A 15-year review of characteristics and outcomes of patients leaving against medical advice.

PURPOSE: Discharging against medical advice can have significant, detrimental effects on burn patient outcomes as well as higher hospital readmission rates and healthcare expenditures. The goal of this study is to identify characteristics of patients who left against medical advice and suggest solutions to mitigate these factors. Data were collected at our American Burn Association verified Burn Unit over a 15-year period. RESULTS: Between 2007 and 2022, 37 patients were identified as having left against medical advice from the burn unit. The average patient age was 37 years old with 64.9% being male, and 70.2% were identified as having a substance abuse history. The majority (51.4%) had Medicaid or State health insurance, 29.7% had no insurance, and 18.9% had private insurance. The mechanism of injury was most commonly frostbite (43.2%). The majority sustained < 1% total body surface area injuries. Most (83.7%) had social work and/or case management involved during their admission, and all (100%) had their involvement if the length of admission was greater than one day. Over half (59.5%) returned to the ED within 2 weeks with complications. CONCLUSIONS: This study found that patients discharging against medical advice from the burn unit suffered from smaller injuries, often due to cold related injuries. These patients had comorbid substance abuse or psychiatric histories, and the majority had Medicaid or state health insurance. Recruiting interdisciplinary care members, including social work, psychiatry, and addiction medicine, early may help these patients by encouraging completion of their hospital care and setting up crucial follow-up care.

A 10-Year Retrospective Review of Playground-Associated Craniofacial Injuries in the Pediatric Patient Population.

This retrospective study utilized the National Electronic Injury Surveillance System (NEISS) database to identify pediatric emergency department (ED) patients with playground-associated craniofacial injuries between January 2012 and December 2021. A total of 25 414 patients were identified. The majority of injuries occurred in preschool and elementary school-age children (90.3%) and patients were more commonly boys (59.3%). Injuries most often involved the head/scalp (52.4%), face (30.4%), and mouth (11.9%). Infant (32.7%) and teen (40.0%) injuries most commonly involved swings, whereas preschool (23.1%) and elementary school (28.1%) injuries were mostly associated with slides and climbers, respectively. Most patients were treated in the ED and discharged to home (96.5%), a small portion required hospitalization (1.6%), and one death was reported. Although the majority of the injuries were relatively minor and resulted in same-day discharges, these injuries can result in serious physical harm, emotional stress, and unexpected financial burdens. Proper education and supervision regarding safe play is important to prevent these injuries.

Availability and Readability Level of Online Patient Education Materials Provided by Cleft Lip and Palate Teams.

OBJECTIVES: Evaluate the readability of online English and Spanish cleft lip and palate patient education materials. DESIGN: Review of free online materials. SETTING: English and Spanish language online patient education materials on cleft lip and palate were collected from American Cleft Palate-Craniofacial Association (ACPA) approved teams. PARTICIPANTS: American Cleft Palate-Craniofacial Association (ACPA) approved teams. INTERVENTIONS: English materials were analyzed using the Flesch-Kincaid, SMOG, and Coleman-Liau readability calculators. Spanish materials were analyzed using the Fry Graph, Fernandez Huerta, and INFLESZ calculators. A one-way analysis of variance (ANOVA) was used to test for variability between the readability tools. OUTCOMES: Readability levels were examined for both sets of materials. RESULTS: 171 (90.5%) teams provided English language materials online, with an average readability score calculated as 10.5 ± 2.9 (10th-11th grade). A total of 44 (23.2%) teams listed Spanish language materials online, with average readability score of 7.9 ± 1.2 (8th grade). ANOVA demonstrated statistically significant variability between the readability assessment tools (P < .01). CONCLUSION: Online cleft lip and palate patient education material provided by ACPA craniofacial teams were more available in English than in Spanish. Both sets of materials demonstrated readability levels above the recommended 6th-7th grade. Refining readability is associated with lowered healthcare costs and increased patient satisfaction.

Readability Analysis of Online Breast Cancer Surgery Patient Education Materials from National Cancer Institute-Designated Cancer Centers Compared with Top Internet Search Results.

