Primary Attending Research Articles

174 Evaluation of Undifferentiated Dyspnea with Point of Care Ultrasound Performed by Primary Emergency Department Physician Compared to a Dedicated Emergency Department Ultrasound Team

Undifferentiated dyspnea is among the most challenging emergency department (ED) presentations. Emergency physicians (EP) must often perform critical actions while operating with diagnostic uncertainty. Point of care ultrasound (POCUS) has been shown to be highly beneficial in the initial evaluation of dyspneic patients but prior studies often study POCUS performed by experts or a dedicated physician ultrasound (US) team. Performance of POCUS by the primary treating team is often limited by the time and workflow constraints. This study aims to evaluate the effectiveness of POCUS in narrowing diagnostic uncertainty and guiding initial management of acutely dyspneic patients when performed by treating EP compared to a dedicated US team. This is a multi-center, prospective non-inferiority cohort study investigating the effect of POCUS on the differential diagnosis of patients presenting with undifferentiated dyspnea. During the initial evaluation of these patients, the primary attending provider completed a survey evaluating initial differential diagnosis and treatment plan. The provider team or a separate US team then performed targeted POCUS on the patient. After POCUS, the treating provider completed a second survey to evaluate changes in differential and management. The primary outcome was change in the most likely diagnosis and was assessed for non-inferiority between primary and US team performed POCUS using an a priori specified non-inferiority margin of 20%. Secondary outcomes included change in number of diagnoses considered, change in confidence in diagnosis assessed on a Likert-like scale, and change in interventions. We enrolled physicians evaluating 156 patients presenting with undifferentiated dyspnea at a university affiliated ED or a community hospital ED. In 40% (95% CI, 28 - 52%) of studies performed by the primary team the most likely diagnosis changed compared to 32% (95% CI, 22 - 41%) for studies performed by the US team. This was declared non-inferior using a margin of 20% (p < .0001). Post-POCUS differentials decreased by a mean 1.8 diagnoses and this change was equivalent within a margin of 0.5 diagnoses between primary and US team performed studies (p = 0.034). Secondary outcomes were also notable for a modest change in any management being considered (34% primary team vs 32% US team), an increase in post-POCUS confidence in diagnosis (0.7 vs 0.6-point increase), and 3 cases of cardiac tamponade were found when COPD or CHF was the initial suspected diagnosis. POCUS performed both by the primary team and a dedicated US team resulted in a significant narrowing of the differential diagnosis, a change in the primary diagnosis and an increase in confidence of diagnosis. The change in primary diagnosis was non-inferior when comparing primary to US team performed studies and the two groups were equivalent when considering change in confidence in diagnosis as well as mean reduction in number of diagnoses. There was also no significant difference in effect between performing sites. POCUS is a valuable tool for limiting the cognitive burden in the initial evaluation of undifferentiated dyspneic ED patients when performed in a targeted fashion.

Comparing perspectives on medication treatment for opioid use disorder between national samples of primary care trainee physicians and attending physicians

BackgroundMost people with opioid use disorder (OUD) are not treated with FDA-approved medications methadone, buprenorphine, or naltrexone. Expanding capacity for evidence-based OUD medication in primary care is a national priority. No studies have examined primary care trainee physicians’ attitudes about these medications. This study surveyed a national sample of primary care trainee physicians and compared their views with those of primary care attending physicians (i.e., those who have completed training). MethodsRandom samples of 1,000 trainee physicians and 1,000 attending physicians specializing in family, internal, or general medicine were selected from the American Medical Association Masterfile. Surveys were mailed February-August 2019. 45 % of eligible trainee physicians and 54 % of eligible attending physicians responded. Chi-square tests were used to compare responses between the groups. ResultsTrainee physicians were more likely than attending physicians to agree that treating OUD with medication is more effective than treatment without medication (76 % versus 67 %, p = 0.03). Half of trainee physicians (51 %) expressed interest in treating patients with OUD compared to 20 % of attending physicians. Trainee physicians expressed greater support than attending physicians for policies that loosen restrictions on prescribing OUD medications. ConclusionsRelative to attending physicians, the emerging cohort of primary care physicians may be more receptive to working with patients with OUD and prescribing medication. Enhancing medical training on OUD and its treatment, exposing clinicians to individuals in recovery from OUD, and increasing support for clinicians that provide medication treatment for OUD may strengthen this group’s capacity to respond to the opioid crisis.

