Starting from scratch: New work design to enact entrance screening during the COVID-19 pandemic.

BACKGROUND: Health care organizations are constantly creating new work to achieve evolving goals such as digitalization, equity, value, or well-being. However, scholars have paid less attention to how such work becomes "work" in the first place, despite implications for the design, quality, and experience of work and, consequently, employee and organizational outcomes. PURPOSE: The aim of this study was to investigate how new work becomes enacted in health care organizations. METHODOLOGY: A longitudinal, qualitative case study on the enactment of entrance screening-a new operation in response to COVID-19-in a multihospital academic medical center was performed. RESULTS: Entrance screening comprised four tasks, whose design was initially influenced by institutional guidelines (e.g., Centers for Disease Control and Prevention recommendations) and clinical experts. Organizational-level influences (e.g., resource availability) then became more prominent, necessitating multiple feedback-response loops to calibrate the performance of entrance screening. Finally, entrance screening was integrated into existing operations of the organization to ensure operational sustainability. The treatment of entrance screening as an operation changed over time-initially seen as infection control work, it eventually bifurcated into patient care and clerical work. CONCLUSION: The enactment of new work is constrained by the fit between resources and its intended output. Furthermore, the schema of work influences how and when organizational actors calibrate this fit. PRACTICE IMPLICATIONS: Health care leaders and managers should continuously update their schemas of work so that they can develop more sufficient and accurate representations of the employee capabilities that are required for the performance of new work.

Understanding the impact of transformational leadership on nurse compassion provision through a time-lagged field study.

BACKGROUND: A large volume of literature identifies positive, rejuvenating benefits associated with giving compassion to others. However, the relationship between giving compassion and feelings of exhaustion remains underexplored. Understanding when giving compassion can potentially lead to feelings of emotional exhaustion is particularly important for nurses who are called upon to provide high levels of compassion to suffering patients in their daily work. We suggest that by engaging in transformational leadership behaviors, frontline supervisors can help nurses realize the positive benefits associated with giving compassion. PURPOSE: The aim of this study was to examine the impact of nurses' perceptions of transformational leadership offered by their supervisors on the relationship between the levels of compassionate behaviors nurses report engaging in with patients and feelings of emotional exhaustion and job satisfaction. METHODOLOGY/APPROACH: A time-lagged field survey was conducted across two waves of 112 full-time employed inpatient nurses within the United States. RESULTS: Providing high levels of compassionate behavior to patients was associated with reduced (increased) perceptions of emotional exhaustion and increased (decreased) job satisfaction when supervisors engaged in higher (lower) levels of transformational leadership. DISCUSSION: Transformational leadership serves as an important resource to help caregivers such that nurses feel invigorated and satisfied, as opposed to drained or fatigued, when engaging in high levels of compassionate behaviors toward suffering patients. PRACTICE IMPLICATIONS: For nurses to fully reap the established positive benefits associated with providing compassion to patients, frontline supervisors should be encouraged to engage in behaviors reflective of transformational leadership.

Association of hypoxic ischemic brain injury on early CT after out of hospital cardiac arrest with neurologic outcome.

AIM: This study aimed to describe the prevalence of hypoxic-ischemic brain injury (HIBI) on head CT (HCT) obtained within two hours of return of spontaneous circulation (ROSC) care in the Emergency Department following out-of-hospital cardiac arrest (OHCA) and evaluate the association between early HIBI and neurologic outcome. METHODS: Retrospective single center observational study of post-OHCA patients between 2009 and 2017. Two cohorts were analyzed: those who underwent non-contrast HCT within two hours of ROSC and all others who survived to ICU admission. HIBI was defined as the presence of cerebral edema and/or abnormal gray-white matter differentiation in the HCT interpretation by a neuroradiologist. The primary outcomes were the prevalence of HIBI on early HCT and the magnitude of the association between HIBI and survival with good neurologic outcome using multivariable logistic regression. RESULTS: Following OHCA, 333 of 520 patients (64%) underwent HCT within two hours of ROSC and HIBI was present in 96 of 333 patients (29%). Of the early HCT cohort, those with HIBI had a significantly lower hospital survival (2%) and favorable neurologic outcome (1%). In those without HIBI on imaging, 88 of 237 patients (37%) had a favorable outcome. After adjustment for confounding variables, HIBI on early HCT was independently associated with a decreased likelihood of good neurologic outcome (aOR 0.015, 95% CI 0.002-0.12). CONCLUSION: HIBI was present on 29% of HCTs obtained within 2 h of ROSC in the patients selected for early imaging by emergency physicians and was strongly and inversely associated with survival with a good neurologic outcome.

