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Resilience bundles are designed to work within and enhance existing routines. In the wake of COVID-19, nurses are reporting high levels of burnout and are leaving the field at an alarming rate. Hospital system leaders across the country are working to develop wellness programs to improve nurse morale, decrease burnout, and enhance resilience. Resilience can help mitigate nurse burnout, and using a bundle of tools to help nurses develop resilience is more effective than a single strategy.Using the Connor-Davidson Resilience Scale-10 and the Perceived Stress Scale 4, emergency nurses were surveyed to measure resilience and stress before and after implementation of a 3-strategy resilience bundle. We surveyed at baseline, phase 1 (6 weeks after implementation), and phase 2 (15 weeks after implementation).A statistically significant increase in the Connor-Davidson Resilience Scale-10 scores was identified between the baseline and phase 1 surveys. A measurable decrease in the Perceived Stress Scale 4 was found between the baseline survey and the phase 1 and phase 2 postintervention surveys.Although evidence suggests a multifocal approach to improving resilience, use of resilience bundles is new. To enhance nurse resilience and mitigate burnout, nurse leaders may consider resilience bundles to prioritize the mental health and wellness of their staff.

Sedation Practice in Intensive Care Evaluation (SPICE-III) trial reported significant heterogeneity in mortality with dexmedetomidine treatment. Supplemental propofol was commonly used to achieve desirable sedation.to quantify the association of different infusion rates of dexmedetomidine or propofol, given in combination, with mortality and if this is modified by age.We included 1177 patients randomized in SPICE-III to receive dexmedetomidine and given supplemental propofol, stratified by age (65 or ≤65 years). We used double stratification analysis to produce quartiles of steady infusion rates of dexmedetomidine, while escalating propofol dose and vice versa. We used Cox proportional hazard and multivariable regression, adjusted for relevant clinical variable to evaluate the association of sedative dose with 90-day mortality.Younger patients 598/1177(50.8%) received a significantly higher dose of both sedatives compared with older patients, to achieve comparable sedation depth. On double stratification analysis, escalating infusion rates of propofol to 1.27 mg/kg/h at a steady dexmedetomidine infusion rate (0.54 mcg/kg/h) was associated with reduced adjusted mortality in younger, but not older patients. This was consistent with multivariable regression modelling [hazard ratio: 0.59(95% Confidence Interval 0.43-0.78),P0.0001], adjusted for baseline risk and interaction with dexmedetomidine dose. In contrast, among younger patients using multivariable regression, escalating dexmedetomidine infusion rate was associated with increased adjusted mortality [HR:1.30(95%CI 1.03-1.65), P=0.029].In patients ≤ 65 years sedated with dexmedetomidine and propofol combination, preferentially increasing the dose of propofol was associated with decreased adjusted 90-day mortality. Conversely, increasing dexmedetomidine may be associated with increased mortality. Clinical trial registration available at www.gov, ID: NCT01728558.

Robotic seals have been studied in long-term care settings; though, no studies of patients with dementia in the acute care setting have been reported. The purpose of this study was to evaluate the feasibility of PARO interventions for hospitalized patients with dementia, determine physiological effects and describe social-affective interactions. Using a prospective descriptive design with pre-post PARO intervention physiological measurements, we studied 55 participants who received up to five 15-min PARO interventions. The PARO was favorably accepted for 212 (95%) of the 223 PARO interventions. Differences in pre- and post-physiological measures for mean arterial pressure, pulse, respiration, oxygenation, stress, and pain levels were evaluated using Wilcoxon Signed Rank test with statistically significant pre and post differences (p=

Individual evidence suggests that multiple modalities can be used to treat entrapment pathology by Morton’s neuroma, including injection, neurolysis, and neurectomy. However, their impacts on patient pain and satisfaction have yet to be fully defined or elucidated. Correspondingly, our aim was to pool systematically identified metadata and substantiate the impact of these different modalities in treating Morton’s neuroma with respect to these outcomes. Searches of 7 electronic databases from inception to October 2019 were conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. The incidences of outcomes were extracted and pooled by random-effects meta-analysis of proportions. A total of 35 articles satisfied all criteria, reporting a total of 2998 patients with Morton’s neuroma managed by one of the three modalities. Incidence of complete pain relief after injection (43%; 95% CI, 23–64%) was significantly lower than neurolysis (68%; 95% CI, 51–84%) and neurectomy (74%; 95% CI, 66–82%) (P = 0.02). Incidence of complete satisfaction after injection (35%; 95% CI, 21–50%) was significantly lower than neurolysis (63%; 95% CI, 50–74%) and neurectomy (57%; 95% CI, 47–67%) (P

