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Purpose: A significant number of cancer survivors experience cancer-related cognitive impairment (CRCI), which can impact their ability to think, reason, make decisions, and perform daily actions. In recent years, non-pharmacological interventions for CRCI have gained significant attention. These interventions include exercise, cognitive behavioural therapy, cognitive training/remediation, dietary, mind-body, and multi-modal/complex interventions. This umbrella review provides a critical overview to inform guidelines and current practice, identify the most promising interventions, and uncover gaps in the research literature., Methods: This umbrella review of systematic reviews was pre-registered on Open Science Framework and PROSPERO. Six databases were searched. Systematic reviews (SR) assessing any non-pharmacological interventions to improve cognition in cancer (any type) were included. The overview followed gold-standard guidelines and recommendations. The results were narratively synthesised, and descriptive statistics and effect size ranges were calculated., Results: Sixty-four (n = 64) SRs were included. Results were synthesised into four non-pharmacological domains. Cognitive training/rehabilitation had the strongest evidence for efficacy. Physical activity/exercise showed promising efficacy; however, the variability of findings was considerable. Mind-body and psychological/behavioural therapy interventions were limited, but there was evidence for short-term effectiveness. Multi-modal/complex interventions showed potential for improving cognition in cancer but were poorly defined., Conclusions: Overall, non-pharmacological interventions demonstrated efficacy for improving cognition in cancer. There were limited intervention characteristics within domains which were consistently related to efficacy. Three key recommendations are provided for future research: (1) adopt harmonisation and reporting guidelines; (2) develop definitional guidelines of cognitive domains for CRCI research; and (3) assess intervention and participant characteristics associated with positive versus null/negative findings., Competing Interests: Declarations. Ethics approval: Not Applicable. Consent to participate: Not Applicable. Consent for publication: Not Applicable. Competing interests: This project was completed within a MASCC Cognition Fellowship. NHH is an Associate Editor of the Supportive Care in Cancer journal. DH is a MASCC Cognition Fellow; NHH is Chair of MASCC Fatigue and MASCC Exercise Oncology; NHH is a MASCC Terry Langbaum Survivorship Fellow; AC is the MASCC President-Elect; RJC is MASCC Treasurer; MBL is MASCC Immediate Past President., (© 2025. The Author(s).)

Purpose: Cancer-related cognitive impairment (CRCI) can have a profound impact on the lives of cancer survivors. A multitude of subjective and objective assessment tools exist to assess the presence and severity of CRCI. However, no purpose-built tool exists to assess the unmet needs of cancer survivors directly relating to CRCI. This paper details the development and initial validation of the Multinational Association of Supportive Care in Cancer - Unmet Needs Assessment of Cancer-Related Cognitive Impairment Impact (the MASCC COG-IMPACT)., Methods: A multistep mixed-methods measurement development and validation approach was taken with a strong emphasis on co-design. Qualitative interviews were conducted with cancer survivors (n = 32) and oncology health professionals (n = 19), followed by a modified Delphi survey with oncology health professionals (n = 29). Cognitive interviews with cancer survivors (n = 22) over two rounds were then conducted to finalise the penultimate version of the unmet needs assessment tool for CRCI. Four-hundred and ninety-one (n = 491) cancer survivors then completed the MASCC COG-IMPACT and other established measures to inform structural, reliability, validity, acceptability, appropriateness, and feasibility analyses., Results: The final MASCC COG-IMPACT is a 55-item and eight subscale tool including two indices: "difficulties" and "unmet needs". The MASCC COG-IMPACT was found to have strong structural validity, convergent validity, discriminant validity, internal consistency, and test-retest reliability. The MASCC COG-IMPACT was also found to be highly acceptable, appropriate, and feasible., Conclusion: The MASCC COG-IMPACT may facilitate optimal care and referral in line with a cancer survivor's CRCI-related difficulties and unmet needs. The MASCC COG-IMPACT may also be used to explore factors and contributors to CRCI-related difficulties and unmet needs. Overall, the MASCC COG-IMPACT is a highly reliable and valid tool for the assessment of CRCI-related difficulties and unmet needs in both clinical and research settings. The MASCC COG-IMPACT and supporting materials can be accessed on the MASCC webpage or via the MASCC COG-IMPACT Open Science Framework webpage ( https://osf.io/5zc3a/ )., Competing Interests: Declarations. Ethics approval: Ethics approval was obtained from St. Vincent’s Hospital Melbourne Human Research Ethics Committee prior to data collection (PID05582). Consent to participate: All participants provided informed consent to participate in this research. Consent for publication: All participants consented to their non-identifiable data being used for publication. Competing interests: NHH is an Associate Editor of the Supportive Care in Cancer journal. DH is a MASCC Cognition Fellow; NHH is Chair of MASCC Fatigue and Founding Chair of MASCC Exercise Oncology; NHH is a MASCC Terry Langbaum Survivorship Fellow; AC is the MASCC President-Elect; RJC is MASCC Treasurer; MBL is MASCC Immediate Past President., (© 2025. The Author(s).)

