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Recent Research Articles from JPS Health Network

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Edwardsiella tarda Bacteremia in Untreated Hepatitis C: Alterations in Antimicrobial Therapy for a Pan-Susceptible Pathogen in a Critically Ill Patient.

Tue, 04/30/2019 - 05:35

Edwardsiella tarda Bacteremia in Untreated Hepatitis C: Alterations in Antimicrobial Therapy for a Pan-Susceptible Pathogen in a Critically Ill Patient.

Am J Ther. 2019 Feb 28;:

Authors: Morrisette T, Hewgley WP, Hewgley H

PMID: 31033487 [PubMed - as supplied by publisher]

Single-stage bilateral distal femur replacement for traumatic distal femur fractures.

Fri, 04/26/2019 - 06:23
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Single-stage bilateral distal femur replacement for traumatic distal femur fractures.

Arthroplast Today. 2019 Mar;5(1):26-31

Authors: Neal DC, Sambhariya V, Tran A, Rahman SK, Dean TJ, Wagner RA, Sanchez HB

Abstract
Treatment of periprosthetic distal femur fractures and comminuted intraarticular distal femur fractures with previous arthritis remains a difficult challenge for orthopedic surgeons. Previous case series have shown that distal femur replacement (DFR) can effectively compensate for bone loss, relieve knee pain, and allow for early ambulation in both of these fracture patterns. Owing to the typical low-energy mechanism of these injuries, a bilateral injury treated with DFR is rarely encountered. We present a patient with traumatic open left Rorabeck III/Su III periprosthetic distal femur fracture and closed right intraarticular distal femur fracture (AO fcation 33-C2) with end-stage arthrosis treated with single-stage bilateral DFR. We suggest that in patients with similar injuries, single-stage bilateral DFR can provide the benefits of early mobilization and accelerated recovery.

PMID: 31020017 [PubMed]

Predicting bacterial infections among pediatric cancer patients with febrile neutropenia: External validation of the PICNICC model.

Thu, 04/25/2019 - 08:03
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Predicting bacterial infections among pediatric cancer patients with febrile neutropenia: External validation of the PICNICC model.

Pediatr Blood Cancer. 2018 04;65(4):

Authors: Ojha RP, Asdahl PH, Steyerberg EW, Schroeder H

Abstract
INTRODUCTION: The Predicting Infectious Complications in Neutropenic Children and Young People with Cancer (PICNICC) model was recently developed for antibiotic stewardship among pediatric cancer patients, but limited information is available about its clinical usefulness. We aimed to assess the performance of the PICNICC model for predicting microbiologically documented bacterial infections among pediatric cancer patients with febrile neutropenia.
MATERIALS AND METHODS: We used data for febrile neutropenia episodes at a pediatric cancer center in Aarhus, Denmark between 2000 and 2016. We assessed the area under the receiver operating characteristic curve (AUC), calibration, and clinical usefulness (i.e., net benefit). We also recalibrated the model using statistical updating methods.
RESULTS: We observed 306 microbiologically documented bacterial infections among 1,892 episodes of febrile neutropenia. The AUC of the model was 0.73 (95% confidence limits [CL]: 0.71-0.75). The calibration intercept (calibration-in-the-large) was -0.69 (95% CL: -0.86 to -0.51) and the slope was 0.77 (95% CL: 0.65-0.89). Modest net benefit was observed at a decision threshold of 5%. Recalibration improved calibration but did not improve net benefit.
CONCLUSIONS: The PICNICC model has potential for reducing unnecessary antibiotic exposure for pediatric cancer patients with febrile neutropenia, but continued validation and refinement is necessary to optimize clinical usefulness.

PMID: 29286572 [PubMed - indexed for MEDLINE]

Coming in Warm: Qualitative Study and Concept Map to Cultivate Patient-centered Empathy in Emergency Care.

Tue, 04/23/2019 - 07:22

Coming in Warm: Qualitative Study and Concept Map to Cultivate Patient-centered Empathy in Emergency Care.

