The Kidney Transplant: Maintaining Excellent Outcomes While Increasing Skills Acquisition.

OBJECTIVE/BACKGROUND: Kidney transplantation is a complex operation that incorporates multiple fundamental surgical techniques and is an excellent opportunity for surgical skill development during residency training. We hypothesized that increasing resident competency, measured as anastomosis time, could be demonstrated while maintaining high-quality surgical outcomes during the learning process. METHODS: We performed a retrospective cohort study of surgical resident involvement in kidney transplantation and recorded the anastomosis time. The study population comprised adult, single organ kidney transplants (n = 2052) at a large academic transplant center between 2006 and 2019. Descriptive statistics included frequencies, medians, and means. A mixed model of anastomosis time on number of procedures was fitted. Poisson models were fitted with outcomes of the number of patients with delayed graft function and number of patients that underwent reoperation postoperatively, with the exposure being number of kidney transplants performed by resident. RESULTS: Results from the mixed model suggest that as the number of times a resident performs the surgery increases, the time to conduct the operation decreases with statistical significance. The Poisson regression demonstrated no significant relationship between the operative volume of a resident and postoperative complications. CONCLUSION: This study demonstrated statistical evidence that with an increase in the number of renal transplantations performed by a surgical resident, anastomosis time decreased. It also demonstrated no significant relationship between number of kidney transplants performed by a resident and postoperative complications, suggesting that patient outcomes for this operation are not adversely affected by resident involvement.

Analysis of Need for Intervention in Low-Grade Traumatic Splenic Injury.

BACKGROUND: Blunt splenic injuries are common traumatic injuries. Severe injuries may require blood transfusion, procedural, or operative intervention. Conversely, patients with low-grade injuries and normal vital signs frequently do not require intervention. The level and duration of monitoring required to safely manage these patients are unclear. We hypothesize that low-grade splenic trauma has a low rate of intervention and may not require acute hospitalization. METHODS: This retrospective descriptive analysis included patients admitted to a level I trauma center with low injury burden (injury severity score <15) and The American Association for the Surgery of Trauma (AAST) grade 1 (G1) and 2 (G2) splenic injuries between January 2017 and December 2019 using the Trauma Registry of the American College of Surgeons (TRACS). The primary outcome was the need for any intervention. Secondary outcomes included time to intervention and length of stay. RESULTS: 107 patients met inclusion criteria. 87.9% required no intervention . 9.4% required blood products, with a median time to transfusion of 7.4 hours from arrival. All patients receiving blood products had extenuating circumstances such as bleeding from other injuries, anticoagulant use, or medical comorbidities. 2 patients required splenic artery embolization, one presenting with return precautions 9 days post-injury and 1 with significant comorbidities. One patient with concomitant bowel injury required splenectomy. CONCLUSIONS: Low-grade blunt splenic trauma has a low rate of intervention, which typically occurs within the first 12 hours of presentation. This suggests that outpatient management with return precautions may be appropriate for select patients after a short interval of observation.

Perspectives from women who engaged in prenatal and postpartum cannabis use in a U.S. State with legal non-medical use.

Evidence suggests fetal risks are associated with cannabis use during pregnancy. Yet, insights into women's decision-making and cannabis use during pregnancy are limited. This study explored these concepts with postpartum women who used cannabis during and after pregnancy. We conducted interviews with 15 women (4 self-identifying a race other than White and 4 self-identifying Hispanic ethnicity) who: 1) lived in the Puget Sound region of Washington State, 2) reported past-year cannabis use on a routine screen, and 3) had documented pregnancy and delivery March 2015-May 2017. Semi-structured interviews asked about decision-making and cannabis use during pregnancy and postpartum. We used template analysis for coding and analysis. The key findings included that women: 1) gathered information about cannabis use during pregnancy primarily through internet searches and discussions with peers; 2) were reluctant to talk with health care providers about cannabis; 3) used cannabis while pregnant to treat health issues, including morning sickness, pain, and mental health conditions; 4) were comfortable with their decision to use cannabis while pregnant, but had questions about long-term effects; and 5) tried to mitigate transmission through breastmilk. Women decided about cannabis during pregnancy based on their experience, health symptoms, and information gathered from the internet and peers, often without guidance from their health care provider. Results point to opportunities for providers to become informed about and engage in discussion with patients about cannabis use during preconception, pregnancy, and postpartum.

A Generic Closed-Loop Contaminant Treatment System Package for MODFLOW 6.

