The role of vascular surgeons in the management of pediatric bone tumors.

OBJECTIVES: The objective of this study was to review the outcomes of a multidisciplinary approach to the surgical management of pediatric bone tumors with blood vessel involvement over a 14- year period. METHODS: A retrospective review was conducted of all pediatric bone tumor resections performed with the assistance of vascular surgery at our institution between January 2006 and January 2021. Inclusion criteria for the study included the presence of a vascular surgeon at the operative resection and radiographic evidence of major blood vessel involvement. RESULTS: From 2006 to 2021, 117 patients underwent a bone tumor resection by a single orthopedic surgeon/vascular surgeon team. Sixty were malignant tumors, and 57 were benign. Of the 117 procedures, 5.1% (6/117) required reconstruction of an artery; five in malignant cases and one in benign. No venous reconstructions were undertaken in this study. Ligation of a major artery without reconstruction was performed in 8.8% (5/57) of malignant and 1.7% (1/60) of benign resections. Despite this vessel-sparing approach, microscopic margins were clear in all cases. Local recurrence occurred in a single patient in the malignant group at 61 months. CONCLUSIONS: The ideal management of pediatric bone tumors with major blood vessel involvement remains poorly defined. Our results demonstrate that even in the setting of radiographic evidence of vessel involvement, a multidisciplinary team of vascular and orthopedic surgeons can employ a vessel-sparing approach with minimal blood loss, excellent limb salvage, and minimal local recurrence.

Success rate and factors predictive of redo endothermal ablation of small saphenous veins.

OBJECTIVE: Endothermal ablation, such as endovenous laser ablation (EVLA) and radiofrequency ablation (RFA), has been increasingly used for treatment of small saphenous vein (SSV) insufficiency. Prior studies have shown recurrence rates of 0% to 10% in incompetent SSVs (ISSVs). The objective of the present study was to determine the efficacy of redo venous ablation for symptomatic recanalized SSVs and to predict the factors related to recanalization. METHODS: A retrospective analysis of 2566 procedures in 1752 patients with chronic venous insufficiency due to ISSVs from 2012 to 2018 was performed, using individual medical record review for data extraction. All 2566 procedures were performed using endothermal ablation for patients in whom initial conservative management had failed. Postoperative duplex ultrasound scans were performed within 3 to 7 days after treatment. We defined successful obliteration as a lack of color flow using postoperative duplex ultrasound. We defined recanalization as the presence of reflux on duplex ultrasound in the target vessel during follow-up. We conducted follow-up examinations every 3 months during the first year and every 6 months subsequently. RESULTS: Of the 2566 procedures, redo ablation was performed in 91 ISSVs for 86 patients, including 58 women and 28 men. Of the 91 procedures, 54 were performed on the left lower extremity and 37 on the right lower extremity. The mean body mass index was 32.2 ± 7.66 kg/m2. The mean age was 62.4 ± 15.10 years. The CEAP (Clinical, Etiology, Anatomy, and Pathophysiology) class was C1, C2, C3, C4, C5, and C6 for 0, 0, 29, 43, 1, and 18 patients, respectively. The mean maximum diameter of the targeted veins for the redo procedures was 4.51 ± 1.33 mm. Of the 91 procedures, 40 were performed using EVLA and 51 were performed using RFA. The initial technical success was 98.9%. The redo procedures showed an early closure of 96.7%. At a mean follow-up duration of 24.9 ± 14.9 months, the closure rate was 96.5%. No correlation was found between successful obliteration with the redo procedure and age, gender, CEAP class, laterality, EVLA vs RFA, body mass index, or vein diameter. CONCLUSIONS: The rates of successful closure for ISSVs with initial and redo procedures were comparable. These data have validated the potential usefulness of performing redo SSV ablation.

What Do Emergency Department Patients and Their Guests Expect From Their Health Care Provider in an Active Shooter Event?

BACKGROUND: "Run-Hide-Fight" is the summative life-saving mantra taught by governmental and private agencies in active shooter training. Initial research focused on patient expectations of health care provider responses in life-threatening situations suggests patients believe health care providers will take significant action to protect patient well-being. The potential disparity between expectations of the public and health care practitioner training must be examined, as conflict, confusion, and delays may have mortal consequences in active shooter situations. OBJECTIVE: Public perceptions of the extent of health care practitioners' duties and responsibilities to themselves and their patients during an active shooter event were investigated. METHODS: A survey that queried perceived expectations of health care provider response efforts in 4 emergency department patient case scenarios interrupted by an active shooter event was developed and implemented to patients and retinue of the University of Toledo Emergency Department. Responses were grouped into provider-centric or patient-centric actions. RESULTS: One hundred twenty-seven participants responded to the survey and were included in the analysis: 82 patients and 45 guests. In all 4 scenarios, a mean of 87.4% responses was patient-centric. Frequency of patient-centric responses differed significantly by scenario, and women were more likely to have patient-centric expectations. DISCUSSION: The public has significant expectations that the health care provider will assist them during active shooter situations. Providing for the security of the health care provider and patient simultaneously is in conflict with common hospital crisis training. Efforts must be taken to bring patient expectations and provider training into greater alignment.

Developing a Better and More User-Friendly Numeracy Scale for Patients.

BACKGROUND: A person's ability to work with and understand numerical information (i.e., numeracy) is increasingly important in everyday health and other decision-making contexts. Several survey measures of numeracy have been developed to address this trend, including the widely used General Numeracy Scale (GNS), which is thematically focused on health decision-making and is assumed to measure a unidimensional construct of numeracy. OBJECTIVE: The present research was designed to evaluate this proposed unidimensional structure of general numeracy, for which prior data have given mixed empirical support. METHODS: Three samples completed the GNS, in different forms, and responses were analyzed in terms of underlying factor structure. KEY RESULTS: We show that both one-factor and four-factor models of numeracy are plausible based on the GNS (Study 1), and then develop a multiple-choice version of the GNS (i.e., the MC-GNS) that demonstrates some increased clarity in factor structure due to the consistent response format (Study 2). A further study evaluated the convergent and discriminant validity of the MC-GNS (Study 3), finding it to be as good as or better than the prior scale. CONCLUSIONS: Additionally, the MC-GNS is easier for people to take, likely to be less stressful, and easier for practitioners to score. Collectively, this research identifies a problem with the GNS measure, develops improvements to help address this problem, and in the process creates a way to more easily measure numeracy in practical settings. [HLRP: Health Literacy Research and Practice. 2019;3(3):e174-e180.]. PLAIN LANGUAGE SUMMARY: Numeracy is important across health contexts. Prevalent numeracy scales assumedly measure a single construct but empirical support for this is lacking. We find both one- and four-factor models are consistent with one scale and develop a revision that clarifies this structure without sacrificing validity. This revised numeracy scale is easier to administer and score, and therefore preferable in practical settings.

Techno-economic analysis of decentralized biomass processing depots.

Decentralized biomass processing facilities, known as biomass depots, may be necessary to achieve feedstock cost, quantity, and quality required to grow the future U.S. bioeconomy. In this paper, we assess three distinct depot configurations for technical difference and economic performance. The depot designs were chosen to compare and contrast a suite of capabilities that a depot could perform ranging from conventional pelleting to sophisticated pretreatment technologies. Our economic analyses indicate that depot processing costs are likely to range from ∼US$30 to US$63 per dry metric tonne (Mg), depending upon the specific technology implemented and the energy consumption for processing equipment such as grinders and dryers. We conclude that the benefits of integrating depots into the overall biomass feedstock supply chain will outweigh depot processing costs and that incorporation of this technology should be aggressively pursued.