Digital twin mathematical models suggest individualized hemorrhagic shock resuscitation strategies.

BACKGROUND: Optimizing resuscitation to reduce inflammation and organ dysfunction following human trauma-associated hemorrhagic shock is a major clinical hurdle. This is limited by the short duration of pre-clinical studies and the sparsity of early data in the clinical setting. METHODS: We sought to bridge this gap by linking preclinical data in a porcine model with clinical data from patients from the Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) study via a three-compartment ordinary differential equation model of inflammation and coagulation. RESULTS: The mathematical model accurately predicts physiologic, inflammatory, and laboratory measures in both the porcine model and patients, as well as the outcome and time of death in the PROMMTT cohort. Model simulation suggests that resuscitation with plasma and red blood cells outperformed resuscitation with crystalloid or plasma alone, and that earlier plasma resuscitation reduced injury severity and increased survival time. CONCLUSIONS: This workflow may serve as a translational bridge from pre-clinical to clinical studies in trauma-associated hemorrhagic shock and other complex disease settings.

Research to improve survival in patients with severe bleeding after major trauma presents many challenges. Here, we created a computer model to simulate the effects of severe bleeding. We refined this model using data from existing animal studies to ensure our simulations were accurate. We also used patient data to further refine the simulations to accurately predict which patients would live and which would not. We studied the effects of different treatment protocols on these simulated patients and show that treatment with plasma (the fluid portion of blood that helps form blood clots) and red blood cells jointly, gave better results than treatment with intravenous fluid or plasma alone. Early treatment with plasma reduced injury severity and increased survival time. This modelling approach may improve our ability to evaluate new treatments for trauma-associated bleeding and other acute conditions.

Bicuspid valve CT registry of balloon-expandable TAVR: BETTER TAVR registry.

BACKGROUND: The anatomic substrate of bicuspid valves may lead to suboptimal TAVR stent expansion and geometry. AIM: We evaluated determinants of stent geometry in bicuspid valves treated with Sapien transcatheter aortic valve replacement (TAVR) valves. METHODS: A multicenter retrospective registry of patients (February 2019 to August 2022) who underwent post-TAVR computed tomography to determine stent area (vs. nominal valve area) and stent ellipticity (maximum diameter/minimum diameter). Predictors of relative stent expansion (minimum area/average of inflow + outflow area) and stent ellipticity were evaluated in a multivariable regression model, including valve calcium volume (indexed by annular area), presence of raphe calcium, sinus diameters indexed by area-derived annular diameter, and performance of pre-dilation and post-dilation. RESULTS: The registry enrolled 101 patients from four centers. The minimum stent area (vs. nominal area) was 88.1%, and the maximum ellipticity was 1.10, with both observed near the midframe of the valve in all cases. Relative stent expansion ≥90% was observed in 64/101 patients. The only significant predictor of relative stent expansion ≥90% was the performance of post-dilation (OR: 4.79, p = 0.018). Relative stent expansion ≥90% was seen in 86% of patients with post-dilation compared to 57% without (p < 0.001). The stent ellipticity ≥1.1 was observed in 47/101 patients. The significant predictors of stent ellipticity ≥1.1 were the indexed maximum sinus diameter (OR: 0.582, p = 0.021) and indexed intercommisural diameter at 4 mm (OR: 2.42, p = 0.001). Stent expansion has a weak negative correlation with post-TAVR mean gradient (r = -0.324, p < 0.001). CONCLUSION: Relative stent expansion ≥90% was associated with the performance of post-dilation, and stent ellipticity ≥1.1 was associated with indexed intercommisural diameter and indexed maximum sinus diameter. Further studies to determine optimal deployment strategies in bicuspid valves are needed.

Comparison of Long-Term Healthcare Cost and Utilisation of Nonoperative and Surgical Management of Thumb CMC Arthritis.