AEM Educ Train. 2019 Apr;3(2):136-144

Authors: Pettit KE, Rattray NA, Wang H, Stuckey S, Mark Courtney D, Messman AM, Kline JA

Abstract
Background: Increased empathy may improve patient perceptions and outcomes. No training tool has been derived to teach empathy to emergency care providers. Accordingly, we engaged patients to assist in creating a concept map to teach empathy to emergency care providers.
Methods: We recruited patients, patient caretakers and patient advocates with emergency department experience to participate in three separate focus groups (n = 18 participants). Facilitators guided discussion about behaviors that physicians should demonstrate to rapidly create trust; enhance patient perception that the physician understood the patient's point of view, needs, concerns, and fears; and optimize patient/caregiver understanding of their experience. Verbatim transcripts from the three focus groups were read by the authors, and by consensus, five major themes with 10 minor themes were identified. After creating a codebook with thematic definitions, one author reviewed all transcripts to a library of verbatim excerpts coded by theme. To test for inter-rater reliability, two other authors similarly coded a random sample of 40% of the transcripts. Authors independently chose excerpts that represented consensus and strong emotional responses from participants.
Results: Approximately 90% of opinions and preferences fell within 15 themes, with five central themes: provider transparency, acknowledgment of patient's emotions, provider disposition, trust in physician, and listening. Participants also highlighted the need for authenticity, context, and individuality to enhance empathic communication. For empathy map content, patients offered example behaviors that promote perceptions of physician warmth, respect, physical touch, knowledge of medical history, explanation of tests, transparency, and treating patients as partners. The resulting concept map was named the "Empathy Circle."
Conclusions: Focus group participants emphasized themes and tangible behaviors to improve empathy in emergency care. These were incorporated into the Empathy Circle, a novel concept map that can serve as the framework to teach empathy to emergency care providers.

PMID: 31008425 [PubMed]

Treatment patterns for ductal carcinoma in situ with close or positive mastectomy margins.

Sat, 04/20/2019 - 07:38
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Treatment patterns for ductal carcinoma in situ with close or positive mastectomy margins.

J Surg Res. 2018 11;231:36-42

Authors: Jones CE, Richman J, Jackson BE, Wallace AS, Krontiras H, Urist MM, Bland KI, Parker CC

Abstract
BACKGROUND: Mastectomy remains an effective treatment for ductal carcinoma in situ (DCIS) but whether further therapy is warranted for close or positive margins is controversial. We aim to characterize the treatment practices of DCIS throughout the United States in patients who undergo mastectomy with close or positive margins to better understand the use of postmastectomy radiation therapy (PMRT).
MATERIALS AND METHODS: Using the 2004-2013 National Cancer Database, we identified all female patients with a diagnosis of DCIS who underwent mastectomy. Distributional characteristics were summarized for overall and margin-stratified samples. Characteristic differences were assessed by region and receipt of radiation. Chi-square and independent sample t-tests were used to assess differences for categorical and continuous variables, respectively.
RESULTS: In 21,591 patients who met inclusion criteria, 470 patients with close/positive margins were identified. Sixteen percent of patients with close/positive margins received PMRT compared to 1.5% with negative margins (P < 0.01). There was no difference in PMRT and patient race, insurance status, treatment facility, or endocrine therapy. Patients with close/positive margins who received PMRT were more likely to be in an urban setting from the Midwest (24.6%) and Northeast (21.8%) compared to the West (11.0%) and South (10.7%) (P < 0.01).
CONCLUSIONS: Use of PMRT for DCIS following mastectomy with close/positive margins differs across the country. Regional variations in treatment patterns reinforce a need to determine whether PMRT improves survival to establish treatment guidelines.

PMID: 30278953 [PubMed - indexed for MEDLINE]

Prehospital Blood Product and Crystalloid Resuscitation in the Severely Injured Patient: A Secondary Analysis of the Prehospital Air Medical Plasma Trial.

Fri, 04/19/2019 - 06:51
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Prehospital Blood Product and Crystalloid Resuscitation in the Severely Injured Patient: A Secondary Analysis of the Prehospital Air Medical Plasma Trial.