BACKGROUND: The National Institutes of Health (NIH) recommends patient education materials reflect the average reading grade level of the US population. Due to the importance of shared decision-making in breast cancer surgery, this study evaluates the reading level of patient education materials from National Cancer Institute-designated cancer centers (NCI-DCC) compared with top Internet search results. METHODS: Online materials from NCI-DCC and top Internet search results on breast cancer, staging, surgical options, and pre- and postoperative expectations were analyzed using three validated readability algorithms: Simplified Measure of Gobbledygook Readability Formula, Coleman-Liau index, and Flesch-Kincaid grade level. Mean readability was compared across source groups and information subcategories using an unpaired t-test with statistical significance set at p < 0.05. Mean readability was compared using a one-way analysis of variance. RESULTS: Mean readability scores from NCI-DCC and Internet groups ranged from a 9th-12th grade level, significantly above the NIH recommended reading level of 6th-7th grade. There was no significant difference between reading levels from the two sources. The discrepancy between actual and recommended reading level was most pronounced for "surgical options" at a 10th-12th grade level from both sources. CONCLUSIONS: Patient education materials on breast cancer from both NCI-DCC and top Internet search results were written several reading grade levels higher than the NIH recommendation. Materials should be revised to enhance patient comprehension of breast cancer surgical treatment and guide patients in this important decision-making process to ultimately improve health outcomes.

Pyridine based dual binding site aromatase (CYP19A1) inhibitors.

Aromatase (CYP19A1) inhibitors are the mainstay therapeutics for the treatment of hormone dependant breast cancer, which accounts for approximately 70% of all breast cancer cases. However, increased resistance to the clinically used aromatase inhibitors, including letrozole and anastrazole, and off target effects, necessitates the development of aromatase inhibitors with improved drug profiles. The development of extended 4th generation pyridine based aromatase inhibitors with dual binding (haem and access channel) is therefore of interest and here we describe the design, synthesis and computational studies. Cytotoxicity and selectivity studies identified the pyridine derivative (4-bromophenyl)(6-(but-2-yn-1-yloxy)benzofuran-2-yl)(pyridin-3-yl)methanol (10c) as optimal with CYP19A1 IC50 0.83 nM (c.f. letrozole IC50 0.70 nM), and an excellent cytotoxicity and selectivity profile. Interestingly, computational studies for the 6-O-butynyloxy (10) and 6-O-pentynyloxy (11) derivatives identified an alternative access channel lined by Phe221, Trp224, Gln225 and Leu477, providing further insight into the potential binding mode and interactions of the non-steroidal aromatase inhibitors.

A Comprehensive Assessment of Cleft Lip and Palate Websites and Patient Education Information.

OBJECTIVE: The objective of this study is to evaluate online educational resources on cleft lip and palate teams. DESIGN: A Cross-Sectional Study. SETTING: An International, Multi-Institutional Study. PARTICIPANTS: All American Cleft Palate and Craniofacial Association-approved teams with websites. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Websites were assessed for patient education and support content. Affiliation between presence of materials and U.S. Newsweek Top 100 Hospitals was also assessed. RESULTS: 187 teams were included. Presence of educational videos were available in 29.4% of websites, educational infographics in 18.2%, written materials in 66.8%, perioperative instructions in 19.3%, diagnosis information in 34.8% and treatment information in 63.1%. Information on team members were available on 77.0% of websites, resources in languages other than English in 38.5%, and support group resources in 25.7%. Cleft lip and palate diagnosis information was significantly associated with geographic region, with the largest impact from the West region (P = .03). There was a significant difference between teams affiliated with U.S. Newsweek Top 100 hospitals: Top 100 hospitals had a higher presence of educational infographics, perioperative instructions, definitions, diagnosis, and treatment (P < .01). There was no significant difference between presence of educational videos (P = .37). CONCLUSION: While many websites had basic educational materials, very few included detailed information on peri-operative planning, as well as additional forms of information including videos, infographics, and non-English languages. Providing comprehensive patient education materials online is an important supplement for patients with cleft lip and palate and should be prioritized by cleft teams.

One Size Does Not Fit All; Patient Preference for Breast Reconstruction.

Background: A myriad of patient education modalities for breast reconstruction exist, although the optimal tools for patient education remain undetermined. The aim of this study is to determine patient preferences for breast reconstruction education modalities based on demographic variables. Methods: A prospective observational study at a tertiary care university health system was conducted between November 2020 and May 2021. A questionnaire was administered to breast reconstruction patients to collect information on demographics, research sources used before the initial appointment, and preferred education modalities. Differences based on age were analyzed using an independent samples t test, whereas a Fisher exact test was used to analyze differences based on ethnicity and education level. Statistical significance was defined as P < .05. Results: The most preferred patient education tools overall were books/written materials and videos. Younger patients were significantly more likely than older patients to have referenced additional physician sources (P = .0174) and to seek out information on the institution's website (P = .0465). Those with a college degree were significantly more likely to have performed research prior to the initial appointment (P = .0206). White patients were significantly more likely than nonwhite patients to talk to friends/family as a research source (P = .0150). Conclusions: Regardless of age, education, or ethnicity, most patients prefer books/written materials and video presentations for education on breast reconstruction. Providers should strive to include written and video options to meet the needs of this diverse patient population.

