Treatment selection and real-world analysis of immunotherapy with or without chemotherapy in PD-L1-high metastatic non-small cell lung cancer.

BACKGROUND: Lung cancer is the leading cause of cancer death in Australia. Immunotherapy has improved outcomes in patients with metastatic non-small cell lung cancer (NSCLC). Pembrolizumab is approved in first-line treatment as single-agent immunotherapy (SAI) or combination chemoimmunotherapy (CIT). In metastatic NSCLC programmed death-ligand 1 (PD-L1) ≥50% either regimen may be used. AIMS: We aim to identify patient and tumour characteristics that influence treatment selection. METHODS: This is a retrospective observational study. Pharmacy records identified patients with metastatic/recurrent NSCLC receiving pembrolizumab at two metropolitan centres in Victoria, Australia, since 2018. Demographics, tumour characteristics, Charlson Comorbidity Index (CCI) and treatment data were collected. Descriptive and multivariate analyses were performed. RESULTS: Sixty-one patients had metastatic NSCLC PD-L1 ≥50% and received pembrolizumab with median age of 65.6 years, Eastern Cooperative Oncology Group 0-1 in 82%. CIT was administered to 23% (14) with no difference in rate of delivery between centres (P = 0.808). CCI mean score differed (3.38 SAI vs 2.36 CIT, P = 0.042). Patients with high CCI score (≥2) were less likely to receive CIT (OR = 0.15, P = 0.003, 95% confidence interval (CI) 0.04-0.57). Primary tumours over 5 cm were more likely to receive CIT (OR = 3.74, P = 0.043, 95% CI = 1.04-13.42). Site-specific metastases of liver, brain and pericardial effusion were not associated with CIT. CONCLUSIONS: Patients with higher comorbidity score were less likely to receive CIT, suggesting chemotherapy avoidance in comorbid patients. Larger tumours are associated with CIT use, indicating that oncologists may use tumour size as a surrogate of disease burden. Limitations include small sample size and data cut-off. Future prospective studies could incorporate comorbid status and a validated disease burden score to stratify patients.

A 10-Year Update of Outcome Measures Used to Assess Results After Surgery for Cubital Tunnel Syndrome: A Systematic Review of the Literature.

HYPOTHESIS: Outcomes reporting for the surgical release of ulnar nerve cubital tunnel entrapment have variability in subjective, objective, and validated measures. The aim of this study is to review the literature to reassess the measures used to report surgical outcomes for ulnar neurolysis at the elbow. METHODS: This study was conducted in accordance with the PRISMA guidelines on systematic reviews. Six electronic databases were queried from the past 10 years using specific search terms and Boolean operators. Two independent reviewers assessed 4290 unique titles and abstracts that were screened for inclusion criteria. Sixty-eight full text articles were included for analysis. RESULTS: Statistical significance was noted in the number of outcome measures reported between studies from journals of impact factor within the first and third quartiles (P = 0.0086) and first and fourth quartiles (P = 0.0247), although no significance exists in the number of cubital tunnel-specific measures based on impact factor (P = 0.0783). Seventy-nine percent (n = 54) of the included studies report subjective measures; 54% (n = 37) included objective measures. Seventy percent (n = 48) of the studies report disease-specific outcome measures. CONCLUSION: There exists a discordance within the literature regarding the most appropriate, descriptive, and translational measures for reporting surgical outcomes of cubital tunnel syndrome. We recommend journal editors implement a requirement that authors reporting outcomes of ulnar nerve decompression must use a standard, validated measure to make comparisons across the literature universal. Furthermore, a minimum of at least 1 subjective and 1 objective measure should be standard.

Immediate Interventions After Surgery to Reduce Readmission for Upper Extremity Infections.