Ann Surg. 2019 Apr 13;:

Authors: Guyette FX, Sperry JL, Peitzman AB, Billiar TR, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Putnam T, Duane TM, Phelan HA, Brown JB

Abstract
MINI: Hemorrhage is the primary cause of preventable trauma death. Secondary analyses of scene patients from the PAMPer trial demonstrated that prehospital packed red blood cell and plasma had the greatest reduction in 30-day mortality compared with crystalloid-only resuscitation. Patients with hemorrhagic shock should receive prehospital blood products when available, preferably packed red blood cell and plasma.
OBJECTIVE: The aim of this study was to determine whether prehospital blood products reduce 30-day mortality in patients at risk for hemorrhagic shock compared with crystalloid only resuscitation.
SUMMARY OF BACKGROUND DATA: Hemorrhage is the primary cause of preventable death after injury. Large volume crystalloid resuscitation can be deleterious. The benefits of prehospital packed red blood cells (PRBCs), plasma, or transfusion of both products among trauma patients is unknown compared with crystalloid.
METHODS: Secondary analysis of the multicenter PAMPer trial was performed on hypotensive injured patients from the scene. The trial randomized 27 helicopter bases to prehospital plasma or standard resuscitation. Standard resuscitation at the sites was equally divided between crystalloid and crystalloid + PRBC. This led to 4 prehospital resuscitation groups: crystalloid only; PRBC; plasma; and PRBC+plasma. Cox regression determined the association between resuscitation groups and risk-adjusted 30-day mortality. The dose effect of resuscitation fluids was also explored.
RESULTS: Four hundred seven patients were included. PRBC+plasma had the greatest benefit [hazard ratio (HR) 0.38; 95% confidence interval (95% CI) 0.26-0.55, P < 0.001], followed by plasma (HR 0.57; 95% CI 0.36-0.91, P = 0.017) and PRBC (HR 0.68; 95% CI 0.49-0.95, P = 0.025) versus crystalloid only. Mortality was lower per-unit of PRBC (HR 0.69; 95% CI 0.52-0.92, p = 0.009) and plasma (HR 0.68; 95% CI 0.54-0.88, P = 0.003). Crystalloid volume was associated with increased mortality among patients receiving blood products (HR 1.65; 95% CI 1.17-2.32, P = 0.004).
CONCLUSION: Patients receiving prehospital PRBC+plasma had the greatest mortality benefit. Crystalloid only had the worst survival. Patients with hemorrhagic shock should receive prehospital blood products when available, preferably PRBC+plasma. Prehospital whole blood may be ideal in this population.

PMID: 30998533 [PubMed - as supplied by publisher]

Retrograde dorsalis pedis angiosomal flow compromised by small puncture wound leading to transmetatarsal amputation.

Fri, 04/12/2019 - 06:31

Retrograde dorsalis pedis angiosomal flow compromised by small puncture wound leading to transmetatarsal amputation.

Foot (Edinb). 2019 Feb 14;39:60-67

Authors: Ernst JJ, Ryba D, Brower B

Abstract
Pedal puncture wounds can precipitate a variety of complications, often resulting from a delay in treatment. Although the risk of infection predominates, direct vascular insult and subsequent ischemia is a lesser reported complication of these injuries. Consequently, this may have morbid results, especially on a background of pre-existing peripheral vascular disease. A case involving a small, plantar forefoot puncture wound, ultimately resulting in transmetatarsal amputation due to ischemic dry gangrene in an uncontrolled, but sensate, diabetic with profound vasculopathy is presented. This presentation highlights the importance of considering the potential for macrovascular damage via pedal puncture, and the potentially magnified complications in patients with dependent retrograde angiosomal flow and compromised collateral circulation. Based on a thorough analysis of the literature and the findings in this clinical example, a detailed investigation of angiosomal blood supply through direct and indirect vessel flow in patients with peripheral arterial disease incurring puncture wounds is advocated. In these patients, lack of compensatory avenues of the pedal circulation may portend significant tissue loss in an otherwise inoffensive situation. Knowledge of this complication, although rare, may prompt the clinician to assess for its potential, and emphasize a preference for direct revascularization in those with critical limb ischemia. Level of Clinical Evidence: 4.

