A Ventral Hernia Management Pathway; A "Getting It Right First Time" approach to Complex Abdominal Wall Reconstruction.

INTRODUCTION: Abdominal wall reconstruction (AWR) is an emerging specialty, involving complex multi-stage operations in patients with high medical and surgical risk. At our hospital, we have developed a growing interest in AWR, with a commitment to improving outcomes through a regular complex hernia MDT. An MDT approach to these patients is increasingly recognized as the path forward in management to optimize patients and improve outcomes. METHODS: We conducted a literature review and combined this with our experiential knowledge of managing these cases to create a pathway for the management of our abdominal wall patients. This was done under the auspices of GIRFT (Getting It Right First Time) as a quality improvement project at our hospital. RESULTS: We describe, in detail, our current AWR pathway, including the checklists and information documents we use with a stepwise evidence and experience-based approach to identifying the multiple factors associated with good outcomes. We explore the current literature and discuss our best practice pathway. CONCLUSION: In this emerging specialty, there is limited guidance on the management of these patients. Our pathway, the "Complex Hernia Bundle," currently provides guidance for our abdominal wall team and may well be one that could be adopted/adapted by other centers where challenging hernia cases are undertaken.

Identification of Knee Effusions With Ultrasound: A Comparison of Three Methods.

OBJECTIVES: To determine whether simple methods can improve identification of suprapatellar joint fluid during sonographic evaluation of the knee. DESIGN: Prospective cohort study. SETTING: Outpatient orthopaedic clinic. PATIENTS: Fifty-two patients were sequentially recruited from an orthopaedic clinic. INTERVENTIONS: Bilateral sonographic evaluation of the suprapatellar recess with static scanning, parapatellar pressure, or patient-initiated quadriceps contraction. MAIN OUTCOME MEASURES: Identification of fluid in the suprapatellar recess. RESULTS: Fifty-two patients (104 knees), consisting of 57 (54.8%) painful knees, were examined. Static scanning identified 45 effusions, parapatellar pressure identified 58 effusions, and quadriceps contraction identified 77 effusions. Quadriceps contraction was superior to parapatellar pressure for identifying an effusion {P < 0.001, proportion ratio [PR] = 1.33 [95% confidence interval (CI) = 1.16, 1.52]}, painful knee effusions [P = 0.036, PR = 1.24 (95% CI = 1.06-1.44)], and painless knee effusions (P = 0.006, PR = 1.50 [95% CI = 1.16-1.93]). Both methods were superior to static scanning. Parapatellar pressure identified effusions in 16.9% of knees not seen on static scanning, whereas quadriceps contraction identified effusions in 54.2% of knees not seen on static scanning. Inter-rater reliability kappa values were 0.771 for static scanning (95% CI = 0.605-0.937), 0.686 for parapatellar pressure (95% CI = 0.531-0.840), and 0.846 for quadriceps contraction (95% CI = 0.703-0.990). CONCLUSIONS: Parapatellar pressure and patient-initiated quadriceps contraction both improve sonographic detection of suprapatellar joint fluid with high inter-rater reliability; however, quadriceps contraction was superior to parapatellar pressure when assessing for grade 1 or occult effusions.

Current Controversies of Alignment in Total Knee Replacements.

Total knee replacement is an increasingly popular operation for end stage knee arthritis. In the majority it alleviates pain and improves function. However up to 20% of patients remain dissatisfied, even with well-aligned and secure implants. Restoration of a neutral mechanical axis has traditionally been strived for, to improve both function and implant survival and there is historical data to support this. More recently this view has been questioned and some surgeons are trying to improve the function and outcomes by moving away from standard alignment principles in an attempt to reproduce the kinematics of the pre-arthritic knee of that individual. Others are using computers, robots and patient specific guides to improve accuracy. This article aims to review the traditional alignment concept and the newer techniques, along with the evidence behind it.

Cardiobacterium hominis endocarditis presenting as acute embolic stroke: a case report and review of the literature.

We report on a case of endocarditis attributable to Cardiobacterium hominis in a 31-year-old man who presented with acute-onset, left-sided hemiparesthesia. Magnetic resonance imaging of the brain showed acute infarctions in 2 areas of the right cerebral cortex, and a transesophageal echocardiogram revealed vegetation in a previously unrecognized bicuspid aortic valve. The patient completed a 6-week course of ceftriaxone and aspirin, with resolution of the vegetation and neurological complications. Our literature review of C. hominis endocarditis suggests that aortic-valve involvement is associated with high stroke and valve-surgery rates. Favorable outcomes and treatment success are evident with either penicillin or ceftriaxone, in combination with (if indicated) valve surgery in patients with neurological complications.

The influence of literacy on patient-reported experiences of diabetes self-management support.