ABSTRACT: Upper extremity infections (UEIs), commonly caused by intravenous drug use and direct trauma to the hand, can be devastating. Many studies support hand therapy postoperatively to improve outcomes. This population of patients often experience increased returns to the emergency department (ED) for treatment, repeat surgery, poor function, and increased hospital expenditure.This is a 2-phase study to investigate and intervene on the care pathway for patients undergoing surgery for UEI at a single urban university hospital. For the first 6-month phase, all patients with UEI requiring surgery received the standard of care, including written discharge instructions, a scheduled follow-up, and a determination for hand therapy based on evaluation. During the second phase, over the following 6 months, all patients with UEI requiring surgery received an intervention before discharge, in addition to standard of care, including a scripted educational session on the importance of hand therapy by a resident physician, home exercise program instructions, and a referral to hand therapy before discharge. Outcome measures were assessed for 6 months. Outcome measures included follow-up, hand therapy attendance, ED visits for the same complaint, readmissions, and reoperations.Forty-seven patients were in the first control group without intervention and 41 patients were in the second intervention group. Of the control group, 43% attended a follow-up appointment, 2% attended hand therapy, and 45% presented to the ED, resulting in a total of 167 visits. Eleven presented to the ED and were readmitted for complications from surgery, all 11 required a second operation. In the intervention group, 54% attended a follow-up appointment (P = 0.044), more patients attended hand therapy (22% P = 0.013), and 24% presented to the ED (P = 0.047), resulting in 40 ED visits.Seven were readmitted for complications from surgery and 4 required a second operation (P = 0.1). Early, simple intervention and education prove to be an effective method to decrease emergency department burden and healthcare expenditure for treatment of a challenging population. Although additional education and referral to hand therapy utilization do not change operation rates, it decreased returns to the ED, readmissions, and increased follow-up.

Cancer patients' perceptions of palliative care.

PURPOSE: Despite clear benefits of early integration of palliative care (PC) and oncology, concerns remain about negative perceptions of PC. Our aim was to explore current knowledge and perceptions of PC in cancer patients. METHODS: We conducted a prospective, cross-sectional survey. A 16-item questionnaire was distributed to all cancer patients (N = 103) upon admission to the oncology ward of an Australian tertiary academic hospital. Chi-squared test was used to examine for significant factors related to patients' perceptions. RESULTS: Ninety-six patients (93%) completed the questionnaire; 76% had metastatic cancer. We explored the following domains:Experience and knowledge: 76% had heard of PC; 21% had received PC. Self-rated PC knowledge was varied. Forty-five percent believed that PC was only associated with EOLC; those more likely to disagree had received PC services (p = 0.039).Integration of PC and oncology: Majority believed that they could receive oncology care (86%) and anti-cancer treatment (81%) whilst receiving PC. Those who had heard of PC and with better self-rated knowledge were more likely to believe that they could receive concurrent anti-cancer treatment (p = 0.005, p = 0.045, respectively).Feelings: 77% felt comforted with PC involvement; this was significantly associated with older age (p = 0.047) and understanding that oncology (p < 0.005) and anti-cancer treatment (p = 0.013) could continue. However, some felt frightened (40%) and hopeless (29%) about referral to PC. Fifty percent felt more comfortable with referral to 'supportive care' services (versus PC). CONCLUSIONS: Our survey demonstrates reasonable understanding and relatively positive feelings about PC, associated with experience and knowledge. Nonetheless, there is ongoing need for better patient and public education about PC.

Perspectives of cancer treatment providers regarding voluntary assisted dying in Victoria.

A survey of cancer treatment providers at our institution exploring their perspectives regarding voluntary assisted dying in Victoria and the imminent legislation showed that while almost all were aware of the Bill (92%), reported knowledge and understanding of it was much less (38%). As many clinicians supported the Bill as opposed it (28%); 44% were uncertain of their stance. Most were unwilling to directly provide voluntary assisted dying; if they did, would refer to palliative care services for ongoing support.

Failed Thumb Carpometacarpal Arthroplasty: Common Etiologies and Surgical Options for Revision.

Carpometacarpal (CMC) arthroplasty surgery, although modifications have occurred over time, continues to be commonly performed and has provided patients with their desired pain relief and return of function. The complications of primary surgery, although relatively rare, can present in various clinical ways. An understanding of the underlying anatomy, pathology of coexisting conditions, and specific techniques used in the primary surgery is required to make the best recommendation for a patient with residual pain following primary CMC arthroplasty. The purpose of this review is to provide insights into the history of CMC arthroplasty and reasons for failure and to offer an algorithmic treatment approach for the clinical problem of persistent postoperative symptoms.

Donor nerve sources in free functional gracilis muscle transfer for elbow flexion in adult brachial plexus injury.

