Surgical Care Research Articles

Implementasi Five Moment Hand Hygiene Pada Perawat Di Ruang Rawat Medikal Bedah Rumah Sakit Santa Elisabeth Medan

The prevalence of nosocomial infections worldwide has become a serious concern for healthcare professionals, especially in hospitals. One contributing factor is the inadequate implementation of the five moments hand hygiene in handwashing procedures that do not conform to operational procedure standards. The aim of this research is to determine how the implementation of the five moments hand hygiene among nurses in the surgical medical care ward at Santa Elisabeth Hospital in Medan. This study utilized a descriptive cross-sectional approach, employing observation sheets. The sample size included 30 nurses in the Surgical Medical Care Ward at Santa Elisabeth Hospital in Medan, using total sampling technique. The measurement tool was an observation sheet, and the data analysis employed univariate analysis. The research findings revealed that, in the first moment before patient contact, 56.7% of nurses did not adhere to the practice, while 43.3% did. In the second moment, before aseptic procedures, 56.7% of nurses did not comply, and 43.3% did. In the third moment, after exposure to patient body fluids, all nurses (100%) adhered to the practice. In the fourth moment, after patient contact, all nurses (100%) complied. In the fifth moment, after contact with the patient's environment, all nurses (100%) followed the practice. It is hoped that nurses can consistently implement the five moments hand hygiene to prevent disease transmission and nosocomial infections, fostering a habit of incorporating these practices into nosocomial infection prevention.

Primary Palliative Care in Urology: Quality Improvement Summit 2021-2022.

The AUA convened a 2021-2022 Quality Improvement Summit to bring together interdisciplinary providers to inform the current state and to discuss potential strategies for integrating primary palliative care into urology practice. We hypothesized that the Summit findings would inform a scalable primary palliative care model for urology. The 3-part summit reached a total of 160 interdisciplinary health care professionals. Webinar 1, "Building a Primary Palliative Care Model for Urology," focused on a urologist's role in palliative care. Webinar 2, "Perspectives on Increasing the Use of Palliative Care in Advanced Urologic Disease," addressed barriers to possible implementation of a primary palliative care model. The in-person Summit, "Laying the Foundation for Primary Palliative Care in Urology," focused on operationalization of primary palliative care, clinical innovations needed, and relevant metrics. Participants agreed that palliative care is needed early in the disease course for patients with advanced disease, including those with benign and malignant conditions. The group agreed about the important domains that should be addressed as well as the interdisciplinary providers who are best suited to address each domain. There was consensus that a primary "quarterback" was needed, encapsulated in a conceptual model-UroPal-with a urologist at the hub of care. The Summit provides the field of urology with a framework and specific steps that can be taken to move urology-palliative care integration forward. Urologists are uniquely positioned to provide primary palliative care for their many patients with serious illness, both in the surgical and chronic care contexts.

Decision-making process regarding passive euthanasia: Theory of planned behavior framework.

Nurses have an essential role in caring for end-of-life patients. Nevertheless, the nurse's involvement in the passive euthanasia decision-making process is insufficient and lower than expected. To explore factors associated with nurses' intention to be involved in non-treatment decisions (NTD) regarding passive euthanasia decision-making versus their involvement in the palliative care of patients requesting euthanasia, using the Theory of Planned Behavior (TPB) framework. A cross-sectional study utilizing a random sample. The study was conducted in one of the largest hospitals in Israel among 125 nurses employed in internal and surgical care wards. Data was collected through face-to-face interviews between March and April 2019. A closed structured questionnaire was developed according to TPB instructions. A paired sample t test and two multiple hierarchical regressions were conducted. Variance explained (R2) and the significance of F change were calculated for each regression. The study used the STROBE statement guideline. The study was approved by the hospital's Helsinki Committee (#20.11.2017). A paired sample t test revealed that nurses' involvement in the palliative care of patients requesting passive euthanasia was significantly higher than in NTD regarding euthanasia. Regression analyses revealed that nurses' position and attitudes explain their intention to be involved in decision-making; attitudes and perceived behavioral control explain nurses' intention to be involved in the care of patients requesting euthanasia. According to the TPB, nurses' attitudes explained their intention to participate in decision-making regarding passive euthanasia. It is recommended to enhance open discussion of this complex issue to encourage nurses' willingness to participate in NTD decision-making regarding euthanasia.

