Assessment of Ventilation Using Adult and Pediatric Manual Resuscitators in a Simulated Adult Patient.

BACKGROUND: The bag-valve-mask (BVM) or manual resuscitator bag is used as a first-line technique to ventilate patients with respiratory failure. Volume-restricted manual resuscitator bags (eg, pediatric bags) have been suggested to minimize overventilation and associated complications. There are studies that both support and caution against the use of a pediatric resuscitator bag to ventilate an adult patient. In this study, we evaluated the ability of pre-hospital clinicians to adequately ventilate an adult manikin with both an adult- and pediatric-size manual resuscitator bag without the assistance of an advanced airway or airway adjunct device. METHODS: This study was conducted at an international conference in 2022. Conference attendees with pre-hospital health care experience were recruited to ventilate an adult manikin using a BVM for 1 min with both an adult and pediatric resuscitator bag, without the use of adjunct airway devices, while 6 ventilatory variables were collected or calculated: tidal volume (VT), breathing frequency, adequate breaths (VT > 150 mL), proportion of adequate breaths, peak inspiratory pressure (PIP), and estimated alveolar ventilation (EAV). RESULTS: A total of 208 participants completed the study. Ventilation with the adult-sized BVM delivered an average VT of 290.4 mL compared to 197.1 mL (P < .001) when using the pediatric BVM. PIP with the adult BVM was higher than with the pediatric BVM (10.6 cm H2O vs 8.6 cm H2O, P < .001). The median EAV with the adult bag (1,138.1 [interquartile range [IQR] 194.0-2,869.9] mL/min) was markedly greater than with the pediatric BVM (67.7 [IQR 0-467.3] mL/min, P < .001). CONCLUSIONS: Both pediatric- and adult-sized BVM provided lower ventilation volumes than those recommended by professional guidelines for an adult. Ventilation with the pediatric BVM was significantly worse than with the adult bag when ventilating a simulated adult subject.

Recovery of Recurrent Laryngeal Nerve Function With Neoadjuvant Treatment: Neural Characterization.

OBJECTIVES: Neoadjuvant targeted therapy has emerged as a promising treatment strategy for locally aggressive thyroid cancer. Its impact on tumor and adjacent tissues remains a nascent area of study. Here we report on a series of six subjects with locally advanced thyroid cancer and recurrent laryngeal nerve (RLN) paralysis who experienced recovery of RLN function with neoadjuvant treatment and describe the morphologic and electrophysiologic characteristics of these recovered nerves. METHODS: This is a multicenter retrospective review. Descriptive analysis was conducted to examine the following parameters for recovered nerves: (1) nerve morphology, characterized as Type A (involving epineurium only) versus Type B (extending beyond epineurium); (2) proximal stimulability (normal vs. abnormal vs. absent); and (3) surgical management (resection vs. preservation). RESULTS: Six subjects with unilateral VFP were identified. Median time to return of VF mobility was 3 months (range 2-13.5). All nerves (100%) were noted to have Type A morphology at surgery. Proximal stimulability was normal in four subjects (66.7%), abnormal in one (16.7%), and absent in one (16.7%). Nerves that had improvement of function through neoadjuvant therapy were able to be surgically preserved in five subjects (83.3%). CONCLUSIONS: This represents the first characterization of RLNs that have recovered function with neoadjuvant treatment of locally advanced thyroid cancer. Although much remains unknown, our findings indicate carcinomatous neural invasion is a reversible process and recovered nerves may demonstrate normal morphology and electrophysiologic activity. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:3415-3419, 2024.

Development of a decision support tool to prevent community acquired pressure injuries for use in the spinal cord injury clinic using the delphi technique.