Effect of intraventricularly administered low-dose recombinant tissue plasminogen activator on interleukin 1-beta and transforming growth factor beta concentrations in cerebrospinal fluid of patients with primary intracerebral hemorrhage associated with intraventricular hemorrhage: A retrospective study.

It is increasingly recognized that modulation of brain inflammation may uncover new potential therapeutic strategies for stroke. Recent studies have shifted focus from immunological implications in ischemic stroke to a more devastating form; the hemorrhagic stroke.The aim of this study was to investigate the neuroinflammatory response in cerebrospinal fluid in patients with primary intracerebral hemorrhage (ICH) associated with intraventricular hemorrhage (IVH) in the presence of low-dose recombinant tissue plasminogen activator (rt-PA).This retrospective study included 88 adults with primary ICH associated with IVH. Patients were divided into 2 groups: rt-PA group and non-rt-PA group, which received normal standard of care for this diagnosis. The rt-PA group was treated via catheter-based clot lysis using low-dose rt-PA injected through the external ventricular drain (EVD) system, and the non-rt-PA group was treated with saline applied to EVD system in equivalent volume. Cerebrospinal fluid samples from rt-PA were obtained from the EVD system at 4 time points: once before the drug administration, and then on day 1, 3, and 7. No attempt at randomization was made. The decision to inject rt-PA was based on the preference of the primary attending neurologist and the ability to obtain consent. Temporal interleukin-1 beta and transforming growth factor beta concentration changes were analyzed and compared between the 2 groups.The concentration of interleukin-1 beta was significantly lower in the rt-PA group than in the non-rt-PA group on day 7. In addition, the concentration of transforming growth factor beta was significantly higher in the rt-PA group than in the non-rt-PA group on day 1. There was a significant difference in interleukin-1 beta concentration between days 0 and 1 in comparison to day 3 in the rt-PA group, and between day 0 in comparison to day 3 and 7 in the non-rt-PA group. We also observed a significant difference in transforming growth factor beta concentration between days 0 and 1 and between days 3 and 7.The different pattern of pro- and anti-inflammatory cytokines in patients with ICH associated with IVH suggest distinct characteristics of secondary brain injury depending on the treatment modality.

Correlation of Serum Prolactin and Thyroid Hormone in Female Infertility

Background: Infertility is a growing problem with adverse medical, social and psychological consequences globally. Apart from several causes of infertility, hormonal imbalance especially thyroid dysfunction and hyperprolactinemia can lead to female infertility. Both these conditions are treatable so Proper management of hormonal imbalance can result in restoration of normal fertility.&#x0D; Aims and objectives: Correlation of serum Prolactin and Thyroid hormone in female infertility.&#x0D; Materials and methods: Descriptive hospital based study was conducted at Nepalgunj medical college and teaching hospital, Nepalgunj, Banke, Nepal. The data was collected from September 2018 to August 2019. Total 30 cases of females of primary and secondary infertility attending outpatient department of gynecology department of Nepalgunj medical college were included in the study. A detailed history and clinical evaluation was done along with estimation of serum Prolactin and Thyroid hormone profile.&#x0D; Result: Hormonal status of subjects showed 15 i.e. 50% participants were thyroid whereas 11 (36.33%) were hypothyroid and 4 (13.33%) were hyperthyroid. Serum Prolactin was raised in 17 (57%) and normal in 13 (43%). Serum TSH and prolactin were found to be significantly positively correlated in female infertility (r=0.507, p =0.004).&#x0D; Conclusion: There is a high incidence of hyperprolactinaemia and thyroid dysfunction in female infertility.

Patient values regarding overlapping surgery: Identification of distinct patient subgroups.

To explore patient values associated with their comfort level with surgical trainees and attending surgeon absence from the operating room. Qualitative interviews with general medical patients. We analyzed data from qualitative interviews with patients that included a quantitative rating on a visual analog scale (VAS) of comfort consenting to three surgical scenarios, including overlapping surgery, to identify subgroups of patients based on comfort level. After identifying subgroups, we compared qualitative responses from participants who were generally comfortable with overlapping surgery to those who were uncomfortable to identify themes associated with these perceptions. We identified three subgroups of patients based on the patterns of VAS responses. Participants who were comfortable with overlapping surgery expressed trust in the surgeon and delegation process. Those who were most uncomfortable expressed a strong desire to know who was operating on them, and a desire for control over their surgical process. Subjects uncomfortable with overlapping surgery were also generally not sensitive to tradeoffs (cost, timing). We identified distinct subgroups of patients based on their comfort level with trainee independence and primary attending availability. By examining the predominant values in these subgroups, we identified potential explanations for patient discomfort with attending absence. Strategies to enhance patients' knowledge about the process of surgery and a sense of control over their own care may improve comfort with trainee participation and overlapping surgery. 6 Laryngoscope, 2019.

