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.

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.

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.

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.

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.

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.

Developing a decision support tool to prevent community-acquired pressure injuries in spinal cord injury in ambulatory care: A nurse-led protocol for mix methods research.

BACKGROUND: There is a lack of formal guidelines and decision support tools to prevent community-acquired pressure injuries (CAPrIs) in Veterans with spinal cord injury (SCI). PURPOSE: In this article we present our research protocol that describes our plans to create and test a decision support tool to prevent CAPrIs in SCI. METHODS: In Aim 1, we identified mental-models of CAPrI prevention from the perspectives of Veterans (using photovoice, guided tours), and Veterans Health Administration SCI providers (using interviews), and triangulation to compare the two mental-models. This led to a decision support tool developed and validated using Delphi approaches in Aim 2 and will be followed by tool automation and system redesign for pilot implementation in Aim 3. FINDINGS: The nurse-led research protocol provides a map to systematically explore, address and translate research into evidence-based practice. DISCUSSION: Refinement of the protocol will guide future research and implementation.

Assessing the Ability of Comorbidity Indexes to Capture Comorbid Disease in the Inpatient Rehabilitation Spinal Cord Injury Population.

OBJECTIVE: To examine whether commonly used comorbidity indexes (Deyo-Charlson comorbidity index, Elixhauser comorbidity index, the Centers for Medicare and Medicaid Services [CMS] comorbidity tiers) capture comorbidities in the acute traumatic and nontraumatic SCI inpatient rehabilitation population. DESIGN: Retrospective cross-sectional study. PARTICIPANTS: Data were obtained from the Uniform Data System for Medical Rehabilitation from October 1, 2015 to December 31, 2017 for adults with spinal cord injury (SCI) (Medicare-established Impairment Group Codes 04.110-04.230, 14.1, 14.3). This study included SCI discharges (N=66,235) from 833 inpatient rehabilitation facilities. MAIN OUTCOME MEASURES: International Classification of Diseases-10th Revision-Clinical Modifications (ICD-10-CM) codes were used to assess 3 comorbidity indexes (Deyo-Charlson comorbidity index, Elixhauser comorbidity index, CMS comorbidity tiers). The comorbidity codes that occurred with >1% frequency were reported. The percentages of discharges for which no comorbidities were captured by each comorbidity index were calculated. RESULTS: Of the total study population, 39,285 (59.3%) were men and 11,476 (17.3%) were tetraplegic. The mean number of comorbidities was 14.7. There were 13,939 distinct ICD-10-CM comorbidity codes. There were 237 comorbidities that occurred with >1% frequency. The Deyo-Charlson comorbidity index, Elixhauser comorbidity index, and the CMS tiers did not capture comorbidities of 58.4% (95% confidence interval, 58.08%-58.84%), 29.4% (29.07%-29.76%), and 66.1% (65.73%-66.46%) of the discharges in our study, respectively, and 28.8% (28.42%-29.11%) of the discharges did not have any comorbidities captured by any of the comorbidity indexes. CONCLUSION: Commonly used comorbidity indexes do not reflect the extent of comorbid disease in the SCI rehabilitation population. This work suggests that alternative measures may be needed to capture the complexity of this population.

Invasive non-urachal adenocarcinoma of the bladder: analysis of the National Cancer Database.

PURPOSE: To review the United States National Cancer Database (NCDB) from 2004 to 2015 and analyze survival outcomes of invasive non-urachal adenocarcinoma based on treatment modality. METHODS: The NCDB 2004-2015 bladder dataset was queried for adenocarcinoma histology, excluding urachal variant, and limited to patients with clinical stage T2-T4 disease. Treatment modality was categorized as no treatment, cystectomy (partial or radical), external beam radiation therapy (EBRT), or EBRT plus cystectomy. Our primary outcome was overall survival. Cox regression (CR) and Kaplan-Meier (KM) analysis were performed. RESULTS: 851 patients were identified with invasive (cT2-T4) adenocarcinoma of the bladder. Treatment modalities included 398 (47.8%) no treatment, 298 (35.8%) cystectomy, 124 (14.9%) EBRT, and 31 (3.7%) EBRT plus cystectomy. On KM analysis excluding those with metastatic disease, the 5-year survival was significantly better (p < 0.001) for patients who underwent cystectomy (39.6%), versus no treatment (21.0%), EBRT (18.6%), or EBRT plus cystectomy (26.9%) (log rank, p < 0.001). On CR for mortality, age (HR 1.030, p < 0.001), Charlson score 1 (HR 1.287, p = 0.034), cT4 (HR 1.768, p < 0.001), and receiving treatment at a low-volume center (HR 1.289, p = 0.026) were associated with worsened survival; however, cystectomy (HR 0.593, p < 0.001) was the only factor associated with improved survival. For those undergoing cystectomy, the mean length of stay was 8.5 days and the 30-day readmission rate was 7.0%. CONCLUSIONS: Invasive non-urachal adenocarcinoma of the bladder is a rare diagnosis. Survival benefits in patients without metastatic disease are seen only in those patients undergoing definitive surgery.

Squamous cell carcinoma of the bladder: poor response to neoadjuvant chemotherapy.