STUDY DESIGN: Delphi Technique. OBJECTIVES: Describe the development of a decision support tool to prevent community-acquired pressure injuries (CAPrIs) in individuals with spinal cord injury (SCI) for use in SCI clinics, called the Community-Acquired Pressure Injury Prevention-Field Implementation Tool (CAPP-FIT). SETTING: Veteran Health Administration Hospital, Chicago, Illinois, USA. METHODS: Concept mapping of current pressure injury (PrI) guidelines and qualitative research describing risks, actions, and resources needed to prevent CAPrIs associated with SCI were used to develop 40 veteran checklist items (Items) along with 37 associated provider actions (Actions) for the tool. The Delphi technique was used to refine Items and Actions with a panel of interprofessional SCI providers (n = 15), veterans with SCI (n = 4), and caregivers (n = 3) to determine consensus on a 4-point Likert scale (strongly agree-strongly disagree) for each Item and Action. A 75% agreement was set for responses rated as strongly agree or agree. RESULTS: Panelists were 60% female, 62% White, 33% veterans with SCI or caregivers, 33% wound care certified with a mean age of 59 years. Two survey rounds were required for consensus for 41 Item and 38 Action CAPP-FIT. Response rate was 95% for both rounds. Delphi round 1 showed all but two Actions affirming agreement above 75%. Substantive comments from panelists required revision to 5 Items and 9 Actions and one additional Item/Actions related to coping, meeting threshold percent agreement in Round 2. CONCLUSIONS: The CAPP-FIT could become a useful tool for Veterans living with SCI, caregivers, and SCI providers.

Medical Student Mentorship in the COVID-19 Era.

Background: The Covid-19 pandemic led to a reduction of in-person, guided mentorship due to social distancing and an emphasis on virtual meetings. The effect of these changes on medical students' experiences and specialty choice has yet to be studied in a large-scale manner. Objective: To determine the perspective of third- and fourth-year medical students regarding the impact of the COVID-19 pandemic on mentorship. Design: The authors distributed a modified Likert scale questionnaire (score: 1-10) to assess responses. Participants: Third- and fourth-year medical students at two large US allopathic medical schools. Main Measures: Responses to each survey item were analyzed to characterize the impact of the COVID-19 pandemic on mentorship relationships in medical school. A score of 1-5 was considered "disagree" and a score of 6-10 was considered "agree." Key Results: A total of 144 responses were collected with a response rate of 16.2%. Overall, 80.6% (n = 116) of respondents agree that the COVID-19 pandemic has had a negative impact on their medical school experience. Nearly half (41.0%, n = 59) expressed concern over the lack of mentorship opportunities, and 66.0% (n = 95) reported that the pandemic has made it more difficult to form or maintain connections with their mentors. Importantly, 43.6% (n = 61) of respondents reported that having close mentoring relationships reduced the impact of the pandemic on their medical training. While many respondents (79.9%, n = 114) did not change career plans due to the pandemic, most students are concerned about evaluating prospective residency programs (88.9%, n = 128). Notably, M3s have much lower confidence than M4s in their ability to choose a specialty (5.9 vs. 8.2, p = 6.43e - 08). Conclusions: This investigation illustrates the concerns that medical students have regarding access to mentorship opportunities due to the COVID-19 pandemic. We hope that these findings encourage medical schools to evaluate and expand their current mentorship programs. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-023-01838-4.

Traumatic blunt urethral injuries in females A retrospective study of the National Trauma Data Bank.

INTRODUCTION: Female blunt urethral injury (FBUI) is much less common than in males. Due to this rarity, studies of FBUI are largely confined to smaller case series. This study analyzes circumstances associated with FBUI and its contribution to mortality in greater detail. METHODS: Using the National Trauma Data Bank, we analyzed predictors of FBUI, and tested FBUI as a predictor of mortality. Univariate analysis used Chi-squared for categorical data and T-test for continuous data. Multivariate analysis used multiple logistic regression. RESULTS: A total of 245 (0.021%) of 1 185 904 female blunt trauma patients sustained FBUI vs. 2242 (0.145%) for males (p<0.001). Eighty-seven FBUIs (0.097%) occurred under age 16 vs. 153 (0.016%) in older patients (p<0.001). FBUI was more common with motorcycle (n=14, 0.203%), bicycle (n=11, 0.110%), and automobile vs. pedestrian accidents (n=47, 0.146%) than falls (n=72, 0.011%) or automobile accidents (n=61, 0.029%) (p<0.001). FBUI occurred in 114 (0.011%) patients with Injury Severity Score (ISS) <15 vs. 131 (0.091%) with ISS >15 (p<0.001). Slightly more than half (56.7%) of FBUI occurred with pelvic fractures. Age (odds ratio [OR ] 0.95, p<0.001), injury severity (OR 1.05, p<0.001), auto vs. pedestrian (OR 4.1, p<0.001), motorcycle crashes (OR 6.9, p<0.001), and bicycle crashes (OR 3.9, p<0.001) independently predicted FBUI. A total of 9.4% of FBUI patients died vs. 2.5% without FBUI (p<0.001). The association of FBUI with death was not significant on multivariate analysis. CONCLUSIONS: FBUI is more prevalent in young patients with high-force direct trauma. FBUI is not an independent predictor of mortality, suggesting that it is a marker of severe injury rather than a direct cause of death.