1043. Love Thy Steward – Who Does Not Love Antimicrobial Stewardship?

BackgroundThe impact of antimicrobial stewardship programs (ASPs) depends on physician perception of antimicrobial stewardship and institutional antibiotic prescribing culture. At Rush University Medical Center (RUMC), we conducted an antimicrobial stewardship study targeting inpatient levofloxacin (FQ) use and assessed rates of implementation of recommendations (IORs) by general medicine (GM), vs. surgical services (SS) (general surgery, urology, orthopedics and neurosurgery), vs. transplant surgery-immunocompromised host (T-ICH) teams when made by either infectious disease pharmacists (IDPharmD) or infectious disease fellows (IDMDF).MethodsBetween August 13, 2018 and January 15, 2019 at RUMC, IDPharmDs reviewed 251 inpatients on FQ, and made ASP recommendations on 36 (14%) that were communicated via telephone. No scripted discussion or note was utilized. From January 15, 2019 to April 19, 2019, an IDMDF reviewed 207 inpatients on FQ, and made ASP recommendations on 47 (22%). IDMDF’s recommendations were communicated via a scripted discussion describing the role of ASP, highlighting the importance of optimizing FQ use due to toxicity, low rates of RUMC’s FQ susceptibilities and to decrease rates of resistance. Telephone recommendations were made to the primary team house staff or attending followed by a templated electronic note left in the medical chart. Rates of IORs were assessed during each period and by each group.ResultsIn 20 out of 83 recommendations (24%), no antibiotic was indicated (Figure 1). GM teams had the highest overall (IDPharmD + IDMDF) IOR (76%), compared with 40% IOR for both SS and T-ICH groups. For all groups, the scripted IDMDF recommendations had higher IOR compared with the nonscripted IDPharmD recommendations (GM 89% vs. 61%; SS 50% vs. 29%; T-ICH 50% vs. 0%).ConclusionASP interventions using scripted discussions and notes by an IDMDF were more effective than nonscripted IDPharmD interventions across all service lines. Both interventions were less successful with SS or T-ICH compared with GM services. These findings demonstrate the need for further research to understand the importance of scripted vs. nonscripted communication methods by pharmacists and ID physicians, and to develop alternative communication models for nongeneral medicine service providers. Disclosures All authors: No reported disclosures.

63. THE NEXT MORNING: MODIFICATIONS MADE ON ROUNDS TO ORDERS PLACED BY OVERNIGHT ADMITTING RESIDENTS

Background An increased focus on quality and safety has resulted in increased resident supervision by attending physicians. At our large pediatric academic medical center, the overnight shift is when residents admit general pediatrics patients without immediate attending supervision. As such, admission orders are not evaluated by an attending until morning rounds. To the authors’ knowledge these orders have not been previously evaluated in the academic literature. Objectives To categorize orders placed by residents overnight that were subsequently discontinued on medical rounds the next morning and to examine the reasons for those changes. Methods We utilized our hospital's Enterprise Data Warehouse to generate a report of all orders placed on newly admitted patients by residents on the general pediatrics night shift over a 12-month period that were subsequently discontinued the following morning on rounds. All charts were reviewed by two independent reviewers. Orders were categorized by type of order and perceived reason for discontinuation. Disagreements on categorization were discussed with the research team until consensus was achieved. Results 290 discontinued patient orders were included in the analysis. Inter-rater agreement was very good with a kappa of 0.91. 66% of orders were medicines, 11% were diets, 4% were diagnostic testing, and 19% were for patient care. Within medication orders, 29% were antibiotics, 17% were antiasthmatics, and 10% were non-narcotic analgesics. The reason for order discontinuation was due to a change in clinical trajectory in 44% of cases (98% of which was patient improvement), primary attending decision in 11% of cases, and due to medical errors in 8% of cases. The most common medical error was a duplicate order (37.5%). Conclusions This study suggests that admission orders placed by pediatrics residents overnight are clinically appropriate. Medical errors were most commonly duplicate orders. This pilot identifies the need for further study to better understand the overnight care delivered by residents and to identify areas for increased resident autonomy.

