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Risk Factors for Abdominal Surgical Site Infection after Exploratory Laparotomy among Combat Casualties.

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Risk Factors for Abdominal Surgical Site Infection after Exploratory Laparotomy among Combat Casualties.

J Trauma Acute Care Surg. 2021 Feb 16;:

Authors: Bozzay JD, Walker PF, Schechtman DW, Shaikh F, Stewart L, Carson ML, Tribble DR, Rodriguez CJ, Bradley MJ, Infectious Disease Clinical Research Program Trauma Infectious Disease Outcomes Study Group

Abstract
BACKGROUND: Surgical site infections (SSI) are well-recognized complications after exploratory laparotomy for abdominal trauma; however, little is known about SSI development after exploration for battlefield abdominal trauma. We examined SSI risk factors after exploratory laparotomy among combat casualties.
METHODS: Military personnel with combat injuries sustained in Iraq and Afghanistan (6/2009-5/2014) who underwent laparotomy and were evacuated to participating U.S. military hospitals were included. Log-binominal regression was used to identify SSI risk factors.
RESULTS: Of 4304 combat casualties, 341 patients underwent a total of 1053 laparotomies. Abdominal SSIs were diagnosed in 49 (14.4%) patients; 8% with organ space SSI, 4% with deep incisional SSI, and 4% with superficial SSIs (4 patients had multiple SSIs). Patients with SSIs had more colorectal (p<0.001), small bowel (p=0.010), duodenum (p=0.006), pancreas (p=0.032), and abdominal vascular injuries (p=0.040), as well as prolonged open abdomen (p=0.004) and more infections diagnosed before the SSI (or final ex-lap) versus non-SSI patients (p<0.001). Sustaining colorectal injuries (risk ratio [RR]: 3.20; 95% CI: 1.58-6.45), duodenum injuries (RR: 6.71; 95% CI: 1.73-25.58), and being diagnosed with prior infections (RR: 10.34; 95% CI: 5.05-21.10) were independently associated with any SSI development. For either organ space or deep incisional SSIs, non-intraabdominal infections, fecal diversion, and duodenum injuries were independently associated, while being injured via an improvised explosive device (IED) was associated with reduced likelihood compared to penetrating non-blast (e.g., gunshot wounds) injuries. Non-intraabdominal infections and hypotension were independently associated with organ space SSIs development alone, while sustaining blast injuries were associated with reduced likelihood.
CONCLUSIONS: Despite severity of injuries and the battlefield environment, the combat casualty laparotomy SSI rate is relatively low at 14% and is comparable to risk factors and rates reported following severe civilian trauma.
LEVEL OF EVIDENCE: Epidemiological, Level III.

PMID: 33605707 [PubMed - as supplied by publisher]

Considerations in Free Flap Reconstruction of the Midface.

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Considerations in Free Flap Reconstruction of the Midface.

Facial Plast Surg. 2021 Feb 15;:

Authors: Hammer D, Vincent AG, Williams F, Ducic Y

Abstract
Midface reconstruction has been a consistent challenge for reconstructive surgeons even with the significant advances in technology and technique achieved over the recent years. A meticulous preoperative assessment of the patient is required to properly assess the defect or anticipated defect, determine proper reconstructive surgical plan, and discuss expected functional and aesthetic outcomes with the patient. For years we have employed local flaps, regional flaps, obturators, alloplastic implants, free flaps, or a combination of the previously mentioned techniques to address complex midface reconstruction. Free flap reconstruction in the midface requires special considerations for the pedicle, flap selection, and flap design to ensure an optimal outcome. The introduction of virtual surgical planning for reconstruction has enhanced patient outcomes to include advances in immediate dental rehabilitation at the time of free flap surgery. Postoperative considerations including quality of life, functional and aesthetic outcomes, and management of complications will also be discussed.

PMID: 33588473 [PubMed - as supplied by publisher]

PCSK9 Inhibitors

2021 Feb 13. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–.

ABSTRACT

Familial hypercholesterolemia is characterized by extremely high levels of total and LDL-cholesterol, premature vascular disease, and tendon xanthomas. In the vast majority of cases, this is due to a genetic mutation of the LDL receptor, rarely mutations of the apoprotein B100 or PCSK9 genes. At present, there are two pharmaceutical products available in the United States that reduce PCSK9 activity: alirocumab and evolocumab, which reduce PCSK9 activity, lowering LDL-cholesterol levels, and decrease the risk of cardiovascular disease. This activity outlines the indications, mechanism of action, administration methods, significant adverse effects, contraindications, monitoring, and toxicity of PCSK9 inhibitors so providers can direct patient therapy to optimal outcomes in serum lipid management with these agents and obtain improved cardiovascular outcomes.