BACKGROUND: With complete plexus injuries or late presentation, free functional muscle transfer (FFMT) becomes the primary option of functional restoration. Our purpose is to review cases over a 10-year period of free functioning gracilis muscle transfer after brachial plexus injury to evaluate the effect of different donor nerves used to reinnervate the FFMT on functional outcome. METHODS: A retrospective study from April 2001 to January 2011 of a single surgeon's practice was undertaken. During this time period 22 patients underwent FFMT at Washington University in St Louis, Missouri for elbow flexion. RESULTS: Thirteen patients for whom FFMT was performed for elbow flexion met all of the requirements for inclusion in this study. Average time from injury to first operation was 12.8 months (range 4-60), and average time from injury to FFMT was 29 months (range 8-68). Average follow-up was 31.8 months (range 11-84). The nerve donors utilized included the distal accessory nerve, intercostal with or without rectus abdominis nerves, medial pectoral nerves, thoracodorsal nerve, and flexor carpi ulnaris fascicle of ulnar nerve. Functional recovery of elbow flexion was measured using the MRC grading system which showed 1 M5/5, 5 M4, 4 M3, and 3 M2 outcomes. CONCLUSION: Intraplexal donor motor nerves if available will provide better transferred muscle function because they are higher quality donors closer to the muscle and can be done in one stage without a nerve graft. Otherwise, intercostal, rectus abdominis, or the distal accessory nerve should be used in a staged fashion. © 2016 Wiley Periodicals, Inc. Microsurgery 37:377-382, 2017.

Lower Extremity Reconstruction with Free Gracilis Flaps.

Background There have been significant advancements in lower extremity reconstruction over the last several decades, and the plastic surgeon's armamentarium has grown to include free muscle and fasciocutaneous flaps along with local perforator and propeller flaps. While we have found a use for a variety of techniques for lower extremity reconstruction, the free gracilis has been our workhorse flap due to the ease of harvest, reliability, and low donor site morbidity. Methods This is a retrospective review of a single surgeon's series of free gracilis flaps utilized for lower extremity reconstruction. Demographic information, comorbidities, outcomes, and secondary procedures were analyzed. Results We identified 24 free gracilis flaps. The duration from injury to free flap coverage was ≤ 7 days in 6 patients, 8-30 days in 11 patients, 31-90 days in 4 patients, and > 90 days in 3 patients. There were 22 (92%) successful flaps and an overall limb salvage rate of 92%. There was one partial flap loss. Two flaps underwent incision and drainage in the operating room for infection. Two patients developed donor site hematomas. Four patients underwent secondary procedures for contouring. Our subset of pediatric patients had 100% flap survival and no secondary procedures at a mean 30-month follow-up. Conclusion This study demonstrates the utility of the free gracilis flap in reconstruction of small- to medium-sized defects of the lower extremity. This flap has a high success rate and a low donor site morbidity. Atrophy of the denervated muscle over time allows for good shoe fit, often obviating the need for secondary contouring procedures.

Percutaneous Sacroplasty for Painful Bone Metastases: A Case Report.

INTRODUCTION: The occurrence of bone metastases is common in patients with advanced cancer. The literature supports percutaneous vertebroplasty and kyphoplasty as minimally invasive procedures to relieve pain and improve quality of life for selected patients with disabling pain from pathological vertebral fractures secondary to bone metastases. CASE: We describe a case of a 71-year-old patient with castrate-resistant metastatic prostate cancer who underwent sacroplasty for painful sacral metastases. The patient had previously been treated with maximally tolerated analgesics and anticancer therapies including systemic anticancer treatments and local radiotherapy. After sacroplasty, he experienced significant pain reduction and improvement in mobility and function. CONCLUSION: This case and recent literature demonstrate positive outcomes of sacroplasty in terms of pain reduction and improved mobility. Further research is warranted to establish the role of such minimally invasive percutaneous procedures for pain management in cancer patients.

Refinement and revalidation of the demoralization scale: The DS-II-external validity.