Outcomes and Safety of Overlapping Surgery in Patients Undergoing Microvascular Decompression for Hemifacial Spasm and Trigeminal Neuralgia

Overlapping surgery, performed by the same primary attending surgeon asynchronously, has gained significant attention from the government and media as potentially harmful to patients. Therefore, the goal of this study was to evaluate the outcomes and safety of overlapping versus nonoverlapping microvascular decompression (MVD) operations. Patients who underwent MVD operations were retrospectively reviewed: 1153 with hemifacial spasm (HFS), 694 (60.2%) of whom underwent overlapping procedures, and 935 with trigeminal neuralgia (TN), 612 (65.5%) of whom underwent overlapping procedures. Collected variables included patient age, sex, side, disease duration, clinical characteristic, comorbidity, affected vessel, intraoperative neuroelectrophysiology, operation time under microscope, total surgical procedure times, mean length of stay (LOS), efficacy (at discharge, 6 months, 1 year), short-term complications, and long-term complications. χ2 and t tests were performed to compare overlapping versus nonoverlapping cases, and then multivariate analysis were conducted to adjust for patient demographics, clinical characteristics, and comorbidity between the 2 groups. Patient variables (age, sex, side, disease duration, clinical characteristic, and comorbidity), affected vessel, and intraoperative neuroelectrophysiology were similar between the 2 groups. After adjustment for patient demographics, clinical characteristics, and comorbidity, overlapping surgeries had longer total surgical procedure times (HFS: standardized coefficient= 0.066, P < 0.05; TN: standardized coefficient= 0.086, P < 0.05). Overlapping surgery was not associated with a significant difference in operation time under microscope, mean LOS, efficacy (at discharge, 6 months, 1 year), short-term complications, and long-term complications. Overlapping MVD operations may be performed safely at our institution. Further prospective studies are needed to understand the association of overlapping surgery among MVD operations.

Association of Medicare Spending With Subspecialty Consultation for Elderly Hospitalized Adults

High use of subspecialty care is an important source of health care spending. Medical subspecialty care in particular may duplicate the scope of practice of the primary attending physicians for patients hospitalized for medical conditions. Under value-based payments, which aim to control overall spending during an episode of hospitalization (including Part B physician fees), subspecialty consultations may be a target for hospitals working to reduce costs. To measure the use of subspecialty consultation for Medicare beneficiaries hospitalized for nonsurgical conditions; to compare payments for consultative and nonconsultative care, adjusted for case mix and demographics; and to measure variation in payments across hospital referral regions (HRRs). This retrospective cross-sectional study included a 15% random sample of Medicare fee-for-service beneficiaries enrolled in Parts A and B and identified all discharges after acute care hospital stays for nonsurgical conditions from January 1 through December 31, 2014. A total of 735 627 discharges were included. The analyses were conducted from December 1, 2017, through February 12, 2019. Total Part B payments were extrapolated to the population of Medicare fee-for-service beneficiaries. Probability of any consultation during a hospitalization was estimated using logistic regression. The number of consultations per stay and the number of consultative visits per hospital day were estimated using Poisson regression. Part B payments for consultative and nonconsultative care were estimated using generalized linear regression with gamma-log link. All models were adjusted for patient demographics and case mix. Payment models also included HRR fixed effects. A total of 735 627 discharges from 4534 hospitals in 2014 were included in the analysis (41.2% men and 58.8% women; mean [SD] age, 79.6 [8.9] years; 84.7% white, 10.1% black, and 5.2% other race). After adjusting for patient case mix and demographics, a 6-fold variation between the top and bottom quintiles of hospitals (relative difference, $401 [95% CI, $368-$434]) and HRRs (relative difference, $363 [95% CI, $337-$389]) was found in payments per stay for consultative care. Part B payments for consultative care by medical subspecialists accounted for 41.3% of payments for physician visits during hospitalization and totaled $1.3 billion in 2014. The substantial variation in the use of subspecialty consultative care suggests potential opportunities for cost savings.

