Search

Pulmonary abscess is a complication of lung infection with localized necrosis and purulent cavity formation. Pulmonary abscesses are typically managed using antibiotic therapy with anatomic surgical resection reserved as a rescue. Percutaneous drainage is considered relatively contraindicated in some centers due to perceived risk of bronchopleural fistula. However, drain placement has been frequently employed at our institution. The purpose of this study was to review and describe our longitudinal experience. Medical records of children diagnosed with lung abscess and treated with percutaneous drainage from 2005 through 2023 were reviewed. Patient clinical parameters, follow-up imaging, and clinical outcomes were evaluated. Percutaneous drainage (n = 24) or aspiration alone (n = 4) under imaging guidance was performed by interventional radiologists for 28 children with lung abscesses. A single catheter (8–12 Fr) was deployed in the pulmonary abscess cavity and remained for a median of 6 days (IQR: 6–8 days). The median hospital stay was 10 days (IQR: 8.8–14.8 days). The technical success rate for percutaneous drainage or aspiration of primary pulmonary abscesses was 100% (26/26). Two children were later diagnosed with secondarily infected congenital pulmonary airway malformations that were both successfully drained and ultimately surgically resected. The abscess cavities resolved in all patients and catheters were removed upon clinical, radiographic, and laboratory improvement. Complications included the presence of two bronchopleural fistula, both of which were treated with immediate pleural drain placement. Percutaneous drainage of pulmonary abscesses is an effective therapeutic option in children and can be considered alongside antibiotics as part of the initial treatment for pulmonary abscesses. Bronchopleural fistula can occur, but at a lower frequency than previously reported. Level V. [ABSTRACT FROM AUTHOR]

We quantified antibiotic prescribing for ambulatory pediatric acute respiratory illness at 22 institutions in "pre-shortage" (Jan 2019-Sep 2022) and "shortage" (Oct 2022-Mar 2023) periods for amoxicillin. While acute respiratory illness prescribing increased across settings, the proportion of amoxicillin prescriptions decreased. Variation was seen within and between institutions. [Display omitted] [ABSTRACT FROM AUTHOR]

Islet cell autotransplantation is an effective method to prevent morbidity associated with type IIIc diabetes after total pancreatectomy. However, there is no valid method to predict long-term endocrine function. Our aim was to assess computed tomography texture analysis as a strategy to predict long-term endocrine function after total pancreatectomy and islet cell autotransplantation. All patients undergoing total pancreatectomy and islet cell autotransplantation from 2007 to 2020 who had high-quality preoperative computed tomography imaging available for texture analysis were included. The primary outcome was optimal long-term endocrine function, defined as stable glycemic control with <10 units of insulin/day. Sixty-three patients met inclusion criteria. Median yield was 6,111 islet equivalent/kg body weight. At a median follow-up of 64.2 months, 12.7% (n = 8) of patients were insulin independent and 39.7% (n = 25) demonstrated optimal endocrine function. Neither total islet equivalent nor islet equivalent/kg body weight alone were associated with optimal endocrine function. To improve endocrine function prediction, computed tomography texture analysis parameters were analyzed, identifying an association between kurtosis (odds ratio, 2.32; 95% confidence interval, 1.08–4.80; P =.02) and optimal endocrine function. Sensitivity analysis discovered a cutoff for kurtosis = 0.60, with optimal endocrine function seen in 66.7% with kurtosis ≥0.60, compared with only 26.2% with kurtosis <0.60 (P <.01). On multivariate logistic regression including islet equivalent yield, only kurtosis ≥0.60 (odds ratio, 5.61; 95% confidence interval, 1.56–20.19; P =.01) and fewer small islet equivalent (odds ratio, 1.00; 95% confidence interval, 1.00–1.00; P =.02) were associated with optimal endocrine function, with the whole model demonstrating excellent prediction of long-term endocrine function (area under the curve, 0.775). Computed tomography texture analysis can provide qualitative data, that when used in combination with quantitative islet equivalent yield, can accurately predict long-term endocrine function after total pancreatectomy and islet cell autotransplantation. [Display omitted] [ABSTRACT FROM AUTHOR]

