Describing the Medical Needs of Hawai'i's Houseless Population During COVID at Free Student Run Outpatient Clinics (Hawai'i HOME Project).

Hawai'i experiences some of the highest rates of houselessness per capita in the country. COVID-19 has exacerbated these disparities and made it difficult for these individuals to seek medical care. Hawai'i's Houseless Outreach in Medical Education (HOME) clinic is the largest student run free clinic in the state, which provides medical services to this patient population. This article reports the demographics, medical needs, and services provided to patients of Hawai'i's HOME clinic during the era of COVID-19. From September 2020 to 2021, the HOME clinic saw 1198 unique visits with 526 distinct patients. The most common chief complaints included wound care (42.4%), pain (26.9%), and skin complaints (15.7%). A large portion of the population suffered from comorbidities including elevated blood pressure (66%), a formal reported history of hypertension (30.6%), diabetes (11.6%), and psychiatric concerns including schizophrenia (5.2%) and generalized anxiety (5.1%). Additionally, a large portion of patients (57.2%) were substance users including 17.8% of patients endorsing use of alcohol, 48.5% tobacco and 12.5% marijuana. The most common services provided were dispensation of medication (58.7%), wound cleaning/dressing changes (30.7%), and alcohol or other drug cessation counseling (25.2%). This study emphasizes that the houseless are a diverse population with complex, evolving medical needs and a high prevalence of chronic diseases and comorbidities.

Craniofacial Assault Against Women: A National Evaluation Defining At-risk Populations and Outcomes.

INTRODUCTION: Few studies have analyzed epidemiologic factor associated with female patients presenting to the emergency department from facial fractures because of assault. Clearly understanding these factors may assist in developing effective strategies to decrease the incidence and sequelae of these injuries. OBJECTIVES: To determine the epidemiology of facial fractures because of assault in the female population. METHODS: All female facial fracture visits were queried in the 2019 Nationwide Emergency Department (ED) Sample database. The likelihood of a facial fracture encounter resulting from assault was modeled using logistic regression adjusting for demographics, insurance status, geographic region, location of patient residence, and income. Secondary outcomes analyzed hospitalization costs and adverse events. RESULTS: Of all facial fractures 12.4% of female encounters were due to assault were due to assault. Of assaulted females, 72.8% were between the ages of 20 and 40, and Black women experienced a disproportionate share of assault encounters (odds ratio [OR]=2.55; CI, 2.29-2.84). A large portion (46.4%) of encounters occurred in patients living in the lowest quartile of median household income, and 22.8% of patients were uninsured (OR=1.34; CI, 1.09-1.66). Assaulted patients were more likely to have fractures in nasal bone (58.1% vs. 42.5%), orbit (16.8% vs. 10.9%), zygoma (4.1% vs 3.6%), and mandible (8.7% vs. 4.8%) compared with their nonassaulted counterparts. CONCLUSIONS: Facial fractures were especially common in lower income, uninsured, urban, and Black populations. Examining the patterns of injury and presentation are critical to improve prevention strategies and screening tools, identifying critical patients, and develop a more efficient and effective system to treat and support female patients suffering facial fractures secondary to assault.

Description of Otolaryngology (OTO) Disease in Houseless Patients on O'ahu, Hawai'i.

This retrospective study assesses the prevalence of otolaryngology (OTO) disease in houseless patients on O'ahu based on data from the Houseless Outreach and Medical Education (HOME) clinics, a medical student-run, primary health care service. It is important to note that this data represents only a snapshot in time of the OTO diseases present in this population. Records were examined from September 3, 2020 to September 30, 2021. Patients with at least 1 OTO disease were included in this study. A total of 597 patient records were reviewed; a total of 58 patients were included in this study. The most common OTO diagnoses in this sample were facial trauma (n = 12, 21%), dental caries (n = 7, 12%), cerumen impaction (n = 6, 10%), viral upper respiratory infection (n = 5, 9%), otitis media (n = 4, 7%), and allergic conjunctivitis (n = 3, 5%). Roughly 10% of patients seen in HOME clinics between September 2020 and September 2021 were seen for OTO disease.

Improving Operating Room Efficiency Through Reducing First Start Delays in an Academic Center.