Prevalence and Clinical Correlates of Sexual Dysfunction among Primary Care Diabetes Mellitus Enrollees Attending National Health Insurance Scheme (NHIS) Clinic in Uyo, South-South, Nigeria

Prevalence and Clinical Correlates of Sexual Dysfunction among Primary Care Diabetes Mellitus Enrollees Attending National Health Insurance Scheme (NHIS) Clinic in Uyo, South-South, Nigeria

Genetic Differentiation between Color Morphs of a Color-Polymorphic Aphid Macrosiphoniella yomogicola

Maintenance of intraspecific polymorphisms is important for biodiversity. The aphid Macrosiphoniella yomogicola has two color morphs (green and red) in Hokkaido. Their primary attending ants (Lasius japonicus) can manipulate the frequency of the green morph to match that of the red morph to maintain the polymorphism in an aphid colony. Ants prefer the green morph owing to its high-quality honeydew; however, the ants intentionally maintain nutritionally inferior red morphs in every colony because the ants only manipulate the reproductive rate of the green morph, i.e., the ants discriminate between the two morphs. Thus, the benefit of the red morphs to the ants should differ from nutrient exploitation. This hypothesis requires a genetic trade-off between the two morphs. Here based on three microsatellites, we show that the genetic distance between both morphs collected from the same sampling site is small suggesting that there is no genetic differentiation between their whole genomes. However, there were significant differences between the two morphs at a locus at the three sites examined. Our results suggest that intermorph copulations occur; however, the loci controlling morph-specific traits should be linked with the differentiated locus.

Erythromycin and Reflux Events in Premature Neonates: A Randomized Clinical Trial.

Gastroesophageal reflux disease (GERD) in premature neonates may manifest as apnea, bradycardia, growth failure, aspiration, or feeding intolerance. Erythromycin ethylsuccinate (EES), is often used as a pro-kinetic in the management of GERD, despite lack of evidence or safety from randomized controlled trials. We sought to study the efficacy of enteral EES at a dose of 50 mg · kg · day in decreasing the frequency of gastroesophageal reflux events as determined by pH-multichannel intraluminal impedance (pH-MII) monitoring. In a randomized, double-blind, placebo-controlled trial, eligible premature neonates with clinical signs of GERD underwent 24-hour pH-MII monitoring. If >5 reflux events were identified on pH-MII, then subjects were randomized to receive either EES or placebo. Repeat 24-hour pH-MII was performed on day 7 of study treatment and compared to initial pH-MII. Forty-three premature neonates were enrolled. Of those, 31 neonates were randomized, 15 to EES and 16 to placebo with a median (IQR) pretreatment total reflux events per 24 hours of 23 (16-40) and 29 (12-40), respectively. Day 7 total events per 24 hours decreased by 4 events in the EES group to 19 (15-33) and by 10 events in the placebo group to 19 (11-26) (P = 0.09). There were no differences in pretreatment and day 7 acidic and nonacidic reflux, proximal reflux, total or percent reflux time, median or longest bolus clearance time, or nurse-reported apnea events between groups. Enteral EES did not decrease reflux events on 24-hour pH-MII at the dose studied. Therefore, it may be ineffective in the treatment of GERD in premature neonates.

Multi-locus sequence typing of Treponema pallidum subsp. pallidum present in clinical samples from France: Infecting treponemes are genetically diverse and belong to 18 allelic profiles.

Treponema pallidum subsp. pallidum, the causative agent of sexually transmitted syphilis, detected in clinical samples from France, was subjected to molecular typing using the recently developed Multilocus Sequence Typing system. The samples (n = 133) used in this study were collected from 2010–2016 from patients with diagnosed primary or secondary syphilis attending outpatient centers or hospitals in several locations in France. Altogether, 18 different allelic profiles were found among the fully typed samples (n = 112). There were five allelic variants identified for TP0136, 12 for TP0548, and eight for TP0705. Out of the identified alleles, one, seven, and three novel alleles were identified in TP0136, TP0548, and TP0705, respectively. Partial allelic profiles were obtained from 6 samples. The majority of samples (n = 110) belonged to the SS14-like cluster of TPA isolates while 7 clustered with Nichols-like isolates. Patients infected with Nichols-like samples were more often older (p = 0.041) and more often diagnosed with secondary syphilis (p = 0.033) compared to patients infected with SS14-like samples. In addition, macrolide resistance caused by the A2058G mutation was found to be associated with allelic profile 1.3.1 or with strains belonging to the 1.3.1 lineage (p<0.001). The genetic diversity among TPA strains infecting the European population was surprisingly high, which suggests that additional studies are needed to reveal the full genetic diversity of TPA pathogens infecting humans.