Background: Thumb carpometacarpal joint (CMC) osteoarthritis is the most symptomatic hand arthritis but the long-term healthcare burden for managing this condition is unknown. We sought to compare total healthcare cost and utilisation for operative and nonoperative treatments of thumb CMC arthritis. Methods: We conducted a retrospective longitudinal analysis using a large nationwide insurance claims database. A total of 18,705 patients underwent CMC arthroplasty (trapeziectomy with or without ligament reconstruction tendon interposition) or steroid injections between 1 October 2015 and 31 December 2018. Primary outcomes, healthcare utilisation and costs were measured from 1 year pre-intervention to 3 years post-intervention. Generalised linear mixed effect models adjusted for potentially confounding factors such as the Elixhauser comorbidity score with propensity score matching were applied to evaluate the association between the primary outcomes and treatment type. Results: A total of 13,646 patients underwent treatment through steroid injections, and 5,059 patients underwent CMC arthroplasty. At 1 year preoperatively, the surgery group required $635 more healthcare costs (95% CI [594.28, 675.27]; p < 0.001) and consumed 42% more healthcare utilisation (95% CI [1.38, 1.46]; p < 0.0001) than the steroid injection group. At 3 years postoperatively, the surgery group required $846 less healthcare costs (95% CI [-883.07, -808.51], p < 0.0001) and had 51% less utilisation (95% CI [0.49, 0.53]; p < 0.0001) annually. Cumulatively over 3 years, the surgical group on average was $4,204 costlier than its counterpart secondary to surgical costs. Conclusions: CMC arthritis treatment incurs high healthcare cost and utilisation independent of other medical comorbidities. At 3 years postoperatively, the annual healthcare cost and utilisation for surgical patients were less than those for patients who underwent conservative management, but this difference was insufficient to offset the initial surgical cost. Level of Evidence: Level III (Therapeutic).

Cultivating a "Feminine" Surgical Culture: Lessons from Indonesia.

BACKGROUND: Despite a growing number of female physicians, most practicing surgeons in the U.S. are still men. By contrast, Indonesia has achieved notable gender parity among surgeons, with the number of women practicing as plastic surgeons projected to soon surpass men. Achieving more female representation in plastic surgery is important for delivering high-quality care, especially in the face of physician shortages and high burnout. METHODS: This survey study was conducted at the 26th Annual Scientific Meeting of the Indonesian Association of Plastic Reconstructive and Aesthetic Surgeons (InaPRAS) in Manado, Indonesia, during August 2023. Respondents were asked about their perceptions of plastic surgery, mentorship, career motivations, and caregiving responsibilities. Responses were scored using a 3-point Likert scale of agreement to statements (Disagree, Neutral, Agree); χ2 and Fischer's exact test were performed to assess differences in responses by gender. RESULTS: In this validated survey of 175 plastic surgeon trainees and attendings, there were no significant difference between genders in the perception and roles of mentorship in preparing for a career in plastic surgery. Respondents for both genders espoused optimistic views on work-life balance items, including time for family and friends and flexibility of work schedules. CONCLUSION: Indonesia can serve as a model for encouraging greater gender parity in plastic surgery. Community-level interventions such as family leave policies, childcare provisions, and initiatives to promote an inclusive culture will create a more supportive workplace to increase women's representation in plastic surgery in the United States and around the world.

P-Value Reporting and Reliability in Plastic and Reconstructive Surgery: A Primer for Readers and Investigators.

The p-value is ubiquitous in research. However, misuse and misinterpretation are common. This special topics article aims to demystify the p-value for researchers, students, physicians, and experienced investigators alike. To accomplish this aim, the origins of the p-value, what they represent, and principles of application are described through use of examples from real datasets. Developing understanding of the true meaning of this statistical measure has the power to improve and inform clinical research.

Increasing Eligibility to Transplant Through the Selective Cytopheretic Device: A Review of Case Reports Across Multiple Clinical Conditions.

A stable, minimum physiological health status is required for patients to qualify for transplant or artificial organ support eligibility to ensure the recipient has enough reserve to survive the perioperative transplant period. Herein, we present a novel strategy to stabilize and improve patient clinical status through extracorporeal immunomodulation of systemic hyperinflammation with impact on multiple organ systems to increase eligibility and feasibility for transplant/device implantation. This involves treatment with the selective cytopheretic device (SCD), a cell-directed extracorporeal therapy shown to adhere and immunomodulate activated neutrophils and monocytes toward resolution of systemic inflammation. In this overview, we describe a case series of successful transition of pediatric and adult patients with multiorgan failure to successful transplant/device implantation procedures by treatment with the SCD in the following clinical situations: pediatric hemophagocytic lymphohistiocytosis, and adult hepatorenal and cardiorenal syndromes. Application of the SCD in these cases may represent a novel paradigm in increasing clinical eligibility of patients to successful transplant outcomes.

Carpal tunnel syndrome.