We present a contaminant treatment system (CTS) package for MODFLOW 6 that facilitates the simulation of pump-and-treat systems for groundwater remediation. Using the "nonintrusive" MODFLOW 6 application programming interface (API) capability, the CTS package can balance flows between extraction and injection wells within the outer flow solution loop and applies blended concentration/mass treatment efficiency within the outer transport solution loop. The former can be important when the requested extraction rate cannot be satisfied by the current simulated groundwater system conditions, while the latter can be important for simulating incomplete/imperfect treatment schemes. Furthermore, the CTS package allows users to temporally vary all aspects of a simulated CTS system, including the configuration and location of injection and extraction wells, and the CTS efficiency. This flexibility combined with the API-based implementation provide a generic and general CTS package that can be applied across the wide range of MODFLOW 6 simulation options and that evolves in step with MODFLOW 6 code modifications and advancements without needing to update the CTS package itself.

The Cancer Financial Experience (CAFÉ) study: randomized controlled trial of a financial navigation intervention to address cancer-related financial hardship.

BACKGROUND: There is an urgent need for evidence on how interventions can prevent or mitigate cancer-related financial hardship. Our objectives are to compare self-reported financial hardship, quality of life, and health services use between patients receiving a financial navigation intervention versus a comparison group at 12 months follow-up, and to assess patient-level factors associated with dose received of a financial navigation intervention. METHODS: The Cancer Financial Experience (CAFÉ) study is a multi-site randomized controlled trial (RCT) with individual-level randomization. Participants will be offered either brief (one financial navigation cycle, Arm 2) or extended (three financial navigation cycles, Arm 3) financial navigation. The intervention period for both Arms 2 and 3 is 6 months. The comparison group (Arm 1) will receive enhanced usual care. The setting for the CAFÉ study is the medical oncology and radiation oncology clinics at two integrated health systems in the Pacific Northwest. Inclusion criteria includes age 18 or older with a recent cancer diagnosis and visit to a study clinic as identified through administrative data. Outcomes will be assessed at 12-month follow-up. Primary outcomes are self-reported financial distress and health-related quality of life. Secondary outcomes are delayed or foregone care; receipt of medical financial assistance; and account delinquency. A mixed methods exploratory analysis will investigate factors associated with total intervention dose received. DISCUSSION: The CAFÉ study will provide much-needed early trial evidence on the impact of financial navigation in reducing cancer-related financial hardship. It is theory-informed, clinic-based, aligned with patient preferences, and has been developed following preliminary qualitative studies and stakeholder input. By design, it will provide prospective evidence on the potential benefits of financial navigation on patient-relevant cancer outcomes. The CAFÉ trial's strengths include its broad inclusion criteria, its equity-focused sampling plan, its novel intervention developed in partnership with clinical and operations stakeholders, and mixed methods secondary analyses related to intervention dose offered and dose received. The resulting analytic dataset will allow for rich mixed methods analysis and provide critical information related to implementation of the intervention should it prove effective. TRIAL REGISTRATION: ClinicalTrials.gov NCT05018000 . August 23, 2021.

Patient and Family Preferences on Health System-Led Direct Contact for Cascade Screening.

Health benefits to relatives of people at known genetic risk for hereditary cancer syndromes is key to realizing the promise of precision medicine. We conducted a qualitative study to design a patient- and family-centered program for direct contact of relatives to recommend cascade genetic testing. We conducted two rounds of data collection using focus groups followed by individual interviews with patients with HBOC or Lynch syndrome and a separate sample of people with a family history of hereditary cancers. Results indicate that U.S.-based health system-led direct contact of relatives is acceptable to patients and families, should take a programmatic approach, include consent of relatives before proband testing, complement to existing patient-mediated disclosure, and allow for relative control of information. Our findings suggest a set of requirements for U.S.-based direct contact programs that could ultimately benefit more relatives than current approaches.

Investigating Bias from Missing Data in an Electronic Health Records-Based Study of Weight Loss After Bariatric Surgery.

PURPOSE: Missing data is common in electronic health records (EHR)-based obesity research. To avoid bias, it is critical to understand mechanisms that underpin missingness. We conducted a survey among bariatric surgery patients in three integrated health systems to (i) investigate predictors of disenrollment and (ii) examine differences in weight between disenrollees and enrollees at 5 years. MATERIALS AND METHODS: We identified 2883 patients who had bariatric surgery between 11/2013 and 08/2014. Patients who disenrolled before their 5-year anniversary were invited to participate in a survey to ascertain reasons for disenrollment and current weight. Logistic regression was used to investigate predictors of disenrollment. Five-year percent weight change distributions were estimated using inverse-probability weighting to adjust for (un)availability of EHR weight data at 5 years among enrollees and survey (non-)response among disenrollees. RESULTS: Among 536 disenrolled patients, 104 (19%) completed the survey. Among 2347 patients who maintained enrollment, 384 (16%) had no weight measurement in the EHR near 5 years. Insurance, age, Hispanic ethnicity, and site predicted disenrollment. Disenrollees had slightly greater weight loss than enrollees. CONCLUSION: We found little evidence of weight loss differences by enrollment status. Collecting information through surveys can be an effective tool to investigate and adjust for missingness in EHR-based studies.