OBJECTIVE Arteriovenous malformations (AVMs) are a major cause of intracerebral hemorrhage in children, resulting in significant morbidity and mortality. Moreover, the rate of AVM recurrence in children is significantly higher than in adults. The aim of this study was to define the risk of delayed pediatric AVM (pAVM) recurrence following confirmed radiological obliteration. Further understanding of this risk could inform the role of long-term radiological surveillance. METHODS The authors conducted a retrospective review of ruptured and unruptured pAVM cases treated at a single tertiary care referral center between 1994 and 2019. Demographics, clinical characteristics, treatment modalities, and AVM recurrence were analyzed. RESULTS A total of 102 pediatric patients with intracranial AVMs, including 52 (51%) ruptured cases, were identified. The mean patient age at presentation was 11.2 ± 4.4 years, and 51 (50%) patients were female. The mean nidus size was 2.66 ± 1.44 cm. The most common Spetzler-Martin grades were III (32%) and II (31%). Stereotactic radiosurgery was performed in 69.6% of patients. AVM obliteration was radiologically confirmed in 68 (72.3%) of 94 patients with follow-up imaging, on angiography in 50 (73.5%) patients and on magnetic resonance imaging in 18 (26.5%). AVM recurrence was identified in 1 (2.3%) of 43 patients with long-term surveillance imaging over a mean follow-up of 54.7 ± 38.9 months (range 2–153 months). This recurrence was identified in a boy who had presented with a ruptured AVM and had been surgically treated at 5 years of age. The AVM recurred 54 months after confirmed obliteration on surveillance digital subtraction angiography. Two other cases of presumed AVM recurrence following resection in young children were excluded from recurrence analysis because of incomplete sets of imaging available for review. CONCLUSIONS AVM recurrence following confirmed obliteration on imaging is a rare phenomenon, though it occurs more frequently in the pediatric population. Regular long-term follow-up with dedicated surveillance angiography is recommended even after obliteration following resection.

Objective The aim of this study was to reduce the turnover of new RNs (NRNs) completing a 1-year nurse residency program. Background Businesses use touchpoints to retain both internal and external customers, yet no evidence was found in retaining NRNs. Touchpoints, distinct points in the company-customer experience, play a vital role in the customer's experience with the company. Employees are one of a company's many customer types. Methods This quality-improvement project implemented touchpoints to improve NRN retention rates. Results Retention rates and job-satisfaction scores were significantly higher among the touchpoint-intervention cohort compared with the nonintervention cohort. Implementation costs were far less than those associated with NRN turnover. Conclusions Touchpoints are a practical management approach for NRN retention.

OBJECTIVEThe authors sought to investigate the incidence and predictors of venous thromboembolic events (VTEs) after craniotomy for tumor resection, which are not well established, and the efficacy of and risks associated with VTE chemoprophylaxis, which remains controversial.METHODSThe authors investigated the incidence of VTEs in a consecutive series of patients presenting to the authors’ institution for resection of an intracranial lesion between 2012 and 2017. Information on patient and tumor characteristics was collected and independent predictors of VTEs were determined using stepwise multivariate logistic regression analysis. Review of the literature was performed by searching MEDLINE using the keywords “venous thromboembolism,” “deep venous thrombosis,” “pulmonary embolism,” “craniotomy,” and “brain neoplasms.”RESULTSThere were 1622 patients included for analysis. A small majority of patients were female (52.6%) and the mean age of the cohort was 52.9 years (SD 15.8 years). A majority of intracranial lesions were intraaxial (59.3%). The incidence of VTEs was 3.0% and the rates of deep venous thromboses and pulmonary emboli were 2.3% and 0.9%, respectively. On multivariate analysis, increasing patient age (unit OR 1.02, 95% CI 1.00–1.05; p = 0.018), history of VTE (OR 7.26, 95% CI 3.24–16.27; p < 0.001), presence of motor deficit (OR 2.64, 95% CI 1.43–4.88; p = 0.002), postoperative intracranial hemorrhage (OR 4.35, 95% CI 1.51–12.55; p < 0.001), and prolonged intubation or reintubation (OR 3.27, 95% CI 1.28–8.32; p < 0.001) were independently associated with increased odds of a VTE. There were 192 patients who received VTE chemoprophylaxis (11.8%); the mean postoperative day of chemoprophylaxis initiation was 4.6 (SD 3.8). The incidence of VTEs was higher in patients receiving chemoprophylaxis than in patients not receiving chemoprophylaxis (8.3% vs 2.2%; p < 0.001). There were 30 instances of clinically significant postoperative hemorrhage (1.9%), with only 1 hemorrhage occurring after initiation of VTE chemoprophylaxis (0.1%).CONCLUSIONSThe study results show the incidence and predictors of VTEs after craniotomy for tumor resection in this patient population. The incidence of VTE within this cohort appears low and comparable to that observed in other institutional series, despite the lack of routine prophylactic anticoagulation in the postoperative setting.

Introduction: Our aim was to describe feasibility and outcomes of skin-to-skin care (SSC) that began during cesarean surgery and continued, uninterrupted, for about 5 hours. We described maternal/newborn measures of physiologic stability and stress; maternal measures of comfort; maternal satisfaction with surgery and SSC; and exclusive breast milk feeding at discharge. Materials and Methods: We used a quasiexperimental, time-interrupted design and randomly assigned women to receive SSC that began during surgery (Group 1, intervention; n = 20) or after surgery, before transfer to recovery (Group 2, standard care; n = 20). We analyzed differences across time and for five observations: before transfer to the operating room (OR); in the OR, about 20 minutes after birth; in the recovery room, about 1 hour after admission; in the New Family Center (NFC), about 1 hour after admission; and in the NFC, about 2 hours after admission. Results: Group 1 began SSC an average of 0.89 minutes after birth and continued an average of 300 minutes and Group 2 began an average of 46 minutes after birth and continued an average of 126 minutes. Women who began SSC during surgery were more satisfied with the experience (p = 0.015) and had lower levels of salivary cortisol across time (p = 0.003). We found no negative effects on maternal or newborn measures of physiologic stability and no difference in exclusive breast milk feeding rates at discharge. Conclusion: Immediate and uninterrupted SSC during medically uncomplicated cesarean surgery is a feasible, low-cost intervention that can safely begin during surgery and continue, uninterrupted, for extended durations.