Carpal tunnel syndrome (CTS) is the most common nerve entrapment disorder worldwide. The epidemiology and risk factors, including family burden, for developing CTS are multi-factorial. Despite much research, its intricate pathophysiological mechanism(s) are not fully understood. An underlying subclinical neuropathy may indicate an increased susceptibility to developing CTS. Although surgery is often performed for CTS, clear international guidelines to indicate when to perform non-surgical or surgical treatment, based on stage and severity of CTS, remain to be elucidated. Neurophysiological examination, using electrophysiology or ultrasonography, performed in certain circumstances, should correlate with the history and findings in clinical examination of the person with CTS. History and clinical examination are particularly relevant globally owing to lack of other equipment. Various instruments are used to assess CTS and treatment outcomes as well as the effect of the disorder on quality of life. The surgical treatment options of CTS - open or endoscopic - offer an effective solution to mitigate functional impairments and pain. However, there are risks of post-operative persistent or recurrent symptoms, requiring meticulous diagnostic re-evaluation before any additional surgery. Health-care professionals should have increased awareness about CTS and all its implications. Future considerations of CTS include use of linked national registries to understand risk factors, explore possible screening methods, and evaluate diagnosis and treatment with a broader perspective beyond surgery, including psychological well-being.

An assessment tool for the international healthy eating report card for preschool-aged children: a cross-cultural validation across Australia, Hong Kong, Singapore, and the United States.

Objective: This study aimed to develop and validate a globally applicable assessment tool of the 43-item International Healthy Eating Report Card Scale (IHERCS) which was designed to assess preschool-aged children's eating behaviours and family home food environments (FHFEs) across different cultural settings. In particular, we examined the factor structure, internal consistency and measurement invariance of the IHERCS across four cultural samples, including Australia, Hong Kong, Singapore, and the US. Convergent and discriminant validity were then conducted. Methods: In this cross-cultural study, a total of 2059 parent-child dyads from these four regions were recruited, and the parents were asked to complete the IHERCS. An exploratory structural equational modelling approach was employed to examine two higher-order factor models of children's eating behaviours and FHFEs in the IHERCS and its cross-cultural measurement invariance. Results: The findings demonstrated robust factor structures of the scales of children's eating behaviours and FHFEs in the IHERCS (i.e., CFI and TLI > 0.90; RMSEA and SRMR < 0.08) and an acceptable level of internal consistency (i.e., Cronbach's α = 0.55-0.84). Full configural invariance and metric invariance were established across the four cultural contexts, but full scalar invariance was not achieved. Partial scalar invariance was found only in the scale of FHFEs. The convergent validity and discriminant validity were supported. Conclusion: Overall, the current findings provided preliminary support for the construct validity and measurement invariance of the IHERCS. It provides a reliable, valid and comprehensive assessment of eating behaviours and FHFEs among children in different cultural settings.

The effectiveness of a positive psychological intervention for promoting preschool teachers' well-being and professional competence: EASP intervention program.

The present study investigated the effectiveness of the Early Advancement in Social-Emotional Health and Positivity (EASP) program, a positive psychological intervention promoting preschool teachers' well-being and the motivational aspect of professional competence. Participants were 273 in-service preschool teachers (Mage = 34.56 years, SD = 9.52, range = 22-58; female = 98.90%) who participated in a 2-month randomized controlled trial. Participants were randomly assigned to the intervention group (n = 143) receiving 1) four online workshops, 2) a smartphone app, and 3) an online activity, or to the wait-list control group (n = 130), which received the intervention materials after all the data collection. Participants reported their well-being dimensions, teaching self-efficacy, and autonomous motivation for teaching before and after the intervention. Results from a path analytic model exhibited excellent fit with the data, χ2 = 37.62, df = 33, CFI = .99, TLI = .98, RMSEA = .02 [90% CI = 0.00, 0.05], SRMR = .02. The intervention had direct effects on changes in well-being dimensions, including positivity, outcome, strength, engagement, and resilience (ß = .14 to .26, ps = .00 to .04), and indirect intervention effects on changes in teaching self-efficacy and autonomous motivation for teaching (ß = .14 to .15, ps = .00 to .01). These findings highlighted the potential value of implementing positive psychological interventions in educational settings to promote the well-being and professional competence among preschool teachers.

Child behavioral problems and parental adjustment: Family, interparental, and parent-child processes as simultaneous mediators.