Dual utilization of Medicare and VA outpatient care among Veterans with spinal cord injuries and disorders.

OBJECTIVE: Veterans with spinal cord injuries and disorders (SCI/D) utilizing Veterans Affairs healthcare facilities are also Medicare eligible. Use of multiple health care systems potentially duplicates or fragments care in this population; yet little is known about those using multiple systems. This study describes dual use of services paid for by VA and Medicare among Veterans with SCI/D. DESIGN: Retrospective, cross-sectional, observational study. PARTICIPANTS: Veterans with SCI/D (n = 13,902) who received healthcare services within the VA SCI System of Care and were eligible for or enrolled in Medicare in 2011. INTERVENTIONS: N/A. OUTCOME MEASURES: Patient characteristics, average number of visits and patient level frequencies of reasons for visits were determined for individuals within healthcare utilization (VA only, Medicare only, or dual VA/Medicare) groups. Multinomial logistic regression analyses were used to investigate associations of patient variables on dual use. RESULTS: 65.3% of Veterans with SCI/D were VA only users for outpatient encounters, 4.4% had encounters paid for by Medicare only, and 30.3% were dual users. Veterans were less likely to be VA only users if they were older than 69 and if they had been injured for greater than ten years. African American Veterans with SCI (compared to white) were more likely to be VA only users. CONCLUSION: A substantial number (∼30%) of Veterans with SCI/D are dual users. These numbers highlight the importance of improved strategies to coordinate care and increase health information sharing across systems.

Telemedicine Use Among Physiatrists During the Early Phase of the COVID-19 Pandemic and Potential for Future Use.

Introduction: With the coronavirus disease 2019 (COVID-19) pandemic causing the need for social distancing, telemedicine saw a significant increase in use to provide routine medical care. As a field, physiatry had already been implementing telemedicine prior to the pandemic. In this study, we characterized the use of telemedicine among physiatrists during the early phase of the COVID-19 pandemic to understand the barriers and facilitators to implementing telemedicine use in the field of physiatry in the future. Methods: Online survey of a cross-sectional sample of physiatrists. Analysis was conducted using logistic regression. Results: One hundred seventy one (n = 171) participants completed the survey. Before the pandemic, only 17.5% of respondents used telemedicine. In the logistic regression, physicians who used a hospital-provided platform were more likely to use telemedicine in the future compared with those who used their own secure platform, conducted a phone visit, and used a non-secure platform or other platforms. The three most popular barriers identified were "inability to complete the physical examination," "patients lack of access to technology," and "patients lack of familiarity with the technology." Discussion: Focus on education on telemedicine functional examination strategies and technology strategies for patients and providers (including addressing the digital divide and hospital-provided secure platforms) are potential targets of implementation strategies for greater telemedicine uptake for physiatrists in the future.

Use of the Veterans Health Administration online patient portal among Veterans with spinal cord injuries and disorders.