4th generation nonsteroidal aromatase inhibitors: An iterative SAR-guided design, synthesis, and biological evaluation towards picomolar dual binding inhibitors.

One in every eight women will be diagnosed with breast cancer during their lifetime and approximately 70% of all patients are oestrogen receptor (ER) positive depending upon oestrogen for their growth accounting for third generation aromatase (CYP19A1) inhibitors being the mainstay in the treatment of ER-positive breast cancer. Despite the success of current aromatase inhibitors, acquired resistance occurs after prolonged therapy. Although the precise mechanisms of resistance are not known, lack of cross resistance among aromatase inhibitors drives the need for a newer generation of inhibitors to overcome this resistance alongside minimising toxicity and adverse effects. Novel triazole-based inhibitors were designed based on previously published parent compound 5a, making use of the now available crystal structure of CYP19A1 (PDB 3S79), to make modifications at specific sites to explore the potential of dual binding at both the active site and the access channel. Modifications included adding long chain substituents e.g. but-2-ynyloxy and pent-2-ynyloxy at different positions including the most active compound 13h with IC50 value in the low picomolar range (0.09 nM). Aromatase inhibition results paired with molecular dynamics studies provided a clear structure activity relationship and favourable dual binding mode was verified. Toxicity assays and CYP selectivity profile studies for some example compounds were performed to assess the safety profile of the prepared inhibitors providing the basis for the 4th generation nonsteroidal aromatase inhibitors.

Assessing Use of Gender Diverse Language in Patient Education Materials on Breast Reconstruction.

Utilizing inclusive terminology in patient education materials is an increasing area of focus in plastic surgery. Over 300,000 cases of breast cancer were diagnosed in 2020, affecting cisgender and gender diverse patients alike. Both cisgender and gender diverse patients may choose to undergo breast reconstruction. This study aims to assess the use of inclusive language in online patient education materials on reconstruction after breast cancer. Methods: Materials were collected from all academic hospitals with a plastic surgery integrated and/or independent residency program, 97 in total. Programs were further classified by the presence of a comprehensive gender program. Materials were analyzed for gender diverse terminology outlined by the National LGBTQIA+ Health Education Center. A chi-square test evaluated for statistical significance of inclusive terminology based on the presence or absence of a comprehensive gender program. Results: The majority (75%) of programs referenced cis women alone, with 25% referring to both men and women or using gender neutral terms such as "patients." Although most (85%) programs wrote in second person ("you"), 15% used she/her/hers pronouns alone, and no programs utilized gender diverse language outlined by the National LGBTQIA+ Health Education Center. The presence or absence of a comprehensive gender program was not predictive of the use of inclusive terminology (P = 0.32). Conclusions: This study found that only 25% of breast reconstruction materials contained inclusive gender terminology. Plastic surgeons should provide patient education materials with language that supports members of a gender diverse population to facilitate a safe, inclusive space and conversation.

It's not all White: Implicit Racial Bias in Imagery Used in Plastic Surgery Resident Education.

OBJECTIVE: Plastic surgery education relies heavily on images featuring patient skin tone; while images can be useful representations, it is highly susceptible to implicit bias, a known contributor to healthcare disparities. Using skin tone as a proxy, this study evaluates patient representation in images used in the American Society of Plastic Surgery Resident Education Curriculum. DESIGN: Color photographs, graphics, and videos featured in the American Society of Plastic Surgery "Course Materials" for each module were categorized using the Fitzpatrick scale (I-II, III-IV, or V-VI) by six reviewers. Proportional data and average number ± standard deviation of photos and graphics for each category were reported. Significant difference between Fitzpatrick I to II and V to VI was investigated via a one-way analysis of variance with a Tukey's post-test to adjust for multiple comparisons. RESULTS: An average of 1861 photographs and 237 graphics were assessed with 82% (1518 ± 25.11) of photos and 97% (231 ± 24.45) of graphics categorized as Fitzpatrick I to II. A one-way analysis of variance with a Tukey's post-test demonstrates a statistical difference between images and graphics categorized as Fitzpatrick I to II and Fitzpatrick V to VI (p < 0.001). CONCLUSIONS: Our data reveals an opportunity to improve racial representation in resident education. When 76% of patients in the United States are white and 13% are Black, our findings demonstrate both an unequal and unrepresentative distribution of photos and graphics of non-white patients. Residency is a formative time in a surgeon's career and therefore, exposure to accurate representation of a diverse patient population is of the utmost importance.