This study examined the associations of child behavioral problems with parental adjustment and whether family processes mediated such associations. Cross-sectional data were collected from the fathers, mothers, and class teachers of 186 kindergarten-aged children with special educational needs from Hong Kong, China (mean age = 61.6 months, and 136 of them were boys). Using questionnaires, parents reported their children's behavioral problems and their own adjustment and family processes. Meanwhile, class teachers rated children's behavioral problems. Multigroup analyses supported a mediation model that was invariant across fathers and mothers. Controlling for child and family demographic information, child behavioral problems were linked positively to parental depression and negatively to parental life satisfaction. Moreover, the link of child behavioral problems with parental depression was fully mediated by family economic pressures, marital conflict, and parent-child conflict, whereas the link of child behavioral problems with parental life satisfaction was fully mediated by family economic pressures and marital conflict. Theoretically, our findings pointed to the importance of considering multiple family processes in understanding the relationship between child characteristics and parental well-being among families with children with special educational needs. Practically, our findings highlighted the possible utility of equipping fathers and mothers of children with special educational needs with skills to reduce children's problem behaviors, cope with financial hardship, and manage marital and parent-child conflict. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Management of Scar Contractures of the Hand-Our Therapeutic Strategy and Challenges.

The essence of treating scar contractures lies in covering the skin deficit after releasing the contractures, typically using flaps or skin grafts. However, the specific characteristics of scar contractures, such as their location, shape, and size, vary among patients, which makes surgical planning challenging. To achieve excellent outcomes in the treatment of scar contractures, we have developed a dimensional classification system for these contractures. This system categorizes them into four types: type 1 (superficial linear), type 2-d (deep linear), type 2-s (planar scar contractures confined to the superficial layer), and type 3 (planar scar contractures that reach the deep layer, i.e., three-dimensional scar contractures). Additionally, three factors should be considered when determining surgical approaches: the size of the defect, the availability of healthy skin around the defect, and the blood circulation in the defect bed. Type 1 and type 2-d are linear scars; thus, the scar is excised and sutured in a straight line, and the contracture is released using z-plasty or its modified methods. For type 2-s, after releasing the scar contracture band, local flaps are indicated for small defects, pedicled perforator flaps for medium defects, and free flaps and distant flaps for large defects. Type 2-s has good blood circulation in the defect bed, so full-thickness skin grafting is also a suitable option regardless of the defect's size. In type 3, releasing the deep scar contracture will expose important structures with poor blood circulation, such as tendons, joints, and bones. Thus, a surgical plan using flaps, rather than skin grafts, is recommended. A severity classification and treatment strategy for scar contractures have not yet been established. By objectively classifying and quantifying scar contractures, we believe that better treatment outcomes can be achieved.

The effect of Medicaid expansion on rates of carpal tunnel release: an interrupted time series analysis.

BACKGROUND: Medicaid expansion through the Affordable Care Act (ACA) has been associated with greater access and utilization of surgical services in underserved populations. However, its impact on use of hand surgical care is less understood. The purpose of this study was to evaluate the association between New York State adoption of the ACA and carpal tunnel release (CTR) procedural volume in Medicaid beneficiaries. METHODS: We conducted a pooled cross-sectional analysis of patients who underwent CTR using the Healthcare Cost and Utilization Project New York State all-payer database (2010-2018). An interrupted time series (ITS) analysis using an autoregressive integrated moving average model estimated the immediate and long-term impact of Medicaid expansion in January 2014 on CTR procedural volume in Medicaid beneficiaries and uninsured individuals. RESULTS: A total of 112,569 patients were included in the sample. After expansion, we observed an absolute increase of 6% in the share of CTR procedures provided to Medicaid beneficiaries. Policy implementation was associated with an immediate 1.81% increase (95% CI=0.0085, 0.0277; p<0.001) in the probability of Medicaid as the primary payer and an annual increase of 1.68% (95% CI=0.0134, 0.0202; p<0.001) after reform. ITS analysis found this resulted in 4,190 additional CTR procedures in Medicaid beneficiaries than predicted without expansion. CONCLUSIONS: Study results suggest New York's adoption of the ACA was associated with an immediate and steady increase in use of outpatient CTR in Medicaid beneficiaries. Most of this increase represented newly treated patients rather than those who were previously uninsured.

Sepsis-associated acute kidney injury: recent advances in enrichment strategies, sub-phenotyping and clinical trials.