Association of Overlapping Surgery With Increased Risk for Complications Following Hip Surgery

Overlapping surgery, also known as double-booking, refers to a controversial practice in which a single attending surgeon supervises 2 or more operations, in different operating rooms, at the same time. To determine if overlapping surgery is associated with greater risk for complications following surgical treatment for hip fracture and arthritis. This was a retrospective population-based cohort study in Ontario, Canada (population, 13.6 million), for the years 2009 to 2014. There was 1 year of follow-up. This study encompassed 2 large cohorts. The "hip fracture" cohort captured all persons older than 60 years who underwent surgery for a hip fracture during the study period. The "total hip arthroplasty" (THA) cohort captured all primary elective THA recipients for arthritis during the study period. We matched overlapping and nonoverlapping hip fractures by patient age, patient sex, surgical procedure (for the hip fracture cohort), primary surgeon, and hospital. Procedures were identified as overlapping if they overlapped with another surgical procedure performed by the same primary attending surgeon by more than 30 minutes. Complication (infection, revision, dislocation) within 1 year. There were 38 008 hip fractures, and of those, 960 (2.5%) were overlapping (mean age of patients, 66 years [interquartile range, 57-74 years]; 503 [52.4%] were female). There were 52 869 THAs and of those, 1560 (3.0%) overlapping (mean age, 84 years [interquartile range, 77-89 years]; 1293 [82.9%] were female). After matching, overlapping hip fracture procedures had a greater risk for a complication (hazard ratio [HR], 1.85; 95% CI, 1.27-2.71; P = .001), as did overlapping THA procedures (HR, 1.79; 95% CI, 1.02-3.14; P = .04). Among overlapping hip fracture operations, increasing duration of operative overlap was associated with increasing risk for complications (adjusted odds ratio, 1.07 per 10-minute increase in overlap; P = .009). Overlapping surgery was relatively rare but was associated with an increased risk for surgical complications. Furthermore, increasing duration of operative overlap was associated with an increasing risk for complications. These findings support the notion that overlapping provision of surgery should be part of the informed consent process.

Building a collaborative culture in cardiothoracic operating rooms: pre and postintervention study protocol for evaluation of the implementation of teamSTEPPS training and the impact on perceived psychological safety

IntroductionThe importance of effective communication, a key component of teamwork, is well recognised in the healthcare setting. Establishing a culture that encourages and empowers team members to speak openly in...

Effects of Cryopreserved Amniotic Membrane Allograft on Total Ankle Arthroplasty Wound Healing

Category: Ankle, Ankle Arthritis, Basic Sciences/Biologics Introduction/Purpose: Despite improvements in newer-generation total ankle arthroplasty (TAA) implants, relatively high wound-healing complication rates continue to be reported with the anterior ankle incision. Only 66% heal without wound-healing complications, 25% have minor complications requiring local care and/or oral antibiotics, and 9% experience major complications requiring reoperation (Raikin et al., 2010). Recently, multiple regenerative adjuncts have been investigated to reduce postoperative complications by enhancing local healing factors and reducing risk of infection. The relatively novel use of adjunctive therapy utilizing cryopreserved amniotic membrane modulate wound healing by down-regulating inflammation and scar formation (Hanselman et al., 2015). The purpose of our study is to determine whether the local application of cryopreserved amniotic membrane wound allograft may enhance soft tissue wound healing of the TAA anterior ankle incision. Methods: Patients with symptomatic ankle arthritis who failed conservative management underwent TAA by two senior foot and ankle surgeons at single tertiary hospital. Both senior surgeons were present and involved in all surgeries, and all patients underwent the same procedure as indicated by their pathology, postoperative regimen, and rehabilitation protocol. At skin closure, patients were either allocated to the treatment or control group strictly by the designated primary attending. The skin closure of the treatment group was performed in standard fashion with local application of cryopreserved amniotic membrane to the extensor retinacular layer and no allograft was used for the control group. Demographics, sagittal and coronal correction, and patient comorbidity information was collected. The primary outcome was time to skin healing as determined by suture removal and surgical site skin apposition without evidence of granulation tissue or eschar. Secondary outcomes were skin dehiscence, local wound care, and use of antibiotics. Results: Local application of amniotic membrane allograft significantly decreased overall time to skin healing (40 days to 28.5 days, p=0.0377). There were no reoperations for wound complications in either group. However, there was a trend in decreased dehiscence (13% to 6%, p=0.29) and antibiotic prescription (23% to 9%, p=0.09). There was no significant difference in treatment versus control group with respect to body mass index, sagittal or coronal correction, sex, history of smoking, prior arthrodesis, or primary or revision. There was a significantly higher percentage of patients with history of diabetes who received amniotic membrane than those who did not receive the adjunct therapy (20% versus 2%, p=0.01). Conclusion: Regenerative technology using local application of cryopreserved amniotic membrane allograft may enhance TAA outcomes by decreasing time to healing. Although there was a trend in decreased dehiscence and antibiotic usage, larger randomized controlled trials are necessary to determine whether local application of cryopreserved amniotic membrane allograft may enhance soft tissue wound healing and ultimately reduce the incidence of devastating soft tissue complications.