CONTEXT/OBJECTIVE: Online patient portals like the Veteran Health Administration's (VA) My HealtheVet (MHV) may be particularly useful for Veterans with spinal cord injuries/disorders (SCI/D), many of whom experience barriers to care. The objective of this analysis was to examine MHV use among Veterans with SCI/D. DESIGN: Retrospective database analysis. SETTING: VA SCI/D System of Care. PARTICIPANTS: Veterans with SCI/D who utilize VA care. INTERVENTIONS: N/A. OUTCOME MEASURES: MHV registration and use of key portal features among Veterans who newly registered for MHV. Veteran characteristics associated with registration and use of portal features using multiple logistic regression. RESULTS: 14.6% of Veterans with SCI/D in our sample registered to use MHV. 48.7% used the medication refill feature, 28.7% used the appointment view feature, 25.0% sent or read at least one secure message and 10.8% used the Blue Button feature. Adjusted analyses indicate that having a C5-8 (OR: 1.36, CI95%: 1.06-1.76, P < 0.05) or T1-S5 (OR: 1.41, CI95%: 1.13-1.78, P < 0.01) (vs. C1-C4), having (vs. not having) neurogenic bladder (OR: 1.45, CI95%: 1.18-1.77, P < 0.01), being married (vs. not married) (OR: 2.00, CI95%: 1.67-2.39, P < 0.01), and increased healthcare utilization in the third (OR: 1.71, CI95%: 1.31-2.24, P < 0.01) and fourth (OR: 1.73, CI95%: 1.27-2.34, P < 0.01) quartiles (vs. first quartile) were associated with increased odds of MHV registration. We also identified factors associated with use of key MHV features. CONCLUSIONS: Our results suggest that MHV registration and use of key portal features was limited among Veterans with SCI/D. Effort to increase portal use in this population are warranted.

Triangulation of veteran and provider models of preventing community-acquired pressure injuries in spinal cord injury to reveal convergence and divergence of perspectives.

CONTEXT/OBJECTIVE: Community-acquired pressure injuries (CAPrI) are a common and costly complication of spinal cord injury (SCI). The majority of PrIs occur in the community, but there is little guidance in CAPrI prevention. This study describes how provider and veteran perspectives of CAPrI prevention converge and diverge. DESIGN: The Farmer triangulation method was used to compare two models from previous qualitative research describing provider and veteran perspectives of CAPrI prevention based on the framework of CAPrI risks, resources, and preventive activities. The previous qualitative research revealed the provider model of CAPrI prevention using semi-structured interviews with interprofessional SCI providers at the Veteran Health Administration (VA) (n = 30). A qualitative descriptive design using photovoice (n = 30) with or without guided tours (n = 15) revealed the Veteran model of CAPrI prevention. SETTING: The previous qualitative research was conducted at three geographically different VA spinal cord injury/disorder centers in the United States (north, south, west). PARTICIPANTS: 30 interprofessional SCI providers; 30 Veterans living with SCI at three VA SCI Centers in the United States. INTERVENTIONS: n/a. OUTCOME MEASURES: Provider-Veteran perspectives of CAPrI prevention that demonstrated agreement, partial agreement, divergence, and silence. RESULTS: Providers and veterans agreed on what is basic care, and the importance of family, caregiver and health provider/system supports, but they viewed motivation, veteran role, informal supports, and adequacy of supports differently. CONCLUSION: Understanding how SCI providers and veterans living with SCI view prevention in the community informs how to promote preventive care in the context of veterans' lives.

Provider perspectives of community-acquired pressure injury prevention in veterans with spinal cord injury.

CONTEXT/OBJECTIVE: Community-acquired pressure injuries (CAPrI) are a common and costly complication of spinal cord injury (SCI). Most studies and interventions focus on the prevention of pressure injuries acquired in the hospital. The goal of this study is to better understand SCI provider perspectives of the risks, actions and resources needed to prevent CAPrIs. DESIGN: Qualitative descriptive, semi-structured interviews of SCI providers analyzed using a deductive-inductive approach. SETTING: Three geographically different veteran health administration spinal cord injury/disorder centers. PARTICIPANTS: 30 interprofessional SCI providers. INTERVENTIONS: Not applicable. OUTCOME MEASURES: Provider perspective of risks, actions and resources for CAPrI prevention in veterans with SCI. RESULTS: 30 interviews revealed a model of provider perspectives of CAPrI prevention including veteran risk characteristics, veteran preventive activities and provider, family, community caregiving resources. CONCLUSION: Understanding provider perspectives of Veteran CAPrI preventive risks, actions and resources guides more appropriate interventions to prevent CAPrIs in individuals living with SCI.