Multiple studies have reported the loss of trimethylation at lysine (K) 27 on histone 3 (H3K27me3) in high-grade malignant peripheral nerve sheath tumors (MPNSTs). However, the diagnostic potential of this finding in MPNSTs remains yet to be fully substantiated. Correspondingly, our aim was to pool systematically-identified metadata in the literature and substantiate the incidence of H3K27me3 loss in this setting. Searches of 7 electronic databases from inception to May 2019 were conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. The incidence of loss was then pooled by random-effects meta-analysis of proportions. Nine pertinent studies described a total of 823 high-grade MPNST samples. When pooled, incidence (sensitivity) of complete H3K27me3 loss was estimated to be 53% (95% CI 42–64%). For MPNST subtypes, estimated incidences of complete loss in NF1 subtype was 52% (95% CI 41–62), in sporadic subtype was 53% (95% CI 36–70%), in the epithelioid subtype was 0% (95% CI 0–7%), and radiation-associated subtype was 98% (95% CI 86–100%). Finally, incidence of incomplete loss (specificity) in 1231 MPNST-mimic samples was estimated to be 96% (95% CI 90–99%). Certainty of these outcomes ranged from very low to high. The incidence of complete H3K27me3 loss is substantial in high-grade MPNSTs and is low in MPNST-mimics. Greater cohort study and biological investigation will validate the certainty of these findings as well as elucidate their true molecular and clinical significances.

No definitive guidelines exist to assist clinicians in determining when a chronic wound is infected or at risk for infection, nor do guidelines exist to aid in determining the indication or duration of systemic antibiotics. The lack of widely accepted guidelines can lead to excessive and improper use of systemic antibiotics, which can contribute to adverse drug events and the rise of multidrug-resistant organisms. Implementing a simple tool to measure the risk of infection in patients with chronic wounds could help clinicians determine the indication and appropriate use of systemic antibiotics as well as potentially reduce the use of systemic antibiotics.This evidence-based practice project aims to identify both chronic wounds at risk for infection and the risk factors associated with chronic wound infection, evaluate the use of systemic antibiotics in patients with chronic wounds, and reduce the use of systemic antibiotics in chronic wounds that are not infected or at risk for infection by implementing a Wounds at Risk (WAR) score for all patients admitted with chronic wounds.In this pre- and post-observational study, a convenience sample of all patients admitted with chronic wounds over a 6-week period were given a WAR score based on electronic medical record observations. Data were collected on the use and indication of systemic antibiotics and were compared with the same data of a control group of patients admitted with chronic wounds during a 6-week period before project implementation. Other clinical, microbiological, and demographic data also were collected and compared between the 2 groups.Though not significant, the overall use of systemic antibiotics was decreased in the post-intervention group. A significant reduction was seen in wound-related indications for antibiotics, most notably in the "infected ulcer" category. Diabetic foot ulcers were at highest risk for infection, and pathogen or microbiological burden did not play a significant role in infection risk.The WAR score can help guide clinicians in determining the need for antibiotics, thus helping to reduce unnecessary antibiotic exposure, which can reduce the incidence of adverse drug events and multidrug-resistant organisms.

OBJECTIVEIn this study, the authors sought to compare tumors with intradural extension to those remaining in the epidural or paraspinal space with the hypothesis that intradural extension may be a mechanism for seeding of the CSF with malignant cells, thereby resulting in higher rates of CNS metastases and shorter overall survival.METHODSThe authors searched the medical record for cases of malignant peripheral nerve sheath tumors (MPNSTs) identified from 1994 to 2017. The charts of the identified patients were then reviewed for tumor location to identify patients with paraspinal malignancy. All patients included in the study had tumor specimens that were reviewed in the surgical pathology department. Paraspinal tumors with intradural extension were identified in the lumbar, sacral, and spinal accessory nerves, and attempts were made to match this cohort to another cohort of patients who had paraspinal tumors of the cranial nerves and lumbar and sacral spinal regions without intradural extension. Further information was collected on all patients with and without intradural extension, including date of diagnosis by pathology specimen review; nerve or nerves of tumor origin; presence, location, and diagnostic date of any CNS metastases; and either the date of death or date of last follow-up.RESULTSThe authors identified 6 of 179 (3.4%) patients who had intradural tumor extension and compared these patients with 12 patients who harbored paraspinal tumors that did not have intradural extension. All tumors were diagnosed as high-grade MPNSTs according to the surgical pathology findings. Four of 6 (66.7%) patients with intradural extension had documented CNS metastases. The presence of CNS metastases was significantly higher in the intradural group than in the paraspinal group (intradural, 66.7% vs paraspinal, 0%; p < 0.01). Time from diagnosis until death was 11.2 months in the intradural group and approximately 72 months in the paraspinal, extradural cohort.CONCLUSIONSIn patients with intradural extension of paraspinal MPNSTs, significantly higher rates of CNS metastases are seen with a reduced interval of time from diagnosis to metastatic lesion detection. Intradural tumor extension is also a poor prognostic factor for survival, with these patients showing a reduced mean time from diagnosis to death.