Postmastectomy radiation therapy is known to increase risk of complications in the reconstruction setting. We aim to identify the variables associated with reconstruction failure and other major complications. A prospectively collected institutional database was queried for patients with up to stage IIIC breast cancer treated from 2000 to 2017, undergoing mastectomy, immediate implant or autologous tissue reconstruction, and radiation to the reconstructed breast within 1 year of surgery. Reconstruction failure was defined as complication requiring surgical revision or implant removal. Additional major complications were defined as any infection, contracture, necrosis, or fibrosis. Covariates of interest included age, body mass index, smoking status, stage, hormone receptor and HER2 status, systemic therapy timing, radiation technique, nodal irradiation, and interval between surgery and start of postmastectomy radiation therapy. Differences in complication rates were assessed with χ² or Fisher exact tests. Competing risk regression was used to estimate hazard ratios; covariates were included one at a time to avoid over adjustment. A total of 206 reconstructed breasts in 202 patients resulted from our initial query, with 139 treated with intensity-modulated radiation therapy (IMRT) and 67 treated with conventional radiation therapy (CRT). Median follow-up was 45 months (range, 4-210 months); patient cohorts were generally similar. Eight patients were excluded from toxicity analysis for insufficient follow-up (<2 years). Overall, reconstruction failure and major complication rates were significantly lower in the IMRT group. Reconstruction failure rates were 3.0% for IMRT versus 16.4% for CRT (P =.002), and major complication rates were 6.8% for IMRT versus 24.6% for CRT (P <.001). On univariate analysis, CRT was significantly predictive of implant failure (hazard ratio, 5.54; P =.003) and increased complication rates (hazard ratio, 3.83; P =.001). Significance persisted on multivariable analysis. Survival outcomes were similar, with no difference in 2 year overall survival (P =.12) and local recurrence (P =.41). Using IMRT may improve reconstruction outcomes over CRT, with significantly lower reconstruction failure and complication rates without compromising local control or survival. [ABSTRACT FROM AUTHOR]

Household air pollution, primarily from solid fuels, globally caused 3.2 million premature deaths in 2020. India houses more than a quarter of global solid fuel users, and transitioning them to cleaner fuels offers an opportunity for global environmental and socio-economic impacts and addressing multiple sustainable development goals. This study compares cooking fuels from the perspective of health, environmental impacts, cost, supply-demand dynamics, and relevant policies. Liquefied petroleum gas (LPG) and piped natural gas (PNG) are being aggressively promoted as cleaner fuel alternatives. However, their sustained use, high reliance on imports, volatile prices, and environmental impacts remain a concern. Moreover, LPG and PNG might not be clean enough as NO x and ultrafine particle emissions have been associated with adverse health impacts. Replacing current solid fuels with LPG will annually add about 91 million metric tons of CO 2 (just from combustion), translating to an increase of about 3.5 % of the country's CO 2 emissions. Direct and indirect imports constituted 96.5 % of the total LPG consumption in 2021-22, and the same has remained above 90 % for the last decade. Furthermore, the current subsidy-based policy promoting LPG adoption doubled the active user base in just seven years. However, annual LPG consumption has steadily declined from ∼110 kg to ∼85 kg per user over the same period, indicating non-sustained adoption. Unlike developed countries, electricity for cooking has not gained popularity in India, even though it has the potential to address the shortcomings of LPG and PNG. Decentralization and integration of renewables in the power generation sector can provide energy with lower carbon intensity, lesser reliance on imports, and relatively stable prices. The cooking energy portfolio of India will be a mixed bag, but more comprehensive forward-looking policies are needed to optimize its composition. • India's transition to cleaner cooking fuels will have global implications. • LPG and natural gas are cleaner fuels but might not be clean enough. • High reliance on imported LPG poses an energy security risk. • Electricity and biogas are suitable alternatives but yet untapped. • Policies on cooking fuel need to be more holistic. [ABSTRACT FROM AUTHOR]