Optimize Your First Impression: A Comparison of the Aesthetic Websites of Private Practices and Academic Institutions.

BACKGROUND: An aesthetic surgery offering within academic programs has positive financial and educational implications. To compete with private practices, academic institutions must view their website as integral to patient recruitment. OBJECTIVE: This study examines the aesthetic surgery websites of academic and private practices to compare objective website characteristics. METHODS: Integrated plastic surgery programs with an aesthetic surgery website were matched with nearby private practices offering cosmetic surgery. Data was collected from websites, including information about procedures, media, surgeon characteristics, design, reputation, finances, and readability, and compared using Chi-square and T tests. RESULTS: The websites of 68 academic institutions (AP) and 68 location-matched private practices (PP) were examined. Fourteen (17.07%) programs did not have a website. Private practice websites provided information about a greater number of procedures (mean AP 21.82, PP 27.04, p = 0.013), preparation for surgery (AP 52.94%, PP 83.82%, p < 0.001), and expectations after surgery (AP 70.59%, PP 88.24%, p = 0.01). Board certification was listed more frequently for private practices (AP 87%, PP 98%, p = 0.01). Academic websites were more likely to discuss research (AP 76%, PP 57.35%, p = 0.02). There was no significant difference in the readability of AP and PP websites (mean SMOG AP 7.70, PP 7.19, p = 0.06). CONCLUSIONS: This work demonstrates a significant content gap between private and academic aesthetic websites and serves as an action item for institutions to enhance their online presence. In a field traditionally associated with high overhead costs, website modifications represent a cost-effective way for academic practices to increase their appeal in the cosmetic surgery market. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Clinical Trial Outcomes in Urology: Assessing Early Discontinuation, Results Reporting and Publication in ClinicalTrials.Gov Registrations 2007-2019.

PURPOSE: Clinical trials require significant resources, but benefits are only realized after trial completion and dissemination of results. We comprehensively assessed early discontinuation, registry results reporting, and publication by trial sponsor and subspecialty in urology trials. MATERIALS AND METHODS: We assessed trial registrations from 2007 to 2019 on ClinicalTrials.gov and publication data from PubMed®/MEDLINE®. Associations between sponsor or subspecialty with early discontinuation were assessed using Cox proportional hazards and results reporting or publication with logistic regression at 3 years after completion. RESULTS: Of 8,636 trials 3,541 (41.0%) were completed and 999 (11.6%) were discontinued. Of completed trials 26.9% reported results and 21.6% were published. Sponsors included academic institutions (53.1%), industry (37.1%) and the U.S. government (9.8%). Academic-sponsored (adjusted HR 0.81, 95% CI 0.69-0.96, p=0.012) and government-sponsored trials (adjusted HR 0.62, 95% CI 0.49-0.78, p <0.001) were less likely than industry to discontinue early. Government-sponsored trials were more likely to report (adjusted OR 1.72, 95% CI 1.17-2.54, p=0.006) and publish (adjusted OR 1.89, 95% CI 1.23-2.89, p=0.004). Academic-sponsored trials were less likely to report (adjusted OR 0.65, CI:0.48-0.88, p=0.006) but more likely to publish (adjusted OR 1.72, 95% CI 1.25-2.37, p <0.001). These outcomes were similar across subspecialties. However, endourology was more likely to discontinue early (adjusted HR 2.00, 95% CI 1.53-2.95, p <0.001), general urology was more likely to report results (adjusted OR 1.54, 95% CI 1.13-2.11, p=0.006) and andrology was less likely to publish (adjusted OR 0.53, 95% CI 0.35-0.81, p=0.003). CONCLUSIONS: Sponsor type is significantly associated with trial completion and dissemination. Government-sponsored trials had the best performance, while industry and academic-sponsored trials lagged in completion and results reporting, respectively. Subspecialty played a lesser role. Lack of dissemination remains a problem for urology trials.