Acute kidney injury (AKI) often complicates sepsis and is associated with high morbidity and mortality. In recent years, several important clinical trials have improved our understanding of sepsis-associated AKI (SA-AKI) and impacted clinical care. Advances in sub-phenotyping of sepsis and AKI and clinical trial design offer unprecedented opportunities to fill gaps in knowledge and generate better evidence for improving the outcome of critically ill patients with SA-AKI. In this manuscript, we review the recent literature of clinical trials in sepsis with focus on studies that explore SA-AKI as a primary or secondary outcome. We discuss lessons learned and potential opportunities to improve the design of clinical trials and generate actionable evidence in future research. We specifically discuss the role of enrichment strategies to target populations that are most likely to derive benefit and the importance of patient-centered clinical trial endpoints and appropriate trial designs with the aim to provide guidance in designing future trials.

Inappropriate wrist MRI: did guidelines have an impact?

OBJECTIVES: To assess the national prevalence and cost of inappropriate MRI in patients with wrist pain prior to and following American College of Radiology (ACR) guideline publication. STUDY DESIGN: We used administrative claims from the IBM MarketScan Research Databases to evaluate the appropriateness of wrist MRI in a national cohort of patients with commercial insurance or Medicare Advantage. METHODS: Adult patients with a diagnosis of wrist pain between 2016 and 2019 were included and followed for 1 year. We made assessments of appropriateness based on ACR guidelines for specific wrist pain etiologies. We tabulated the total costs and out-of-pocket expenses associated with inappropriate MRI studies using weighted mean payments for facility and professional fees. We performed segmented logistic regression on interrupted time series data to identify predictors of receiving inappropriate imaging and the impact of guideline publication on MRI use. RESULTS: The study cohort consisted of 867,119 individuals. Of these, 40,164 individuals (4.6%) had MRI, of whom 52.6% received an inappropriate study. Inappropriate studies accounted for $44,493,234 in total payments and $8,307,540 in out-of-pocket expenses. The interrupted time series found an approximately 1% monthly decrease in the odds of receiving an inappropriate study after guideline dissemination. CONCLUSIONS: MRI as a diagnostic tool for wrist pain is often inappropriate and expensive. Our findings support interventions to increase guideline adherence, such as integrated clinical decision support tools.

Pyrocarbon Lunate Arthroplasty: An Option for the Young Patient with Advanced Kienbock Disease.

Kienbock disease, or avascular necrosis of the lunate, is an uncommon cause of a painful and stiff wrist. Management options range from conservative treatment in the form of immobilization and corticosteroid injections to a wide variety of surgical treatments that depend on the structural integrity of the lunate, intercarpal relationships, and the condition of the articular cartilage of the wrist. A particularly difficult problem lies in the management of young patient in whom vascularized bone grafting of the lunate has failed but in whom arthritis has not yet developed. Pyrocarbon lunate implant arthroplasty is a newer treatment option for such a patient, and allows the preservation of the remainder of the proximal carpal row while directly addressing the degenerative lunate. This article describes the evidence and surgical technique for lunate implant arthroplasty and presents an illustrative case example.

Decision for Carpal Tunnel Surgery: High-deductible Health Plans versus Traditional Health Plans.

Background: Delay in surgical treatment for carpal tunnel syndrome (CTS) may result in long-term decreased functional outcomes. Few investigators have examined the relationship between type of health insurance plan and time to definitive treatment of CTS following diagnosis. We investigated the relationship between insurance type, treatment decision, and the time between diagnosis and surgery across groups. Methods: This was a retrospective cohort study using the MarketScan Commercial Claims and Encounters Database 2011-2020. We used χ2 tests, linear regression, and logistic regression models to analyze demographic data and the time lag interval between CTS diagnosis and treatment. Results: Overall, 28% of high-deductible health plan (HDHP) patients underwent carpal tunnel release, compared with 20% of traditional insurance patients (P < 0.001). HDHPs are defined by the internal revenue service as a deductible of $1400 for an individual or $2800 for a family per year. The odds of undergoing surgery versus no treatment for HDHP patients were 47% higher than traditional patients (P < 0.001). Among the patients who underwent surgery, HDHP patients underwent surgery 65 days earlier on average following diagnosis compared with traditional patients (P < 0.001). Conclusions: Patients with HDHPs who receive a diagnosis of CTS are more likely to undergo surgery, with a shorter time lag between diagnosis and surgery. The results from this study call attention to differences in surgical decision-making between patients enrolled in different insurance plans.