BACKGROUND: The recently refined Demoralization Scale-II (DS-II) is a 16-item, self-report measure of demoralization. Its 2 factors-Meaning and Purpose and Distress and Coping Ability-demonstrate sound internal validity, including item fit, unidimensionality, internal consistency, and test-retest reliability. The convergent and discriminant validity of the DS-II with various measures is reported here. METHODS: Patients who had cancer or other progressive diseases and were receiving palliative care (n = 211) completed a battery of questionnaires, including the DS-II and measures of symptom burden, quality of life, depression, and attitudes toward the end of life. Spearman ρ correlations were determined to assess convergent validity. Mann-Whitney U tests with calculated effect sizes were used to examine discriminant validity and establish the minimal clinically important difference (MCID). Cross-tabulation frequencies with chi-square analyses were used to examine discriminant validity with major depression. RESULTS: The DS-II demonstrated convergent validity with measures of psychological distress, quality of life, and attitudes toward the end of life. It also demonstrated discriminant validity, as the DS-II differentiated patients who had different functional performance levels and high/low symptoms, with a difference of 2 points between groups on the DS-II considered clinically meaningful. Furthermore, discriminant validity was demonstrated, as comorbidity with depression was not observed at moderate levels of demoralization. CONCLUSIONS: The DS-II has sound psychometric properties and is an appropriate measure of demoralization. Given its structural simplicity and brevity, it is likely to be a useful tool in meaning-centered therapies. Cancer 2016;122:2260-7. © 2016 American Cancer Society.

Refinement and revalidation of the demoralization scale: The DS-II-internal validity.

BACKGROUND: The Demoralization Scale (DS) was initially validated in 2004 to enable the measurement of demoralization in patients with advanced cancer. Subsequent shortcomings indicated the need for psychometric strengthening. Here, the authors report on the refinement and revalidation of the DS to form the DS-II, specifically reporting the scale's internal validity. METHODS: Patients with cancer or other progressive diseases who were receiving palliative care (n = 211) completed a revised version of the 24-item DS and a measure of symptom burden (the Memorial Symptom Assessment Scale). Exploratory factor analysis and Rasch modeling were used to evaluate, modify, and revalidate the scale, providing information about dimensionality, suitability of response format, item fit, item bias, and item difficulty. Test-retest reliability was examined for 58 symptomatically stable patients at a 5-day follow-up. RESULTS: Exploratory factor analysis supported a 22-item, 2-component model. Separate Rasch modeling of each component resulted in collapsing the response option categories and removing 3 items from each component. Both final 8-item subscales met Rasch model expectations and were appropriate to sum as a 16-item total score. The DS-II demonstrated internal consistency and test-retest reliability (Meaning and Purpose subscale: α = .84; intraclass correlation [ICC] = 0.68; Distress and Coping Ability subscale: α = .82; ICC = 0.82; total DS: α = .89; ICC = 0.80). CONCLUSIONS: The DS-II is a 3-point response, self-report scale comprising 16 items and 2 subscales. Given its revalidation, psychometric strengthening, and simplification, the DS-II is an improved and more practical measure of demoralization for research and clinical use. External validation of the DS-II will be reported subsequently. Cancer 2016;122:2251-9. © 2016 American Cancer Society.

A Randomized Controlled Trial of a Nurse-Led Supportive Care Package (SurvivorCare) for Survivors of Colorectal Cancer.