PMID: 30974342 [PubMed - as supplied by publisher]

Ledipasvir/Sofosbuvir Effectively Treats Hepatitis C Virus Infections in an Underserved Population.

Fri, 04/12/2019 - 06:31
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Ledipasvir/Sofosbuvir Effectively Treats Hepatitis C Virus Infections in an Underserved Population.

Dig Dis Sci. 2018 12;63(12):3233-3240

Authors: Stewart RA, MacDonald BR, Chu TC, Moore JD, Fasanmi EO, Ojha RP

Abstract
BACKGROUND: Underserved populations have an unequal burden of HCV infections and poor outcomes with interferon-based treatments. Direct-acting antivirals have the potential to reduce these inequalities.
AIMS: We aimed to estimate sustained virologic response (SVR) following treatment with sofosbuvir-based regimens for HCV infections among underserved individuals and summarize the frequency of SVR across published studies of underserved populations.
METHODS: We used data from a clinical cohort of patients aged ≥ 18 years who initiated sofosbuvir-based regimens for HCV infection between February 2014 and June 2016 at an urban public hospital network that serves as the healthcare safety-net for Tarrant County, Texas. We estimated SVR with corresponding 95% confidence limits (CL). In addition, we systematically reviewed the evidence to identify other studies of direct-acting antivirals among underserved populations.
RESULTS: Our study population comprised 435 patients. The majority of patients were aged ≥ 50 years (76%), male (52%), non-Hispanic White (54%), HCV genotype 1 (79%) and treated with ledipasvir/sofosbuvir (69%). Overall SVR was 89% (95% CL 86, 92%) and highest for ledipasvir/sofosbuvir (SVR = 95%, 95% CL 92, 97%). The reported SVR following direct-acting antivirals among 837 underserved patients from three other studies ranged between 90 and 99%.
CONCLUSIONS: Our results suggest that direct-acting antivirals, particularly ledipasvir/sofosbuvir, are generally effective for achieving SVR among underserved patients with HCV infections and may help reduce inequalities in HCV prevalence and outcomes for this vulnerable population.

PMID: 30014226 [PubMed - indexed for MEDLINE]

Corrigendum to "Reliability of the classification of proximal femur fractures: Does clinical experience matter?" [Injury 49 (1) (2018) 819-823].

Mon, 03/25/2019 - 13:22
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Corrigendum to "Reliability of the classification of proximal femur fractures: Does clinical experience matter?" [Injury 49 (1) (2018) 819-823].

Injury. 2019 Mar 19;:

Authors: Crijns TJ, Janssen SJ, Davis JT, Ring D, Sanchez HB, Science of Variation Group

PMID: 30902425 [PubMed - as supplied by publisher]

A Research Agenda for Assessment and Management of Psychosis in Emergency Department Patients.

Tue, 03/19/2019 - 07:54
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A Research Agenda for Assessment and Management of Psychosis in Emergency Department Patients.

West J Emerg Med. 2019 Mar;20(2):403-408

Authors: Peltzer-Jones J, Nordstrom K, Currier G, Berlin JS, Singh C, Schneider S

Abstract
Introduction: Emergency departments (ED) manage a wide variety of critical medical presentations. Traumatic, neurologic, and cardiac crises are among the most prevalent types of emergencies treated in an ED setting. The high volume of presentations has led to collaborative partnerships in research and process development between experts in emergency medicine (EM) and other disciplines. While psychosis is a medical emergency frequently treated in the ED, there remains a paucity of evidence-based literature highlighting best practices for management of psychotic presentations in the ED. In the absence of collaborative research, development of best practice guidelines cannot begin. A working group convened to develop a set of high-priority research questions to address the knowledge gaps in the care of psychotic patients in the ED. This article is the product of a subgroup considering "Special Populations: Psychotic Spectrum Disorders," from the 2016 Coalition on Psychiatric Emergencies first Research Consensus Conference on Acute Mental Illness.
Methods: Participants were identified with expertise in psychosis from EM, emergency psychiatry, emergency psychology, clinical research, governmental agencies, and patient advocacy groups. Background literature reviews were performed prior to the in-person meeting. A nominal group technique was employed to develop group consensus on the highest priority research gaps. Following the nominal group technique, input was solicited from all participants during the meeting, questions were iteratively focused and revised, voted on, and then ranked by importance.
Results: The group developed 28 separate questions. After clarification and voting, the group identified six high-priority research areas. These questions signify the perceived gaps in psychosis research in emergency settings. Questions were further grouped into two topic areas: screening and identification; and intervention and management strategies.
Conclusion: While psychosis has become a more common presentation in the ED, standardized screening, intervention, and outcome measurement for psychosis has not moved beyond attention to agitation management. As improved outpatient-intervention protocols are developed for treatment of psychosis, it is imperative that parallel protocols are developed for delivery in the ED setting.