Objectives: Cinch sutures attempt to counteract alar base widening but may lead to unintended increases in the nasolabial angle and nasal tip elevation. The aim of this investigation was to assess nasolabial angle changes after maxillary osteotomies with and without alar base cinch sutures in the short and long terms.Study Design: Seventy-eight patients were assessed, with 51 in the cinch group (38 females, 13 males; age range 16-39 years) and 27 in the no-cinch group (12 females, 15 males; age range 17-27 years). The upper component (nasal tip elevation), lower component (lower lip inclination), and the overall nasolabial angle were measured on preoperative, postoperative, and long-term follow-up lateral cephalometric radiographs.Results: The overall nasolabial angle (P = .006) and its upper component (P < .001) increased significantly in the cinch group immediately postoperatively but resolved by 6 to 12 months for the overall nasolabial angle and by 12+ months (up to 5.7 years) for the upper component. There were no significant changes in the no-cinch group.Conclusions: In the short term, the alar base cinch suture increases nasal tip elevation and the overall nasolabial angle. In the long term, there was no significant difference, suggesting that the initial nasal tip elevation resolves over time and that the cinch suture may have a limited effect on nasal tip elevation in the longer term. [ABSTRACT FROM AUTHOR]

Owing to significant time spent indoors, indoor air quality (IAQ) and thermal comfort are critical to ensure occupants' well-being. Buildings already account for a considerable fraction of developed nations' energy consumption, primarily for maintaining thermal comfort. Measures to improve IAQ can further increase the energy demand. Thus, optimizing IAQ, energy consumption, and thermal comfort is critical. This work presents a dynamic optimization model to investigate the complex and interdependent relationship between personal exposure to particulate matter (PM), thermal comfort, and energy consumption in a test house during typical cooking activities and intense holiday cooking. Surface deposition dominated PM removal for both scenarios (72–78 %). During optimization of the cost function with higher weightage for exposure, exfiltration became the primary PM removal mechanism due to the increased outdoor-indoor air change rate. However, this also increased air conditioning energy consumption. Adding a filter to the recirculation system and increasing the indoor set temperature can save energy while maintaining the same level of exposure reduction achieved via exfiltration alone. Simulations corresponding to higher outdoor temperatures demonstrated that increasing the indoor set temperature from 25°C to 27°C reduces exposure and energy consumption relative to the benchmark without considerable compromise to the comfort level. A high normalized exposure reduction results in an energy-efficient system but might not always translate to a desirable exposure reduction, thus indicating an energy-exposure trade-off. • Indoor PM mitigation and energy consumption trade-off require optimization. • Normalized Exposure Reduction (NER) quantifies the energy-exposure trade-off. • Desired exposure reductions with higher NER can be achieved via optimization. • Increasing indoor set temperature lowers energy penalty when it is hotter outside. • Internal filtration offsets the high energy penalty associated with exfiltration. [ABSTRACT FROM AUTHOR]