BACKGROUND: Delays in operating room (OR) first-case start times can cause additional costs for hospitals, healthcare team frustration and delay in patient care. Here, a novel process improvement strategy to improving first-case start times is presented. METHODS: First case in room start times were recorded for ORs at an academic medical center. Three interventions-automatic preoperative orders, dot phrases to permit re-creation of unavailable consent forms, and improved H&P linking to the surgical encounter-were implemented to target documentation-related delays. Monthly percentages of first-case on-time starts (FCOTS) and time saved were compared with the "preintervention" time period, and total cost savings were estimated. RESULTS: During the first 3-months after implementation of the interventions, the percentage of FCOTS improved from an average of 36.7%-52.7%. Total time savings across all ORs over the same time period was found to be 55.63 hours, which is estimated to have saved a total of $121,834.52 over the 3-month interventional period. CONCLUSIONS: By implementing multiple quality improvement interventions, delays to first start in room OR cases can be meaningfully reduced. Quality improvement protocols targeted toward root causes of OR delays can be a significant driver to reduce healthcare costs.

Update on Current Concepts of Blood Flow Restriction in the Perioperative Period of Anterior Cruciate Ligament Reconstruction.

Anterior cruciate ligament tears or ruptures are common orthopedic injuries. Anterior cruciate ligament reconstruction (ACLR) is an orthopedic procedure allowing for earlier return to sports, improved maintenance of lifestyle demands, and restored knee stability and kinematics. A perioperative rehabilitative adjunct recently gaining interest is blood flow restriction (BFR), a method in which temporary restriction of blood flow to a chosen extremity is introduced and can be used as early as a few days postoperative. There has been increasing investigation and recent literature regarding BFR. This review synthesizes current concepts of BFR use in the ACLR perioperative period. [Orthopedics. 2023;46(6):e333-e340.].

Severe patellofemoral arthritis does not compromise 6-month post-operative range of motion or function following unicondylar knee arthroplasty.

BACKGROUND: The presence of significant patellofemoral arthritis (PFA) is still considered a contraindication for unicondylar knee arthroplasty (UKA) by many surgeons. The purpose of this study was to determine if the presence of severe PFA at the time of UKA compromised early (< 6 months) post-operative knee range of motion or functional outcomes. METHODS: This retrospective review evaluated unilateral and bilateral UKA (323 patients; 418 knees) between 2015 and 2019. Procedures were grouped by degree of PFA present at the time of surgery, including mild PFA (Group 1; N = 266), moderate to severe PFA (Group 2; N = 101), and severe PFA with lateral compartment bone-on-bone contact (Group 3; N = 51). Knee range of motion and Knee Society Knee (KSS-K) and Function (KSS-F) scores were collected both before and at 6 months following surgery. Group differences were evaluated with Kruskal-Wallis and Chi-square tests for continuous and categorical variables, respectively. Univariate and multivariable logistic regressions were performed to determine influential variables associated with post-operative knee flexion being ≤ 120° and presented as odds ratios (OR) and 95% confidence intervals (CI). RESULTS: Pre-operative flexion was lowest in Group 3 (p = 0.010) with 17.6% of knees having flexion ≤ 120°. Post-operative flexion was lowest in Group 3 (119.1° ± 8.4°, p = 0.003) with 19.6% knees having flexion ≤ 120° compared to 9.8% and 8.9% in Groups 1 and 2, respectively. No significant difference in KSS-F following surgery was found; all three groups demonstrated similar clinical improvement. Increased age (OR 1.089, CI 1.036-1.144; p = 0.001) and body mass index (OR 1.082, CI 1.006-1.163; p = 0.034) were found to be associated with post-operative knee flexion ≤ 120°, while high pre-operative flexion (OR 0.949, CI 0.921-0.978; p = 0.001) was found to be inversely associated with poor knee flexion following surgery. CONCLUSION: Patients with severe PFA demonstrate similar clinical improvement following UKA at 6 months as patients with less severe PFA.

Racial Disparities in Postoperative Breast Reconstruction Outcomes: A National Analysis.