People affected by breast cancer experience a multitude of toxicities and unmet needs across physical, cognitive, psychosocial, and economic domains that adversely impact their quality of life. High-quality and diverse supportive care is required to improve outcomes and rehabilitation for people affected by breast cancer. However, the availability and access to high-quality supportive care services is limited due to factors including cost and demand. As such, many people affected by breast cancer do not receive optimal supportive care. The Think Pink Foundation facilitates free-of-charge supportive care services to breast cancer survivors, their families, and caregivers through 'The Living Centre'. Think Pink seeks to provide a high-quality survivorship care model that overcomes barriers associated with the economic burden of cancer. Within its suite of services, The Living Centre offers ongoing exercise classes, creative therapy, support groups, specialist breast cancer nurse consultations, wellness services, and education support through face-to-face and online service provision. This paper outlines the development, model of care, service provision, and planning for future outcomes and economic evaluation of The Living Centre as a supportive care model for others to consider establishing in their local context. This paper may therefore directly inform the development of cancer survivorship care services globally to increase equitable access to optimal supportive care., Competing Interests: Declarations. Ethics approval: Not applicable. Consent to participate: Not applicable. Consent for publication: Not applicable. Competing interests: NHH holds a position on the editorial board of Supportive Care in Cancer. DH is a MASCC Cognition Fellow; NHH is Chair of MASCC Fatigue and MASCC Exercise Oncology; NHH is a MASCC Terry Langbaum Survivorship Fellow. DH and NHH are Principal Scientific Advisors of the Think Pink Foundation. JK and NS are employees of the Think Pink Foundation. IH is the Director of the Think Pink Foundation and D Hendel is the Director of Operations., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Mental health for cancer survivors in both research and clinical applications has strongly adopted a traditional nosological approach, involving the classification of psychopathology into discrete disorders. However, this approach has recently faced considerable criticism due to issues such as high comorbidity and within-disorder symptom heterogeneity across populations. Moreover, there are additional specific issues impacting the validity of traditional approaches in cancer survivorship populations, including the physiological effects of cancer and its treatments. In response, we provide the case for the hierarchical dimensional approach within psycho-oncology, in particular the Hierarchical Taxonomy of Psychopathology (HiTOP). We discuss not only the potential utility of HiTOP to research and clinical applications within psycho-oncology, but also its limitations, and what is required to apply this approach within cancer survivorship., Competing Interests: Declaration of interests D.H., R.K., R.F.K., A.G.C.W., and M.K.F. are members of the HiTOP Consortium. Otherwise, the authors declare no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

(1) Background : A significant proportion of cancer survivors report experiencing a cognitive 'fog' that affects their ability to think coherently and quickly, and reason with clarity. This has been referred to as cancer-related cognitive impairment (CRCI). CRCI has extensive impacts on the daily lives of people living with or beyond cancer, including occupational, social, and psychological functioning. Oncology health professionals report feeling under-resourced to effectively assess the needs of an individual with CRCI and then provide optimal care and referral. (2) Methods : The objective of this project is to develop and provide an initial validation of the first purpose-built unmet needs assessment for CRCI: the Unmet Needs Assessment of Cancer-Related Cognitive Impairment Impact (COG-IMPACT). We will use a multiple-stage, co-design, mixed-methods approach to develop and provide an initial validation of the COG-IMPACT. (3) Results : The primary anticipated result of this research is the production of the COG-IMPACT, the first purpose-built unmet needs assessment for CRCI. The assessment could be used by health professionals to understand the unmet needs and facilitate optimal care and referral for cancer survivors, by survivors to elucidate their supportive needs and advocate for their care, and by researchers to examine the correlates of unmet needs relating to CRCI, as well as how best to support people with CRCI.

Background: Many cancer survivors experience cancer-related cognitive impairment (CRCI), often with significant negative consequences across various life domains. Emerging evidence suggests that allowing additional time to process information before acting may be a useful strategy for those with CRCI to mitigate some of its impacts. The Wisconsin Card Sorting Task (WCST), a measure of general cognition, has shown that for some cancer survivors, longer task completion time facilitates similar task performance outcomes to control populations concerning perseveration errors; a key performance metric of the WCST. However, assessing if this strategy may be useful, as well as determining for whom it may be useful, with regard to strengths and weaknesses among select cognitive domains, is challenging due to factors such as the problem of task impurity. Accordingly, this study provides an initial computational and experimental assessment of whether additional time to process information before acting is a useful strategy for those with CRCI., Methods: We simulated individual cognitive differences observed in humans by varying contributions of executive functioning components (updating, shifting, inhibition) to yield 48 distinct computational models of the WCST. Our main manipulation was then to provide these models with more or less time (at three levels of 20, 40 and 60 cycles) before models executed an action to sort a given card. We compared the number of perseveration errors on the WCST produced by the computational models. Additionally, we determined models that simulated the performance of cancer survivors on the WCST by comparing the number of perseveration errors produced by the models to human data., Results: Additional processing time resulted in the models producing significantly fewer perseveration errors, supporting our hypothesis. In addition, 8 unique models simulated the performance of cancer survivors on the WCST. Additional time appeared to have a positive influence on performance primarily by mitigating the impacts of severe inhibition impairments. For more severe global executive function impairments, a substantial amount of additional time was required to mitigate the impacts of the impairments. For the most severe impairments, additional time was unable to adequately mitigate the impact on performance., Conclusion: Additional processing time may be a useful strategy to rectify perseveration errors among cancer survivors with CRCI. Our findings have implications for the development of practical strategies, such as workload and deadline management in occupational settings, which may mitigate the negative effects of CRCI., (© 2024. The Author(s).)