PMID:28846236 | Bookshelf:NBK448100

Be the Change.

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Be the Change.

Fam Med. 2021 Feb;53(2):159

Authors: Elliott TC

PMID: 33566357 [PubMed - as supplied by publisher]

Eastern association for the surgery of trauma - quality, patient safety, and outcomes committee - transitions of care: healthcare handoffs in trauma.

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Eastern association for the surgery of trauma - quality, patient safety, and outcomes committee - transitions of care: healthcare handoffs in trauma.

Am J Surg. 2021 Feb 01;:

Authors: Appelbaum R, Martin S, Tinkoff G, Pascual JL, Gandhi RR

Abstract
BACKGROUND: Handoffs are defined as the transfer of patient information, professional responsibility, and accountability between caregivers. This work aims to clarify the current state of transitions of care related to the management of trauma patients.
METHODS: A PubMed database and web search were performed for articles published between 2000 and 2020 related to handoffs and transitions of care. The key search terms used were: handoff(s), handoff(s) AND healthcare, and handoff(s) AND trauma. A total of 55 studies were included in qualitative synthesis.
RESULTS: This systematic review explores the current state of healthcare handoffs for trauma patients. Factors found to impact successful handoffs included process standardization, team member accountability, effective communication, and the incorporation of culture. This review was limited by the small number of prospective randomized studies available on the topic.
CONCLUSION: Handoffs in trauma care have been studied and should be utilized in the context of published experience and practice. Standardization when applied with accountability has proven benefit to reduce communication errors during these transfers of care.

PMID: 33558061 [PubMed - as supplied by publisher]

Is Golf a Contact Sport? Protection of the Spine and Return to Play After Lumbar Surgery.

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Is Golf a Contact Sport? Protection of the Spine and Return to Play After Lumbar Surgery.

Global Spine J. 2021 Feb 05;:2192568220983291

Authors: Haddas R, Pipkin W, Hellman D, Voronov L, Kwon YH, Guyer R

Abstract
STUDY DESIGN: Narrative review.
OBJECTIVE: To address the gap in the literature on specific return to play protocols and rehabilitation regimens for golfers undergoing lumbar spine surgery with a high impact swing.
METHODS: This review did not involve patient care or any clinical prospective or retrospective review of patient information and thus did not warrant institutional review board approval. The available literature of PubMed, Medline, and OVID was utilized to review the existing literature.
RESULTS: Studies have shown that the forces through the lumbar spine in the modern-era golf swing are like other contact sports. Methods of protecting the lumbar spine include proper swing mechanics, abdominal and paraspinal musculature strengthening and flexibility as well as physical fitness. There are a variety of treatment options available to treat lumbar spine pathology each with a different return to play recommendations from doctors in the field.
CONCLUSIONS: With the introduction of a high impact, modern-era swing to the game of golf, the pathology is seen in the lumbar spine of both young, old, professional, and amateur golfers with low back pain are similar to other athletes in contact sports. Surgery is effective in returning athletes to a similar level of play even though no protocols exist for an effective and safe return. There have been many studies conducted to determine appropriate treatment and return to play for these injuries, but there is a gap in the literature on specific return to play protocols and rehabilitation regimens for golfers undergoing lumbar spine surgery with a high impact swing. As return to competitive play is important, especially with professional golfers, studies combining the use of swing mechanics changes, rehabilitation regimens and the type of surgery performed would be able to provide some insight into this topic now that golf may begin to be considered a contact sport.

PMID: 33541112 [PubMed - as supplied by publisher]

Facial Protection to Prevent Facial Trauma and Allow for Optimal Protection after Facial Fracture Repair.

Roderick Y. Kim DDS, MD - Wed, 02/03/2021 - 23:06
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Facial Protection to Prevent Facial Trauma and Allow for Optimal Protection after Facial Fracture Repair.

Facial Plast Surg. 2021 Feb 01;:

Authors: Kim R, Shokri T, Wang W, Ducic Y

Abstract
Facial skeletal fractures continue to affect humankind, and many methods to alleviate and prevent the injuries outright have been sought after. Prevention is desired, but the implementation and general compliance may contribute to missed opportunities to decrease the burden of facial skeletal trauma. In this article, we explore the preventative as well as postoperative options for the protection of the facial skeleton.