The number of children diagnosed with mental and behavioral health issues is increasing each year. Early identification and intervention for these issues are vital to improving long-term outcomes. School nurses are among the frontline healthcare providers for school-age children, screening and coordinating care for multiple physical and mental health conditions. This article describes the implementation of a national mental health online training program at a local district. Outcomes of the implementation project and implications for school nurses are discussed.

Background It is important to differentiate low-grade malignant peripheral nerve sheath tumors (MPNSTs) from benign nerve sheath tumors as MPNSTs may require a more aggressive treatment strategy during and after initial resection. Loss of expression of the trimethyl histone H3 at the Lys27 position (H3K27-me3) has recently been described in MPNSTs and may help distinguish this tumor from pathologic mimics. Methods A 43-year-old woman presented with symptoms of radiculopathy and a history of pelvic radiation for cervical cancer 7 years prior. Imaging and surgical pathology were initially consistent with an L5 schwannoma including spindle morphology without mitoses and retained S100 expression. After an aggressive recurrence 11 months later, pathology was consistent with high-grade MPNST including heightened mitotic activity and loss of S100 expression. Results After the identification of MPNST, H3K27M me3 immunostaining was applied to both the initial and recurrent pathologic specimens. The initial specimen demonstrated patchy loss of H3K27M me3 expression, more consistent with low-grade MPNST than schwannoma. Conclusion This case highlights the role of H3K27M me3 immunostaining to help differentiate MPNSTs that may mimic more benign nerve sheath tumors, especially in patients who have a history of radiation to the region in question.

Background: Patients often receive broad-spectrum antibiotics for nosocomial infections commonly with activity against Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus. Previous retrospective and/or single-center studies have suggested that the combination of vancomycin and piperacillin/tazobactam might be associated with an increased risk of acute kidney injury. Objectives: To compare the incidence of nephrotoxicity in patients receiving intravenous vancomycin in combination with cefepime, meropenem, or piperacillin/tazobactam. Methods: This was a prospective, multicenter observational study of patients receiving vancomycin in combination with piperacillin/tazobactam versus cefepime or meropenem. Adult patients 18 years of age or older who were hospitalized and received 72 or more hours of intravenous vancomycin and 72 hours or more of cefepime, meropenem, or piperacillin/tazobactam were eligible. Patient and medication characteristics were examined for the 242 patients included. Results: The incidence of acute kidney injury for patients treated with vancomycin and piperacillin/tazobactam was significantly higher than for those treated with vancomycin and cefepime or meropenem, 29.8% versus 8.8%, respectively, P < 0.001. Binary logistic regression demonstrated that patients receiving vancomycin and piperacillin/tazobactam were 6.7 times more likely to develop acute kidney injury compared with the other cohort. Conclusions: The combination of vancomycin with piperacillin/tazobactam significantly increases the risk of acute kidney injury compared with other broad-spectrum antibiotic combinations. Clinicians should be vigilant when employing this regimen.

Research suggests that stimuli that prime social concepts can fundamentally alter people’s behavior. However, most researchers who conduct priming studies fail to explicitly report double-blind procedures. Because experimenter expectations may influence participant behavior, we asked whether a short pre-experiment interaction between participants and experimenters would contribute to priming effects when experimenters were not blind to participant condition. An initial double-blind experiment failed to demonstrate the expected effects of a social prime on executive cognition. To determine whether double-blind procedures caused this result, we independently manipulated participants’ exposure to a prime and experimenters’ belief about which prime participants received. Across four experiments, we found that experimenter belief, rather than prime condition, altered participant behavior. Experimenter belief also altered participants’ perceptions of their experimenter, suggesting that differences in experimenter behavior across conditions caused the effect. Findings reinforce double-blind designs as experimental best practice and suggest that people’s prior beliefs have important consequences for shaping behavior with an interaction partner.

Background: Approximately 14% to 20% of children and adolescents have a mental health problem. Atypical antipsychotic agents are used to treat behavioral, emotional, and mental health problems in children and adolescents. A discrepancy between best practices and actual practices exists. Objective: The purpose of this quality improvement project was to increase adherence above baseline, through implementation of a checklist, to recommended screening guidelines in children, ages 4 to 18, prescribed atypical antipsychotic agents over 12 weeks. Design/Results: Aggregate comparison of the mean ranks of scores were tested with the Mann–Whitney U test, U = 1,087.5, n1 = n2 = 70, total N =140, p < .001. Variables of body mass index, blood pressure, waist circumference, fasting glucose, fasting lipids, personal history, and family history were observed and tested using the chi-square with Fisher’s exact tests and are significant at or above 99% confidence level ( p < .01). Conclusion: Educating mental health providers, child and adolescent psychiatrists, and psychiatric mental health nurse practitioners on recommended screening guidelines and implementing a checklist had a measurable effect on increasing adherence to the recommended screening guidelines in a community mental health setting.