A significant proportion of cancer survivors will experience some form of mental health compromise across domains including mood, anxiety, psychosis, eating disorders, and substance use. This psychopathology within cancer survivors is related to a range of negative outcomes and can also have a substantial negative impact on quality of life. Along with psychopathology, cognitive impairments are also commonly experienced, resulting in deficits in memory, reasoning, decision-making, speed of processing, and concentration, collectively referred to as cancer-related cognitive impairment (CRCI). Within the non-oncology literature, cognitive deficits are consistently demonstrated to be a key transdiagnostic aetiological feature of psychopathology, functionally contributing to the development and perpetuation of symptoms. Whilst there is an acknowledgement of the role mental health concerns might play in the development of and perception of CRCI, there has been limited acknowledgement and research exploring the potential for CRCI to functionally contribute toward the development of transdiagnostic psychopathology in cancer survivors beyond simply psychosocial distress. Given the theoretical and empirical evidence suggesting cognitive deficits to be an aetiological factor in psychopathology, we provide a rationale for the potential for CRCI to be a factor in the development and perpetuation of transdiagnostic psychopathology in cancer survivors. This potential functional association has significant implications for risk identification, prevention, treatment, and supportive cancer care approaches regarding psychopathology in cancer survivorship. We conclude by providing directions for future research in this area., (© 2024. The Author(s).)

Objective: Paranoid ideation underlies numerous psychological disorders and has debilitating effects on daily life. Deficits in neurocognition are highlighted as a contributing factor to paranoid-related disorders, but the impact on the symptom-level experience of paranoid ideation is unclear. This study aimed to employ a dimensional approach to understand the association between neurocognition and the severity and presence of paranoid ideation., Methods: 400 participants, representative of the general population of the USA, completed an online questionnaire consisting of the Brief Symptom Inventory-53, and demographic and clinical questions. The participants then completed four computerised neurocognitive tasks measuring working memory, shifting, inhibition, and speed of processing., Results: Speed of processing accounted for unique variance in the severity of paranoid ideation with a small effect size, after controlling for covariates. Working memory, shifting, and inhibition could not uniquely or collectively, account for paranoid ideation. Neurocognitive performance could not distinguish between individuals with and without paranoid ideation experiences., Conclusions: This research supports the body of literature that speed of information processing may be a key feature of paranoid ideation. Future research should employ non-linear dynamic methods to better understand the potential interactions between neurocognitive components and how this may relate to paranoid ideation.

This study examines the effect of proteins on the binding property and microstructure of enzymatic-induced calcium carbonate precipitation (EICP) in cementitious environment. The protein modified precipitates generally demonstrated improved binding to a glass slide surface or cement paste surface compared to the control precipitate. A marked decrease in the amount and binding strength of the precipitates in the cementitious environment was observed due to a reduction in the urease enzyme activity. The protein modified precipitates exhibited noticeable improvement compared to the control precipitate in cementitious environment which could arise from the ability of the proteins to partially shield urease from the negative effect of high pH. The protein gel network formation due to the complexation between the proteins and Ca 2+ provides nucleation sites for CaCO 3 crystallization. The FTIR, SEM, TGA, and XRD results indicated that vaterite is the dominant polymorph in cementitious environment compared to calcite in deionized water., Competing Interests: The authors declare no competing interests., (© 2023 The Author(s).)

Many cancer survivors experience cognitive impairments that impact memory, concentration, speed of information processing, and decision making. These impairments, collectively known as cancer-related cognitive impairments (CRCIs), are a key domain of unmet needs and can significantly impact a cancer survivor's identity and quality of life. However, there are no purpose-built, multi-domain, needs assessment tools specifically for CRCI. The development of such tools requires an in-depth understanding of cancer survivors' CRCI-specific challenges and associated needs. This study explored the challenges and associated needs of cancer survivors with persistent CRCI. An in-depth qualitative design using semi-structured interviews with (a) cancer survivors with perceived CRCI (n = 32) and (b) oncology health professionals (n = 19) was utilised. A reflexive thematic analysis of the interviews resulted in five overarching themes: (1) executing regular activities, (2) relational difficulties, (3) occupational functioning, (4) psychological distress, and (5) social functioning, as well as an additional informational needs domain. Ultimately, CRCI was found to directly produce a range of challenges that negatively, and persistently, impact cancer survivors' quality of life. Cancer survivors were also found to have a range of needs associated with these challenges. This research should be used to inform future challenges and needs assessment tools as well as treatment and supportive care priority areas directly relating to CRCI.

Background: Upper extremity (UE) vascular injuries account for 18.4% of all traumatic vascular injuries. Arterial pressure index (API) use in lower extremity injuries to determine the need for further investigations is well established. However, due to collateral circulation in UEs, it is unclear if the same algorithm can be applied. The purpose of this study was to determine if APIs can be used to determine the need for computed tomography angiogram (CTA) in penetrating UE trauma., Methods: All adult trauma patients with penetrating UE trauma and APIs from 2006 to 2016 were identified at 3 urban US level 1 trauma centers. Sensitivity, specificity, and positive and negative predictive values of APIs <.9 in detecting UE arterial injuries were calculated., Results: During the 11-year study period, 218 patients met our inclusion criteria. Gunshot wounds comprised 76.6% and stab wounds 17.9%. Median injury severity score and API were 9 and 1, respectively. Seventy-two of our patients underwent evaluation with CTA. Of the injuries, the most common were thrombus or occlusion (46.7%), transection (23.1%), and dissection (15.4%), radiographically. Ultimately, 32 patients underwent surgical.