Management of Benign Prostatic Hyperplasia.

Benign prostatic hyperplasia (BPH) and associated lower urinary tract symptoms (LUTS) commonly affect older men. Age-related changes associated with metabolic disturbances, changes in hormone balance, and chronic inflammation may cause BPH development. The diagnosis of BPH hinges on a thorough medical history and focused physical examination, with attention to other conditions that may be causing LUTS. Digital rectal examination and urinalysis should be performed. Other testing may be considered depending on presentation of symptoms, including prostate-specific antigen, serum creatinine, urine cytology, imaging, cystourethroscopy, post-void residual, and pressure-flow studies. Many medical and surgical treatment options exist. Surgery should be reserved for patients who either have failed medical management or have complications from BPH, such as recurrent urinary tract infections, refractory urinary retention, bladder stones, or renal insufficiency as a result of obstructive uropathy.

The Hancock® Valved Conduit for Right Ventricular Outflow Tract Reconstruction in Sheep for Assessing New Devices.

BACKGROUND AND AIM OF THE STUDY: Xenograft conduits have been used successfully to repair congenital heart defects, but are prone to failure over time. Hence, in order to improve patient outcomes, better xenografts are being developed. When evaluating a conduit's performance and safety it must first be compared against a clinically available control in a large animal model. The study aim was to evaluate a clinically available xenograft conduit used in right ventricular outflow tract (RVOT) reconstruction in a sheep model. METHODS: RVOT reconstruction was performed in 13 adult and juvenile sheep, using the Medtronic Hancock® Bioprosthetic Valved Conduit (Hancock conduit). The method had previously been used on patients, and a newly modified variant termed 'RVOT Extraction' was employed to facilitate the surgical procedure. Animals were monitored over predetermined terms of 70 to 140 days. Serial transthoracic echocardiography, intracardiac pressure measurements and angiography were performed. On study completion the animals were euthanized and necropsies performed. RESULTS: Two animals died prior to their designated study term due to severe valvular stenosis and distal conduit narrowing, respectively. Thus, 11 animals survived the study term, with few or no complications. Generally, maximal and mean transvalvular pressure gradients across the implanted conduits were increased throughout the postoperative course. Among 11 full-term animals, seven conduits were patent with mild or no pseudointimal proliferation and with flexible leaflets maintaining the hemodynamic integrity of the valve. CONCLUSIONS: RVOT reconstruction using the Hancock conduit was shown to be successful in sheep, with durable and efficient performances. With its extensive clinical use in patients, and ability for long-term use in sheep (as described in the present study) it can be concluded that the Hancock conduit is an excellent control device for the evaluation of new xenografts in future preclinical studies.

Trifecta and optimal perioperative outcomes of robotic and laparoscopic partial nephrectomy in surgical treatment of small renal masses: a multi-institutional study.

OBJECTIVE: To compare the perioperative outcomes of robotic partial nephrectomy (RPN) with laparoscopic PN (LPN) performed for small renal masses (SRMs), in a large multi-institutional series and to define a new composite outcome measure, termed 'optimal outcome' for the RPN group. PATIENTS AND METHODS: Retrospective review of 2392 consecutive cases of RPN and LPN performed in five high-volume centres from 2004 to mid-2013. We limited our study to SRMs and cases performed by surgeons with significant expertise with the technique. The Trifecta was defined as negative surgical margin, zero perioperative complications and a warm ischaemia time of ≤25 min. The 'optimal outcome' was defined as achievement of Trifecta with addition of 90% estimated glomerular filtration rate preservation and no chronic kidney disease stage upgrading. Univariable and multivariable analysis were used to identify factors predicting Trifecta and 'optimal outcome' achievement. RESULTS: In all, 1185 RPN and 646 LPN met our inclusion criteria. Patients in the RPN group were older and had a higher median Charlson comorbidity index and higher R.E.N.A.L. nephrometry score. The RPN group had lower warm ischaemia time (18 vs 26 min), overall complication rate (16.2% vs 25.9%), and positive surgical margin rate (3.2% vs. 9.7%). There was a significantly higher Trifecta rate for RPN (70% vs 33%) and the rate of achievement of 'optimal outcome' for the RPN group was 38.5%. CONCLUSIONS: In this large multi-institutional series RPN was superior to LPN for perioperative surgical outcomes measured by Trifecta. Patients in the RPN group had better outcomes for all three components of Trifecta compared with their LPN counterparts. Our more strict definition for 'optimal outcome' might be a better tool for assessing perioperative and functional outcomes after minimally invasive PN. This tool needs to be externally validated.