Implementation of General Surgery Care into a Student-Run Free Clinic.

BACKGROUND: Student-run free clinics (SRFCs) provide medical care to uninsured, and surgical issues are often outside the normal scope of care of these clinics. The Shade Tree Clinic (STC) is an SRFC serving 300 patients with complex medical conditions. This study describes the implementation and efficacy of a General Surgery Specialty Clinic in this setting. METHODS: This descriptive study examines the demographics and referral patterns of patients seen in two pilot Specialty Clinics and other patients evaluated for general surgical issues from December 2017 to January 2020. Providers were surveyed regarding their experience in clinic. RESULTS: Twenty patients were evaluated by six general surgeons during 22 separate encounters (n = 20). Nine patients were seen in two pilot Specialty Clinics for biliary colic, hernia, hemorrhoids, anal mass, toenail lesion, surgical weight loss, and venous insufficiency. Referrals from these clinics to affiliated Vanderbilt University Medical Center included six ultrasounds; referrals to vascular surgery and podiatry clinics; and referrals for laparoscopic cholecystectomy and anal mass excision. STC also directly referred eight patients for colonoscopies and five patients for major operations through primary care clinic. Hundred percent of care was cost-free to patients. Providers reported a median satisfaction score of five with the Specialty Clinics (Very Satisfied; [4, 5]). Hundred percent of providers felt that the concerns of patients were addressed. CONCLUSIONS: A surgery specialty clinic in the setting of an SRFC is an effective way to provide surgical care to underserved populations with the potential to reduce unplanned hospital utilization.

Molecular Cytogenetic Characterization of a Three-way t(8;14;22)(q24;q32;q11.2) with Involvement of MYC/IGH/IGL in a Case of a Diffuse Large B-cell Lymphoma (DLBCL).

OBJECTIVES: Diffuse large B-cell lymphoma (DLBCL) is a non-Hodgkin's lymphoma (NHL) that is the most common and the most aggressive or fast-growing form of NHL. It can lead to death if left untreated. Cytogenetic abnormalities include rearrangements of the IgH and BCL2 genes. Herein we described a t(8;14;22)(q24;q32;q11.2) within the context of a complex karyotype involving MYC/IGH/IGL in a three-way translocation that was characterized by molecular cytogenetics. The t(8;14)(q24;q32) is a recurrent chromosome abnormality described in non-Hodgkin lymphomas (NHL), especially in 80% of Burkitt lymphoma (BL) and diffuse large B-cell lymphomas. The variant t(8;22) (q24;q11) is also seen in these cases. MYC rearrangements have been observed in up to 10% of cases of diffuse large B-cell lymphomas (DLBCL) and is usually associated with a complex pattern of genetic alterations. This particular pattern with IGH-MYC rearrangements within the context of complex karyotypes is seen in diffuse large B-cell lymphomas. Complex karyotypes are associated with genomic instability and a poor prognosis.

Head & neck cancers: What you'll see, how to proceed.

What physical findings should raise your suspicion? How are tumors treated and what follow-up care can you provide? Here's what you need to know.

Acute Hand Infections.

Acute hand infections are often caused by puncture wounds and are generally classified into superficial or deep infections. Superficial infections occur in the skin and subcutaneous tissues, whereas deep infections can involve the tendon sheaths, adjacent anatomic compartments, deep fascial planes, bursae, joint spaces, and bones. Superficial hand infections are more common than deep infections and are typically managed with elevation, warm soaks, splinting in the position of function, analgesics, and empiric antibiotics when indicated. Paronychia, which can be acute or chronic, is an infection or inflammation of the nail fold. Treatment involves warm soaks, topical antibiotics, and abscess drainage, if indicated. A felon is an infection of the distal pulp of the finger. Treatment often involves surgical drainage and empiric oral antibiotics. Herpetic whitlow is caused by herpes simplex virus and typically resolves without intervention. Deep hand infections include pyogenic flexor tenosynovitis and clenched-fist bite wounds. Pyogenic flexor tenosynovitis is a rapidly progressing bacterial infection of the flexor tendon sheaths in the hand, most commonly caused by a penetrating injury to the finger. Clenched-fist bite wounds result from direct contact of the fist on incisor teeth and are associated with polymicrobial infections. Empiric antibiotics and prompt surgical consultation are indicated to reduce long-term morbidity.