Introduction: "Talk and die" traditionally described occult presentations of fatal intracranial injuries, but we broaden its definition to victims of penetrating trauma., Methods: We conducted a descriptive analysis of patients with penetrating torso trauma who presented with a Glasgow Coma Scale verbal score ≥3 and died within 48 h of arrival from 2008 to 2018., Results: Sixty patients were identified. Eighteen (30.0%) required resuscitative thoracotomy with 7 (11.7%) dying in the trauma bay. Fifty-three (86.9%) patients went to the operating room, and 35 (66.0%) required multicavitary exploration. The most common injuries were hollow viscous (58.5%), intra-abdominal vascular (49.0%), liver (28.3%), pulmonary (26.4%), intrathoracic vascular (18.9%), and cardiac (15.75) injuries. Twenty-three (43.4%) patients survived their initial operation, but died in the first 48 h postoperatively., Conclusions: Patients who "talk and die" most frequently have intra-abdominal vascular injures and require multicavitary exploration., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: At our tertiary academic center, residents undergo formalized training in obtaining informed consent and disclosing a complication. The informed consent portion has previously been shown to benefit a group of surgical and emergency medicine residents. We aimed to determine if the benefits from training persist across a larger number of procedural-based specialties and to ascertain the benefit of training in disclosing complications., Design: This retrospective cohort study examined first-year residents from seven procedural-based specialties who participated in a formal informed consent and disclosures training program, consisting of a didactic lecture and two-part simulation. Two years after the start of the program, the disclosure scenario was added. Participants were given pre- and post-surveys assessing comfort and confidence in the informed consent and disclosure scenarios. Survey results were compared using the signed-rank test and Kruskal-Wallis test as appropriate., Setting: This study occurred at Temple University Hospital, a tertiary academic institution in Philadelphia, PA., Participants: First-year residents from 2014 to 2020 in seven procedural-based specialties, including general surgery, orthopedic surgery, otolaryngology, obstetrics and gynecology, emergency medicine, radiology, and anesthesia, participated in this study. One hundred and ninety-three residents completed the program and surveys., Results: Residents reported improved confidence in filling out an informed consent form (p = 0.036) and more comfortable in obtaining informed consent (p = 0.041), as well as more confidence (p = 0.018) and comfort (p = 0.001) in disclosing a complication. Surgical residents demonstrated greater confidence in obtaining informed consent (p = 0.009) and disclosing a complication (p = 0.0002) after training than non-surgical residents., Conclusions: Across multiple procedural-based specialties, formal training in informed consent and disclosure of complications increases resident ability to perform these tasks. A formal training program is valuable for residents who are expected to perform these tasks across various specialties., (Published by Elsevier Inc.)