Young age is associated with decreased recurrence for renal cell carcinoma.

INTRODUCTION: We aimed to examine stage-specific oncologic outcomes for young versus conventional-age patients with localized disease in a modern cohort. MATERIALS AND METHODS: The Surveillance, Epidemiology and End Results database was queried for patients with T1-T2N0M0 kidney cancer from 1975-2016, including clear cell, papillary, and chromophobe renal cell carcinoma. Patients were stratified into ≤ 40 years-old or > 40 years-old cohorts and underwent definitive treatment via percutaneous ablation, partial nephrectomy, or radical nephrectomy. Primary outcome was cancer-specific survival. Cox regression and Kaplan-Meier analysis were performed. RESULTS: A total of 44,673 patients were identified with 41,812 patients in the conventional-age and 2,861 patients in the young cohort with mean ages of 62.1 and 34.7 years old, respectively. The young cohort had a higher proportion of T1a disease compared to the conventional-age cohort (65.2% vs. 58.6%) and a lower proportion of the cT1b (24.4% vs. 29.3%), cT2a (6.8% vs. 8.4%), and cT2b (3.6% vs. 3.7%) disease. Chromophobe histology was more prevalent in the younger population (10.5% vs. 6.6%). Nuclear grade 3 or 4 were more prominent in the conventional-age population (24.8% vs. 19.1%). Cancer-specific death was significantly higher in the conventional-age cohort (2.4% vs. 0.7%). Cox regression analysis demonstrated patients > 40 years old, increasing stage, and higher grade were at independently increased risk of cancer-specific death. Kaplan-Meier analysis showed significantly improved 5-year cancer-specific survival for the young versus conventional-age cohorts when sub-stratified by stage. CONCLUSION: When stratified by stage, young patients with localized kidney cancer experience improved cancer-specific survival.

Current Approaches in Telehealth and Telerehabilitation for Spinal Cord Injury (TeleSCI).

Purpose of Review: Telehealth and telerehabilitation in spinal cord injury (teleSCI) is a growing field that can improve access to care and improve health outcomes in the spinal cord injury population. This review provides an overview of the recent literature on the topic of teleSCI and provides insights on current evidence, future directions, and considerations when using teleSCI for clinical care. Recent Findings: TeleSCI is used most often for preventive health; management of chronic pain, anxiety, and depression; and rehabilitation-related interventions. As video telehealth becomes mainstream, growth in wearable monitors, bio and neurofeedback mechanisms, and app-based care is expected. Summary: TeleSCI is growing in prevalence, demonstrates positive impact on health outcomes, and requires ongoing study to identify, refine, and implement best practices.

Increasing rate of pathologic upgrading in low risk prostate cancer patients in the active surveillance era.

INTRODUCTION: Management of prostate cancer has seen an increasing predilection for active surveillance in low risk (LR) patients. We aimed to evaluate the rate of pathologic upgrading in patients with very low (VLR) or LR prostate cancer after prostatectomy. MATERIALS AND METHODS: The National Cancer Database (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) Database were queried for patients diagnosed with Gleason 6 prostate cancer and prostate specific antigen (PSA) < 10 ng/mL from 2010 to 2016. All patients underwent 12-core biopsy and a subsequent prostatectomy for final pathologic staging. Our primary outcome was rate of pathologic upgrading over the study period. RESULTS: A total of 35,332 patients from the NCDB and 7,186 patients from the SEER database were collected. Patient population had an average age of about 59 years old and was over 80% white. Mean pre-biopsy PSA was higher for the upgraded cohorts in the NCDB and SEER populations (5.3 versus 4.9 and 5.5 versus 5.1 respectively, p < 0.001). Upgraded cohorts were more likely to have a higher percentage of positive cores at biopsy (p < 0.001). Multivariable analysis demonstrated that increasing age, increasing PSA and year of diagnosis were all predictors of upgrading (p < 0.05) in both databases. African American race was significantly associated with upgrading in the NCDB database only (p = 0.001). Over the studied time period, the rate of upgrading at prostatectomy increased from 41.2% to 56.7% in the NCDB population and from 41.9% to 45.4% in the SEER population. CONCLUSIONS: The rate of pathologic upgrading of VLR and LR prostate cancer at prostatectomy has been increasing in recent years. Increasing age, pre-biopsy PSA and an increasing percentage of positive cores at biopsy are predictors of this outcome. This may relate to improved patient selection for active surveillance and definitive treatment.

