in plasma nor in BALF. Interleukin-1β and interleukin-8 were significantly increased in BALF from injured patients, while plasma levels were similar in both groups. Soluble tumor necrosis factor receptors p55 and p75 and interleukin-lra were markedly elevated in plasma (p ≤ 0.01) and BALF (p ≤ 0.001) from injured patients compared with controls. Conclusion : Highly increased concentrations of proinflammatory cytokines in BALF, but not in circulation, indicate a strong local inflammatory response early after multiple injuries combined with chest injury rather than severe systemic inflammation. In contrast, anti-inflammatory mechanisms seem to be activated locally and systemically.

The promulgation of new coverage guidelines and provisions of the 1988 Medicare Catastrophic Coverage Act indicated that Medicare's role in financing nursing home care could expand greatly. This paper presents a facility-level analysis addressing how the policy changes affected the payer mix of subgroups of Medicare-certified skilled nursing facilities (SNFs). Our analysis found that the new policies increased participation of nursing homes in the Medicare SNF program and suggested that the policies expanded both access to the Medicare SNF benefit and the role of public financing for nursing home care. Greater responsiveness to the policies was observed among proprietary SNFs and among those with more beds.

Congestive heart failure (CHF) is accompanied by increased sympathetic nervous activity. Previous studies have demonstrated that plasma norepinephrine (NE), a marker of sympathetic nervous activity, is elevated in CHF due to increased NE spillover into the circulation and decreased NE clearance. In this study we compared the clearance of NE and isoproterenol (ISO) in eight CHF subjects (plasma NE 601 +/- 133 pg/ml), and in nine controls (plasma NE 285 +/- 53 pg/ml) by using steady-state infusions of tritiated NE ([3H]NE) and tritiated ISO ([3H]ISO). Because ISO is not a substrate of neuronal reuptake but is removed from the circulation in a way that is similar to NE after neuronal reuptake blockade with desipramine, ISO clearance may permit a gross estimation of non-neuronal uptake of circulating NE. The NE clearance was lower in CHF than in the control group (CHF 1.25 +/- 0.13, controls 2.04 +/- 0.22 l.min-1.m-2; P = 0.009). The ISO clearance was reduced similarly in CHF (CHF 0.90 +/- 0.09, controls 1.59 +/- 0.12 l.min-1.m-2; P less than 0.001). Because the ratio of ISO to NE clearance was similar in both groups, our findings suggest that a low cardiac output in CHF decreases the availability of circulating catecholamines to tissue elimination sites.

Neck contracture after burn injury can result in severe functional as well as aesthetic deformities. Contracture can recur even after wide and complete release and full-thickness skin grafting. Recurrence is partly due to the inherent difficulties in both early postoperative immobilization and the required long-term splinting. When adjacent tissues are also burned, adequate local tissue for reconstruction may not be available; therefore, free-tissue transfer may be necessary. The large surface area that is required after adequate release may be provided by tissue expansion before free-tissue transfer. In the case presented the use of tissue-expanded radial forearm free flap for the reconstruction of a recurrent neck contracture is described.

Early tangential excision sometimes results in considerable blood loss, prolonged operative time, and partial loss of the graft secondary to hematoma formation. Previous reports document positive hemostatic effects and improved skin fixation with fibrin "glue." The commercial preparation used in Europe, however, has not been approved by the United States Food and Drug Administration because of the high risk of hepatitis and human immunodeficiency virus transmission. Using a method developed at the University of Virginia, we applied single-donor fibrin glue as an adjunct in early excision and grafting in 16 patients (26 hands). The overall graft take was 99%. In all patients, better adherence of the split-thickness graft to the recipient bed, during and immediately after application, was noted. We have observed no negative effects with regard to infection or healing. We recommend the use of single-donor fibrin glue to reduce operative blood loss, improve survival and ease of graft application, and possibly to accelerate healing.

Reconstruction of the burned penile urethra has received scant attention in the surgical literature. Techniques used in repairing congenital hypospadias may not be applicable in this situation. We describe a dartos musculocutaneous island flap used to reconstruct the distal burned penile urethra in a 13-year-old boy who sustained burns to 85% of his total body surface area. Reconstruction was completed in one surgical procedure, and at two-year follow-up good results were demonstrated.

One way for hospitals to respond to the incentives in Medicare's PPS is to reduce the patients' length of stay by discharging to nursing home care those patients who no longer require hospital care but are not well enough to go home to informal care. In this study, we find that patients experience more discharge delays at hospitals located in areas with few nursing home beds and in states with prospective Medicaid nursing home reimbursement policies. Hospitals with their own nursing home units or swing beds experience earlier discharges, other things being equal. Our findings suggest that some hospitals are at a disadvantage compared with others and that a policy response may be warranted.