Monitoring intracellular oxidative events using dynamic spectral unmixing microscopy.

There is increasing interest in using live cell imaging to monitor not just individual intracellular endpoints, but to investigate the interplay between multiple molecular events as they unfold in real time within the cell. A major impediment to simultaneous acquisition of fluorescent signals from multiple probes is that emission spectra of many fluorophores overlap, often with maxima that are only a few nanometers apart. Spectral acquisition of mixed fluorescence signals captured within a dedicated scanning range can be used to quantitatively separate signals into component spectra. We report here the development of a novel live cell application of spectral unmixing for the simultaneous monitoring of intracellular events reported by closely-emitting fluorophores responding dynamically to external stimuli. We validate the performance of dynamic spectral unmixing microscopy (DynSUM) using genetically encoded sensors to simultaneously monitor changes in glutathione redox potential (Egsh) and H2O2 production in living cells exposed to oxidizing and reducing agents. We further demonstrate the utility of the DynSUM approach to observe the relationship between the increases in Egsh and H2O2 generation induced in airway epithelial cells exposed to an environmental electrophile.

The effect of community based-academic partnerships on student knowledge about plastic surgery and interest in medicine.

BACKGROUND: Programs specific to plastic surgery are necessary to dispel common myths and increase interest in the field. In a previous publication by the authors, a community outreach program was developed for these reasons for middle school students. In the current study, we expanded on the previous research and collected objective data to assess students' initial interest in medicine and knowledge about plastic surgery, compared to their interest and knowledge afterward. METHODS: The program previously developed by the authors was modified and performed for the students at various community outreach events and included a PowerPoint presentation, case didactics, and hands-on activities. A test about plastic surgery and questionnaire about interest in the medical field and becoming a doctor was given to each student before and after the program. RESULTS: One hundred seventy-nine students participated in the program from 2009 to 2013. The pretest mean score was 6.50 of 12 questions whereas the posttest mean score was 9.72 (P = <0.001). After participation in the program, 27% of students that answered "no" or "unsure" about interest in the medical field on the pretest changed their answer to "yes," on the posttest, and 17% of students that answered "no" or "unsure" about interest in becoming a doctor on the pretest changed their answer to "yes," on the posttest (P = <0.001). CONCLUSIONS: A plastic surgery community outreach program is beneficial in increasing students' interest in the field of medicine as a whole, and more specifically in the field of plastic surgery.

Objective Assessment of Facial Rejuvenation After Massive Weight Loss.

BACKGROUND: While the literature is replete with articles about body contouring after bariatric surgery, little information exists regarding the outcomes of facelift following massive weight loss (MWL). A case report and a technique article are the only sources available addressing this issue. This pilot study objectively examines the effects of MWL in the cervicofacial region and results after facelift. METHODS: A retrospective review of seven patients who underwent facelift after MWL (>100 pounds) was performed. Patient's change in appearance was objectively evaluated using an apparent age model. Forty blinded reviewers assessed pre- and postoperative photographs of seven MWL and eleven non-MWL female patients. The reviewers estimated the apparent age for each subject. Reduction in apparent age was calculated by comparing patient's apparent age against actual age. RESULTS: The preoperative apparent age of MWL patients was 5.1 years older than their actual age (p < 0.02) compared to the increased preoperative apparent age of 1.2 years in non-MWL subjects (p > 0.05); suggesting MWL patients appear older than their actual age. Post-operatively, the apparent age reduction in MWL patients was 6.0 years; and their apparent age after surgery was 0.9 year less than their actual age (p > 0.05). In contrast, the control group exhibited an apparent age reduction of 5.4 years and a postoperative apparent age 4.2 years younger than their actual age (p < 0.01). Apparent age reduction was not significantly different for the two groups (p > 0.05). Age, BMI, and follow-up were similar between groups (p > 0.05). CONCLUSIONS: MWL may accelerate apparent cervicofacial aging. Facelift following MWL enhances cervicofacial appearance and significantly reduces apparent age. We hope this study stimulates further interest in the study of facial esthetics in this increasing population. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Evaluation of renal mass biopsy risk stratification algorithm for robotic partial nephrectomy--could a biopsy have guided management?