PMID: 30881564 [PubMed - in process]

Opportunities for Research in Mental Health Emergencies: Executive Summary and Methodology.

Tue, 03/19/2019 - 07:54
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Opportunities for Research in Mental Health Emergencies: Executive Summary and Methodology.

West J Emerg Med. 2019 Mar;20(2):380-385

Authors: Wilson MP, Shenvi C, Rives L, Nordstrom K, Schneider S, Gerardi M

Abstract
Introduction: Despite the ever-increasing numbers of mental health patients presenting to United States emergency departments, there are large gaps in knowledge about acute care of the behavioral health patient. To address this important problem, the Coalition on Psychiatric Emergencies convened a research consensus conference in December 2016 consisting of clinical researchers, clinicians from emergency medicine, psychiatry and psychology, and representatives from governmental agencies and patient advocacy groups.
Methods: Participants used a standardized methodology to select and rank research questions in the order of importance to both researchers and patients.
Results: Three working groups (geriatrics, substance use disorders, and psychosis) reached consensus on 26 questions within their respective domains. These questions are summarized in this document.
Conclusion: The research consensus conference is the first of its kind to include non-clinicians in helping identify knowledge gaps in behavioral emergencies. It is hoped that these questions will prove useful to prioritize future research within the specialty.

PMID: 30881561 [PubMed - in process]

Free-Flap Reconstruction of the Mandible.

Thu, 03/14/2019 - 07:03
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Free-Flap Reconstruction of the Mandible.

Semin Plast Surg. 2019 Feb;33(1):46-53

Authors: Kim RY, Sokoya M, Ducic Y, Williams F

Abstract
Mandible reconstruction has evolved over the years with advances in surgical options and three-dimensional technology. Although nonvascularized bone grafting is still used, vascularized flaps show advantages with immediate reconstruction, the possibility of immediate dental implants, and the ability to reconstruct composite defects of both soft tissue and bone. This article discusses current vascularized techniques for mandible reconstruction. While each reconstructive method has advantages and disadvantages, a defect-based reconstruction focused on full rehabilitation allows surgeons to plan and counsel the patient for the best available reconstruction.

PMID: 30863212 [PubMed]

Free Flap Reconstruction of the Maxilla.

Thu, 03/14/2019 - 07:03
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Free Flap Reconstruction of the Maxilla.

Semin Plast Surg. 2019 Feb;33(1):30-37

Authors: Vincent A, Burkes J, Williams F, Ducic Y

Abstract
Tumors of the maxilla and midface are some of the most difficult to manage, not only in terms of treatment but also in terms of achieving acceptable orofacial reconstruction. Today, free flaps dominate the reconstructive field. Many patients can achieve successful reconstruction after free flap transfer with a return of intelligible speech, a regular diet, and acceptable cosmesis. Herein, the authors review free flap reconstruction of the maxilla, with a focus on the classifications of defects, when obturators are appropriate, types and sources of free flaps, and complications for which to beware.

PMID: 30863210 [PubMed]

Primary Care Physician Characteristics Associated with Low Value Care Spending.

Sun, 03/10/2019 - 06:30
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Primary Care Physician Characteristics Associated with Low Value Care Spending.