The Impact of the Pandemic on Reproductive Autonomy and Gender Equality: Perspectives from the Sustainable Development Agenda

Abstract The COVID-19 pandemic had mixed effects on reproductive autonomy. While some governments excluded reproductive health care from the category of “essential” services that could be provided during shutdown orders, the pandemic also gave researchers an opportunity to study the efficacy and safety of telemedicine abortion and self-managed abortion. Feminist organizations around the world have also organized to provide cross-border services and far more women now know how to obtain abortion medications. This can be empowering, not only during a public emergency but also when legal rights are suddenly taken away. Unfortunately, for those women who require surgical abortion care, overly strict laws can still lead to tragic outcomes. This is why it is important that human rights treaty bodies and courts are gradually recognizing a right to reproductive autonomy under regional and international human rights law. Hopefully, even conservative governments can be persuaded to provide compassionate exceptions in their laws regulating abortion. A more compassionate approach to the subject of abortion would promote both maternal health and gender equality, helping governments to achieve the ambitious targets in the Sustainable Development Goals.

Surgeon compensation in academic medicine

Academic surgery is the best career one could ever aspire to have; however, given the long duration of training and the anticipated education debt, surgeon compensation has not kept pace with the compensation of other comparable careers. As surgeon compensation has experienced increased downward pressure, it has become of growing importance to those in academic medicine/surgery. Competitive compensation is necessary, even if not sufficient, for successful faculty recruitment and retention. The optimal compensation system should encourage the best possible patient care, inspire teamwork, maximize the department’s or physician practice’s ability to recruit and retain faculty, support all missions, and be viewed as equitable and transparent. The goal of an optimal compensation system is to have faculty minds focused on things other than compensation—those elements of their job that are most important, such as career development, multidisciplinary clinical programs, research, and education. One way to ensure that compensation stays in the background for academic surgeons is for leadership to keep this front and center. Compensation plans can influence behavior and time management and affect the clinical, academic, and educational contributions of surgeons and physicians of all specialties. As we strive to optimize the productivity and engagement of a health system’s most valuable resource—those who deliver surgical care and create new knowledge—compensation is an important variable in need of constant attention.

Clinical Outcomes and Complication Profile of Spine Surgery in Septuagenarians and Octogenarians: Case Series

IntroductionThe aging global population presents an increasing challenge for spine surgeons. Advancements in spine surgery, including minimally invasive techniques, have broadened treatment options, potentially benefiting older patients. This study aims to explore the clinical outcomes of spine surgery in septuagenarians and octogenarians. MethodsThis retrospective analysis, conducted at a US tertiary center, included patients aged 70 and older who underwent elective spine surgery for degenerative conditions. Data included the Charlson Comorbidity Index, ASA classification, surgical procedures, intraoperative and postoperative complications, and reoperation rates. The objective of this study was to describe the outcomes of our cohort of older patients and discern whether differences existed between septuagenarians and octogenarians. ResultsAmong the 120 patients meeting the inclusion criteria, there were no significant differences in preoperative factors between the age groups(p>0.05). Notably, the septuagenarian group had a higher average number of fused levels(2.36 vs. 0.38, p=0.001), while the octogenarian group underwent a higher proportion of minimally invasive procedures(p=0.012), resulting in lower overall bleeding in the oldest group(p<0.001). Mobility outcomes were more favorable in septuagenarians, whereas octogenarians tended to maintain or experience a decline in mobility(p=0.012). A total of 6(5%) intraoperative complications and 12(10%) post-operative complications were documented, with no statistically significant differences observed between the groups. ConclusionThis case series demonstrates that septuagenarians and octogenarians can achieve favorable clinical outcomes with elective spine surgery. Spine surgeons should be well-versed in the clinical and surgical care of older adults, providing optimal management that considers their increased comorbidity burden and heightened fragility.