Primary cardiovascular manifestations of SSc include pericardial disease, myocardial disease, conduction abnormalities, and cardiac arrhythmias. Significant cardiac abnormalities are present in more than half of SSc patients at autopsy. As the frequency of subclinical cardiac involvement is now appreciated and noninvasive cardiac diagnostic modalities continue to improve, the ability to detect early asymptomatic involvement in SSc has improved. Two-dimensional echocardiography, radionucleotide imaging, and ambulatory ECG allow recurrent serial testing with virtually no morbidity. The current treatment of cardiac involvement in SSc is emperic and primarily directed at symptomatology. Large prospective randomized trials are needed to determine if preventive therapy is effective. With the advent of new immunological and cardiotropic agents and a better understanding of the primary disease process, our ability to alter the pathogenesis and final outcome of cardiac involvement in SSc should improve.

Treatment of burn injuries of the head and neck can be divided into acute and chronic stages. The acute phase consists of physiologic resuscitation of the patient and early care of the burn wound. The chronic stage begins from completion of wound coverage until the wound has matured. A major advance in the care of the patient with head and neck burns has been the realization that clinical application of exercise, traction, and pressure can reduce the development of contractures and hypertrophic scarring. Once the burn scars mature, the residual scar deformity can be improved by reconstructive surgical procedures.

Ambulatory patients with large sacral ulcers can represent extremely challenging coverage problems. Technical options become fewer when sacral ulcers are coupled with radiation dermatitis. Latissimus dorsi free flap transfer, with direct anastomoses to sacral vessels, is described in 2 patients.

A case report of a cystic preauricular mass that changed in size and position with jaw movement is presented. This tumor proved to be a ganglion of the temporomandibular joint (TM) cyst, which is relatively rare. When a preauricular mass retrudes into the masseter muscle in jaw opening, pathological conditions associated with the TMJ should be considered. Ganglion cysts of the TMJ are a benign pathological entity which can mimic parotid tumors. Temporomandibular joint radiography and perhaps ultrasonography of the region are useful in the preoperative evaluation of preauricular masses. The TMJ ganglion cyst can be successfully treated by direct excision and repair of the joint capsule. This approach avoids the potential morbidity of a superficial parotidectomy.

At the University of Virginia Hospital we have developed a new technique of urethroplasty utilizing a full-thickness flap of bladder wall. Tubing and transfer of the flap may be completed in two stages. The bladder flap is approximately 28 X 4 cm in size. Strictures have not occurred with this technique, but special care is needed in placing the tube to avoid kinking of the new urethra at the angle where the penile urethra passes anterior to the pubic bone. In conjunction with modern methods of phalloplasty, a two-stage reconstruction of the entire phallus, including a functioning urethra, can be performed by combining the bladder wall flap with a modern (axial vessel) abdominal or groin skin flap. This will allow a patient to have satisfactory intercourse and permit orthostatic micturition with a minimum number of operative procedures.

Early tangential excision and immediate grafting of the burn-injured patient has been shown to be effective. Along with the use of this technique, however, comes the potential for significant blood loss, prolonged operative time, and partial loss of graft due to underlying hematoma formation. Based on experience using a pooled fibrinogen preparation, European and Japanese surgeons have provided evidence for the positive hemostatic and skin transplant fixation effects of fibrin glue. This commercial preparation, however, has not been approved by the U.S. Food and Drug Administration for use in the United States because of high risk of hepatitis and HIV transmission. Using a method of preparing highly concentrated fibrinogen utilizing standard blood bank techniques developed at the University of Virginia, we have applied single-donor fibrin glue as an adjunct in the early excision and grafting of 26 patients. Since we have been using fibrin glue, we have noted a marked reduction in operative blood loss and time involved in obtaining hemostasis. Additionally, we have found the application of the grafts to be facilitated by the "stickiness" of the recipient bed. In follow-up, grafts applied utilizing the fibrin glue technique have proceeded to uncomplicated wound healing with an overall 98% graft take.

Summary A cutting forceps and suture removal scissors have been specially designed for removal of percutaneous sutures. Our clinical experience with these instruments indicate that they facilitate removal of percutaneous sutures in the surgical patient.

The purpose of this study was to measure the degree of pain elicited by either staple implantation and by removal in human subjects. Included in the study were conventional rectangular staples and the new arcuate staples. The pain associated with staple implantation was significantly greater than that associated with staple removal. The configuration of the staple did not influence the magnitude of pain associated with either staple implantation or staple removal.

Toxic epidermal necrolysis (TEN) is a symptom complex characterized by a devastating skin disorder, erosive involvement of two or more mucous membranes, and severe constitutional symptoms. The disorder shares features with erythema multiforme and is thought to be an expression of the syndrome. Although a wide range of etiologic factors have been incriminated in TEN, only a few cases have provided convincing evidence of a direct causal link. Most cases of TEN have been associated with drug administration.