INTRODUCTION: Colorectal cancer (CRC) and its treatments can cause distressing sequelae. We conducted a multicenter randomized controlled trial aiming to improve psychological distress, supportive care needs (SCNs), and quality of life (QOL) of patients with CRC. The intervention, called SurvivorCare (SC), comprised educational materials, needs assessment, survivorship care plan, end-of-treatment session, and three follow-up telephone calls. METHODS: At the end of treatment for stage I-III CRC, eligible patients were randomized 1:1 to usual care (UC) or to UC plus SC. Distress (Brief Symptom Inventory 18), SCNs (Cancer Survivors' Unmet Needs measure), and QOL (European Organization for Research and Treatment of Cancer [EORTC] QOL questionnaires C30 and EORTC CRC module CR29) were assessed at baseline and at 2 and 6 months (follow-up 1 [FU1] and FU2, respectively). The primary hypothesis was that SC would have a beneficial effect on distress at FU1. The secondary hypotheses were that SC would have a beneficial effect on (a) SCN and QOL at FU1 and on (b) distress, SCNs, and QOL at FU2. A total of 15 items assessed experience of care. RESULTS: Of 221 patients randomly assigned, 4 were ineligible for the study and 1 was lost to FU, leaving 110 in the UC group and 106 in the SC group. Patients' characteristics included the following: median age, 64 years; men, 52%; colon cancer, 56%; rectal cancer, 35%; overlapping sites of disease, 10%; stage I disease, 7%; stage II, 22%; stage III, 71%. Baseline distress and QOL scores were similar to population norms. Between-group differences in distress at FU1 (primary outcome) and at FU2, and SCNs and QOL at FU1 and FU2 were small and nonsignificant. Patients in the SC group were more satisfied with survivorship care than those in the UC group (significant differences on 10 of 15 items). CONCLUSION: The addition of SC to UC did not have a beneficial effect on distress, SCNs, or QOL outcomes, but patients in the SC group were more satisfied with care. IMPLICATIONS FOR PRACTICE: Some survivors of colorectal cancer report distressing effects after completing treatment. Strategies to identify and respond to survivors' issues are needed. In a randomized controlled trial, the addition of a nurse-led supportive care package (SurvivorCare) to usual post-treatment care did not impact survivors' distress, quality of life, or unmet needs. However, patients receiving the SurvivorCare intervention were more satisfied with survivorship care. Factors for consideration in the design of subsequent studies are discussed.

CYP2B6*6 allele and age substantially reduce steady-state ketamine clearance in chronic pain patients: impact on adverse effects.

AIMS: Ketamine analgesia is limited by low intrinsic efficacy compounded by large interindividual variability in drug responses, possibly due to the heterogeneity in drug concentration. The CYP2B6*6 allele is associated with substantially reduced ketamine metabolism in vitro and, therefore, may affect ketamine clearance. Our aims were to examine the impact of the CYP2B6*6 allele on ketamine plasma clearance and on adverse effects in chronic pain patients. METHODS: CYP2B6 genotypes were identified in 49 chronic pain patients who received 24 h continuous subcutaneous infusions of ketamine. Steady-state plasma concentrations of ketamine (Css,k ) and norketamine (Css,nk ) were determined using HPLC. RESULTS: The median plasma clearance of ketamine after 100 mg 24 h(-1) dose was significantly lower in patients with the CYP2B6*6/*6 (21.6 l h(-1) ) and CYP2B6*1/*6 (40.6 l h(-1) ) genotypes compared with patients with the CYP2B6*1/*1 genotype (68.1 l h(-1) , P < 0.001). The ketamine : norketamine plasma metabolic ratio was significantly higher in patients with the CYP2B6*6/*6 genotype than in those with the CYP2B6*1/*6 and the CYP2B6*1/*1 genotypes (P < 0.001). Patients who experienced adverse effects had lower plasma clearance (45.6 l h(-1) ) than those who did not (52.6 l h(-1) , P = 0.04). The CYP2B6*6 genotype and age, and their combined impact explained 40%, 30% and 60% of the variation in Css,k , respectively. Similar results were observed after higher doses. CONCLUSIONS: The CYP2B6*6 allele is associated with a substantial decrease in steady-state ketamine plasma clearance in chronic pain patients. The decreased clearance and resultant higher plasma concentrations may be associated with a higher incidence of ketamine adverse effects.

A model evaluation study for treatment planning of laser-induced thermal therapy.

A cross-validation analysis evaluating computer model prediction accuracy for a priori planning magnetic resonance-guided laser-induced thermal therapy (MRgLITT) procedures in treating focal diseased brain tissue is presented. Two mathematical models are considered. (1) A spectral element discretisation of the transient Pennes bioheat transfer equation is implemented to predict the laser-induced heating in perfused tissue. (2) A closed-form algorithm for predicting the steady-state heat transfer from a linear superposition of analytic point source heating functions is also considered. Prediction accuracy is retrospectively evaluated via leave-one-out cross-validation (LOOCV). Modelling predictions are quantitatively evaluated in terms of a Dice similarity coefficient (DSC) between the simulated thermal dose and thermal dose information contained within N = 22 MR thermometry datasets. During LOOCV analysis, the transient model's DSC mean and median are 0.7323 and 0.8001 respectively, with 15 of 22 DSC values exceeding the success criterion of DSC ≥ 0.7. The steady-state model's DSC mean and median are 0.6431 and 0.6770 respectively, with 10 of 22 passing. A one-sample, one-sided Wilcoxon signed-rank test indicates that the transient finite element method model achieves the prediction success criteria, DSC ≥ 0.7, at a statistically significant level.