Patients undergoing complex surgery at safety net hospitals have been shown to suffer inferior short-term outcomes. Liver transplantation, one of the most complex surgical interventions, is offered at certain safety net hospitals. We sought to identify whether patients undergoing liver transplantation at safety net hospitals have inferior outcomes compared with lower burden centers. Using a link between the University HealthSystem Consortium and Scientific Registry of Transplant Recipient databases, we identified 11,047 patients undergoing liver transplantation at 63 centers between 2009 and 2012. Hospitals were grouped by safety net burden, defined as the proportion of Medicaid or uninsured patient encounters during that time. The highest quartile (safety net hospitals) was compared to medium- and low-burden hospitals regarding recipient and donor characteristics, perioperative outcomes, and long-term survival. Liver transplantation recipients at safety net hospitals were more often black and of lower socioeconomic status (P <. 01), but had similar model for end-stage liver disease scores (20 vs 20 vs 18) compared with median-burden hospitals and low burden hospitals. Length of stay and readmission rates were similar; however, safety net hospitals demonstrated higher in-hospital mortality (5.2% vs 4.5% vs 2.9%, P <. 01). Despite this, there was no significant difference in overall patient or graft survivals in patients who underwent liver transplantation at safety net hospitals and survived the perioperative setting at a median follow-up of 2 years (P >. 05). Despite differences in perioperative outcomes at safety net hospitals, these centers achieve noninferior long-term patient and graft survival for potentially vulnerable patients requiring liver transplantation. Strict care standardization, as achieved in liver transplantation, may be a mechanism by which outcomes can be improved at safety net hospitals after other complex surgical procedures. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is available in the text Objective: To compare the survival outcomes associated with clinical and pathological response in pancreatic ductal adenocarcinoma (PDAC) patients receiving neoadjuvant chemotherapy (NAC) with FOLFIRINOX (FLX) or gemcitabine/nab-paclitaxel (GNP) followed by curative-intent pancreatectomy. Background: Newer multiagent NAC regimens have resulted in improved clinical and pathological responses in PDAC; however, the effects of these responses on survival outcomes remain unknown. Methods: Clinicopathological and survival data of PDAC patients treated at 7 academic medical centers were analyzed. Primary outcomes were overall survival (OS), local recurrence-free survival (L-RFS), and metastasis-free survival (MFS) associated with biochemical (CA 19–9 decrease ≥50% vs <50%) and pathological response (complete, pCR; partial, pPR or limited, pLR) following NAC. Results: Of 274 included patients, 46.4% were borderline resectable, 25.5% locally advanced, and 83.2% had pancreatic head/neck tumors. Vein resection was performed in 34.7% and 30-day mortality was 2.2%. R0 and pCR rates were 82.5% and 6%, respectively. Median, 3-year, and 5-year OS were 32 months, 46.3%, and 30.3%, respectively. OS, L-RFS, and MFS were superior in patients with marked biochemical response (CA 19–9 decrease ≥50% vs <50%; OS: 42.3 vs 24.3 months, P < 0.001; L-RFS-27.3 vs 14.1 months, P = 0.042; MFS-29.3 vs 13 months, P = 0.047) and pathological response [pCR vs pPR vs pLR: OS- not reached (NR) vs 40.3 vs 26.1 months, P < 0.001; L-RFS-NR vs 24.5 vs 21.4 months, P = 0.044; MFS-NR vs 23.7 vs 20.2 months, P = 0.017]. There was no difference in L-RFS, MFS, or OS between patients who received FLX or GNP. Conclusion: This large, multicenter study shows that improved biochemical, pathological, and clinical responses associated with NAC FLX or GNP result in improved OS, L-RFS, and MFS in PDAC. NAC with FLX or GNP has similar survival outcomes. [ABSTRACT FROM AUTHOR]

Background Variability in blood use after pancreaticoduodenectomy and the associated impact on readmission, mortality, and cost is not well understood at the national level. Methods The University HealthSystem Consortium database was queried for all pancreaticoduodenectomies performed between the years 2011–2013 (n = 9,582). Patients were grouped according to transfusion requirements into none (0 units, 64%), low (1–2 units, 15%), medium (3–5 units, 13%), and high (>5 units, 8%). Multivariable analyses were used to determine predictors of increased transfusions, readmission, in-hospital mortality, and cost. Results Of the patients undergoing pancreaticoduodenectomy, 36% received blood perioperatively. Patients with high transfusion requirements were less often white, more often male, and had a higher severity of illness (all P <.01). High transfusion requirements correlated with higher readmission rates (OR 1.23, P =.03), cost (RR 1.84, P <.01), length of stay (18 vs. 13 vs. 10 vs. 8 days, P <.01), and in-hospital mortality (12.5% vs. 3.1% vs. 0.5% vs. 0.4%, P <.01). Higher-volume surgeons demonstrated lower transfusion requirements (OR 0.61, P <.01). Conclusion Significant variability exists nationally in transfusion practices for patients undergoing pancreaticoduodenectomy, which may be driven most by severity of illness and surgeon volume. Efforts to reduce such variability could lead to improved outcomes and healthcare cost savings. [ABSTRACT FROM AUTHOR]