As practicing clinicians, most of us have not had formal education on many of the business fundamentals that allow us to run a thriving practice. This article serves as a primer for understanding revenue cycle management, practical steps for engaging in insurance contract negotiation, and considerations for benchmarking the financial, operational, and human resources of your clinic., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Police transport (PT) of penetrating trauma patients decreases the time between injury and trauma center arrival. Our study objective was to characterize trends in the rate of PT and its impact on mortality. We hypothesized that PT is increasing and that these patients are more injured., Methods: We conducted a single-center, retrospective cohort study of adult (≥18 years) patients presenting with gunshot wounds (GSWs) to a level 1 center from 2012 to 2018. Patients transported by police or ambulance (emergency medical service [EMS]) were included. The association between mode of transport (PT vs. EMS) and mortality was evaluated using χ2, t tests, Mann-Whitney U tests, and logistic regression., Results: Of 2,007 patients, there were 1,357 PT patients and 650 EMS patients. Overall in-hospital mortality was 23.7%. The rate of GSW patients arriving by PT increased from 48.9% to 78.5% over the study period (p < 0.001). Compared with EMS patients, PT patients were sicker on presentation with lower initial systolic blood pressure (98 vs. 110, p < 0.001), higher Injury Severity Score (median [interquartile range], 10 [2-75] vs. 9 [1-17]; p < 0.001) and more bullet wounds (3.5 vs. 2.9, p < 0.001). Police-transported patients more frequently underwent resuscitative thoracotomy (19.2% vs. 10.0%, p < 0.001) and immediate surgical exploration (31.3% vs. 22.6%, p < 0.001). There was no difference in adjusted in-hospital mortality between transport groups. Of patients surviving to discharge, PT patients had higher Injury Severity Score (9.6 vs. 8.3, p = 0.004) and lower systolic blood pressure on arrival (126 vs. 130, p = 0.013) than EMS patients., Conclusion: Police transport of GSW patients is increasing at our urban level 1 center. Compared with EMS patients, PT patients are more severely injured but have similar in-hospital mortality. Further study is necessary to understand the impact of PT on outcomes in specific subsets in penetrating trauma patients., Level of Evidence: Epidemiological, level III., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Major venous injury (MVI) affecting the lower extremity can result in subsequent amputation. The contribution of intraoperative resuscitation efforts on the need for amputation is not well defined. We hypothesized that intraoperative large volume crystalloid resuscitation (LVCR) increases the risk of amputation after MVI, while massive transfusion (MT) does not., Methods: We performed a retrospective review of patients with infrarenal MVI from 2005 to 2015 at seven urban level I trauma centers. The outcome of interest was the need for secondary amputation., Results: 478 patients were included. 31 (6.5%) patients with MVI required amputation. LVCR(p < 0.001), combined arterial/venous injury (p = 0.001), and associated fracture (p = 0.001) were significant risk factors for amputation. MT did not significantly increase amputation risk (p = 0.44). Multivariable logistic regression model demonstrated that patients receiving ≥5L LVCR(aOR (95% CI): 9.7 (2.9, 33.0); p < 0.001), with combined arterial/venous injury (aOR (95% CI):3.6 (1.5, 8.5); p = 0.004), and with an associated fracture (aOR (95% CI):3.2 (1.5, 7.1); p = 0.004) were more likely to require amputation., Conclusion: Patients with MVI who receive LVCR, have combined arterial/venous injuries and have associated fractures are more likely to require amputation. MT was not associated with delayed amputation., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The relationship between behavioral health disorders (BHDs) and outcomes after traumatic injury is not well understood. The objective of this study was to evaluate the association between BHDs and outcomes in the trauma patient population., Materials and Methods: We performed a review of the Trauma Quality Improvement Program database from 2013 to 2016 comparing patients with and without a BHD, which was defined as a psychiatric disorder, alcohol or drug use disorders, dementia, or attention deficit hyperactivity disorder. Outcomes of interest were mortality, length of stay (LOS), and inpatient complications., Results: In the study population, 254,882 patients (25%) had a BHD. Of these, psychiatric disorders comprised 38.3% (n = 97,668) followed by alcohol (33.3%, n = 84,845) and drug (26.4%, n = 67,199) use disorders, dementia (20.2%, n = 51,553), and attention deficit hyperactivity disorder (1.7%, n = 4301). On multivariable analysis, overall mortality was lower in the BHD group (odds ratio [OR] 0.83, confidence interval [CI] 0.79-0.83; P < 0.001). Patients with dementia had higher mortality when controlling for other risk factors (OR 1.62, CI 1.56-1.69; P < 0.001). LOS was 8.5 d (s = 0.02) for patients with a BHD versus 7.4 d (s = 0.01) for patients without a BHD (P < 0.001). Comorbid BHD was associated with any inpatient complication (OR 1.19, CI 1.18-1.20; P < 0.001)., Conclusions: Trauma patients with a BHD had lower overall mortality compared with those without a BHD. However, on subgroup analysis, those with dementia had increased mortality. BHDs increased risk for any inpatient complication and prolonged LOS. Trauma patients with BHDs represent a vulnerable population and warrant special attention to minimize harm and improve outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Venous thromboembolism (VTE) after major vascular injury (MVI) is particularly challenging because the competing risk of thrombosis and embolization after direct vessel injury must be balanced with risk of bleeding after surgical repair. We hypothesized that venous injuries, repair type, and intraoperative anticoagulation would influence VTE formation after MVI., Methods: A multi-institution, retrospective cohort study of consecutive MVI patients was conducted at three urban, Level I centers (2005-2013). Patients with MVI of the neck, torso, or proximal extremities (to elbows/knees) were included. Our primary study endpoint was the development of VTE (DVT or pulmonary embolism [PE])., Results: The 435 major vascular injury patients were primarily young (27 years) men (89%) with penetrating (84%) injuries. When patients with (n = 108) and without (n = 327) VTE were compared, we observed no difference in age, mechanism, extremity injury, tourniquet use, orthopedic and spine injuries, damage control, local heparinized saline, or vascular surgery consultation (all p > 0.05). VTE patients had greater Injury Severity Score (ISS) (17 vs. 12), shock indices (1 vs. 0.9), and more torso (58% vs. 35%) and venous (73% vs. 48%) injuries, but less often received systemic intraoperative anticoagulation (39% vs. 53%) or postoperative enoxaparin (47% vs. 61%) prophylaxis (all p < 0.05). After controlling for ISS, hemodynamics, injured vessel, intraoperative anticoagulation, and postoperative prophylaxis, multivariable analysis revealed venous injury was independently predictive of VTE (odds ratio, 2.7; p = 0.002). Multivariable analysis of the venous injuries subset (n = 237) then determined that only delay in starting VTE chemoprophylaxis (odds ratio, 1.3/day; p = 0.013) independently predicted VTE after controlling for ISS, hemodynamics, injured vessel, surgical subspecialty, intraoperative anticoagulation, and postoperative prophylaxis. Overall, 3.4% of venous injury patients developed PE, but PE rates were not related to their operative management (p = 0.72)., Conclusion: Patients with major venous injuries are at high risk for VTE, regardless of intraoperative management. Our results support the immediate initiation of postoperative chemoprophylaxis in patients with major venous injuries., Level of Evidence: Therapeutic/care management, level IV.