(126) Medicolegal Considerations for Patients Undergoing Urologic Surgical Interventions and the Development of an Audio-Recording Application for use During Genital Gender-Affirming Surgical Consultation

Abstract Introduction Patient recollection of details discussed during medical consultation is often limited (Figure 1a). For genital gender-affirming surgery (gGAS) consultations, lengthy discussions and deep contemplation surrounding surgical options are critical. Inadequate communication can result in patient complaints and medico-legal action, whereupon issues such as a lack of discussion or poor documentation can lead to medico-legal liability against the care provider and hospital system. As a result, strategies must be developed to ensure that information discussed during complex medical consultations are made available so patients can properly weigh out the care options presented. Objective 1) Assess medico-legal incidents in Urologic and surgical specialties in the UK, US, and a Californian quaternary care center, 2) evaluate the advantages and feasibility of offering audio-recordings of patient consultations, and 3) create a user-friendly smartphone app for recording healthcare consultations. Methods A literature review evaluated current evidence on medical liability claims in the UK and US was conducted. Additionally, our center's Department of Risk Management provided information pertaining to medico-legal cases against our institution. Separately, gGAS patients consented to audio-record their consultation. Copies were provided to patients and kept in their medical records. A follow-up survey assessed its usefulness, and based upon patient feedback, a smartphone application was developed. Results A PubMed search yielded 921 results on "medical malpractice claims" from 2013–2023. In Urologic Surgery, 32 papers addressed medical malpractice, with 2 providing data over the last 15 years. In the UK, 660 claims were made from 2010–2020, of which 8.2% were due to poor communication (37 = informed consent; 17 = lack of follow-up). In the US, from 2020–2022, 38.3% of Urologists faced at least one legal proceeding in their career, and 5.3% were sued within 1 year for any reason. Our institution's Department of Risk Management reported 32% of lawsuits were related to surgical care. Informed consent involved 8% of cases and had a component in 32%. The average financial settlement for medical malpractice was $125,000.00 USD, and trial costs averaged $75,000.00 USD. 50/71 patients completed an anonymized, online survey post-audio recording. Positive results were noted regarding recording quality, comfort whilst being recorded, and wishes for future consultation recordings (Figure 1b). In addition, most patients felt less anxiety, and had greater confidence in their treatment choice (Figure 1c) Based upon patient responses, we developed a smartphone App which records 90 minutes of audio, allows for file and hyperlink attachments to be sent to patients before immediately deleting all information (Figure 1d). Routine use of audio-recordings led to a reduction in patient queries to our office. Conclusions Routine audio recording of patient consultations provides significant benefits with minimal cost to providers. As per our institution's Office of Risk Management, it offers protection against medico-legal risks. Adequate discussion, good documentation and providing adjuncts for patients can help prevent a large proportion of medicolegal complaints in addition to optimizing patient care. Considering that patients face similar challenges across different disciplines and regions, a larger study (multi-center, international, multi-language) is warranted. Disclosure No.

Gastric perforation after polyurethane foam ingestion

Introduction Acute intoxication rarely produces conditions that require urgent surgical care. Case summary A 45-year-old man presented to the emergency department with severe abdominal pain after the deliberate ingestion of 200 cm3 of polyurethane mixed with methylene diphenyl diisocyanate and urethane primers. On an initial laparoscopic examination, foreign material was observed in the peritoneal space with haemoperitoneum. Emergency exploration was then undertaken for suspected gastric perforation. Full-thickness damage was identified on the stomach wall during the operation. The material in the gastrointestinal tract and peritoneal space was gently removed. Moulded casts of the entire stomach and distal oesophagus were extracted successfully. The patient was discharged 14 days after surgery. Images Computed tomography revealed foreign material occupying the entire gastric chamber, as well as diffuse gastric perforation. Conclusions Life-threatening gastric perforation can occur after polyurethane foam ingestion. Clinical/medical toxicologists and emergency physicians need to be aware of the highly expandable nature of this agent.