The Distribution of Metastatic Renal Cell Carcinoma by Presenting Tumor Stage in the Modern Era.

INTRODUCTION: There is a stage migration for detection of kidney cancer, thus we aim to evaluate the distribution of metastatic renal cell carcinoma by presenting clinical T stage over time. MATERIALS AND METHODS: The National Cancer Database was evaluated for patients with metastatic kidney cancer from 2010 to 2016. The primary outcome was the temporal trend of presenting clinical T stage over time. The secondary outcome was overall survival. Kaplan-Meier and Cox regression analyses were performed. RESULTS: The incidence of metastatic kidney cancer has increased, from 3426 new cases in 2010 to 4510 in 2016. While diagnosis of metastasis has increased for all tumor stages over time, there has been a more rapid increase in metastasis of localized renal masses (cT1-T2) as compared to locally advanced disease (cT3-T4). In 2010, 46% of the new metastatic cases diagnosed were cT3-T4, while in 2016 this proportion decreased to 38.2%. Conversely, metastatic cases with cT1-T2 tumors increased from 54% in 2010 to 61.9% in 2016. Cox regression noted an increased risk of death correlating with higher clinical T stage. On Kaplan Meier analysis, the 2-year survival was 29.3%, 30.3%, 28.3%, and 16.0% for cT1, cT2, cT3, and cT4, respectively (logrank P < .001). CONCLUSION: Metastatic kidney cancer is increasingly diagnosed at a lower presenting cT stage. Survival outcomes worsen with increasing cT stage in the setting of metastasis.

Promoting informed prostate cancer screening decision-making for African American men in a community-based setting.

PURPOSE: Current screening guidelines for prostate cancer (PCa) encourage men to make individual screening decisions after consulting with their primary care provider to weigh the risks and benefits of undergoing prostate specific antigen (PSA) testing, but many men at high risk of PCa diagnosis (notably African American men) are more likely to be uninsured and lack a primary care provider. An academic-community partnership redesigned its community-based screening program to ensure access to services for African American men, incorporating a session with a trained clinical educator in community settings, designed to increase knowledge and promote informed decision-making regarding PSA testing. This study evaluated effects of the intervention on decision-making outcomes. METHODS: To evaluate program efficacy, 88 men completed pre- and post-test surveys assessing outcomes of interest. RESULTS: Participants' knowledge, beliefs, attitudes, anxiety levels, and self-efficacy all improved from pre- to post-test at a statistically significant level. Most notably participants' awareness that PCa is often not life-threatening, and watchful waiting is a reasonable treatment option increased after the encounter. More than half of the study sample felt they had received enough knowledge to make an informed decision about whether the PSA test was right for them. CONCLUSION: Our findings show the program had positive effects on men's ability to make informed decisions about PCa screening and demonstrate that educational outreach programs with an emphasis on informed decision-making can effectively balance screening guidelines with the needs of underserved populations in community settings to improve outcomes.

Capture rates of comorbidity measures at inpatient rehabilitation facilities after a stroke or brain injury.