J Am Board Fam Med. 2019 Mar-Apr;32(2):218-225

Authors: Barreto TW, Chung Y, Wingrove P, Young RA, Petterson S, Bazemore A, Liaw W

Abstract
BACKGROUND: Previous work has shown that $210 billion may be spent annually on unnecessary medical services and has identified patient and hospital characteristics associated with low value care (LVC). However, little is known about the association between primary care physician (PCP) characteristics and LVC spending. The objective of this study was to assess this association.
METHODS: We performed a retrospective analysis by using Medicare claims data to identify LVC and American Medical Association Masterfile data for PCP characteristics. We included PCPs of adults aged 65 years and older who were enrolled in Medicare in 2011. We measured Medicare spending per attributed patient on 8 low value services.
RESULTS: Our final sample contained 6,873 PCPs with 1,078,840 attributed patients. Lower per-patient LVC Medicare spending was associated with the following PCP characteristics: allopathic training, smaller Medicare patient panel, practiced family medicine, practiced in the Midwest region, were a recent graduate, or practiced in rural areas. The largest associations were seen in Medicare patient panel size and geographic region. The average per-patient LVC spending was $14.67. LVC spending among PCPs with small patient panels was $3.98 less per patient relative to those with larger panels. PCPs in the Midwest had $2.80 less per patient LVC spending than those in the Northeast.
CONCLUSION: Our analysis suggests that LVC services are associated with specific PCP characteristics. Further research should assess the strength of these associations, and future policy efforts should focus on systemic interventions to reduce LVC spending.

PMID: 30850458 [PubMed - in process]

Status of Emergency Department Seventy-Two Hour Return Visits Among Homeless Patients.

Wed, 03/06/2019 - 07:17
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Status of Emergency Department Seventy-Two Hour Return Visits Among Homeless Patients.

J Clin Med Res. 2019 Mar;11(3):157-164

Authors: Knowles H, Huggins C, Robinson RD, Mbugua R, Laureano-Phillips J, Trivedi SM, Kirby J, Zenarosa NR, Wang H

Abstract
Background: We aim to externally validate the status of emergency department (ED) appropriate utilization and 72-h ED returns among homeless patients.
Methods: This is a retrospective single-center observational study. Patients were divided into two groups (homeless versus non-homeless). Patients' general characteristics, clinical variables, ED appropriate utilization, and ED return disposition deviations were compared and analyzed separately.
Results: Study enrolled a total of 63,990 ED visits. Homeless patients comprised 9.3% (5,926) of visits. Higher ED 72-h returns occurred among homeless patients in comparison to the non-homeless patients (17% versus 5%, P < 0.001). Rate of significant ED disposition deviations (e.g., admission, triage to operation room, or death) on return visits were lower in homeless patients when compared to non-homeless patient populations (15% versus 23%, P < 0.001).
Conclusions: Though ED return rate was higher among homeless patients, return visit case management seems appropriate, indicating that 72-h ED returns might not be an optimal healthcare quality measurement for homeless patients.

PMID: 30834037 [PubMed]

Laryngeal Spindle Cell/Pleomorphic Lipoma: A Case Report. An In-Depth Review of the Adipocytic Tumors.

Mon, 03/04/2019 - 05:45

Laryngeal Spindle Cell/Pleomorphic Lipoma: A Case Report. An In-Depth Review of the Adipocytic Tumors.

J Oral Maxillofac Surg. 2019 Feb 07;:

Authors: Burkes JN, Campos L, Williams FC, Kim RY

Abstract
Spindle cell and pleomorphic lipomas (SC/PLs) are a rare form of lipomatous tumors. They typically occur as a slow-growing localized mass in the subcutaneous fatty tissue of the posterior neck, back, and shoulders. This benign variant represents less than 1.5% of all lipomas and is relatively uncommon in the head and neck area. A manifestation in the larynx is even rarer. Unlike other anatomic locations, laryngeal lipomas can pose life-threatening symptoms secondary to acute obstruction of the upper aerodigestive tract. This report presents a case of a large SC/PL of the larynx associated with hoarseness, dysphagia, globus sensation, and neck fullness. The tumor was successfully removed through an anterior transcervical approach with infrahyoid myotomy. The authors review the literature concerning head and neck adipocytic tumors with spindle cells and discuss the difficulties in distinguishing SC/PLs from liposarcomas. To the best of the authors' knowledge, this is the first case to be reported in the oral and maxillofacial surgery literature.