PURPOSE: We evaluated a published biopsy directed small renal mass management algorithm using a large cohort of patients who underwent robotic partial nephrectomy for tumors 4 cm or smaller. MATERIALS AND METHODS: A simplified algorithm of biopsy directed small renal mass management previously reported using risk stratified biopsies was applied to 1,175 robotic partial nephrectomy cases from 5 academic centers. A theoretical assumption was made of perfect biopsies that were feasible for all patients and had 100% concordance to final pathology. Pathology risk groups were benign, favorable, unfavorable and intermediate. The algorithm assigned favorable or intermediate tumors smaller than 2 cm to active surveillance and unfavorable or intermediate 2 to 4 cm tumors to treatment. Higher surgical risk patients were defined as ASA® 3 or greater and age 70 years or older. RESULTS: Patients were assigned to the pathology risk groups of benign (23%), favorable (13%), intermediate (51%) and unfavorable (12%). Patients were also assigned to the management groups of benign pathology (275, 23%), active surveillance (336, 29%) and treatment (564, 48%). Most of the 611 (52%) patients in the benign or active surveillance groups were low surgical risk and had safe treatment (2.6% high grade complications). A biopsy may not have been feasible or accurate in some tumors that were anterior (378, 32%), hilar (93, 7.9%) or less than 2 cm (379, 32%). Of 129 (11%) high surgical risk patients the biopsy algorithm assigned 70 (54%) to benign or active surveillance groups. CONCLUSIONS: The theoretical application of a biopsy driven, risk stratified small renal mass management algorithm to a large robotic partial nephrectomy database suggests that about half of the patients might have avoided surgery. Despite the obvious limitations of a theoretical assumption of all patients receiving a perfect biopsy, the data support the emerging role of renal mass biopsies to guide management, particularly in high surgical risk patients.

Perioperative complications of robot-assisted partial nephrectomy.

The incidence of renal cell carcinoma continues to increase with utilization of diagnostic abdominal imaging with migration towards a proportionally greater detection of small renal masses (SRM). Robot-assisted partial nephrectomy (RAPN) has become an attractive minimally invasive treatment modality for SRM's due to the technical advantages and shortened learning curve compared to laparoscopic partial nephrectomy (LPN) while preserving comparable perioperative outcomes. With advances in ablative approaches for stage I renal cell carcinoma (RCC) and controversy surrounding the role of extirpative surgery for SRM's, systematic understanding of the complications associated with RAPN has become even more imperative. This review aims to summarize and evaluate the contemporary literature, compile reported intraoperative complications, describe conventional and nephron-sparing surgery (NSS) specific postoperative complications, and assess factors associated with an increased likelihood for perioperative complications following RAPN.

Defining the fat compartments in the neck: a cadaver study.