BACKGROUND: Comorbidity indices have been used to represent the overall medical complexity of patient populations in clinical research; however, it is not known how well they capture the comorbidities of patients with a stroke or brain injury admitted to inpatient rehabilitation facilities (IRFs). OBJECTIVE: To determine how well commonly used comorbidity indices capture the comorbidities of patients admitted to IRFs after a stroke or brain injury. DESIGN: Cross-sectional, retrospective study. SETTING: IRFs nationwide. PARTICIPANTS: Adults from four impairment groups: (1) hemorrhagic stroke, (2) ischemic stroke, (3) nontraumatic brain injury (NTBI), and (4) traumatic brain injury (TBI). MAIN OUTCOME MEASURES: International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes were extracted from the Uniform Data System for Medical Rehabilitation (UDSMR) for IRF discharges from October 1, 2015 to December 31, 2017. The percentage of discharges captured by Deyo-Charlson, Elixhauser, and Centers for Medicare and Medicaid Services (CMS) tiers was determined, as was the percentage of comorbidities captured. These measures were also compared with respect to their ability to capture chronic medical complexity by examining the percentage of codes captured after removal of codes deemed to represent hospital complications or sequela of the admission diagnosis. RESULTS: The percentage of discharges without at least one ICD-10-CM code captured by any index ranged from 0.3%-3.8%. The percentage of comorbidities with a prevalence exceeding 1% captured by at least one index ranged from 37.1%-43.6%. Chronic comorbidities were most likely to be captured by Elixhauser (40.7%-44.4%), followed by Deyo-Charlson (7.8%-9.6%), then CMS tiers (4.5%-6.9%). Existing comorbidity measures capture most IRF discharges related to a brain injury or stroke, whereas most medical comorbidities escape representation. Several common, functionally relevant diagnoses were not captured. CONCLUSION: The use of comorbidity indices in the IRF neurologic injury population should account for the fact that these measures miss several common, important comorbidities.

Veteran model of preventing community-acquired pressure injuries associated with spinal cord injury: A qualitative descriptive study.

CONTEXT/OBJECTIVE: Pressure injuries (PrIs) are the second leading cause of hospitalization in people with spinal cord injury (SCI). The majority of PrIs occur in the community, but there is little known about prevention of community acquired PrI (CAPrI). The purpose of this study was to better understand risks, resources, and actions associated with CAPrI prevention from the perspective of veterans living with SCI in the community. METHODS: A qualitative descriptive design using photovoice (n = 30) with or without guided tours (n = 15) was conducted with Veterans living with SCI at 3 sites across the United States to determine environmental/lifestyle risks at home, prevention activities, resources used, and challenges in CAPrI prevention. Interviews were audio-recorded, transcribed and analyzed using thematic analysis, followed by inductive thematic synthesis. RESULTS: Qualitative analyses revealed a model describing veteran's perspective of preventing CAPrIs associated with SCI. The model included 3 themes and 9 subthemes: Factors that Lead to Risk for Pressure Injury (Challenges and Barriers), Factors that Affect Chosen Actions (Veteran Motivators, Veteran Values, Veteran Satisfaction with Provider Relationships, and Veteran Supports), and Preventive Activities within Context of Life (Physical Care, Coping, Advocacy). CONCLUSION: Incorporating the veteran model of prevention within the context of life into clinical care could support provider-veteran collaboration to identify and integrate successful strategies that prevent CAPrIs while also improving veteran quality of life.

Minimally invasive management versus open surgery in the treatment of penetrating bladder injuries: a retrospective cohort study.

BACKGROUND: While blunt extra-peritoneal bladder injury is typically treated non-operatively or with minimally invasive management, the treatment for penetrating bladder injury is generally open surgery. We identify a group of patients with penetrating bladder injury who were treated with minimally invasive management and compare the results with those who underwent traditional open surgical treatment. METHODS: This retrospective cohort study analyzes penetrating bladder injuries from a single trauma center from 2012 through 2019, and from the National Trauma Data Bank for 2016 and 2017. Mortality, complications, and length of stay were compared for minimally invasive management versus open surgery. We used Chi square to test significance for categorical variables, Mann-Whitney U test for ordinal variables, and T-test for continuous variables. Multivariate analysis was performed with multiple logistic, ordinal, and linear regression. RESULTS: Local: 117 (0.63%) had a bladder injury; 30 (25.6%) were penetrating. 6 (20.0%) were successfully treated with minimally invasive management with no complication versus 24 complications in 11 patients (45.8%) for open surgery (p = 0.047). Open surgical management was not a significant independent predictor of mortality or hospital length of stay. National Trauma Data Bank: 5330 (0.27%) had a bladder injury; 963 (19.5%) were penetrating. 97 (10.1%) were treated with minimally invasive management. The minimally invasive management group had 12 complications in 5 patients (4.9%) versus 280 complications in 169 patients (19.7%) for open surgery (p = < 0.001). Open surgery was a significant independent predictor of complications (OR 1.57, p = 0.003) and longer hospital length of stay (B = 5.31, p < 0.001). CONCLUSIONS: Most penetrating bladder injury requires open surgery, however a small proportion can safely be managed with minimally invasive management. Minimally invasive management is associated with lower total complications and shorter hospital length of stay in select patients.