Introduction Plasmacytomas, considered to be the solitary counterparts of multiple myeloma, are neoplastic monoclonal plasma cell proliferations within soft tissue or bone. Plasmacytomas often present as a collection of findings known as POEMS-syndrome (Polyneuropathy, Organomegaly, Endocrinopathy, M-Protein spike, and Skin changes). Case description We present a report of a 47 yo male diagnosed with POEMS-syndrome secondary to a skull base plasmacytoma. The mass resulted in marked instability of the cranio-cervical junction due to bony erosion. Following an induction course of chemotherapy, he showed clinical improvement with a marked reduction in tumor size and underwent an autologous peripheral blood stem cell transplant for systemic treatment of his POEMS-syndrome. Following completion of systemic treatment, he then underwent a definitive occipital-cervical fusion without complications. His neurologic exam upon dismissal was stable with subjective improvement in left upper extremity strength. Postoperative radiographs confirmed spinal alignment and pathological examination of a small biopsy from C1 revealed benign fibrous tissue. Conclusion To the best of our knowledge, this is the first report of a skull-base plasmacytoma associated with POEMS-syndrome, causing cranio-cervical instability. The approach of systemic therapy combined with temporary external fixation, followed by definitive occipital cervical fusion resulted in a good outcome for this patient.

Background:Childhood obesity is an epidemic in the United States affecting 12.7 million children (Centers for Disease Control and Prevention, 2015a), and costing the United States $14.1 billion every year (Cawley, 2010). It also costs corporate America about $9 billion in direct costs (Adeagbo, 2015) and $4.3 billion in indirect costs for health-care expenditures (Cawley, 2010). Studies suggest interventions implemented by employers involving the whole family are twice as effective as interventions with employees alone (Adeagbo, 2015).Methods:This quality improvement pilot study used a quasi-experimental pretest and posttest design in an outpatient employee health clinic to evaluate a coaching method for empowering parents to manage childhood obesity. A convenience sample of 10 employed parents who had children between the ages of 2 and 19 years who were overweight or obese and met study criteria, were enrolled. Three coaching sessions lasting 20–30 minutes were provided before administering the posttest questionnaire.Results:The Mann–Whitney U test showed a measurable positive difference after coaching on healthy behaviors and was statistically and clinically significant (Mann–Whitney U = 80, Wilcoxon W = 125, standard error = 12.26 and p = .003).Conclusion:Findings indicate management of childhood obesity through parental education, coaching, and family-based interventions can promote healthy lifestyle changes among children.

OBJECTIVE With improving medical therapies for chronic conditions, elderly patients increasingly present as candidates for operative intervention for degenerative diseases of the spine. To date, there is a paucity of studies examining complications in lumbar decompression, without fusion, that include patients older than 80 years. Using a multicenter national database, the authors of this study evaluated lumbar decompression in the elderly, including octogenarians, to evaluate for associations between age and patient outcomes. METHODS The 2011–2013 American College of Surgeons' National Surgical Quality Improvement Program data set was queried for patients 65 years and older with diagnosis and procedure codes inclusive of degenerative spine disease and lumbar decompression without fusion. Morbidity and mortality within the 30-day postoperative period were the primary outcomes. Secondary outcomes of interest included unplanned readmission within 30 days or discharge to a nonhome facility. Outcomes and operative characteristics were compared using chi-square tests, Kruskal-Wallis tests, and multivariable logistic regression models. RESULTS A total of 8744 patients were identified; of these patients 4573 (52.30%) were 65 years and older. Elderly patients were stratified into 3 age categories: 85 years or older (n = 314), 75–84 years (n = 1663), and 65–74 years (n = 2596). Univariate analysis showed that, compared with age younger than 65 years, increased age was associated with the number of levels (≥ 3), readmissions within 30 days, nonhome discharge, any complication, length of stay, and blood transfusion (all p < 0.001). On multivariable analysis and with younger than 65 years as the reference, increased age was associated with any minor complication (p < 0.001; ≥ 85 years: OR 3.47, 95% CI 1.69–7.13; 75–84 years: OR 2.34, 95% CI 1.45–3.78; and 65–74 years: OR 1.44, 95% CI 0.94–2.20), as well as discharge location other than home (p < 0.001; ≥ 85 years: OR 13.59, 95% CI 9.47–19.49; 75–84 years: OR 5.64, 95% CI 4.33–7.34; and 65–74 years: OR 2.61, 95% CI 2.05–3.32). CONCLUSIONS The authors' high-powered, multicenter analysis of lumbar decompression without fusion in the elderly, specifically including patients older than 80 years, demonstrates that increased age is associated with more extensive operations, resulting in longer hospital stays, increased rates of nonhome discharge, and minor complications.

Individual evidence suggests that multiple modalities can be used to treat entrapment pathology by Morton's neuroma, including injection, neurolysis, and neurectomy. However, their impacts on patient pain and satisfaction have yet to be fully defined or elucidated. Correspondingly, our aim was to pool systematically identified metadata and substantiate the impact of these different modalities in treating Morton's neuroma with respect to these outcomes.Searches of 7 electronic databases from inception to October 2019 were conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. The incidences of outcomes were extracted and pooled by random-effects meta-analysis of proportions.A total of 35 articles satisfied all criteria, reporting a total of 2998 patients with Morton's neuroma managed by one of the three modalities. Incidence of complete pain relief after injection (43%; 95% CI, 23-64%) was significantly lower than neurolysis (68%; 95% CI, 51-84%) and neurectomy (74%; 95% CI, 66-82%) (P = 0.02). Incidence of complete satisfaction after injection (35%; 95% CI, 21-50%) was significantly lower than neurolysis (63%; 95% CI, 50-74%) and neurectomy (57%; 95% CI, 47-67%) (P 0.01). The need to proceed to further surgery was significantly greater following injection (15%; 95% CI, 9-23%) versus neurolysis (2%; 95% CI, 0-4%) or neurectomy (5%; 95% CI, 3-7%) (P 0.01). Incidence of procedural complications did not differ between modalities (P = 0.30).Although all interventions demonstrated favorable procedural complication incidences, surgical interventions by either neurolysis or neurectomy appear to trend towards greater incidences of complete pain relief and complete patient satisfaction outcomes compared to injection treatment. The optimal decision-making algorithm for treatment for Morton's neuroma should incorporate these findings to better form and meet the expectations of patients.