High-value innovations in otolaryngology born from a tertiary hospital in Rwanda: opportunities for bi-directional learning

Introduction: The objective of this paper is to discuss bidirectional innovation sharing between high-income countries (HICs) and low-income countries and middle-income countries (LMICs) in otolaryngology surgery. The authors aim to highlight several high-value, context-appropriate innovations in otolaryngology care that have been developed in a tertiary hospital in Rwanda and discuss their safety and efficacy compared to the standard of care. Methods: Five surgeons (three Rwandan surgeons, two United States surgeons with longitudinal experience in Rwanda) provided their recommendations for high-value innovations currently being employed in their experience at a tertiary hospital in Rwanda. Results: Otolaryngologists provided feedback on the utility, safety, and efficacy of ten ‘innovations’ that aim to optimize resource utilization and improve access to otolaryngology care. The authors emphasize the need for tailored, context-appropriate solutions in surgical care and the importance of research and evaluation to ensure the safety and efficacy of LMIC innovations. The authors also highlight the potential for HICs to learn from LMICs in terms of high-value and environmentally sustainable surgical practices. Further research is needed to guide national health systems in prioritizing their infrastructure, equipment, and training needs for scaling up otolaryngology services. Discussion: Our review highlights the importance of bidirectional learning in surgical innovation and the potential for high-value innovations to improve surgical care in LMICs.

Economic Impact of COVID-19 on a Free-Standing Pediatric Ambulatory Center.

Operating safely throughout the coronavirus disease 2019 (COVID-19) pandemic has required surgical centers to adapt and raise their level of readiness. Intuitively, additional expenses related to such adaptation may have resulted in an increase in the cost of surgical care. However, little is known about the magnitude of such an increase, and no study has evaluated the temporal variation in the costs of care throughout the pandemic. The aim of the current study was to evaluate the impact of COVID-19 on the cost of surgical and anesthetic care in a free-standing, pediatric ambulatory care center. We performed a retrospective review of the electronic medical record (EMR) and financial data for pediatric ambulatory settings between 2019 and 2020 (April - August) from our tertiary care children's hospital. The primary outcomes were the inflation-adjusted surgical cost for elective tonsillectomy, adenoidectomy, and tympanostomy tubes (BTI) placement procedures in children less than 18 years of age. These data were obtained from financial databases and aggregated into categories including anesthesia services, operating room services, recovery room services, and supply and medical devices. Costs per case to provide care were significantly higher following the COVID-19 pandemic in 2020 compared to 2019 across all services: anesthesia ($1,268 versus $1,143; cost ratio (CR): 1.11, 95% confidence interval (CI): 1.08 - 1.14, P-value < 0.001), operating room ($1,221 vs. $1,255; CR: 1.03, 95% CI: 1.02 - 1.04, P-value < 0.001), recovery room ($659 vs. $751; CR: 1.14, 95% CI: 1.10 - 1.18, P-value < 0.001), and supply ($150 vs. $271; CR: 1.81, 95% CI: 1.26 - 2.6, P-value = 0.001). There was an overall increase in healthcare service costs in 2020, with significant fluctuations in the early and mid-year months. Our study identified specific economic impacts of COVID-19 on free-standing pediatric ambulatory centers, thereby highlighting the need for innovative practices with cost containment for sustainability of such specialized centers when dealing with future pandemics related to COVID-19 or other viral pathogens.

Pediatric Plastic Surgery in the COVID-19 Era.

The COVID-19 pandemic has forced the healthcare system to adopt novel strategies to treat patients. Pediatric plastic surgeons are uniquely exposed to high rates of infections during examinations and surgeries via aerosol-generating procedures, in part because of the predilection of viral particles for the nasal cavities and pharynx. Telemedicine has emerged as a useful virtual medium for encouraging prolonged patient follow-up while maintaining physical distance. It has proven beneficial in mitigating infection risks while decreasing the financial burden on patients, their families, and healthcare teams. New trends driven by the pandemic added multiple elements to the patient-physician relationship and have left a lasting impact on the field of pediatric plastic surgery in clinical guidelines, surgical care, and patient outcomes. Lessons learned help inform pediatric plastic surgeons on how to reduce future viral infection risk and lead a more appropriately efficient surgical team depending on early triage.

Changing Surgical Culture Through Surgical Education: Introduction to the PACTS Trial

The Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum was developed to improve surgical resident cultural dexterity, with the goal of promoting health equity by developing cognitive skills to adapt to individual patients' needs to ensure personal, patient-centered surgical care through structured educational interventions for surgical residents. Funded by the National Institute of Health (NIH)'s National Institute on Minority Health and Health Disparities, PACTS addresses surgical disparities in patient care by incorporating varied educational interventions, with investigation of both traditional and nontraditional educational outcomes such as patient-reported and clinical outcomes, across multiple hospitals and regions. The unique attributes of this multicenter, multiphased research trial will not only impact future surgical education research, but hopefully improve how surgeons learn nontechnical skills that modernize surgical culture and surgical care. The present perspective piece serves as an introduction to this multifaceted surgical education trial, highlighting the rationale for the study and critical curricular components such as key stakeholders from multiple institutions, multimodal learning and feedback, and diverse educational outcomes.