Technology Use Among Youth While Operating Farm Equipment.

Distracted driving by using modern technologies has been linked with increased risk of injuries, however, the current research has focused primarily on the use of technology while operating roadway vehicles. The purpose of this study was to explore the use of technology while operating farm equipment among members of an agricultural youth organization (Pennsylvania FFA Association members). An online survey was used to examine the use of technology while operating a tractor, ATV/UTV, skid steer, and truck/car. Survey responses with 10 types of technology use were analyzed in relation to a wide variety of factors including frequency of use, safety beliefs, safety concern, and seeing others using technology. One hundred forty-three youth completed the questionnaire in 2017. Eighty-eight percent of youth surveyed used technology to some extent while operating farm equipment. Self-reported technology use was most influenced by safety beliefs and seeing others using technology while operating farm equipment regardless of the farm equipment type. Findings from this study provide insights into factors behind technology use while engaged in farm work-related driving by youth.

Patient counseling materials: The effect of patient health literacy on the comprehension of printed prescription drug information.

BACKGROUND: Counseling patients with written materials relies equally on patients' health literacy to understand their disease and its treatment, and the written materials' effectiveness communicating clearly in accessible and actionable ways. Only about 12% of the US population is adequately health literate. OBJECTIVES: To explore the impact of reducing the health literacy demands of written patient health information. METHODS: 805 patients were screened for health literacy, and recruited for balanced cohorts of adequate and low literacy, and high and normal blood pressure. Half of each patient cohort received either standard or "health literacy-friendly" drug summaries (i.e. Patient Package Inserts, or PPIs or "leaflets") along with a standardized health literacy assessment scale. RESULTS: The literacy-friendly drug summary improved comprehension of drug-related information overall from 50% to 71% correct responses. Adequate literacy patients improved from 58% correct to 90%, while lower literacy patients improved from 42% to 52% correct in response to the health literacy-friendly PPIs. CONCLUSIONS: Health literacy demands require special attention in developing and using written drug summary materials. Additionally, pharmacists should be provided additional information and counseling support materials to facilitate communications with low health literacy level patients.

The use of intramuscular benzodiazepines and antipsychotic agents in the treatment of acute agitation or violence in the emergency department.

The management of an agitated, abusive or violent patient is a common and challenging problem in Emergency Medicine. Priorities include measures to ensure the safety of the patient and the emergency staff, including provision of physical restraint of the patient and evaluation for correctable medical causes of such behavior. Medications used in the treatment of such patients include benzodiazepines and antipsychotic agents. The newer atypical antipsychotic agents seem to provide a safe and effective treatment for such patients. The atypical antipsychotic agents may have fewer short-term side effects than older typical antipsychotic agents, such as haloperidol and droperidol. Currently available atypical antipsychotic medications for the treatment of acute agitation include ziprasidone and olanzapine, which can be administered in an intramuscular formulation, and risperidone, which is available in a rapidly dissolvable tablet and liquid formulation.

The hedgehog pathway is a modulator of retina regeneration.

The embryonic chick has the ability to regenerate its retina after it has been completely removed. Here, we provide a detailed characterization of retina regeneration in the embryonic chick at the cellular level. Retina regeneration can occur in two distinct manners. The first is via transdifferentiation, which is induced by members of the Fibroblast growth factor (Fgf) family. The second type of retinal regeneration occurs from the anterior margin of the eye, near the ciliary body (CB) and ciliary marginal zone (CMZ). We show that regeneration from the CB/CMZ is the result of proliferating stem/progenitor cells. This type of regeneration is also stimulated by Fgf2, but we show that it can be activated by Sonic hedgehog (Shh) overexpression when no ectopic Fgf2 is present. Shh-stimulated activation of CB/CMZ regeneration is inhibited by the Fgf receptor (Fgfr) antagonist, PD173074. This indicates that Shh-induced regeneration acts through the Fgf signaling pathway. In addition, we show that the hedgehog (Hh) pathway plays a role in maintenance of the retina pigmented epithelium (RPE), as ectopic Shh expression inhibits transdifferentiation and Hh inhibition increases the transdifferentiation domain. Ectopic Shh expression in the regenerating retina also results in a decrease in the number of ganglion cells present and an increase in apoptosis mostly in the presumptive ganglion cell layer (GCL). However, Hh inhibition increases the number of ganglion cells but does not have an effect on cell death. Taken together, our results suggest that the hedgehog pathway is an important modulator of retina regeneration.