BACKGROUND: Squamous cell carcinoma (SCC) of the bladder is a rare, aggressive malignancy. Unlike urothelial cell carcinoma, SCC is resistant to chemotherapy and guidelines recommend radical cystectomy (RC) without neoadjuvant chemotherapy (NAC). We aimed to evaluate the current management and survival of patients with invasive SCC treated with or without NAC. METHODS: 671 patients with invasive SCC bladder cancer from 2004 to 2015 in the National Cancer Data Base were identified. Patients were stratified by treatment with RC alone or NAC prior to RC (NAC + RC). Survival analysis was performed with Kaplan-Meier and Cox regression. Secondary outcomes included length of stay and readmission. RESULTS: Of 671 patients, 92.8% were treated with RC alone and 7.2% with NAC + RC. Cox regression for mortality was performed including age, Charlson score, clinical stage, and NAC. Increased risk of mortality was noted with increasing age (OR 1.01, p = 0.023) and Charlson score of 1-3 (HR 1.58-1.68, p < 0.05). NAC did not confer survival advantage (HR 1.17, p = 0.46). On Kaplan-Meier analysis, the overall survival was equivalent (log-rank p = 0.804). Hospital stay and readmission were similar between RC and NAC + RC groups. CONCLUSIONS: Analysis of a national tumor registry suggests a lack of overall survival benefit for NAC with localized, muscle invasive SCC of the bladder. Further research directed at chemotherapy regimens for SCC is needed to optimize treatment and improve survival outcomes.

Lymph node density for stratification of survival outcomes with node positive upper tract urothelial carcinoma.

INTRODUCTION: The use of lymph node density (LND) as a predictor of survival outcomes has been studied with urothelial carcinoma of the bladder. Similar results can be postulated to upper tract urothelial carcinoma (UTUC). This study aims to determine the overall survival of patients with lymph node positive UTUC based on LND, utilizing the National Cancer Database (NCDB). MATERIALS AND METHODS: Data was derived from NCDB Participant User Kidney Dataset using the histology code 'transitional cell carcinoma', utilizing pN+ patients from 2004-2015. LND was calculated as number of positive nodes divided by total number of nodes removed. Patients were stratified by traditional AJCC pN stage and compared to LND groups (< 30%, ≥ 30%). Primary outcome was overall survival. Kaplan-Meier and Cox regression analyses were performed. RESULTS: A total of 2049 patients were identified (pN1 = 1022, pN2 = 1027; LND < 30% = 370, ≥ 30% = 1679). Mean LND was 71%. Cox regression for mortality using pN stage was not significant (p = 0.11); however, Cox regression for mortality using LND group noted significantly worsened survival with LND ≥ 30% (HR 1.54, p = 0.001). Kaplan Meier analysis for overall survival at 2 years showed no difference between pN1 and pN2 stages (35.3% versus 34.1%; log rank p = 0.37). Kaplan Meier analysis for overall survival at 2 years revealed significant difference between LND groups (LND < 30%, 47.3% versus LND ≥ 30%, 32.0%; log rank p < 0.001). CONCLUSIONS: LND provides improved prognostic information regarding overall survival, compared to traditional AJCC pN staging. Future studies need to evaluate LND to improve prognostic understanding of lymph node positive UTUC.

Chemotherapy increases survival and downstaging of upper tract urothelial cancer.

INTRODUCTION: To evaluate the overall survival and pathologic downstaging effect of neoadjuvant chemotherapy for upper tract urothelial cell carcinoma. MATERIALS AND METHODS: The National Cancer Database (NCDB) was queried for patients with stage II-IV upper tract urothelial cell carcinoma undergoing definitive surgical resection (nephroureterectomy) from 2004-2015. Patients with metastatic disease were excluded. Cohorts were stratified by receipt of neoadjuvant chemotherapy (NAC). Kaplan-Meier analysis and Cox regression were used to evaluate overall survival. Logistic regression was used to predict the odds of pathologic downstaging to non-invasive disease (< pT2). Propensity score matched analysis was performed between groups. RESULTS: A total of 3634 patients were identified with non-metastatic stage II-IV disease undergoing surgical resection; 3364 received no chemotherapy and 270 received NAC. Patients undergoing NAC had a 10.9% rate of downstaging to non-invasive disease (OR 6.35, p < 0.001). Moreover, on Kaplan-Meier analysis, median survival was 27.3 months and 44.8 months for no chemotherapy versus NAC, respectively (log-rank, p = 0.001). Cox regression for death also revealed benefits for receiving NAC (HR 0.67, p < 0.001). Findings were confirmed on propensity score matching (532 matched patients). After matching, Cox regression for death noted improvement with neoadjuvant as compared to no chemotherapy (HR 0.61, p < 0.001). CONCLUSION: Neoadjuvant chemotherapy increases likelihood of downstaging to non-invasive disease in patients with upper tract urothelial cell carcinoma. Chemotherapy also provides an overall survival benefit in patients undergoing nephroureterectomy.

Outcomes of renal salvage for penetrating renal trauma: a single institution experience.