Effect of Age and Body Mass Index on Time to Advanced Imaging and Surgery in Young Athletes With Anterior Cruciate Ligament Injury.

In young athletes with anterior cruciate ligament (ACL) injury, increased times from injury to magnetic resonance imaging (MRI) and injury to surgery can lead to the accrual of new injuries over time. To determine the patient characteristics associated with differences in timing between injury, MRI, and surgery in young athletes with ACL tears. Case-control study; Level of evidence, 3. We reviewed the electronic medical records of patients aged 13 to 25 years who underwent isolated primary ACL reconstruction between January 2017 and June 2020 at a single orthopaedic surgery department. The times from injury to MRI, MRI to surgery, and injury to surgery were documented. Patient demographic data (age, sex, body mass index [BMI], race and ethnicity, and insurance type) were recorded. Multivariable analysis was used to determine if any patient characteristic had a significant association with increased time to MRI or surgery. A total of 369 patients (mean age, 18.0 years; 56% female) were included. Both age and BMI were found to be significantly associated with timing of care while holding all other predictors constant. For every 1-year increase in patient age, time from injury to MRI increased by 9.6 days (95% CI, 1.8-17.4 days; P = .02), time from MRI to surgery increased by 7.4 days (95% CI, 4.4-10.5 days; P < .001), and time from injury to surgery increased by 17.0 days (95% CI, 8.4-25.6 days; P < .001). Compared with patients with normal BMI, overweight patients (BMI range, 25-29.9 kg/m2) had an MRI-to-surgery time that was on average 37.2 days (95% CI, 11.7-62.7 days; P < .004) longer and an injury to surgery time that was on average 71.8 days (95% CI, 0.5-143.0 days; P = .048) longer. Obese patients (BMI ≥30 kg/m2) did not demonstrate a significant relationship with the studied time intervals. Increasing age and elevated BMI were found to be associated with increased time to MRI and surgical care in young athletes with ACL injuries.

Prevalence and Risk Factors for Cerebral Palsy in Children With Congenital Heart Disease Based on Risk of Surgical Mortality

BackgroundChildren with congenital heart disease (CHD) have a higher prevalence of motor impairment secondary to brain injury, resulting in cerebral palsy (CP). The purpose of this study is to determine the prevalence of CP in CHD in a single-center cohort, stratify risk based on surgical mortality using Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) categories and identify risk factors. MethodsRetrospective cohort study of pediatric patients registered in the University of Florida (UF) Society of Thoracic Surgeons Congenital Heart Surgery database from 2006 to 2017 with a diagnosis of CHD who continued follow-up for more than two years at UF. ResultsA total of 701 children with CHD met inclusion criteria. Children identified to have CP were 54 (7.7%). Most common presentation was spastic hemiplegic CP with a Gross Motor Function Classification System of level 2. Analysis of surgical and intensive care factors between the two groups showed that children with CHD and CP had longer time from admission to surgery (P = 0.003), higher STAT categories 4 and 5 (P = 0.038), and higher frequency of brain injury and seizures (P < 0.001). Developmental disabilities and rehabilitation needs were significantly greater for children with CHD and CP when compared with those with CHD alone (P < 0.001). ConclusionsIn our cohort, 7.7% children with CHD develop CP; this is significantly higher than the 2010 US population estimate of 0.3%. Our study suggests higher STAT categories, brain injury, and seizures are associated with developing CP in children with CHD.

Los últimos avances en prostatectomía robótica: ¿cómo lo hacemos en Cataluña, España?