Background: The role of systemic intraoperative anticoagulation (SIAC) during surgical repair of major arterial injuries is controversial. Any potential improvement in arterial patency must be weighed against the risk of hemorrhage in these critically injured patients. We hypothesized that SIAC would increase arterial patency without increasing bleeding complications., Methods: We conducted a multi-institution, retrospective cohort study of trauma patients with major vascular injury from 2005 to 2013 in three Level I centers. Arterial injuries of the neck, torso, and proximal extremities requiring operative management were included. Our primary endpoint was maintenance of arterial patency during index hospitalization. Complications related to bleeding were assessed. The association between SIAC and arterial patency was evaluated using chi-square, t test, and multiple logistic regression modeling., Results: Of 323 study patients, most were male (88%) and injured by gunshot wounds (69%). Patients repaired with SIAC (n = 154) were compared to those repaired without SIAC (n = 169). No difference in age, gender, mechanism, admission heart rate, or concomitant injury was detected between the groups (all p > 0.05). SIAC use was associated with greater arterial patency rates (93% vs. 85%, p = 0.02) without increasing return to OR for bleeding (4% vs. 6%, p = 0.29). After controlling for gender, admission hemodynamics, ISS, injury location, and postoperative anticoagulation, multivariable regression determined that SIAC patients were 2.6 times more likely (OR 2.6, 95% CI 1.1-6.2, p = 0.03) to maintain patency. Patients who maintained arterial patency were then less likely to return to the OR (9% vs. 78%, p < 0.001) with shorter intensive care unit (median 3 vs. 9 days, p < 0.01) and hospital length of stay (median 13 vs. 21 days, p < 0.01)., Conclusion: Patients who underwent operative repair of arterial injuries utilizing SIAC experienced better arterial patency without additional bleeding complications as compared to those repaired without SIAC. Our data suggest that SIAC may improve arterial patency rates after repair and the attributable bleeding risk of SIAC may be overstated., Level of Evidence: Therapeutic/care management, level IV.

As left ventricular assist devices (LVADs) are increasingly used for patients with end-stage heart failure, the need for noncardiac surgical procedures (NCSs) in these patients will continue to rise. We examined the various types of NCS required and its outcomes in LVAD patients requiring NCS. The National Inpatient Sample Database was examined for all patients implanted with an LVAD from 2007 to 2010. Patients requiring NCS after LVAD implantation were compared to all other patients receiving an LVAD. There were 1,397 patients undergoing LVAD implantation. Of these, 298 (21.3%) required 459 NCS after LVAD implantation. There were 153 (33.3%) general surgery procedures, with abdominal/bowel procedures (n = 76, 16.6%) being most common. Thoracic (n = 141, 30.7%) and vascular (n = 140, 30.5%) procedures were also common. Patients requiring NCS developed more wound infections (9.1 vs. 4.6%, p = 0.004), greater bleeding complications (44.0 vs. 24.8%, p < 0.001) and were more likely to develop any complication (87.2 vs. 82.0%, p = 0.001). On multivariate analysis, the requirement of NCSs (odds ratio: 1.45, 95% confidence interval: 0.95-2.20, p = 0.08) was not associated with mortality. Noncardiac surgical procedures are commonly required after LVAD implantation, and the incidence of complications after NCS is high. This suggests that patients undergoing even low-risk NCS should be cared at centers with treating surgeons and LVAD specialists.

Introduction: Impaired wound healing due to immunosuppression has led some surgeons to preferentially use open gastrostomy tube (OGT) over percutaneous gastrostomy tube (PEG) in heart transplant patients when long-term enteral access is deemed necessary., Methods: The National Inpatient Sample (NIS) database (2005-2010) was queried for all heart transplant patients. Those receiving OGT were compared to those treated with PEG tube., Results: There were 498 patients requiring long-term enteral access treated with a gastrostomy tube, with 424 (85.2%) receiving a PEG and 74 (14.8%) an OGT. The PEG cohort had higher Charlson comorbidity Index (4.1 vs. 2.0, p = 0.002) and a higher incidence of post-operative acute renal failure (31.5 vs. 12.7%, p = 0.001). Post-operative mortality was not different when comparing the two groups (13.8 vs. 6.1%, p = 0.06). On multivariate analysis, while both PEG (OR: 7.87, 95%C.I: 5.88-10.52, p < 0.001) and OGT (OR 5.87, 95%CI: 2.19-15.75, p < 0.001) were independently associated with mortality, PEG conferred a higher mortality risk., Conclusions: This is the largest reported study to date comparing outcomes between PEG and OGT in heart transplant patients. PEG does not confer any advantage over OGT in this patient population with respect to morbidity, mortality, and length of stay.

Introduction: Lung transplant patients require a high degree of immunosuppression, which can impair wound healing when surgical procedures are required. We hypothesized that because of impaired healing, lung transplant patients requiring gastrostomy tubes would have better outcomes with open gastrostomy tube (OGT) as compared to percutaneous endoscopic gastrostomy tube (PEG)., Methods: The National Inpatient Sample (NIS) Database (2005-2010) was queried for all lung transplant recipients requiring OGT or PEG., Results: There were 215 patients requiring gastrostomy tube, with 44 OGT and 171 PEG. The two groups were not different with respect to age (52.0 vs. 56.9 years, p = 0.40) and Charlson Comorbidity Index (3.3 vs. 3.5, p = 0.75). Incidence of acute renal failure was higher in the PEG group (35.2 vs. 11.8%, p = 0.003). Post-operative pneumonia, myocardial infarction, surgical site infection, DVT/PE, and urinary tract infection were not different. Post-operative mortality was higher in the PEG group (11.2 vs. 0.0%, p = 0.02). Using multiple variable analysis, PEG tube was independently associated with mortality (HR: 1.94, 95%C.I: 1.45-2.58). Variables associated with survival included age, female gender, white race, and larger hospital bed capacity., Discussion: OGT may be the preferred method of gastric access for lung transplant recipients., Conclusions: In lung transplant recipients, OGT results in decreased morbidity and mortality when compared to PEG.