Evaluation of the injection moulding conditions in soy/nanoclay based composites

Biocomposites, and generally bio-based plastics, are seen as a promising alternative to conventional plastics because they are based on renewable natural components (eco-friendly) with a lower cost. Biocomposites using soy protein and glycerol were obtained with an injection moulding technique as the thermoprocessing method. Nanoclay (Montmorillonite, MMT-Na+) was included to improve physicochemical properties of novel SPI/MMT nanocomposites prepared by injection moulding, primary attending to water uptake capacity (WUC), but also considering rheological and mechanical properties. The influence of processing conditions has been studied in order to assess the modifications taking place in the microstructure and properties of these nanocomposites. Addition of MMT-Na+ improves mechanical properties and WUC of SPI-based materials, depending on processing conditions. Injection pressure only exerts a slight enhancement of mechanical properties and WUC. However, an increase in mixing time leads to a relevant increase in WUC without impairing the mechanical properties of nanocomposites.

Wound Care: What the Medical Director Needs to Know

Wound Care: What the Medical Director Needs to Know

Technical Considerations in the Surgical Management of External Laryngotracheal Trauma: Surgical Outcomes

Introduction: External laryngotracheal (ELT) trauma is rarely encountered in clinical practice. In most circumstances, this injury is overlooked by the primary attending team. Surgical management of ELT trauma is complicated, because there is no established management approach for this potentially life-altering, high morbidity injury. It is important for this injury to be identified early, as any delay in surgical intervention may result in poor airway and phonatory outcomes. The aim of surgical reconstruction is to minimise the above debilitating morbidities by restoring the main laryngeal functions as much as possible. Methods: We reviewed the outcomes of six surgical interventions for ELT trauma at Tengku Ampuan Afzan Hospital from June 2007 to June 2014. Clinical presentations, computed tomography (CT) scans features, intraoperative findings, and postoperative outcomes were evaluated. Results: All patients made a good recovery in terms of phonation except for one patient who had reduced speech function. After one year, one patient was still dependent on a fenestrated tracheostomy. This article describes the surgical reconstruction techniques used to achieve these positive outcomes. Stenting is helpful to aid healing and re-epithelialisation. Conclusion: Prompt recognition and non-traumatised airway control are essential for addressing laryngotracheal trauma. Subcutaneous emphysema is an important hallmark that should alert the attending physician to the possibility of ELT trauma. Immediate surgical intervention using appropriate techniques can produce favorable patient outcomes.

Invasive Fungal Disease in Pediatric Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplant.

Invasive fungal disease (IFD) remains a major cause of morbidity and mortality in pediatric patients after allogeneic hematopoietic stem cell transplant (HSCT). We analyzed the outcome of 152 consecutive pediatric patients who underwent allogeneic HSCT from 2005 to 2012: 126 of these without a history of IFD and 26 with IFD before HSCT. Antifungal prophylaxis agent was determined by the primary transplant attending. The rate of IFD after HSCT among patients with or without prior IFD was similar (7.7% with and 7.1% without a history of fungal disease before transplant). Mortality in these 2 populations did not differ (35% vs. 28%, P=0.48, χ). Patients deemed at higher risk for IFD were generally placed on voriconazole prophylaxis; however, this did not affect rates of posttransplant IFD. All-cause mortality in patients with posttransplant IFD was significantly higher than those without posttransplant IFD (67% vs. 21%, P<0.0001,χ). Identifying risk factors for posttransplant IFD remains a high priority to improve outcome of HSCT.