Lightning causes more deaths than any other weather phenomenon. It is an electrical current that will choose the shortest paths between the contact points of the human body and may involve vital structures in its pathway. Almost every organ system can be injured by the electrical current of lightning. A broad spectrum of complications resulting from damage to the various organ systems has been reported. The sequelae peculiar to this specific type injury will dictate the choice of therapy.

The purpose of this study was to identify a skin wound cleanser that could be used safely to cleanse lacerations of the periorbital region. The irritation and toxicity to the eye of the commercially available skin wound cleansers were quantitated using numerical values and weights for the ocular lesions in experimental animals. Shur Clens ® did not elicit lesions in experimental animals or in a series of 20 patients with periorbital lacerations. On the basis of this study, Shur Clens ® is recommended as a safe skin wound cleanser for periorbital lacerations.

The reliability and accuracy of pulse oximetry as a monitoring device in deep superficial and full-thickness circumferential burns of the upper extremity were evaluated clinically. Pulse oximetry was correlated with the laser Doppler flowmeter experimentally in healthy volunteers. By continuously monitoring oxygen saturation levels, the pulse oximeter detected extremity hypoxia before it resulted in an adverse outcome. Extremities exhibiting oxygen saturation above 95% were treated with early excision and skin grafting without escharotomy. Extremities with O2 saturations of less than 95% underwent immediate escharotomy with return to normal saturation levels. The pulse oximeter is easy to use by nursing personnel; is noninvasive and accurate; and displays the oxygen saturation level within seconds.

Women field-lacrosse players, except the goalkeeper, do not wear protective equipment and are therefore susceptible to bony injuries by either the lacrosse stick or ball. The purpose of this article is to document one case of a finger fracture and another of a nasal fracture caused by an impact injury from lacrosse sticks in women field-lacrosse players. The Consumer Product Safety Commission estimates that 73.6% of the fractures in women field-lacrosse players that occur annually are located in the head, face, hand, or fingers. These injuries could be easily prevented by protective equipment (face mask or helmet) or gloves.

Burns are the second most common cause of death in childhood. More than half of pediatric burns are partial-thickness scald burns; the majority occur in the kitchen. Generally, minor burns may be treated on an outpatient basis, while moderate burns are treated in a community hospital. Children with major burns should be transferred to a regional burn unit as soon as possible after stabilization, provision of fluids and, if necessary, intubation.

Power lawnmower accidents are one of the most frequent causes of mutilating injuries in pediatric patients. Guidelines for the optimal surgical management of children differ from adult patients by several key anatomic, physiologic, and rehabilitative features. Small blood vessels in children less than 2 years old may prohibit microvascular surgery. Older children with larger vessels are often better candidates for microvascular flaps than their adult counterparts. Pediatric patients also resist recurrent ulceration of foot skin grafts, tolerate prolonged immobilization, and are rehabilitated more readily than adults. In considering these facts, we outlined an algorithm for surgical reconstruction. Split-thickness skin grafts are generally the first choice for coverage. The medial gastrocnemius is the workhorse of the knee and upper third leg. The soleus provides coverage for the middle third leg; microvascular flaps are used for large lower third leg defects. Crossleg fasciocutaneous flaps are good alternatives when microsurgery is not feasible. When possible, the weight-bearing surface of the foot should be covered with local vascularized sensate flaps; larger defects may require free flaps, crossleg, or gluteal-thigh flaps. Excellent functional rehabilitation has been achieved in our young patients through the combined efforts of the trauma service, plastic and orthopedic surgery, and physical and occupational therapy services. Language: en

This article is a collective review of all the prospective clinical studies that assessed the therapeutic value of antibiotics in minor soft tissue lacerations. This review critically evaluates each study that tests the hypothesis that antibiotic treatment reduces the incidence of infection. Even though the design of each of the studies was scientifically inadequate, important factors were identified that influenced the incidence of infection. On the basis of this collective review as well as other studies, indications for antibiotic therapy of minor soft tissue lacerations have been identified. Future clinical studies must be designed to test more precisely the validity of these recommendations.

Days that a patient remains in a hospital due to inability to secure nursing home placement are termed administratively necessary days (ANDs). Some hospitals under Medicare's prospective payment system have incurred discharge delays of this kind. Nursing home bed supply is one major problematic factor; others include adequacy of Medicare nursing home reimbursement rates relative to nursing home costs in an area, the willingness of facilities in an area to serve those needing skilled care, and stringency of relevant Medicaid reimbursement policy. Two promising approaches for dealing with ANDs are increasing nursing home reimbursement rates, and adjusting Medicare payments for exceptionally long-staying patients or those requiring exceptionally intensive care in hospitals.

The postoperative dressing is an integral part of an otoplasty. The dressing should fit securely, provide protection, and be comfortable for the patient to wear. Wrestling headgear can be used to fill these needs.