Utilizing a Comprehensive Wound Care Team to Lower Hospital-Acquired Pressure Injuries in an Academic Public Hospital: A Retrospective Cohort Study.

PURPOSE: Hospital-acquired pressure injuries (HAPIs) have significant impacts on patient morbidity and mortality, with approximately 2.5 million patients treated for pressure-related injuries annually.1 This study aimed to describe the influence of a comprehensive wound care team on HAPIs over an 8-year period. DESIGN: Retrospective cohort study. SUBJECTS AND SETTING: All inpatients at an academic public hospital system with HAPIs during the study period from May 2012 to February 2020. METHODS: Data on wound stage, location, infection, medical device location if applicable, and risk factors were recorded from medical records. A 1-way analysis of variance was performed to assess for significance of mean number of cases, National Pressure Injury Advisory Panel (NPIAP) stage on initial presentation, and mean number of medical device-related wounds by year. RESULTS: A total of 957 cases were included. The median stage of pressure injury on assessment was 2, with the mean NPIAP stage declining from 2012 to 2020 (P = .003). Thirty-three percent of pressure injuries were attributed to medical devices, most commonly endotracheal tubing. The most common site of pressure injury was the sacrum (33.6%). CONCLUSION: Creation of a comprehensive wound care team within our academic public hospital system demonstrated a significant decline in device-related and pressure injury cases over the past 8 years. The wound care team focused on frequent assessment, education, and evidence-based treatment to lower these HAPI events.

Breast Implants: A Historical Review With Implications for Diagnosis and Modern Surgical Planning.

ABSTRACT: Modern breast surgery was first introduced in the United States in 1962 with the use of silicone gel-filled breast implants. Over the past 6 decades, development of breast implants has been challenged by a variety of influencers including aesthetic appeal in shape, texture, and material; challenges in managing outcomes such as contracture, disease, and rupture; and public perception of risks associated with implants. In 1992, silicone breast prostheses were banned by the US Food and Drug Administration with exception for use in breast reconstruction, congenital deformities, or to replace existing implants.The ban led to heightened concerns about implants and possible disease manifestations. Knowledge of the historical evolution of breast prostheses is useful for understanding the associated risks and outcomes unique to each breast implant era. This article aimed to explore characteristics of breast implants by generation, with implications for diagnosis and assistance to modern surgical planning for novice plastic surgeons.

Analysis of Pediatric Dog Bite Injuries at a Level 1 Trauma Center Over 10 Years.

BACKGROUND: Dog bite injuries cause significant preventable patient morbidity and health care expenditure in children. This study aimed to characterize the patient and healthcare burden related to pediatric dog bite injuries at a level 1 trauma center. METHODS: This is a retrospective review of 356 pediatric patients who presented to Virginia Commonwealth University Pediatric Emergency Department between July 2007 and August 2017 after sustaining dog bite injuries. Demographic information, injury details, management, outcomes, and financial information were analyzed. RESULTS: Most pediatric dog bite injuries afflicted male children (55.6%), ages 6 to 12 years (45.7%), by a household dog (36.2%). The most common offending breed was a pit bull or pit bull mix (53.0%). Infants and grade schoolers were more likely to sustain bites to the head/face (P = 0.001). Usual management consisted of primary repair (75.9%), whereas approximately 25% of the patients required advanced reconstructive techniques. Most patients healed uneventfully, but prolonged antibiotics, additional wound care, or procedures were necessary in 8.4% of the patients. Hospital charges per patient averaged US $8830.70 and tended to be higher in the younger age groups. Insurance status was statistically associated with use of conscious sedation, surgical consult placement, and surgical repair. CONCLUSIONS: Although most pediatric dog bite injuries in this study healed uneventfully from primary management in the emergency department, 25% required additional interventions. Furthermore, patient care for these injuries was associated with significant but potentially avoidable personal and financial burden to families. Our data reflect a need for safety education on animal care, behavior, and interaction.

A 15-Year Review of Iatrogenic Burn Injuries in an Academic Public Hospital.