BACKGROUND: Incisional negative pressure wound therapy (NPWT) is used in many surgical specialties to prevent postoperative dehiscence and surgical site infections (SSIs). However, little is known about the role of incisional NPWT in spine fusion surgery. Therefore, we sought to report a single surgeon’s experience using incisional NPWT and describe its effects on dehiscence and SSIs after instrumented spine surgery. METHODS: We compared rates of hospital readmission and return to the operating room for dehiscence and SSIs in a consecutive series of patients who underwent spinal fusion surgery with or without NPWT from 2015 to 2018. RESULTS: A total of 393 patients without and 76 patients with NPWT were included for analysis. Half way through the data collection period, all patients who underwent anterior lumbar fusion received NPWT. Three of 15 (20.0%) of non-NPWT patients who underwent anterior lumbar fusion had dehiscence or SSI compared with zero of 23 (0.0%) of NPWT patients (P = 0.01). NPWT for posterior surgeries was used on a case-by-case basis using risk factors that contribute to SSIs and dehiscence. NPWT patients had higher rates of spinal neoplasia (0.5% vs. 11.3%, P < 0.0001), osteomyelitis/diskitis (1.3% vs. 7.5%, P = 0.02), durotomy (14.9% vs. 28.6%, P = 0.007), revision surgery (32.2% vs. 59.6%, P = 0.0001), and longer fusion constructs (7 vs. 11 levels, P < 0.0001) but had similar rates of dehiscence and SSIs as non-NPWT patients (5.6% vs. 5.7%, P = 0.98). CONCLUSIONS: NPWT decreases dehiscence and SSIs in patients undergoing lumbar fusion through an anterior approach. When preferentially used in patients at high risk for postoperative wound complications, NPWT prevents increased rates of dehiscence and SSI.

Background Mycobacterium avium complex (MAC) and Achromobacter xylosoxidans (AX) are uncommon sources of neurosurgical infections, particularly in immunocompetent hosts. We report the first published case of intracranial AX abscess and polymicrobial AX-MAC abscess, as well as the fourth MAC abscess in a non-immunocompromised patient. Methods This case report was conducted via retrospective chart review. A literature review was completed in compliance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Results Ten years following mucocele resection, a 60-year-old man presented with sinus congestion and headache. Head imaging revealed a left frontal lesion abutting the cribriform plate and ethmoid roof. The patient had a left frontal craniotomy for abscess drainage. Intraoperative cultures demonstrated polymicrobial growth of AX and MAC, managed with antimicrobial therapy and staged skull base reconstruction. Three cases of MAC abscess and 16 cases of AX ventriculitis or meningitis have been reported in immunocompetent patients. All MAC cerebral abscesses occurred in adults, one of whom succumbed to the infection. Of the 9 AX meningitis cases, 4 occurred in neonates and 2 in pediatric patients. Six of the 7 AX ventriculitis cases occurred after neurosurgical operations at the same hospital from contaminated chlorhexidine basins. Except for the neonates, AX ventriculitis or meningitis patients had undergone neurosurgery or had a history of cranial trauma. There were no reports of polymicrobial AX-MAC intracranial abscess. Conclusions AX and MAC are rare causes of intracranial infection. Patients with these pathogens identified in the central nervous system require a multidisciplinary approach for successful management.

Background Tranexamic acid reduces blood loss and transfusion requirements in cardiac surgery but may increase the risk of coronary graft thrombosis. We previously reported the 30-day results of a trial evaluating tranexamic acid for coronary artery surgery. Here we report the 1-year clinical outcomes. Methods Using a factorial design, we randomly assigned patients undergoing coronary artery surgery to receive aspirin or placebo and tranexamic acid or placebo. The results of the tranexamic acid comparison are reported here. The primary 1-year outcome was death or severe disability, the latter defined as living with a modified Katz activities of daily living score of less than 8. Secondary outcomes included a composite of myocardial infarction, stroke, and death from any cause through to 1 year after surgery. Results The rate of death or disability at 1 year was 3.8% in the tranexamic acid group and 4.4% in the placebo group (relative risk, 0.85; 95% confidence interval, 0.64-1.13; P = .27), and this did not significantly differ according to aspirin exposure at the time of surgery (interaction P = .073). The composite rate of myocardial infarction, stroke, and death up to 1 year after surgery was 14.3% in the tranexamic acid group and 16.4% in the placebo group (relative risk, 0.87; 95% CI, 0.76-1.00; P = .053). Conclusions In this trial of patients having coronary artery surgery, tranexamic acid did not affect death or severe disability through to 1 year after surgery. Further work should be done to explore possible beneficial effects on late cardiovascular events.