PMID: 30826392 [PubMed - as supplied by publisher]

The American Association for the Surgery of Trauma Severity Grade is valid and generalizable in adhesive small bowel obstruction.

Sat, 03/02/2019 - 05:11
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The American Association for the Surgery of Trauma Severity Grade is valid and generalizable in adhesive small bowel obstruction.

J Trauma Acute Care Surg. 2018 02;84(2):372-378

Authors: Hernandez MC, Haddad NN, Cullinane DC, Yeh DD, Wydo S, Inaba K, Duane TM, Pakula A, Skinner R, Rodriguez CJ, Dunn J, Sams VG, Zielinski MD, Choudhry A, Turay D, Yune JM, Watras J, Widom KA, Cull J, Toschlog EA, Graybill JC, EAST SBO Workgroup

Abstract
BACKGROUND: The American Association for the Surgery of Trauma (AAST) anatomic severity grading system for adhesive small bowel obstruction (ASBO) was validated at a single institution. We aimed to externally validate the AAST ASBO grading system using the Eastern Association for the Surgery of Trauma multi-institutional small bowel obstruction prospective observational study.
METHODS: Adults (age ≥ 18) with (ASBO) were included. Baseline demographics, physiologic parameters (heart rate, blood pressure, respiratory rate), laboratory tests (lactate, hemoglobin, creatinine, leukocytosis), imaging findings, operative details, length of stay, and Clavien-Dindo complications were collected. The AAST ASBO grades were assigned by two independent reviewers based on imaging findings. Kappa statistic, univariate, and multivariable analyses were performed.
RESULTS: There were 635 patients with a mean (±SD) age of 61 ± 17.8 years, 51% female, and mean body mass index was 27.5 ± 8.1. The AAST ASBO grades were: grade I (n = 386, 60.5%), grade II (n = 135, 21.2%), grade III (n = 59, 9.2%), grade IV (n = 55, 8.6%). Initial management included: nonoperative (n = 385; 61%), laparotomy (n = 200, 31.3%), laparoscopy (n = 13, 2.0%), and laparoscopy converted to laparotomy (n = 37, 5.8%). An increased median [IQR] AAST ASBO grade was associated with need for conversion to an open procedure (2 [1-3] vs. 3 [2-4], p = 0.008), small bowel resection (2 [2-2] vs. 3 [2-4], p < 0.0001), postoperative temporary abdominal closure (2 [2-3] vs. 3 [3-4], p < 0.0001), and stoma creation (2 [2-3] vs. 3 [2-4], p < 0.0001). Increasing AAST grade was associated with increased anatomic severity noted on imaging findings, longer duration of stay, need for intensive care, increased rate of complication, and higher Clavien-Dindo complication grade.
CONCLUSION: The AAST ASBO severity grading system has predictive validity for important clinical outcomes and allows for standardization across institutions, providers, and future research focused on optimizing preoperative diagnosis and management algorithms.
LEVEL OF EVIDENCE: Prognostic, level III.

PMID: 29117026 [PubMed - indexed for MEDLINE]

Association between emergency physician self-reported empathy and patient satisfaction.

Fri, 03/01/2019 - 06:54
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Association between emergency physician self-reported empathy and patient satisfaction.

PLoS One. 2018;13(9):e0204113

Authors: Wang H, Kline JA, Jackson BE, Laureano-Phillips J, Robinson RD, Cowden CD, d'Etienne JP, Arze SE, Zenarosa NR