As extracorporeal membrane oxygenation (ECMO) is increasingly used for patients with cardiac and/or pulmonary failure, the need for noncardiac surgical procedures (NCSPs) in these patients will continue to increase. This study examined the NCSP required in patients supported with ECMO and determined which variables affect outcomes. The National Inpatient Sample Database was examined for patients supported with ECMO from 2007 to 2010. There were 563 patients requiring ECMO during the study period. Of these, 269 (47.8%) required 380 NCSPs. There were 149 (39.2%) general surgical procedures, with abdominal exploration/bowel resection (18.2%) being most common. Vascular (29.5%) and thoracic procedures (23.4%) were also common. Patients requiring NCSP had longer median length of stay (15.5 vs. 9.2 days, p = 0.001), more wound infections (7.4% vs. 3.7%, p = 0.02), and more bleeding complications (27.9% vs. 17.3%, p = 0.01). The incidences of other complications and inpatient mortality (54.3% vs. 58.2%, p = 0.54) were similar. On logistic regression, the requirement of NCSPs was not associated with mortality (odds ratio [OR]: 0.91, 95% confidence interval [CI]: 0.68-1.23, p = 0.17). However, requirement of blood transfusion was associated with mortality (OR: 1.70, 95% CI: 1.06-2.74, p = 0.03). Although NCSPs in patients supported with ECMO does not increase mortality, it results in increased morbidity and longer hospital stay.

Introduction: There is a paucity of data on outcomes for lung transplant (LT) recipients requiring general surgery procedures. This study examined outcomes after cholecystectomy in LT recipients using a large database., Methods: The National Inpatient Sample Database (2005-2010) was queried for all LT patients requiring laparoscopic cholecystectomy (LC) and open cholecystectomy (OC)., Results: There were a total of 377 cholecystectomies performed in LT patients. The majority were done for acute cholecystitis (n = 218; 57%) and were done urgently/emergently (n = 258; 68%). There were a total of 304 (81%) laparoscopic cholecystectomies and 73 (19%) OC. There was no difference in age when comparing the laparoscopic and open groups (53.6 vs 55.5 years; P = .39). In addition, the Charlson Comorbidity Index was similar in the 2 groups (P = .07). Patients undergoing OC were more likely to have perioperative myocardial infarction, pulmonary embolus, or any complication compared with the laparoscopic group. Total hospital charges ($59,137.00 vs $106,329.80; P = .03) and median duration of stay (4.0 vs 8.0 days; P = .02) were both greater with open compared with LC., Conclusion: Cholecystectomy can be performed safely in the LT population with minimal morbidity and mortality., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background and Purpose: In the past 50 years, fluoroscopic guidance has been used to improve upon lumbar puncture (LP) technique that was unchanged for over a century. Recently, CT has seen increasing use as a guidance modality due to its ability to demonstrate soft tissue contrast and provide millimeter accuracy with needle targeting. This study compared procedure time and radiation dosages for fluoroscopic and CT guided LP., Materials and Methods: This institutional review board and Health Insurance Portability and Accountability Act (HIPAA) compliant study was a retrospective review of a consecutive cohort referred for image guided LP. For CT, 45 patients aged 49 years (range 20-78, SD 14) with body mass index (BMI) values of 33 kg/m(2) (range 20-50, SD 12) were included. For fluoroscopy, 100 patients aged 47 years (range 18-88, SD 17) with BMI values of 29 kg/m(2) (range 15-56, SD 9) were included. CT procedure time was determined using picture archiving and communication system (PACS) image time stamps. Radiation dose was determined using the CT dose report and effective dose conversion factors. Fluoroscopic procedure time was determined from nursing. Fluoroscopic radiation dose was calculated from dose-area product (DAP) and fluoroscopy times, with effective dosage calculated using simulation software., Results: For CT, procedure time average was 14 min (range 5-42, SD 8.5). Average dose-length product was 120 mGy×cm (range 39-211, SD 43) and average effective dose was 1.98 mSv (range 0.2-8.18, SD 4.4). For fluoroscopy, procedure time averaged 12 min (range 12-30, SD 6). Average DAP was 10 Gy×cm(2) (range 0.1-70, SD 11) and effective dose estimate averaged 2.9 mSv (range 0.9-9.4, SD 1.9). There were no unsuccessful taps or complications., Conclusions: Both fluoroscopic and CT guidance may be used to perform an LP in an obese population with a short procedure time and low radiation dose.

Context: The Public Health Accreditation Board (PHAB) began accepting applications for national voluntary accreditation in the fall of 2011. There are 3 prerequisites for accreditation: health assessments; health improvement plans; and strategic plans. These prerequisites must be in place for a state or local public health agency to apply for PHAB accreditation. Completion of the prerequisites can become a barrier for agencies that are considering applying for accreditation., Objective: This project looked at all 50 states through a legal lens to identify legal tools in the form of laws, rules, executive orders, contracts, legislative resolutions, and other tools that are used to authorize or require that a state or local health agency complete 1 or more of the prerequisites., Design: Using legal research platforms and a Boolean search stream, an inquiry of legal tools in all 50 states was completed to determine where legal tools are used to authorize or require the 3 PHAB prerequisites. Once legal tools were found, interviews were conducted with key informants from each state to understand the implementation and use of the legal tools found and collect any additional legal tools that were not found from the legal search., Results: The results include key findings and, importantly, an inventory of laws and legal tools that are being used around the country to require and support completion of the prerequisites. Within all 50 states, 26 states have some type of a mandate regarding 1 or more of the PHAB prerequisites. This includes 1 state that includes a mandate for PHAB accreditation., Conclusions: States use a wide variety of legal tools to implement the prerequisites for voluntary accreditation. It is important to understand the interpretation, enforcement, and support of the laws and legal tools to determine whether the tools have impact in individual states.