BACKGROUND: Variability in disease-related outcomes may relate to how patients experience self-management support in clinical settings. OBJECTIVES: The purpose of this study was to identify factors associated with experiences of self-management support during primary care encounters. METHODS: A cross-sectional survey was conducted of 208 patients seen in a multidisciplinary diabetes program in an academic medicine clinic. Multiple regression analysis was used to test associations between patient-rated experiences of self-management support (Patient Assessment of Chronic Illness Care) and race, gender, insurance status, literacy, duration of diabetes, and intensity of care management. RESULTS: The Patient Assessment of Chronic Illness Care ratings decreased with age (r = -.235, p = .001), were higher for women than for men (3.95 vs. 3.65, t = 2.612, p= .010), and were greater for those with more education (F= 3.927, p = .009) and greater literacy skills (t = 3.839, p< .001). The ratings did not vary between racial (t = -1.108, p = .269) or insurance (F = 1.045, p = .374) groups and were unaffected by the duration of diabetes (r= .052, p = .466) and the intensity of care management (F = 1.028, p = .360). In multivariate models, literacy was the only variable contributing significantly to variation in self-management support ratings. DISCUSSION: Even when considering the objective intensity of health services delivered, literacy was the sole variable contributing to differences in patient ratings of self-management support. Although conclusions are limited by the cross-sectional nature of this study, the results emphasize the need to consider literacy when developing and communicating treatment plans requiring self-management skills.

Safety of treatment of latent tuberculosis infection in compensated cirrhotic patients during transplant candidacy period.

BACKGROUND: Treatment of latent tuberculosis infection with isoniazid (INH) or rifampin (RIF) is controversial in liver transplant candidates due to potential hepatotoxicity. In this study, treatment of latent tuberculosis during transplant candidacy period is explored, and relevant literature is reviewed. METHODS: Liver transplant candidates with latent tuberculosis infection by positive tuberculin skin test (>5 mm) were prospectively enrolled and treated with 9 months of INH or 4 months of RIF, and were monitored monthly for their liver enzyme profiles, adverse effects, compliance, and completion rate. RESULTS: Four of nine patients with INH had asymptomatic, mild elevations of aspartate aminotransferase (AST) or alanine aminotransferase (ALT) versus none of five patients in the RIF group. Two cases of elevations were attributed to INH. Two other cases were attributed to alcoholism or active chronic hepatitis B virus infection. Only one patient in the INH group experienced symptoms possibly attributed to INH hepatotoxicity. Compliance was 100% per patient reporting. Completion rates were 79% for INH and 100% for RIF. No fulminant hepatic failure or death was observed. CONCLUSION: Treatment of latent tuberculosis in liver transplant patients during their candidacy with INH or RIF appears to be a safe, viable option, if carefully monitored for adverse effects and liver enzymes.

Roth 401(k): asking the right questions.

Roth 401(k) provisions are a newly available feature of 401(k) plans. Roth 401(k) provisions are after-tax savings that generally are tax-free at the time of distribution. Questions arise for plan sponsors about whether the new feature is beneficial, and to whom, and what needs to be done if the plan sponsor decides to offer this provision to its employees. This article tries to answer some of those common questions, including a simple computational analysis to try to answer the important question of how much an employee-participant genuinely benefits from this savings approach. Some practical issues of implementation are touched on, and some unanswered questions are identified.

Persistence of Chlamydia trachomatis infection detected by polymerase chain reaction in untreated patients.

BACKGROUND: Prior studies have used Chlamydia trachomatis culture methods to demonstrate both persistence and spontaneous clearance of genital C trachomatis infection. OBJECTIVE: To further assess the issue of persistence and spontaneous clearance of C trachomatis infection, untreated men and women were evaluated with repeated polymerase chain reaction (PCR) testing. METHODS: Ninety four untreated patients with a prior positive C trachomatis PCR test returning to the Denver Metro Sexually Transmitted Disease Clinic were retested by PCR. RESULTS: The median and range intervals from initial to follow-up testing were 9.0 (2-112) days for men and 10.0 (2-231) days for women. Repeated PCR tests were positive for 29 of 36 men (80.6%) and 45 of 58 women (77.6%). Persistent PCR positivity did not decrease with a longer testing interval. By multivariate analysis, independent predictors of a persistently positive PCR test included nonwhite ethnicity, an interval of more than 3 days since last sexual encounter before the initial test, and an initial PCR optical density value of greater than or equal to 3.0. CONCLUSIONS: In the absence of treatment, a large majority of patients testing positive for C trachomatis by PCR are likely to remain positive for variable periods of time, increasing the risk of transmission and immune-mediated damage. A low initial optical density value and recent sexual contact may be markers for exposure that does not establish infection.