Introduction and objectiveRobotic-assisted laparoscopic prostatectomy (RALP) seems to improve functional outcomes, however there is not a consensus of a standard procedure. The aim of this study was to identify the RALP “state of art” in Catalonia, Spain. Material and methodsThis was a cross-sectional survey-based study conducted among urologists across Catalonia. The survey was distributed through online platforms and the professional urology society. All statistical analyses were performed using Stata software, v. 20. ResultsFifty-nine urologists completed the survey, revealing RALP as the most commonly used technique (79.7%). Most urologist (70%) create the pneumoperitoneum using a controlled incision with direct access and 78.3% use the AirSeal® technology. The intraperitoneal approach is performed in more than 90% of cases. Endopelvic fascia preservation is not routinely performed. A percentage of 34.5 of the survey not perform the dorsal vein complex suture. All preserves the bladder neck when oncologically safe. Nerve-vascular bundles bleeding control is performed using standard coagulation or suturing. Thirty-four percent performed posterior reconstruction. Only use hemostatic devices when evident bleeding and 70% does not routinely left a drainage. Multivariable analysis showed that center volume had a significant independent association with dorsal venous complex suturing (OR 0.073, 95% CI 0.07-0.826), nerve-vascular bundles suturing hemostasis (OR 11.67, 95% CI 1.07-127.60) and endopelvic fascia preservation (OR 13.64, 95% CI 1.087-201.27), but there was no correlation with time the bladder catheter or days hospitalized. ConclusionsThe study provides an overview of the state of RALP in Catalonia, Spain, showing significant variability and reflecting a commitment to advancing surgical technology and patient care.

Predicting hypovitaminosis C with LASSO algorithm in adult critically ill patients in surgical intensive care units: a bi-center prospective cohort study

Vitamin C played pleiotropic roles in critical illness and vitamin C insufficiency was predictive of the development of multiple organ failure. Currently, the prevalence of vitamin C insufficiency in Chinese critically ill patients is rarely determined and there are no established bedside tools to predict hypovitaminosis C. To develop a nomogram to identify patients with high risk of hypovitaminosis C, we performed a bi-center prospective cohort study at two ICUs of the first and sixth medical center in PLA General Hospital, Beijing, China from May 6th to July 31st, 2021 We identified 322 eligible patients. 62.4% patients were hypovitaminosis C. 7 features, including source of infection, the level of serum albumin, age, male gender, sepsis, vascular disease, and wasting of vitamin C by the kidney, were selected using LASSO algorithm and therefore included in the nomogram. In the testing set, our model showed moderate discrimination ability with areas under the curve of 0.75 [0.64–0.84]. Variable importance evaluated by SHAP value highlighted two novel important predictors, i.e., abdominal infection and the level of serum albumin. In conclusion, we first reported a high burden of vitamin C insufficiency in Chinese adult patient in the ICU. We also constructed a prediction model to timely identify patients with high risk of hypovitaminosis C, which allows the clinicians to choose appropriate candidates for Vitamin C repletion in clinical practice or clinical trials.

Organization and structure of intensive care management of adult congenital heart disease in the United States

BackgroundThe growing number of adults with congenital heart disease has led to the formation of dedicated centers to provide specialized care. There is a paucity of published data on the organization, staffing, and resources available when adult congenital heart disease (ACHD) patients are hospitalized in intensive care settings. This study aims to describe the delivery of intensive care for ACHD patients in the United States and identify key differences between accredited centers or those pending accreditation and non-accredited Adult Congenital Heart Association (ACHA) centers. MethodsA web-based cross-sectional survey targeting centers with specialized ACHD programs was conducted. ResultsData were obtained from 48 of 96 centers (50%). Twenty-seven (56%) were accredited by the ACHA and 8 (17%) were pending accreditation. Surgical ACHD patients were primarily co-managed by cardiologists and intensivists (n = 11, 23%) and treated within an adult cardiac surgical intensive care unit (n = 34, 72%). Compared to non-accredited centers, ACHA accredited centers or those pending accreditation were more likely to offer daily rounds with ACHD providers (30, 86% vs. 6, 46%, p=<0.01), were more likely to support an ACHD fellowship training program (16, 46% vs. 0, 0%, p=<0.01); and were more likely to have durable mechanical support, such as ventricular assist devices (35, 100% vs. 8, 62%, p < 0.01). ConclusionThis survey reports current trends in organization, staffing, and resources available to ACHD patients requiring intensive care. ACHA accredited centers or those pending accreditation were more likely to have dedicated ACHD rounds, fellowship training programs, and access to durable mechanical support.

