A Comparison of Adverse Short-Term Outcomes After Forefoot Amputation Based on Patient Height.

BACKGROUND: The objective of this investigation was to evaluate adverse short-term outcomes after partial forefoot amputation with a specific comparison performed based on patient height. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was analyzed to select patients with a 28805 Current Procedural Terminology code (amputation, foot; transmetatarsal) who underwent the procedure with "all layers of incision (deep and superficial) fully closed." This resulted in 11 patients with a height of 60 inches or less, 202 with a height greater than 60 inches and less than 72 inches, and 55 with a height of 72 inches or greater. RESULTS: Results of the primary outcome measures found no significant differences among groups with respect to the development of a superficial surgical site infection (0% versus 6.4% versus 5.5%; P = .669), deep incisional infection (9.1% versus 3.5% versus 10.9%; P = .076), or wound disruption (0% versus 5.4% versus 5.5%; P = .730). In addition, no significant differences were observed among groups with respect to unplanned reoperations (9.1% versus 16.8% versus 12.7%; P = .630) or unplanned hospital readmissions (45.5% versus 23.3% versus 20.0%; P = .190). CONCLUSIONS: The results of this investigation demonstrate no differences in short-term adverse outcomes after partial forefoot amputation with primary closure based on patient height. Although height has previously been described as a potential risk factor in the development of lower-extremity pathogenesis, this finding was not observed in this study from a large US database.

A school-based health centre partnership: Faculty practice, nursing student learning and wellness in youth, families and community.

AIMS AND OBJECTIVES: This paper describes the development of a SBHC with an innovative model of care that grew out of a partnership between a public-school district and a university nursing programme in the midwestern region of the United States. BACKGROUND AND PURPOSE: Persistent barriers to health and health care experienced by youth are well documented. School-based health centres (SBHCs) can improve educational and health outcomes, positively impacting health equity. Academic systems are positioned to address health care needs of the school-aged population, yet educators face challenges of accessing quality learning placements for students and faculty practice sites. METHODS: A community-based collaborative methodology guided the planning phases that were driven by priority needs identified by families and stakeholders. With the mission of "partnering with students, families, and communities in the promotion of health and wellness through engagement in practice, education, and research," an ongoing dialogue over a two-year period led to articulating a vision, designing a plan and implementing a nurse-managed SBHC. The Standards for Reporting Qualitative Research (SRQR) checklist was considered in the preparation of this paper. RESULTS: In three years, this SBHC has addressed and identified priority needs and served individual youth and families. The SBHC provides opportunities for the faculty to fulfil a practice requirement for certification and accreditation. Nursing students engage with youth and families in health education and health promotion while strengthening their technical and relational skills. Family nurse practitioner students gain valuable clinical experience. Faculty with expertise in family nursing guide family assessments, support family resiliency and direct therapeutic conversations with family units. CONCLUSION: SBHCs serve youth, families, and community. This academic-practice partnership has the added benefit of providing faculty practice opportunities and nursing student experiential learning. RELEVANCE TO CLINICAL PRACTICE: SHBCs provide practice opportunities that address needs in individuals, families, and communities. Partnerships should be considered at academic nursing programmes to support their needs and fulfil commitments to address health equity gaps.

Advancing the Practice of Family Presence During Resuscitation: A Multifaceted Hospital-Wide Interprofessional Program.

BACKGROUND: After 3 decades of research, much is understood about the benefits of family presence during resuscitation (FPDR), yet translation into clinical practice has been lagging. This article provides guidance for nurse leaders seeking to advance FPDR by sharing the experience of establishing a multifaceted, hospital-wide program of education and policy development. OBJECTIVES: This quality improvement project aimed to (1) implement a hospital-wide FPDR program guided by policy, (2) evaluate classroom and simulation educational interventions, (3) examine chart review data for evidence of FPDR practice change, and (4) act on information learned to further improve the FPDR program and increase practice implementation. METHODS: The Plan-Do-Study-Act (PDSA) cycle provided the model for cyclic evaluation of the FPDR program at a rural Midwestern United States hospital. Interventions were classroom education for existing nursing staff, simulation for new nurses, and implementation of a hospital-wide policy. Outcome measures included nurses' perceptions of FPDR risks and benefits, self-confidence with FPDR, and evidence of practice change via retrospective chart review. RESULTS: Pilot data demonstrated a statistically significant improvement in nurses' perceptions of FPDR benefits and self-confidence post education, and the rate of FPDR practiced in the facility tripled. The PDSA cycle provided a useful paradigm for ongoing process improvement and program sustainability. DISCUSSION: After the delivery of an FPDR policy along with classroom and simulation education, an increase in the clinical implementation of FPDR occurred. The use of the PDSA cycle resulted in expanded approaches including the addition of FPDR to in situ mock codes.

Perceived Concerns of Patients at Risk for Lower Extremity Amputation.