Hospital rapid response team and patients with life-limiting illness: a multicentre retrospective cohort study.

BACKGROUND: Approximately one-third of rapid response team consultations involve issues of end-of-life care. We postulate a greater occurrence in patients with a life-limiting illness, in whom the opportunity for advance care planning and palliative care involvement should be offered. AIMS: We aim to review the characteristics and compare outcomes of rapid response team consultations on patients with and without a life-limiting illness. DESIGN/SETTING: A 3-month retrospective cohort study of all rapid response team consultations was conducted. The sample population included all adult inpatients in a major teaching hospital network. RESULTS: We identified 351 patients - including 139 with a life-limiting illness - receiving a total of 456 rapid response team consultations. The median time from admission to the first rapid response team consultation was 3 days. Patients with a life-limiting illness had a significantly higher mortality rate (41.7% vs 13.2%), were older (72.6 vs 63.5 years), more likely to come from a residential aged-care facility (29.5% vs 4.1%) and had a shorter hospital stay (10 vs 13 days). Rapid response team consultations resulted in a change to more palliative goals of care in 28.5% of patients, of whom two-thirds had a life-limiting illness. CONCLUSION: Patients with a life-limiting illness had worse outcomes post-rapid response team consultation. Our findings suggest that a routine clarification of goals of care for this cohort, within 3 days of hospital admission, may be advantageous. These discussions may provide clarity of purpose to treating teams, reduce the burden of unnecessary interventions and promote patient-centred care agreed upon in advance of any deterioration.

Nasogastric tube insertion followed by intravenous and oral erythromycin in refractory nausea and vomiting secondary to paraneoplastic gastroparesis: A case report.

BACKGROUND: Gastroparesis is an under-recognised cause of refractory nausea and vomiting in patients with malignancy. The most common aetiologies are paraneoplastic and postsurgical dysmotility. There are little data on the efficacy of treatment to direct the management of patients with this symptom. We present a case and brief summary of current literature. CASE PRESENTATION: We present the case of a 72-year-old patient with metastatic neuroendocrine carcinoma of the pancreas with dehydration and renal impairment secondary to nausea and vomiting. Replacement of duodenal stent, gastroscopy, endoscopic retrograde cholangiopancreatogram and gastric motility studies revealed gastroparesis rather than mechanical obstruction. CASE MANAGEMENT: The patient was transferred to an inpatient palliative care unit for symptom management where a nasogastric tube was inserted, followed by intravenous erythromycin with excellent improvement in symptoms and oral intake. He was switched to oral erythromycin with ongoing effect. CASE OUTCOME: With stabilisation of symptoms and renal function, the patient was able to be discharged with maintenance of good symptomatic control. CONCLUSIONS: Further research is needed into the management of gastroparesis in palliative care patients. In particular, we suggest that initial drainage with a nasogastric tube followed by a course of erythromycin warrants further study.

Direct radial to ulnar nerve transfer to restore intrinsic muscle function in combined proximal median and ulnar nerve injury: case report and surgical technique.

A distal median to ulnar nerve transfer for timely restoration of critical intrinsic muscle function is possible in isolated ulnar nerve injuries but not for combined ulnar and median nerve injuries. We used a distal nerve transfer to restore ulnar intrinsic function in the case of a proximal combined median and ulnar nerve injury. Transfer of the nonessential radial nerve branches to the abductor pollicis longus, extensor pollicis brevis, and extensor indicis proprius to the motor branch of the ulnar nerve was performed in a direct end-to-end fashion via an interosseous tunnel. This method safely and effectively restored intrinsic function before terminal muscle degeneration.

The Influence of Advanced Hyperbaric Medical Training on Arterial Gas Embolism Treatment.