Silver carboxylate-TiO2/polydimethyl siloxane is a safe and effective antimicrobial with significant wound care potential.

With the rise in antibiotic resistance, new methodologies are needed to combat musculoskeletal infections. Silver is an antimicrobial that can be synthesized in different forms, but its pharmacokinetics are difficult to control. This study details the antibacterial efficacy and cellular cytotoxicity of a formulation consisting of silver carboxylate (AgCar) released through a titanium dioxide/polydimethylsiloxane matrix with a predictable release profile on Pseudomonas aeruginosa, Acinetobacterium baumannii, and human-derived primary osteoblasts. Through an Institutional Animal Care and Use Committee and IRB-approved protocol, AgCar was applied to live Yucatan porcine skin and histologically analyzed for skin penetration. Graphite Furnace Atomic Absorption Spectroscopy (GFAAS) was used to measure elution of AgCar. Dose-response curves were generated through optical density to assess potency. Finally, 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay was used to quantify the cellular cytotoxicity of the novel formulation. The results were subject to statistical analysis using analysis of variance and post hoc Tukey tests. The silver carboxylate coating demonstrated deep penetration into the epithelium at the level of the deep pilosebaceous glands in animal models. GFAAS testing demonstrated the extended elution profile of silver carboxylate over 96 hours, while 100% silver with no titanium dioxide-polydimethylsiloxane matrix fully eluted within 48 hours. 10x silver carboxylate demonstrated superior antimicrobial activity to antibiotics and other silver formulations and showed minimal cytotoxicity compared with other silver formulations. Current antimicrobial therapies in wound care and surgical antisepsis, such as chlorhexidine gluconate, have pitfalls including poor skin penetration and short duration of efficacy. The broad antimicrobial activity, extended elution, and deep skin penetration of this AgCar formulation show great promise for surgical site infection and wound care treatment. Novel technology to fight the growing threat of microbial resistance should be at the forefront of orthopaedic surgical site infection prevention and treatment.

A Decision Support System For Skill-Based Nurse Scheduling In An Intensive Care Unit

The main target of health institutions is to provide the health services needed by society at the desired quality with the lowest possible cost. Considering the total number of employees in health institutions, nurse assignment and scheduling have an essential role in increasing efficiency and improving service quality due to the one-to-one interaction of nurses with patients. This study proposes a nurse scheduling model based on nurses’ skill levels incorporated into a decision support system. The skill level of nurses is assessed using Analytic Hierarchy Process and Technique for Order Preference by Similarity to Ideal Solution method based on eight criteria. The nurse scheduling problem is then modeled with 0-1 Goal Programming, considering the skill assessment as a constraint. The practicality of the proposed model is examined for the assignment and scheduling conditions of nurses at the 3rd level of surgical intensive care in a general hospital, and the valuable aspects of the proposed approach are discussed. When the proposed solution is compared with the current situation, it is realized that one nurse is saved without worsening the constraints.

Sex-based Disparities in the Management of Pediatric Gonadal Torsion

IntroductionIn 2015, the U.S. News and World Report (USNWR) implemented a quality metric to expedite surgery for testicular torsion (TT), but not ovarian torsion (OT). This study examined OR timing among children with suspected TT and OT before and after this metric. MethodsA single-center retrospective cohort study of children (1–18yr) who underwent surgery for suspected gonadal torsion was performed. Time to OR (TTOR) from hospital presentation to surgery start was calculated. An interrupted time series analysis identified changes in TTOR for suspected TT versus OT after the 2015 USNWR quality metric. ResultsOverall, 216 patients presented with TT and 120 with OT. Median TTOR for TT was 147 min (IQR:99–198) versus 462 min (IQR:308–606) for OT. Post-quality metric, children with TT experienced a 27.8 min decrease (95% CI:-51.7,-3.9, p = 0.05) in annual median TTOR. No significant decrease was observed for children with OT (p = 0.22). Children with history of a known ovarian mass (N = 62) experienced a shorter TTOR compared to those without (422 vs 499min; p = 0.04). ConclusionImplementation of a national quality metric for TT expedited surgical care for children with TT, but not children with OT. These findings highlight the need for equitable quality metrics for children presenting with suspected gonadal torsion. Level of EvidenceIII. Type of StudyRetrospective Comparative Study, Observational Cohort Study.