PMID: 33525032 [PubMed - as supplied by publisher]

Facial Protection to Prevent Facial Trauma and Allow for Optimal Protection after Facial Fracture Repair.

Facial Protection to Prevent Facial Trauma and Allow for Optimal Protection after Facial Fracture Repair.

Facial Plast Surg. 2021 Feb 01;:

Authors: Kim R, Shokri T, Wang W, Ducic Y

Abstract
Facial skeletal fractures continue to affect humankind, and many methods to alleviate and prevent the injuries outright have been sought after. Prevention is desired, but the implementation and general compliance may contribute to missed opportunities to decrease the burden of facial skeletal trauma. In this article, we explore the preventative as well as postoperative options for the protection of the facial skeleton.

PMID: 33525032 [PubMed - as supplied by publisher]

Can HEART Criteria Be Used as an Ideal Tool for Multilayer Clinical Outcome Predictions?

Hao Wang, MD - Wed, 01/27/2021 - 22:32
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Can HEART Criteria Be Used as an Ideal Tool for Multilayer Clinical Outcome Predictions?

Ann Emerg Med. 2021 Feb;77(2):277-278

Authors: Schrader CD, Meyering SH, Wang H

PMID: 33487324 [PubMed - in process]

Can HEART Criteria Be Used as an Ideal Tool for Multilayer Clinical Outcome Predictions?

Chet Schrader, MD - Wed, 01/27/2021 - 22:32
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Can HEART Criteria Be Used as an Ideal Tool for Multilayer Clinical Outcome Predictions?

Ann Emerg Med. 2021 Feb;77(2):277-278

Authors: Schrader CD, Meyering SH, Wang H

PMID: 33487324 [PubMed - in process]

Translating COVID-19 knowledge to practice: Enhancing emergency medicine using the "wisdom of crowds".

Sandra Schneider, MD - Wed, 01/27/2021 - 22:32
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Translating COVID-19 knowledge to practice: Enhancing emergency medicine using the "wisdom of crowds".

J Am Coll Emerg Physicians Open. 2021 Feb;2(1):e12356

Authors: Blutinger EJ, Shahid S, Jarou ZJ, Schneider SM, Kang CS, Rosenberg M

Abstract
In the spring of 2020, emergency physicians found themselves in new, uncharted territory as there were few data available for understanding coronavirus disease 2019 (COVID-19), the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. In response, knowledge was being crowd sourced and shared across online platforms. The "wisdom of crowds" is an important vehicle for sharing information and expertise. In this article, we explore concepts related to the social psychology of group decisionmaking and knowledge translation. We then analyze a scenario in which the American College of Emergency Physicians (ACEP), a professional medical society, used the wisdom of crowds (via the EngagED platform) to disseminate clinically relevant information and create a useful resource called the "ACEP COVID-19 Field Guide." We also evaluate the crowd-sourced approach, content, and attributes of EngagED compared to other social media platforms. We conclude that professional organizations can play a more prominent role using the wisdom of crowds for augmenting pandemic response efforts.

PMID: 33491003 [PubMed]

Translating COVID-19 knowledge to practice: Enhancing emergency medicine using the "wisdom of crowds".

Related Articles

Translating COVID-19 knowledge to practice: Enhancing emergency medicine using the "wisdom of crowds".

J Am Coll Emerg Physicians Open. 2021 Feb;2(1):e12356

Authors: Blutinger EJ, Shahid S, Jarou ZJ, Schneider SM, Kang CS, Rosenberg M

Abstract
In the spring of 2020, emergency physicians found themselves in new, uncharted territory as there were few data available for understanding coronavirus disease 2019 (COVID-19), the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. In response, knowledge was being crowd sourced and shared across online platforms. The "wisdom of crowds" is an important vehicle for sharing information and expertise. In this article, we explore concepts related to the social psychology of group decisionmaking and knowledge translation. We then analyze a scenario in which the American College of Emergency Physicians (ACEP), a professional medical society, used the wisdom of crowds (via the EngagED platform) to disseminate clinically relevant information and create a useful resource called the "ACEP COVID-19 Field Guide." We also evaluate the crowd-sourced approach, content, and attributes of EngagED compared to other social media platforms. We conclude that professional organizations can play a more prominent role using the wisdom of crowds for augmenting pandemic response efforts.

PMID: 33491003 [PubMed]

Can HEART Criteria Be Used as an Ideal Tool for Multilayer Clinical Outcome Predictions?

Related Articles

Can HEART Criteria Be Used as an Ideal Tool for Multilayer Clinical Outcome Predictions?