Abstract
BACKGROUND: Higher physician self-reported empathy has been associated with higher overall patient satisfaction. However, more evidence-based research is needed to determine such association in an emergent care setting.
OBJECTIVE: To evaluate the association between physician self-reported empathy and after-care instant patient-to-provider satisfaction among Emergency Department (ED) healthcare providers with varying years of medical practice experience.
RESEARCH DESIGN: A prospective observational study conducted in a tertiary care hospital ED.
METHODS: Forty-one providers interacted with 1,308 patients across 1,572 encounters from July 1 through October 31, 2016. The Jefferson Scale of Empathy (JSE) was used to assess provider empathy. An after-care instant patient satisfaction survey, with questionnaires regarding patient-to-provider satisfaction specifically, was conducted prior to the patient moving out of the ED. The relation between physician empathy and patient satisfaction was estimated using risk ratios (RR) and their corresponding 95% confidence limits (CL) from log-binomial regression models.
RESULTS: Emergency Medicine (EM) residents had the lowest JSE scores (median 111; interquartile range [IQR]: 107-122) and senior physicians had the highest scores (median 119.5; IQR: 111-129). Similarly, EM residents had the lowest percentage of "very satisfied" responses (65%) and senior physicians had the highest reported percentage of "very satisfied" responses (69%). There was a modest positive association between JSE and satisfaction (RR = 1.04; 95% CL: 1.00, 1.07).
CONCLUSION: This study provides evidence of a positive association between ED provider self-reported empathy and after-care instant patient-to-provider satisfaction. Overall higher empathy scores were associated with higher patient satisfaction, though minor heterogeneity occurred between different provider characteristics.

PMID: 30212564 [PubMed - indexed for MEDLINE]

Actinomyces turicensis Necrotizing Soft-Tissue Infection of the Thigh in a Diabetic Male.

Sat, 02/23/2019 - 06:42
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Actinomyces turicensis Necrotizing Soft-Tissue Infection of the Thigh in a Diabetic Male.

Surg Infect (Larchmt). 2019 Feb 21;:

Authors: Panwar K, Duane TM, Tessier JM, Patel K, Sanders JM

Abstract
BACKGROUND: Necrotizing soft-tissue infections are a devastating infection that is rarely caused by Actinomyces spp.
CASE REPORT: A 45-year-old obese previously healthy male presented to the emergency department with diabetic ketoacidosis. The patient developed systemic signs of infections and right medial thigh pain subsequently diagnosed as a necrotizing soft-tissue infection. Successful treatment included prompt surgical intervention and initiation of broad-spectrum antimicrobial drugs.
CONCLUSION: Actinomyces turicensis may be the pathogen causing certain necrotizing soft-tissue infections. Clinicians should consider the possibility that this organism represents a true pathogen and not colonization/contamination.

PMID: 30789313 [PubMed - as supplied by publisher]

The Radiographic Prepatellar Fat Thickness Ratio Correlates With Infection Risk After Total Knee Arthroplasty.

Thu, 02/14/2019 - 05:10
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The Radiographic Prepatellar Fat Thickness Ratio Correlates With Infection Risk After Total Knee Arthroplasty.

J Arthroplasty. 2018 07;33(7):2251-2255

Authors: Wagner RA, Hogan SP, Burge JR, Bates CM, Sanchez HB

Abstract
BACKGROUND: Obesity has been associated with complications after a total knee arthroplasty (TKA). Surgical site infection (SSI) after TKA is one of the feared complications as it increases revision rates, costs, and stress to the patient. There is conflicting evidence in the literature regarding body mass index (BMI) and risk of infection after TKA, and some studies have suggested that site-specific fat distribution may be a better metric for determining risk of postoperative infections. Here, we investigate the correlation of soft tissue distribution about the knee to SSI after TKA.
METHODS: We retrospectively review 572 patients who underwent primary TKA at a single institution from 2006 to 2010. We introduce the prepatellar fat thickness ratio (PFTR) as a radiographic means to quantitatively assess fat distribution about the knee and evaluate this measurement's ability to assess the risk of developing an SSI after TKA.
RESULTS: The PFTR was shown to be a better predictor of SSI than BMI in both the univariate (P = .05) and multivariate (P = .01) analyses.
CONCLUSION: Although BMI cannot fully account for variations in adipose distribution, the PFTR may account for this variability and may be a helpful tool for assessing a patient's preoperative risk of SSI after TKA.

PMID: 29555491 [PubMed - indexed for MEDLINE]

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