INTRODUCTION: Conservative management of penetrating renal trauma is emerging, with data originating from centers with variable level of trauma care. This study reviews the outcomes of renal salvage after penetrating trauma at a level I trauma center. MATERIALS AND METHODS: An institutional review board approved trauma registry at Saint Louis University Hospital was retrospectively analyzed, for patients with penetrating renal trauma from 2009 to 2014. Patients were divided into nephrectomy group (NG) or non-nephrectomy group (non-NG), and compared. A multi-variable analysis was performed to determine predictors of nephrectomy, with cross validation to evaluate the performance of the multi-variable model. Data was analyzed using R version 3.3.2. A p value of < 0.05 was considered as significant. RESULTS: A total of 121 patients were identified with penetrating renal trauma. Gunshot injury was the leading cause of injury (87%). Eighteen (15%) patients required nephrectomy. The overall mean injury severity score (ISS). was 20. High grade (grade 4-5) renal injuries were noted in 41 patients (34%). Among these, 14 patients (34%) underwent a nephrectomy, while 27 patients (66%) were managed conservatively to salvage renal units. CT grade of renal injury was the only predictor of nephrectomy, on multi-variable analysis (OR 17.09 CI 2.75-105.99, p = 0.002). CT grade of injury and injury severity score were predictors of endoscopic intervention on a sub group analysis of non-NG. CONCLUSIONS: CT grade of injury predicts nephrectomy after penetrating renal trauma. Conservative management is a feasible option in penetrating renal trauma even with a higher grade of injury.

Perceptions of Urologists About the Conversational Elements Leading to Treatment Decision-Making Among Newly Diagnosed Prostate Cancer Patients.

Widespread adoption and use of the practice of shared decision-making among health-care providers, especially urologists, has been limited. This study explores urologists' perceptions about their conversational practices leading to decision-making by newly diagnosed prostate cancer patients facing treatment. Semi-structured, in-depth interviews were conducted with 12 community and academic urologists practicing in the St. Louis, MO, region. Data were analyzed using a consensus coding approach. Urologists reported spending 30-60 min with newly diagnosed prostate cancer patients when discussing treatment options. They frequently encouraged family members' involvement in discussions about treatment, especially patients' spouses and children. Participants perceived these conversations to be difficult given the emotional burden associated with a cancer diagnosis, and encouraged patients to postpone their decisions or to get a second opinion before finalizing their treatment of choice. Initial discussions included a presentation of treatment options relevant to the patient's condition, side effects, outcome probabilities, and next steps. Urologists seldom used statistics while talking about treatment outcome probabilities and preferred to explain outcomes in terms of the patient's practical, emotional, and social experiences. Their styles to elicit the patient's preferences ranged from explicitly asking questions to making assumptions based on clinical experience and subtle patient cues. In conclusion, urologists' routine conversations included most elements of shared decision-making. However, shared decision-making required urologists to have nuanced discussions and be skilled in elicitation methods and risk discussions which requires further training. Further research is required to explore roles of family and clinical staff as participants in this process.

Systematic Review of Decision Aids for Newly Diagnosed Patients with Prostate Cancer Making Treatment Decisions.

PURPOSE: Despite established evidence for using patient decision aids, use with newly diagnosed patients with prostate cancer remains limited partly due to variability in aid characteristics. We systematically reviewed decision aids for newly diagnosed patients with prostate cancer. MATERIALS AND METHODS: Published peer reviewed journal articles, unpublished literature on the Internet and the Ottawa decision aids web repository were searched to identify decision aids designed for patients with prostate cancer facing treatment decisions. A total of 14 aids were included in study. Supplementary materials on aid development and published studies evaluating the aids were also included. We studied aids designed to help patients make specific choices among options and outcomes relevant to health status that were specific to prostate cancer treatment and in English only. Aids were reviewed for IPDAS (International Patient Decision Aid Standards) and additional standards deemed relevant to prostate cancer treatment decisions. They were also reviewed for novel criteria on the potential for implementation. Acceptable interrater reliability was achieved at Krippendorff α = 0.82. RESULTS: Eight of the 14 decision aids (57.1%) were developed in the United States, 6 (42.8%) were print based, 5 (35.7%) were web or print based and only 4 (28.5%) had been updated since 2013. Ten aids (71.4%) were targeted to prostate cancer stage. All discussed radiation and surgery, 10 (71.4%) discussed active surveillance and/or watchful waiting and 8 (57.1%) discussed hormonal therapy. Of the aids 64.2% presented balanced perspectives on treatment benefits and risks, and/or outcome probabilities associated with each option. Ten aids (71.4%) presented value clarification prompts for patients and steps to make treatment decisions. No aid was tested with physicians and only 4 (28.6%) were tested with patients. Nine aids (64.2%) provided details on data appraisal and 4 (28.6%) commented on the quality of evidence used. Seven of the 8 web or computer based aids (87.5%) provided patients with the opportunity to interact with the aid. All except 1 aid scored above the 9th grade reading level. No evidence on aid implementation in routine practice was available. CONCLUSIONS: As physicians look to adopt decision aids in practice, they may base the choice of aid on characteristics that correlate with patient socioeconomic and educational status, personal practice style and practice setting.

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.

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.