Ann Emerg Med. 2021 Feb;77(2):277-278

Authors: Schrader CD, Meyering SH, Wang H

PMID: 33487324 [PubMed - in process]

NSQIP Based Predictors of False Negative and Indeterminate Ultrasounds in Adults With Appendicitis.

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NSQIP Based Predictors of False Negative and Indeterminate Ultrasounds in Adults With Appendicitis.

J Surg Res. 2021 Jan 21;261:326-333

Authors: Atwood R, Blair S, Fisk M, Bradley M, Coleman C, Rodriguez C

Abstract
BACKGROUND: It has been well established that ultrasound (US) is the initial screening tool for children with suspected acute appendicitis. However, computed tomography (CT) has become the standard screening modality for adults presenting with abdominal pain. A recent review of National Surgical Quality Improvement Program (NSQIP) data revealed US is being utilized as a screening modality in adults. We aimed to assess the diagnostic performance of US in evaluating adults with acute appendicitis.
STUDY DESIGN: The American College of Surgeons NSQIP and NSQIP Procedure Targeted Data Files were accessed and examined for all patients in 2016 and 2017 who received an US and underwent an appendectomy. The US results were then correlated to the pathology in order to determine the diagnostic performance. Additionally, we identified predictors for indeterminate and false negative US results.
RESULTS: Our study included 3607 appendectomy patients of which 1135 (30%) had an indeterminate US, 683 (18%) had an US not consistent with appendicitis, and 1789 (49%) had an US consistent with appendicitis. Sensitivity and Specificity were 74.3% and 53.0%, respectively. Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were 95.9% and 12.2%, respectively. On regression analysis, clinically relevant predictors for false negative and indeterminate studies included age, sex, and BMI.
CONCLUSIONS: Ultrasound is an effective initial imaging modality for acute appendicitis in the adult population. Females, age >30 y, and elevated BMI were more likely to have indeterminate or false negative results. These patients may benefit from CT as their initial screening test.

PMID: 33486414 [PubMed - as supplied by publisher]

ASHP Guidelines on Emergency Medicine Pharmacist Services.

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ASHP Guidelines on Emergency Medicine Pharmacist Services.

Am J Health Syst Pharm. 2021 Jan 22;78(3):261-275

Authors: Ortmann MJ, Johnson EG, Jarrell DH, Bilhimer M, Hayes BD, Mishler A, Pugliese RS, Roberson TA, Slocum G, Smith AP, Yabut K, Zimmerman DE

PMID: 33480409 [PubMed - in process]

The Legacy of Leadership: Our Commitment to Future Generations of Family Medicine Leaders.

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The Legacy of Leadership: Our Commitment to Future Generations of Family Medicine Leaders.

Fam Med. 2021 Jan;53(1):78-79

Authors: Elliott TC, Li L

PMID: 33471931 [PubMed - as supplied by publisher]

Positive Psychology and Hope as Lifestyle Medicine Modalities in the Therapeutic Encounter: A Narrative Review.

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Positive Psychology and Hope as Lifestyle Medicine Modalities in the Therapeutic Encounter: A Narrative Review.

Am J Lifestyle Med. 2021 Jan-Feb;15(1):6-13

Authors: Duncan AR, Jaini PA, Hellman CM

Abstract
The majority of deaths in the United States are attributable to lifestyle-associated chronic diseases. Therapeutic encounters must now routinely address lifestyle-related behavior changes and promote patients' active involvement in self-care and chronic disease management. Positive psychology has been recognized in the realm of lifestyle medicine for its potential applications in effecting patient behavior change. One notable framework within positive psychology that is well suited for facilitating specific behavior changes is hope theory, which can be used to elicit change talk and build agency among patients with chronic diseases. This review explores key literature in positive psychology and hope theory and its practical applications to direct patient care, which includes an illustrative case study. There are still many unexplored intersections of health-related variables and hope. The cognitive framework of hope theory lends itself well to a broad range of situations, including brief ambulatory encounters. Clinicians will be instrumental in increasing our understanding of how hope theory can be applied to the therapeutic encounter. There are simple and efficient ways to innovate in this area. Having information about a patient's hope has the potential to make empathic connections easier and create opportunities to ask specific questions to help patients overcome barriers.

PMID: 33456415 [PubMed]

Labor Dystocia in Nulliparous Women.

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Labor Dystocia in Nulliparous Women.