Objectives To explore public health nurses’ knowledge, perceptions, and practices under the Affordable Care Act (ACA). Design and Sample A cross-sectional, web-based survey was completed by a sample of 1,143 public health nurses (PHNs) in the United States. Measures Descriptive statistics were analyzed for variables related to general knowledge and perception of the ACA and for the extent of involvement in activities related to the implementation of the ACA. Qualitative analysis was conducted on free text comments to two open-ended questions about current and future PHNs involvement in the ACA. Results Approximately 45% of PHNs reported changes in their daily work due to the ACA. PHNs reported being very or somewhat involved in these activities of the ACA: integration of primary care and public health (62%), provision of clinical preventive services (60.3%), care coordination (55.4%), patient navigation (55.3%), establishment of private-public partnerships (55.3%), population health strategies (53.6%), population health data assessment and analysis (53.8%), community health assessments (49%), involvement in medical homes (37.8%), provision of maternal and child health home visiting services (32.1%), and involvement in Accountable Care Organizations (29.2%). Conclusion PHNs are making substantial contributions to implementation of the ACA.

Systematic review and meta-analysis.Compare minimally invasive surgery (MIS) and open surgery (OS) spinal fusion outcomes for the treatment of spondylolisthesis.OS spinal fusion is an interventional option for patients with spinal disease who have failed conservative therapy. During the past decade, MIS approaches have increasingly been used, with potential benefits of reduced surgical trauma, postoperative pain, and length of hospital stay. However, current literature consists of single-center, low-quality studies with no review of approaches specific to spondylolisthesis only.This first systematic review of the literature regarding MIS and OS spinal fusion for spondylolisthesis treatment was performed using the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines for article identification, screening, eligibility, and inclusion. Electronic literature search of Medline/PubMed, Cochrane, EMBASE, and Scopus databases yielded 2489 articles. These articles were screened against established criteria for inclusion into this study.A total of five retrospective and five prospective articles with a total of 602 patients were found. Reported spondylolisthesis grades were I and II only. Overall, MIS was associated with less intraoperative blood loss (mean difference [MD], -331.04 mL; 95% confidence interval [CI], -490.48 to -171.59; P 0.0001) and shorter length of hospital stay (MD, -1.74 days; 95% CI, -3.04 to -0.45; P = 0.008). There was no significant difference overall between MIS and OS in terms of functional or pain outcomes. Subgroup analysis of prospective studies revealed MIS had greater operative time (MD, 19.00 minutes; 95% CI, 0.90 to 37.10; P = 0.04) and lower final functional scores (weighted MD, -1.84; 95% CI, -3.61 to -0.07; P = 0.04) compared with OS.Current data suggests spinal fusion by MIS is a safe and effective approach to treat grade I and grade II spondylolisthesis. Moreover, although prospective trials associate MIS with better functional outcomes, longer-term and randomized trials are warranted to validate any association found in this study.2.

We conducted an evidence-based practice project to determine if skin-to-skin contact immediately after cesarean birth influenced the rate of transfer of newborns to the NICU for observation. We analyzed data for 5 years (2011 through 2015) and compared the rates for the period before implementation of skin-to-skin contact with rates for the period after. The proportion of newborns transferred to the NICU for observation was significantly different and lower after implementing skin-to-skin contact immediately after cesarean birth (Pearson's χ2 = 32.004, df = 1, p < .001). These results add to the growing body of literature supporting immediate, uninterrupted skin-to-skin contact for all mother-newborn pairs, regardless of birth mode.

Patients recovering from decompressive laminectomy without fusion may require assistance with activities of daily living and physical/occupational therapy upon hospital discharge.To examine comorbidities and perioperative characteristics of patients undergoing lumbar decompression for associations with discharge status using a multicenter database.A multicenter database was used for this retrospective cohort analysis. Patients admitted from home with degenerative spine disease for lumbar decompression without fusion were included. Thirty-day outcomes and operative characteristics were compared as a function of patient discharge using chi-square and Wilcoxon Rank Sum tests. Multivariable logistic regression was used to determine factors associated with discharge to a nonhome facility.Of the 8627 patients included for analysis, 9.7% were discharged to a nonhome facility. On multivariable analysis, age (85+ vs65, odds ratio [OR] 13.59), number of levels of decompression (3+ vs 1, OR 1.75), African American race vs Non-Hispanic or Hispanic White (OR 1.87), female vs male gender (OR 1.97), body mass index (BMI) (40+ vs 18.5-24.9, OR 1.74), American Society of Anesthesiologists physical classification status (4 vs 1 or 2, OR 2.35), hypertension (OR 1.29), dependent functional status (OR 3.92), diabetes (OR 1.47), smoking (OR 1.40), hematocrit (35 vs 35+, OR 1.76), international normalized ratio (≥1.3 vs1.3, OR 2.32), and operative time (3+ h vs1 h, OR 5.34) were significantly associated with an increased odds of discharge to nonhome facilities.Preoperative status and operative course variables can influence discharge disposition in lumbar decompression patients. Identifying specific factors that contribute to a greater likelihood of dismissal to skilled facility or rehabilitation unit can further inform both surgeons and patients during preoperative counseling and disposition planning.