BACKGROUND: Studies have shown that Black patients are more likely to experience complications following breast reconstruction compared to other racial groups. Most of these studies have been conducted on patient populations focusing on either autologous or implant-based reconstruction without possible predictive indicators for complication disparities for all types of reconstruction procedures. The aim of this study is to elucidate disparities among patient demographics by identifying predictors of complications and postoperative outcomes among different racial/ethnic patients undergoing breast reconstruction utilizing multi-state, multi-institution, and national level data. METHODS: Patients in the Optum Clinformatics Data Mart that underwent all billable forms of breast reconstruction were identified via CPT codes. Demographics, medical history, and postoperative outcome data were collected by querying relevant reports of CPT, ICD-9, and ICD-10 codes. Outcomes analysis was limited to the 90-day global postoperative period. A multivariable logistic-regression analysis was performed to ascertain the effects of age, patient reported ethnicity, coexisting conditions, and reconstruction type on the likelihood of any common postoperative complication occurring. Linearity of the continuous variables with respect to the logit of the dependent variable was confirmed. Odds ratios and corresponding 95% confidence intervals were calculated. RESULTS: From over 86 million longitudinal patient records, our study population included 104,714 encounters for 57,468 patients who had undergone breast reconstruction between January 2003 and June 2019. Black race (relative to White), autologous reconstruction, hypertension, type II diabetes mellitus, and tobacco use were independent predictors of increased likelihood of complication. Specifically, the odds ratios for complication occurrence for Black, Hispanic, and Asian ethnicity (relative to White) were 1.09, 1.03, and 0.77, respectively. Black patients had an overall breast reconstruction complication rate of 20.4%, while the corresponding rate for White, Hispanic, and Asian patients were 17.0%, 17.9%, and 13.2%, respectively. CONCLUSION: Our analysis of a national-level database shows that Black patients undergoing implant-based or autologous reconstruction have increased risk of complications, likely due to multifactorial components that play a role in the care of this patient population. While higher rates of comorbidities have been cited as a possible cause, providers must consider racial influences involving cultural context, historical mistrust in medicine, and physician/health institution factors that may drive this disparity of outcomes among our patients.

Is Iatrogenic Implant Contamination Preventable Using a 16-Step No-Touch Protocol?

Background: Intraoperative contamination of the surgical field during aesthetic breast augmentation may lead to implant infection with devastating consequences. This study covers a period of 30 years and is divided into 2 phases: a retrospective phase from 1992-2004 when a standard approach was used and a prospective phase from 2004-2022 when a no-touch approach was implemented to avoid contamination. Methods: Patients in the standard and no-touch groups underwent aesthetic breast augmentation by the same senior surgeon (FDP) in the same outpatient surgical facility during the 30-year period of the study. Patients are divided into 2 groups: from 1992-2004 and from the implementation of the no-touch protocol in 2004-2022. Results: Patients who underwent breast augmentation using the no-touch approach developed no infections, whereas the standard group had an infection rate of 3.54% (P = .017). The validity of this finding is discussed. Conclusions: The no-touch approach as described in this article was effective in reducing implant infection rate when performing aesthetic breast augmentation by 1 surgeon at 1 surgical center during an 18-year observation period. Multicenter prospective cooperative studies are necessary to validate perioperative iatrogenic contamination as the cause of implant infection and to explore optimal approaches that could eliminate implant contamination.

Review on Nerve Blocks Utilized for Perioperative Total Knee Arthroplasty Analgesia.

Total Knee Arthroplasty (TKA) is an increasingly common procedure performed for advanced osteoarthritis. Optimal perioperative pain management strategies are critical for early mobilization and shorter hospital stays in TKA. Peripheral nerve blocks commonly used in TKA perioperative analgesia including individual and combined femoral, obturator, sciatic, lumbar plexus, and adductor canal nerve blocks. Overall, the safety profile varies depending on which block is utilized, but the current evidence suggests when optimally chosen and delivered, peripheral nerve blocks may provide a safe, effective option for perioperative analgesia. Determining optimal analgesic regimens for total knee arthroplasty is critical to improve postoperative pain, patient satisfaction, decreasing opioid usage, recovery times and functional outcomes, and as such, peripheral nerve blocks may represent a viable option to supplement analgesic requirements in the perioperative period.

Recurrent Tibial Periostitis Due to Blunt Trauma.