Background: Unlike Canada's medical malpractice system, patients in New Zealand who are dissatisfied with the quality of their care may choose between 2 well-established medicolegal paths: one leads to monetary compensation and the other to nonmonetary forms of accountability. We compared the forms of accountability sought by patients and families in New Zealand who took different types of legal action following a medical injury. This study offers insights into the forms of accountability sought by injured patients and may help to inform tort-reform initiatives., Methods: We reviewed compensation claims submitted to the Accident Compensation Corporation (ACC), New Zealand's national no-fault insurer, following injuries associated with admission to a public hospital in 1998 (n = 582). We also reviewed complaint letters (n = 254) submitted to the national Health and Disability Commissioner (HDC) that same year to determine the forms of accountability sought by injured patients. We used univariable and multivariable analyses to compare sociodemographic and socioeconomic characteristics of patients who sought nonmonetary forms of accountability with those of patients who claimed compensation., Results: Of 154 injured patients whose complaints were sufficiently detailed to allow coding, 50% sought corrective action to prevent similar harm to future patients (45% system change, 6% review of involved clinician's competence) and 40% wanted more satisfying communication (34% explanation, 10% apology). The odds that patients would seek compensation were significantly increased if they were in their prime working years (aged between 30 and 64 years) (odds ratio [OR] 1.66, 95% confidence interval [CI] 1.14-2.41) or had a permanent disability as a result of their injury (OR 1.75, 95% CI 1.14-2.70). When injuries resulted in death, the odds of a compensation claim to the ACC were about one-eighth those of a complaint to the HDC (OR 0.13, 95% CI 0.08-0.23)., Interpretation: Injured patients who pursue medicolegal action seek various forms of accountability. Compensation is important to some, especially when economic losses are substantial (e.g., with injury during prime working years or severe nonfatal injuries). However, others have purely nonmonetary goals, and ensuring alternative options for redress would be an efficient and effective response to their needs.

Objective: To illustrate the safety and efficacy of the endoscopic laser approach for cricopharyngeal myotomy (CPM) compared to the traditional transcervical approach., Study Design and Setting: Retrospective chart review of 22 patients undergoing CPM from 1996 to 2003 at the Mayo Clinic, Jacksonville., Results: The laser CPM technique was used in 14 patients, and an open approach in 8. The mean hospital stay and operative times were shorter for the laser group. Functional outcome analyses showed improvement in both groups. There were no major complications in the laser group, while 1 patient in the transcervical group had a pharyngocutaneous fistula., Conclusions: The laser technique is at least as effective as the transcervical approach for CPM to improve dysphagia symptoms in the properly selected patient, with a low risk of major complications., Significance: In this report, we provide the reader with data to support the safety and efficacy of laser CPM., Ebm Rating: B-3b.

Objectives: To determine the appropriate use of the scapula osteocutaneous free flap (SOFF) and to document donor site morbidity., Study Design: Retrospective review and prospective physical therapy evaluation., Methods: A computer database of all free flap procedures performed at a single institution was created. Specific clinical and operative details from cases involving a bone flap were extracted from the database. Rates of usage of the various osteocutaneous flaps were compared over four successive 2-year intervals (1992-1999). A single physical therapist performed a structured evaluation of the donor site., Results: Overall, 64 bone flap procedures were performed, of which 24 (37.5%) were SOFF procedures. The SOFF utilization has increased from 6.6% to 63.6%, while fibula and iliac crest utilization has fallen significantly. This is in part because of the greater versatility of the SOFF, with the possibility of separate skin paddles and adequate bone length. The mean cutaneous area harvested with the SOFF was 110 cm2 (range, 48-200 cm2) compared with 55.4 cm2 (range, 25-102 cm2) and 77.6 cm2 (range, 50-120 cm2) for the fibula and iliac crest, respectively. Mean bone flap lengths were 8.37, 7.65, and 10.1 cm, respectively, for the SOFF, fibula, and iliac crest. Dual skin paddles were used in 50% of the SOFF procedures versus 2.8% for the fibula flap procedures. There were no significant complications of the donor site in any patient, and there was only one flap failure (4.1%). Related to the SOFF, donor site morbidity was subjectively judged as "mild," for pain, mobility, and strength. There were no complaints of poor appearance of the donor site. Activities of daily living were judged as "not limited" or 'limited a little" in the majority of patients. Objective measurements of range of motion revealed an average reduction of 1 degree to 12 degrees in five different shoulder functions. Elbow and arm ranges of motion were not limited. Strength was minimally reduced in the shoulder, while the arm and forearm showed no reduction in strength., Conclusions: The SOFF is a versatile osteocutaneous free flap that can be used for a multitude of reconstructive problems. This and its relative lack of significant donor site morbidity have caused its use to increase significantly.