Background Hospital readmissions are a frequent challenge. Speculation exists that rates of readmission following traumatic injury will be publicly disclosed. The primary aim of this study was to characterize and model 1-year readmission patterns to multiple institutions among patients originally admitted to a single, urban Level I trauma center. Additional analyses within the superutilizers subgroup identified predictors of 30-day readmissions as well as patient loyalty for readmission to their index hospital. We hypothesized that hospital readmission among trauma patients would be associated with socioeconomic, demographic, and clinical features and superutilizers would be identifiable during initial hospitalization. Methods Data were retrospectively gathered for 2,411 unique trauma patients admitted to a Level I American College of Surgeons-certified trauma center over 1 year, with readmissions identified 1 year after index admission. A regional hospital database was queried for readmissions. Outcomes of all readmission encounters were analyzed using a binary logistic regression model including demographic, diagnoses, Injury Severity Score (ISS), procedures, Elixhauser comorbidities, insurance, and disposition data. Subset analysis of superutilizers was also performed to examine patterns among superutilizers. Results A total of 434 patients (21%) were readmitted during the study period, accounting for 720 readmission encounters. Sixty-three patients accounting for 269 encounters were identified as superutilizers (3+ readmissions). A total of 136 patients (6%) were readmitted within 30 days of initial discharge. Fifty-seven percent of readmissions returned to the originating hospital. Conclusion Complications including comorbid disease (diabetes and congestive heart failure), septicemia, weight loss, and trauma recidivism distinguish the superutilizer trauma patient. Having Medicaid funding increased the odds of readmission by 274%. It is imperative that interventions be developed and targeted toward those at high risk of superutilization of health care resources to curb spending. These results strongly support continuation of longitudinal readmission research in trauma patients conducted in multicenter settings. Level of evidence Epidemiologic study, level III.

Aim The purpose of this project was to assess free and low-cost web-based continuing education activities to determine if they reflect updated national guidelines for cervical cancer screening. Methods A qualitative design and descriptive statistics were used to conduct a content analysis. An abstraction tool was used to evaluate 15 continuing education activities. Data collection was conducted between January and February 2013 by two registered nurses. The results were recorded independently and compared for agreement between data collectors, as well as inter-rater reliability of the data collectors, and the abstraction tool was used to collect data for the analysis. Results The majority of the continuing education activities included the updated guidelines for screening intervals, the age to begin screening and when to discontinue screening. Most of the activities also indicated that human papillomavirus (HPV) DNA testing is not recommended for younger women. Very few of the continuing education activities included tips for providers to use when counselling patients. Conclusions The correct information on age-appropriate screening intervals and HPV co-testing was included in the continuing education activities reviewed. The areas that were largely underrepresented in the continuing education activities were the risk factors, prevention measures for transmission of HPV, patient counselling about HPV and the appropriate screening practices.

INTRODUCTION:Recent studies suggest that diabetic patients may be more likely to exhibit back pain. Correlating diabetic disease progression to the presence of back pain could provide insight into the relationship between these conditions.METHODS:A total of 67 132 patients within our institutional d

Skin-to-skin care after birth often is absent, interrupted, or delayed for routine procedures. The purposes of this project were to improve skin-to-skin care and exclusive breastfeeding at hospital discharge.For Part 1, we used a descriptive observational design, with video-ethnography and interaction analysis (PRECESS-Practice, Reflection, Education and training, Combined with Ethnography for Sustainable Success), during a 5-day quality improvement pilot study in a U.S. hospital (August 13-17, 2010). For Part 2, we used electronic health record review to test for differences in monthly rates of skin-to-skin care and exclusive breastmilk feeding (baseline, July 2010; post-intervention, August-December 2010).In Part 1, 11 mothers and babies participated: 10 (91%) received immediate skin-to-skin care, eight (73%) received uninterrupted skin-to-skin care, nine (82%) planned to breastfeed, six (67%) of these babies were exclusively breastfeeding at hospital discharge, and five (83%) of the six babies who completed all nine instinctive stages during skin-to-skin care were exclusively breastfeeding at hospital discharge. In our subsequent review (Part 2), we found a significant improvement (25% above baseline) in the overall rate of skin-to-skin care across post-intervention months (Pearson χ(2)=23.798, df=5, p0.000), predominantly from improvements in the cesarean section population. The rates of exclusive breastfeeding showed no significant change.The PRECESS immersion method may help to rapidly improve skin-to-skin care. Babies who undergo all nine stages during skin-to-skin care may be more likely to exclusively breastfeed. Mothers need support during skin-to-skin care to recognize their baby's readiness to breastfeed. Skin-to-skin care during cesarean surgery may reduce maternal stress and improve satisfaction with the surgical experience.

The science of nursing informatics is becoming increasingly important to delivering quality nursing care to all patient populations. Perioperative nursing informatics skills are practiced within the context of powerful and complex information systems that enhance nurses' ability to view and report clinical data in a manner that has never before been possible. This article explores how the analysis of several examples of two typical system indicators (i.e., the unplanned returns to surgery rate within the same admission event, surgical site infection rate) can result in improved patient outcomes. Nursing informatics is an invaluable tool for identifying trends and communicating them to perioperative nurses in a way that can positively influence the delivery of perioperative care and patient outcomes.