Hospital-acquired burn injuries can result in increased length of hospitalization, costs of stay, and potential for additional procedures. The aim of this study is to describe iatrogenic burn injuries over a 15-year period at an academic public hospital system. Data was collected from January 2004 to June 2019. Data included time of injury, hospital location, mechanism, level of harm caused, and anatomic location of the injury. Demographic information included patient age, gender, body mass index, payer status, primary admission diagnosis and length of stay. 122 patients were identified through an internal hospital database that tracked reported injuries. Incidence was highest between 2005-2012 (12.3 ± 4.1 per year) as compared to 2013-2019 (2.9 ± 2.1 per year). A majority (77%) resulted in harm caused to the patient. Most (41%) of the injuries occurred on the general medical floors, followed by the operating room (33.6%). The most common etiology was scald (23%), followed by electrocautery (14.8%). Five of the injuries resulted in burn consults, although none of these patients required surgery. Iatrogenic burns appear to be decreasing. While a majority were reported to have caused patient harm, none were serious enough to warrant surgery. Most injuries occurred on the medical floors with a scald mechanism. This review presents an opportunity to emphasize in-hospital burn prevention, as well as an opportunity for the burn team to affect change in concert with hospital administration.

Protein disulphide isomerase inhibition as a potential cancer therapeutic strategy.

The protein disulphide isomerase (PDI) gene family is a large, diverse group of enzymes recognised for their roles in disulphide bond formation within the endoplasmic reticulum (ER). PDI therefore plays an important role in ER proteostasis, however, it also shows involvement in ER stress, a characteristic recognised in multiple disease states, including cancer. While the exact mechanisms by which PDI contributes to tumorigenesis are still not fully understood, PDI exhibits clear involvement in the unfolded protein response (UPR) pathway. The UPR acts to alleviate ER stress through the activation of ER chaperones, such as PDI, which act to refold misfolded proteins, promoting cell survival. PDI also acts as an upstream regulator of the UPR pathway, through redox regulation of UPR stress receptors. This demonstrates the pro-protective roles of PDI and highlights PDI as a potential therapeutic target for cancer treatment. Recent research has explored the use of PDI inhibitors with PACMA 31 in particular, demonstrating promising anti-cancer effects in ovarian cancer. This review discusses the properties and functions of PDI family members and focuses on their potential as a therapeutic target for cancer treatment.

Assessing Readability of Patient Education Materials on Breast Reconstruction by Major US Academic Hospitals as Compared With Nonacademic Sites.

PURPOSE: Women undergoing postmastectomy breast reconstruction face many complex choices. A myriad of online patient education materials exist to assist in decision making. Understanding of these materials, termed health literacy, affects surgical decision making and outcomes. The National Institutes of Health recommends writing patient education materials at a sixth- to seventh-grade reading level. The primary goal of this study was to assess readability of online breast reconstruction materials. METHODS AND MATERIALS: Resources were collected from every academic hospital with a plastic surgery residency program, 97 in total. These data were compared with the top nonacademic Web sites ranked by search engine results, 14 in total. Materials were analyzed using 3 validated readability assessment scales: Coleman-Liau Index, SMOG (Simplified Measure of Gobbledygook) Readability Formula, and Flesch-Kincaid Grade Level. Average readability was analyzed, and results were compared using a 1-way analysis of variance to assess for significance between the different tools and a 2-sided t test to assess for significance between academic and nonacademic readability results. RESULTS: The mean readability scores across the academic programs were a Coleman-Liau Index of 13.38 (standard Deviation [SD] 2.81, 13th to 14th grade), Flesch-Kincaid Grade Level of 13.04 (SD = 3.9, 13th grade), and SMOG Readability of 13.64 (SD = 2.99, 13th to 14th grade). For the 14 nonacademic sites, results showed a Coleman-Liau Index of 11.93 (SD = 1.14, 12th grade), Flesch-Kincaid of 11.82 (SD = 2.33, 11th to 12th grade), and SMOG Readability of 10.91 (SD = 1.79, 11th grade). One-way analysis of variance demonstrated no significant differences in mean readability scores across the 3 readability tools used (academic F = 2.7804, P = 0.06; nonacademic F = 1.14, P = 0.33). Two-tailed t test results demonstrated that there was statistical significance between readability of the academic in comparison with nonacademic search engine results (t = 2.04, P = 0.04). CONCLUSIONS: Average readability across all Web sites were much higher than the recommended reading level, at a 13th to 14th grade reading level for academic institutions, and an 11th to 12th grade for nonacademic Web sites. Plastic surgeons may contribute to improving patient understanding and perioperative outcomes through revising patient education materials.