Clinical characteristics of renal cell carcinoma in patients under the age of 40.

BACKGROUND: Renal cell carcinoma (RCC) most commonly afflicts older patients while those 40 years old or younger represent an uncommon population. We aim to describe the tumor characteristics and treatment patterns for young kidney cancer patients utilizing the National Cancer Database. METHODS: The National Cancer Database Participant User File for RCC was queried from 2004 to 2016. Demographics and treatment trends were analyzed and compared between a young cohort, those aged 40 and younger vs. a conventional cohort, those older than 40. Pathology analyzed included clear cell, papillary, chromophobe, RCC not otherwise specified, and miscellaneous uncategorized. Subanalysis was performed for patients with localized disease and treatment type. RESULTS: Amongst the 514,879 patients diagnosed with RCC, 4.7% were ≤40 years old. RCC for individuals ≤40 has a higher proportion of female gender, non-Caucasian race, and chromophobe pathology, relative to the conventional cohort. Younger patients more often presented with cT1 disease with decreased rates of metastasis. Risk of 30-day readmission after surgery was similar between cohorts. For patients with cT1-2N0M0 disease, there was a decreasing rate of radical nephrectomy and increasing rate of partial nephrectomy; however, the conventional cohort had an increasing rate of percutaneous ablation while this remained stable in the younger cohort. CONCLUSION: Young RCC patients had a higher proportion of female gender, chromophobe histology, and favorable tumor characteristics. Partial nephrectomy has seen a dramatic increase in application regardless of age while percutaneous ablation increased only in the conventional cohort.

Contemporary analysis of epididymal tumors using a national database.

INTRODUCTION: Epididymal tumors are rare malignancies with sparse research available to guide recommendations. We sought to characterize malignant epididymal tumors in the United States using population level data. MATERIAL AND METHODS: The Surveillance, Epidemiology, and End-Results database was queried for patients diagnosed with malignant epididymal tumors between 1975-2016. International classification of disease for oncology code C63.0 was used to identify population with disease of interest. Primary objective was to characterize patient demographics, disease characteristics, and management. Secondary objectives included overall and cancer-specific survival (CSS) utilizing Kaplan-Meier (KM) analysis. RESULTS: A total of 66 cases of malignant epididymal tumors were identified during the study period. The cohort was largely white (84.8%), with a mean age of diagnosis of 46.9 years old. The predominant histology consisted of rhabdomyosarcoma 26%, leiomyosarcoma 23%, liposarcoma 17%, adenocarcinoma 9%, and malignant fibrous histiocytoma 5%. During histopathological assessment, 21.1% of tumors were classified as high-grade while 71.2% exhibited sarcomatoid elements. Majority of patients presented with localized disease (68.2%), whereas regional (18.2%) and distant (13.2%) disease was less frequently discovered. All patients were diagnosed by surgical therapy consisting of radical epididymectomy (39.4%), partial epididymectomy (27.3%) or 'unknown surgery' (33.3%). Meanwhile, 15.2% and 34.8% received radiation and chemotherapy, respectively. KM analysis revealed an 84.9% CSS at 5-years. Over 60% of documented cases have arisen since 2000, with 3.0% of the cohort diagnosed in 2016, increased from 1.5% of the diagnoses in 1975. CONCLUSIONS: Malignant epididymal tumors are exceedingly rare and typically present with localized disease. Surgical excision is associated with an estimated 85% CSS at 5-years.