Periostitis is characterized by periosteal inflammation surrounding tubular bones. The pathophysiology is now considered to be multifactorial and a spectrum of disorders, recently being redefined as medial tibial stress syndrome (MTSS). Current treatment modalities include preventative and conservative measures, such as activity modification and footwear alterations. There is a paucity of literature for more invasive treatments, such as steroid injections. In conflict with the currently available limited literature, this study reports a case of recurrent tibial periostitis due to blunt trauma treated with steroid injections resulting in symptom resolution and no adverse events. While this case may suggest a therapeutic role for steroids in the treatment of MTSS from blunt trauma, it also highlights the need for additional studies to elucidate the safety profile and therapeutic efficacy of steroid injections.

Review of Early Signs of Breast Implant Infection.

BACKGROUND: Breast implant infection remains a problem despite various prevention methods. Common pathogens such as staphylococcus aureus typically present acutely with fever, erythema, swelling, and pain. However, with the increasing occurrence of mycobacterial infections, associated early signs and symptoms are typically absent, making early detection difficult. METHOD: A retrospective chart review of patients who underwent esthetic breast augmentation by senior surgeon FDP in an outpatient surgical facility from 1992 to 2021 was conducted. Cases of infections and related information including infection onset, presenting signs and symptoms, and culture results were recorded. Presentation differences between infections caused by common pathogens and mycobacteria were compared. RESULTS: A total of nine infections were reported in 365 patients. Seven cases were due to common pathogens: staphylococcus aureus, pseudomonas aeruginosa, methicillin-resistant staphylococcus aureus (MRSA), and staphylococcus epidermidis. Fever, erythema was presented within an average of 10 days after surgery. Two cases were due to mycobacterium chelonae (non-tuberculous mycobacterium) infection. In the latter, the earliest signs and symptoms consisted of mild pain and swelling in the absence of fever and erythema, which began on average of 54 days after the operation. CONCLUSION: Common breast implant infection pathogens usually present early with fever and erythema. However, our study found that non-tuberculous mycobacteria infections occur much later and fever and erythema are typically absent. The purpose of this study is to increase the awareness of clinicians with this rare but rapidly increasing variety of infections and to advise the operating surgeon to include mycobacteria infections in the differential diagnosis. LEVEL OF EVIDENCE IV: 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 .

Global analysis of Saccharomyces cerevisiae growth in mucin.

Metagenomic profiling of the human gut microbiome has discovered DNA from dietary yeasts like Saccharomyces cerevisiae. However, it is unknown if the S. cerevisiae detected by common metagenomic methods are from dead dietary sources, or from live S. cerevisiae colonizing the gut similar to their close relative Candida albicans. While S. cerevisiae can adapt to minimal oxygen and acidic environments, it has not been explored whether this yeast can metabolize mucin, the large, gel-forming, highly glycosylated proteins representing a major source of carbon in the gut mucosa. We reveal that S. cerevisiae can utilize mucin as their main carbon source, as well as perform both a transcriptome analysis and a chemogenomic screen to identify biological pathways required for this yeast to grow optimally in mucin. In total, 739 genes demonstrate significant differential expression in mucin culture, and deletion of 21 genes impact growth in mucin. Both screens suggest that mitochondrial function is required for proper growth in mucin, and through secondary assays we determine that mucin exposure induces mitogenesis and cellular respiration. We further show that deletion of an uncharacterized ORF, YCR095W-A, led to dysfunction in mitochondrial morphology and oxygen consumption in mucin. Finally, we demonstrate that Yps7, an aspartyl protease and homolog to mucin-degrading proteins in C. albicans, is important for growth on mucin. Collectively, our work serves as the initial step toward establishing how this common dietary fungus can survive in the mucus environment of the human gut.

Measuring In-Vivo Foot Perfusion Distal to a Near-Circumferential Negative Pressure Wound Therapy Dressing via Thermal Imaging.