BACKGROUND: Cervicoplasty is an important component of aesthetic facial and neck surgery, but the fat content in this area has not been described. OBJECTIVES: The authors identify anatomic compartments of fat in the neck (specifically the areas relevant to surgical management), quantify the fat in each compartment, and describe the relationships between each compartment and the submandibular glands. METHODS: The skin was removed from 10 fresh cadaver heads. Each compartment of fat was weighed, along with the submandibular gland. Supraplatysmal fat was found between the skin and the platysma muscle, and it was compartmentalized into suprahyoid and infrahyoid fat. Subplatysmal fat was found deep to the platysma and between the medial edges of the anterior digastric in the midline; this fat also fell into suprahyoid and infrahyoid compartments. The "very deep" fat was deep to the anterior digastric muscles and submandibular gland, and adherent to the strap muscles. RESULTS: On average, supraplatysmal fat represented 44.7% of the fat in the neck, the subplatysmal fat represented 30.7%, and the submandibular gland represented 24.5%. The very deep fat was scant, representing less than 1% of the fat in the neck. CONCLUSIONS: This anatomic study provides a comprehensive review of fat in the neck, and the results should serve as an additional guide as surgeons approach this challenging area in surgical rejuvenation.

Unintended Souvenirs: Case Report of a Retained Foreign Body During Cosmetic Surgery Tourism.

Medical tourism has grown exponentially, spurred by incentives such as cost reductions, minimal wait times, and the allure of recuperative vacations. However, this trend carries substantial risks, as illustrated by the case of a 52-year-old female patient who underwent an abdominoplasty as part of a medical tourism package in Miami, FL, which resulted in a retained foreign body. The case highlights the broader issues of continuity of care, patient safety, and the legal and ethical ramifications faced by patients opting for medical tourism surgical procedures domestically and abroad. It also emphasizes the need for updated standards from professional societies and international cooperation to safeguard patient well-being in the expanding medical tourism sector. Lastly, it underscores the need for physicians and surgeons who manage these complications at home to recognize that prompt management and intervention are critical to avoid the escalation of complications and the increased risk of morbidity and mortality.

Transoral Excision of a Hypopharyngeal Liposarcoma.

Liposarcomas are the most common soft tissue sarcoma in adults, whereas liposarcomas of the head and neck, particularly the hypopharynx, are incredibly rare - with approximately 50 cases reported in the literature. We present a case of an otherwise healthy and asymptomatic 42-year-old male who presented dramatically after vomiting up a large soft tissue mass. The lesion was surgically removed via transoral approach with blue laser, and diagnosis of well-differentiated liposarcoma was made via MDM2 gene amplification by FISH. Oral extrusion is a rare feature of this disease. This is the first documented case of an orally extruded liposarcoma to present in an otherwise asymptomatic and healthy patient, demonstrating how this entity may be indolent until initial presentation. Laryngoscope, 134:4688-4690, 2024.

Managing Surges in Demand: A Grounded Conceptual Framework of Surge Management Capability.

Surge management is important to hospital operations, yet surge literature has mostly focused on the addition of resources (e.g., 25% more beds) during events like pandemics. Such views are limiting, as meeting surge demands requires hospitals to engage in practices tailored to a surge's unique contingencies. We argue that a dynamic view of surge management should include surge management capability, which refers to how resources are deployed to respond to surge contingencies. To understand this capability, we qualitatively studied five hospital systems experiencing multiple surges due to COVID-19 between April 2020 and March 2022. We develop a framework showing that managing surges involves preserving capacity, expanding capacity, smoothing capacity demand, and enabling surge management. We contribute to surge literature by identifying practices hospitals can adopt to address surges and offering a better understanding of surge conditions (e.g., degree of novelty) that make some surge management practices more appropriate than others.

Evidence of scaling advantage for the quantum approximate optimization algorithm on a classically intractable problem.

The quantum approximate optimization algorithm (QAOA) is a leading candidate algorithm for solving optimization problems on quantum computers. However, the potential of QAOA to tackle classically intractable problems remains unclear. Here, we perform an extensive numerical investigation of QAOA on the low autocorrelation binary sequences (LABS) problem, which is classically intractable even for moderately sized instances. We perform noiseless simulations with up to 40 qubits and observe that the runtime of QAOA with fixed parameters scales better than branch-and-bound solvers, which are the state-of-the-art exact solvers for LABS. The combination of QAOA with quantum minimum finding gives the best empirical scaling of any algorithm for the LABS problem. We demonstrate experimental progress in executing QAOA for the LABS problem using an algorithm-specific error detection scheme on Quantinuum trapped-ion processors. Our results provide evidence for the utility of QAOA as an algorithmic component that enables quantum speedups.