3d Reconnaissance Battalion, a forward-deployed Marine Corps unit in Okinawa, Japan, frequently performs diving operations. Often throughout the year, several reconnaissance teams are diving simultaneously in different locations for training. We present a case of an otherwise healthy 30-year-old-male Reconnaissance Marine who surfaced from a dive with abnormal symptoms and received prompt care from exercise participants who were nonmedical personnel. Studies have demonstrated improved morbidity outcomes in decompression illness patients with shorter times to hyperbaric treatment following the onset of symptoms. High-risk military exercises with diving components have a mandatory safety structure that includes recompression chamber support. All United States Marine Corps Reconnaissance, Marine Corps Special Operations Command, and U.S. Navy dive operations are required to have at least one diving supervisor. To expand the diving capabilities of the unit, Marines are encouraged to attend training and qualify as diving supervisors. This case study demonstrates the efficacy and importance of training Recon Marines to recognize decompression illness as diving supervisors.

Educational and Clinical Outcome Measures in an Integrated Hand Service.

Background: We recently sought to integrate our orthopaedic and plastic hand surgeons with the goal of improving education, patient care, and providing seamless, continuous coverage for our trauma center. Our hypothesis was that integration could serve both the orthopaedic and plastic surgery training programs well and provide more consistent care for the trauma patients. Materials and Methods: Program director approval was granted for blinded analysis of case logs from plastic and orthopaedic surgery programs from 2012 through 2019. Data on mean and total number of hand cases were analyzed and compared for both specialties. Institutional Review Board approval was granted for a retrospective review of patient outcomes. Results: For both orthopaedic and plastics resident trainees, the mean number of hand cases increased during this study period suggesting that the integration had a favorable impact on both programs. The mean number of hand cases for orthopaedic residents rose from 163 to 246. The mean number of hand cases for plastic surgery residents rose from 218 to 295. Patient outcomes as reflected in length of stay and time to consultation also improved. Conclusion: To improve hand surgical training and patient care, an integrated orthoplastics approach to hand surgery was implemented at our institution. Plastic surgery trainees are completing more hand surgery cases in an integrated model (p < 0.001), including fracture care (p < 0.047). Orthopaedic surgery trainees have doubled the percentage of integumentary and microsurgery cases in the integrated model (p < 0.001). The educational and clinical changes affected in an integrated model have changed the paradigm for educating future hand surgeons at our institution.

Flat patch mesh versus three-dimensional mesh (plug) for open umbilical or epigastric hernia repair. A retrospective study.

INTRODUCTION: Hernia repair using prosthetic mesh materials has become the preferred method of repair, as the recurrence rates are much lower than with conventional repair techniques. The aim of this retrospective study was to compare open small- and medium-sized abdominal wall hernia repair with flat patch mesh versus three-dimensional mesh (plug) in terms of recurrence and complication rates. METHODS: The medical records of 300 patients who underwent abdominal wall hernia repair using flat patch mesh versus three-dimensional mesh between January 2010 to December 2015 were reviewed. All patients were followed up after 1 month, 3 month and 1 year. The rate of recurrence, and short-term postoperative complications such as incidence of Surgical Site Infections (SSIs), hematoma and seroma were evaluated. RESULTS: Short-term follow-up data were available for all patients. The first group was composed of 150 patients that were treated with a flat polypropylene mesh (68% presened umbilical hernia and 32% presented epigastric hernia). The second group was composed of 150 patients that were treated with a three-dimensional polypropylene mesh (60% presented umbilical hernia and 40% presented epigastric hernia). The majority of postoperative (1-month) complications were wound related, representing superficial SSI or seroma. Our results showed a statistically significant reduction of SSIs [3 (2%) vs 13 (8.6%); p = 0.038] and seroma [2 (1.3%) vs 12 (8%); p = 0.030] in the group of patients treated with plugs compared to flat-mesh group. There was no statistically significant difference in hernia recurrences. DISCUSSION: Usage three-dimensional mesh for open small- and medium-sized umbilical or epigastric hernia repair represents a feasible and safe technique that significantly lowers the incidence of complications such as SSIs and seroma. Furthermore, compared to flat patch mesh, plugs displayed non-inferiority in terms recurrence. Further, well-designed clinical trials could be realized to investigate possible applications of plugs in treatment of small- and medium-sized umbilical and epigastric hernias. KEY WORDS: Mesh, Umbilical Hernia.