Am Fam Physician. 2021 Jan 15;103(2):90-96

Authors: LeFevre NM, Krumm E, Cobb WJ

Abstract
Dystocia (abnormally slow or protracted labor) accounts for 25% to 55% of primary cesarean deliveries. The latent phase of labor begins with onset of regular, painful contractions and continues until 6 cm of cervical dilation. Current recommendations are to avoid admission to labor and delivery during the latent phase, assuming maternal/fetal status is reassuring. The active phase begins at 6 cm. An arrested active phase is defined as more than four hours without cervical change despite rupture of membranes and adequate contractions and more than six hours of no cervical change without adequate contractions. Managing a protracted active phase includes oxytocin augmentation with or without amniotomy. The second stage of labor begins at complete cervical dilation and continues to delivery. This stage is considered protracted if it lasts three hours or more in nulliparous patients without an epidural or four hours or more in nulliparous patients with an epidural. Primary interventions for a protracted second stage include use of oxytocin and manual rotation if the fetus is in the occiput posterior position. When contractions or pushing is inadequate, vacuum or forceps delivery may be needed. Effective measures for preventing dystocia and subsequent cesarean delivery include avoiding admission during latent labor, providing cervical ripening agents for induction in patients with an unfavorable cervix, encouraging the use of continuous labor support (e.g., a doula), walking or upright positioning in the first stage, and not diagnosing failed induction during the latent phase until oxytocin has been given for 12 to 18 hours after membrane rupture. Elective induction at 39 weeks' gestation in low-risk nulliparous patients may reduce the risk of cesarean delivery.

PMID: 33448772 [PubMed - as supplied by publisher]

Dear White People.

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Dear White People.

Ann Fam Med. 2021 Jan-Feb;19(1):66-69

Authors: Foster KE, Johnson CN, Carvajal DN, Piggott C, Reavis K, Edgoose JYC, Elliott TC, Gold M, Rodríguez JE, Washington JC

Abstract
We are living in unprecedented times. While the world is grappling with COVID-19, we find the horrors of racism looming equally large as we, yet again, confront lurid deaths in the center of the news cycle of Black and brown people from police bias and brutality. Those of us who have been championing antiracism and justice work and bearing the burden of the "minority tax" have been overwhelmed by sudden asks from our well-intentioned White colleagues of how to best respond. In the tone of the Netflix series, "Dear White People," we further emphasize that we are not alone in trying to reach out to you, our White colleagues and leaders. Please hear our story and heed our call to action.

PMID: 33431395 [PubMed - in process]

Current Practices in Tranexamic Acid Administration for Pediatric Trauma Patients in the United States.

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Current Practices in Tranexamic Acid Administration for Pediatric Trauma Patients in the United States.

J Trauma Nurs. 2021 Jan-Mar 01;28(1):21-25

Authors: Cornelius B, Cummings Q, Assercq M, Rizzo E, Gennuso S, Cornelius A

Abstract
BACKGROUND: Although controversial, early administration of tranexamic acid (TXA) has been shown to reduce mortality in adult patients with major trauma. Tranexamic acid has also been successfully used in elective pediatric surgery, with significant reduction in blood loss and transfusion requirements. There are limited data to guide its use in pediatric trauma patients. We sought to determine the current practices for TXA administration in pediatric trauma patients in the United States.
METHODS: A survey was conducted of all the American College of Surgeons-verified Level I and II trauma centers in the United States. The survey data underwent quantitative analysis.
RESULTS: Of the 363 Level I and II qualifying centers, we received responses from 220 for an overall response rate of 61%. Eighty of 99 verified pediatric trauma centers responded for a pediatric trauma center response rate of 81%. Of all responding centers, 148 (67%) reported they care for pediatric trauma patients, with an average of 513 pediatric trauma patients annually. The pediatric trauma centers report caring for an average of 650 pediatric trauma patients annually. Of all centers caring for pediatric trauma, 52 (35%) report using TXA, with the most common initial dosing being 15 mg/kg (68%). A follow-up infusion was utilized by 45 (87%) of the programs, most commonly dosed at 2 mg/kg/hr × 8 hr utilized by 24 centers (54%).
CONCLUSION: Although the clinical evidence for TXA in pediatric trauma patients is limited, we believe that consideration should be given for use in major trauma with hemodynamic instability or significant risk for ongoing hemorrhage. If available, resuscitation should be guided by thromboelastography to identify candidates who would most benefit from antithrombolytic administration. This represents a low-cost/low-risk and high-yield therapy for pediatric trauma patients.

PMID: 33417398 [PubMed - as supplied by publisher]

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