Background Negative pressure wound therapy (NPWT) has been shown to promote the healing of acute and chronic wounds. In our previous study, we demonstrated that a near-circumferential NPWT dressing provided "lift-off" on an in-vitro extremity model resulting in decreased pressure. We hypothesized that this decrease in pressure may increase perfusion distal to the NPWT dressing by increasing lymphatic drainage and venous flow. Methods In this study, we tested if a near-circumferential NPWT dressing caused any appreciable skin movement around the dressing. We then used a thermal imaging camera to test if there was an increase in perfusion to the foot when a near-circumferential NPWT dressing was placed around the lower leg and tested at various negative pressures. Finally, we wanted to see if an artificial "lift-off" mechanism would lead to an increase in perfusion. Results The skin was noted to stretch between the short ends of the NPWT dressing, consistent with our previously described "lift-off" mechanism. However, there was no correlation between negative pressure and perfusion to the foot in the other experiments. Conclusion This study demonstrated that a near-circumferential NPWT dressing may not have any appreciable effects on perfusion when applied on a healthy patient, however, future studies are needed to determine if similar results would be seen on a traumatized or otherwise compromised extremity.

Do Gloves Provide Adequate Protection Against Infection?

In the early 1800s gloves were a foreign concept to surgeons, as a result, patient care suffered, and mortality was high due to poor sanitary conditions in the operating room. This all changed in 1889, where the introduction of the surgical glove completely revolutionized surgical aseptic ideals. Through the work of William Halsted and his desire to help his nurse, Caroline Hampton, who was from suffering contact dermatitis, the first pair of rubber gloves were created. Since this invention, there have been significant advancements in glove technology including the use of latex and non-latex gloves. However, significant problems remain including, perioperative contamination in longer procedures, a false sense of sterility, and no consensus in optimal glove donning procedures. Additional measures including patient preparation, limited handling of tissue specimens, minimal coagulation, and in particular a no-touch strategy need to be continued and optimized to minimize iatrogenic infection and sequelae. 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 .

An In Vitro Study Measuring the Effects of Circumferential and Near-Circumferential Closed Incisional Negative Pressure Wound Therapy Dressings.

Background Negative pressure wound therapy (NPWT) and closed incisional negative pressure wound therapy (ciNPWT) have been shown to promote the healing of acute and chronic wounds. Despite the growth in their usage, the mechanism by which they promote healing is not fully understood. Several studies have shown that NPWT results in a combination of microdeformation and macrodeformation, which may promote wound recovery. The macrodeformation forces have raised concerns about circumferential NPWT compressing the extremity and decreasing perfusion distal to the NPWT. The literature on circumferential NPWT is mixed, with some studies showing increased perfusion, while others have shown decreased perfusion. We hypothesized that a near-circumferential ciNPWT dressing applied over intact skin would provide a "lift-off" force rather than a compressive force. We also theorized that as the sponge contracts under negative pressure while in a near-circumferential setting, the dressing will pull on the surrounding skin and tissue, leading to a decrease in the pressure of the extremity. This could potentially translate to improved venous and lymphatic return, increasing perfusion to the tissue beneath the sponge as well as distal to the sponge. Methods This study consisted of three separate experiments. The first experiment measured the width and length of a ciNPWT dressing at various negative pressures. The second experiment utilized an in vitro model consisting of an elastic ball and tubing to examine the effects that circumferential and near-circumferential ciNPWT dressings may have on extremity pressure. Varying lengths of ciNPWT dressings were applied to the ball, ranging from 25% circumferential to 100% circumferential. The pressure within the ball was monitored as varying lengths of circumferential dressings were applied at various negative pressures. The third experiment utilized the same model as the second experiment but with a 66% circumferential dressing and various baseline ball pressures to see how extremity pressure may impact the ability of the ciNPWT dressing to alter extremity pressure. Results The first experiment demonstrated that a ciNPWT dressing decreased in length and width in a linear fashion as negative pressure was applied. The second experiment revealed that both fully circumferential and near-circumferential dressings resulted in a decrease in the pressure of the elastic ball at lower levels of suction. The greatest decrease in ball pressure was noted with the 66% near-circumferential dressing. With greater suction, however, the pressure within the ball was noted to increase above baseline. The third experiment illustrated that as the baseline pressure of a ball was increased, the dressing had less of an ability to change the pressure of the ball. Conclusions These results suggest that near-circumferential and circumferential ciNPWT systems may decrease the pressure of an extremity at certain negative pressures and that compression may be less likely to occur when used on a higher-pressure extremity.