Despite a good understanding of risk factors for amputation and the development of multidisciplinary amputation prevention teams, thousands of lower limb amputations are performed on a daily basis. These amputations are often transformative events in the lives of patients with functional, psychological, social, and economic implications. OBJECTIVE: The objective of this investigation is to qualitatively and quantitatively explore the perceived concerns of patients with chronic wounds at risk for lower extremity amputation. MATERIALS AND METHODS: A guided, physician-administered survey was completed by consenting participants. The survey consisted of both open-ended questions and a 10-point scale for specific questions on a variety of potential patient concerns. RESULTS: Although some questions resulted in relatively high and low mean scores, 9 of the 13 specific questions produced a range of responses on a 10-point modified Likert scale. This indicates that there are not necessarily universal patient concerns and that every patient is different and should be treated as such. With that being said, however, the highest levels of concern (mean measurements ≥ 7/10) had to do with recurrence, function, walking, and self-sufficiency. The lowest levels of concern (mean measurement ≤ 5/10) had to do with pain, shoe gear considerations, cost, and cosmetic appearance of an amputation. CONCLUSIONS: It is the authors' hope that this investigation provides wound care professionals with information that will benefit their approach to the education and treatment of patients at risk for amputation as well as lead to future investigations into the emotional and psychological state of patients with chronic lower extremity wounds.

Liquid Adhesive Contact Dermatitis After Bunionectomy: A Case Report and Literature Review.

Hypersensitivity reactions to the skin adherents used in postoperative dressings are an uncommon but unfavorable complication that can result in poor wound healing, increased scarring, and surgical wound infections. This unexpected and unforeseen complication is not well documented in the current published data. We present the case of a 39-year-old female who had undergone a bunionectomy procedure and developed allergic contact dermatitis postoperatively. We discuss the clinical findings and treatments administered after application of a commonly used liquid skin adhesive applied intraoperatively. Through the use of topical and oral steroids and foot soaks in astringent solutions, over the course of several months, the patient's skin returned to the expected postoperative appearance. With the increased consciousness to minimize surgical scarring to improve cosmesis, one of these causes of the reaction might have been the liquid adhesive used in the surgical closure and dressing application. Therefore, we additionally reviewed the adhesive compound's chemical makeup and any potential cross-reactivity to help surgeons make an informed decision of whether to use a liquid adhesive. The various ingredients in liquid adhesives contain known allergen compounds that can cause a reaction, such as balsam of Peru and colophony or rosin, both of which are reviewed in our report. We also present a treatment algorithm developed from the compiled data in the case of a patient developing an allergic reaction. From our literature review and considering the percentage of incidence, if a surgeon desires to use a liquid adhesive product, Mastisol(®) should be chosen because of its lower reactivity and greater adhesive properties compared with the compound tincture of benzoin.

Can foot and ankle surgeons accurately estimate patient body mass index?

The body mass index (BMI) is an objective patient finding that has been established to have a negative effect on the development and outcomes of podiatric pathologic entities and interventions. The objective of the present investigation was to assess the ability of podiatric physicians to estimate the patient BMI from clinical and radiographic observation. For the clinical estimation of the patient BMI, podiatric specialists across 3 levels of experience (i.e., students, residents, and practicing clinicians) performed 294 estimations on 72 patients in 3 clinical situations (standing, sitting in a treatment chair, and lying in a hospital bed). It was more common to inaccurately estimate the patient BMI (77.9%) than it was to correctly estimate it (22.1%), with underestimations being the most common error (48.3%). The estimations were particularly inaccurate when the patients were in the common clinical situation of sitting in a treatment chair or lying in a hospital bed and with patients actually classified as obese. For the radiographic estimation of patient BMI, 150 consecutive lateral ankle radiographs were analyzed, with the ratio of the overlying soft tissue diameter to the underlying bone diameter calculated and compared. Positive, but weak, relationships were observed with these ratios. From these data, we have concluded that podiatric practitioners should perform an actual calculation of the patient BMI during the patient examination and medical decision-making process to fully appreciate the potential risks inherent to the treatment of obese patients.

Debridement of the noninfected wound.

The utility of wound debridement has expanded to include the management of all chronic wounds, even in the absence of infection and gross necrosis. Biofilms, metalloproteases on the wound base, and senescent cells at the wound edge irreversibly change the physiologic features of wound healing and contribute to a pathologic, chronic inflammatory environment. The objective of this review is to provide surgeons with a basic understanding of the processes of debridement in the noninfected wound.

Débridement of the noninfected wound.

The utility of wound débridement has expanded to include the management of all chronic wounds, even in the absence of infection and gross necrosis. Biofilm, metalloproteases on the wound base, and senescent cells at the wound edge irreversibly change the physiology of wound healing and contribute to a pathologic, chronic inflammatory environment. The objective of this review is to provide surgeons with a baseline understanding of the processes of débridement in the noninfected wound.

Painful diabetic neuropathy.

The podiatric physician often encounters complex painful neuropathies in daily practice. Diabetic neuropathy is one form of chronic neuropathic pain dealt with on a regular basis. The goal of this article is to review the pathophysiology, diagnosis, and treatment options of this complaint. Medical and surgical interventions are discussed, with a clinical emphasis on patient selection and prevention.