Objective: The relevance of margin positivity on recurrence after resection of intraductal papillary mucinous neoplasms (IPMNs) is poorly defined and represents one reason controversy remains regarding optimal surveillance recommendations. Methods: Patients undergoing surgery for noninvasive IPMN at 8 academic medical centers from the Central Pancreas Consortium were analyzed. A positive margin was defined as presence of IPMN or pancreatic intraepithelial neoplasia. Results: Five hundred two patients underwent surgery for IPMN; 330 (66%) did not have invasive cancer on final pathology and form the study cohort. Of these, 20% harbored high grade dysplasia. A positive margin was found in 20% of cases and was associated with multifocal disease (P = 0.02). The majority of positive margins were associated with low grade dysplasia. At a median follow-up of 36 months, 34 (10.3%) patients recurred, with 6.7% developing recurrent cystic disease and 3.6% developing invasive cancer. On multivariate analysis, margin positivity was not associated with recurrence of either IPMN or invasive cancer (P > 0.05). No association between margin status and development of recurrence at the margin was found. Only 6% of recurrences developed at the resection margin and median time to recurrence was 22 months. Of note, 18% of recurrences occurred > 5 years following surgery. Conclusion: Margin positivity after resection for noninvasive IPMNs is primarily due to low grade dysplasia and is not associated with developing recurrence in the remnant pancreas or at the resection margin. Long-term surveillance is required for all patients, as a significant number of recurrences developed over 5 years after the index operation. [ABSTRACT FROM AUTHOR]

Objective:To assess the knowledge and attitudes of orthodontic trainees towards orthodontic therapists (OTs) in the UK. Design:Cross-sectional survey. Setting: UK-based orthodontic trainees. Materials and methods:An electronic survey was sent to all members of the Training Grades Group of the British Orthodontic Society assessing exposure to OTs and their knowledge regarding current supervision guidelines and scope of practice. Attitudes towards OTs were also explored. Results:Seventy-six responses (response rate 57%) were returned. Nearly 90% of trainees had no formal training regarding OTs. A total of 15.5% were aware of the correct current supervision guidelines and there was large variation in the knowledge of OTs’ scope of practice. The majority of trainees were happy to supervise OTs, but only 22.4% felt prepared for this during training. In total, 63% of trainees felt that OTs could impact their own future job prospects. Conclusions:Currently, there is minimal formal training provided to trainees regarding the role of OTs. This is reflected in the lack of knowledge regarding supervision guidelines and scope of practice. Overall, trainees felt OTs were positive for the workforce but were concerned regarding the impact of their own future employment. [ABSTRACT FROM AUTHOR]

Introduction: Permanent first molars (PFM) with a poor prognosis are routinely extracted in children throughout the United Kingdom. National guidelines suggest that to achieve spontaneous closure for the mandibular arch, the PFM should be extracted at 8 to 10 years of age, during bifurcation formation of the second molar. The literature is of limited quality and has suggested alternative variables that may be associated with successful space closure. Our aim was to investigate the radiographic prognostic factors associated with space closure after extraction of PFM. Two objectives of the research are reported in this article: to determine factors that might predict space closure of the second molar after extraction of the PFM, and to develop a tool kit to aid clinical decision making.Methods: We assessed 148 maxillary and 153 mandibular PFM extracted from 81 participants retrospectively. Dental age, second molar developmental stage, second premolar and second molar angulations, and presence or absence of the third molar were assessed on the preextraction orthopantomograms. Outcome was assessed via visual examination, study models, or radiographs.Results: Closure occurred in 89.9% of the maxillary and 49.0% of the mandibular quadrants. Dental age was statistically, but not clinically, significant in the maxillary arch (P <0.05). For the mandibular arch, presence or absence of the third molar and second molar angulation were statistically and clinically significant (P <0.01 and P <0.05, respectively). A tool kit was developed in relation to the mandibular arch variables.Conclusions: These findings are contradictory to the Royal College of Surgeons guidelines and suggest that the presence of the third molar and a mesially angulated second molar are favorable for space closure. The developed tool kit requires further validity testing. [ABSTRACT FROM AUTHOR]

Background Duty-hour regulations have increased the frequency of trainee-trainee patient handoffs. Each handoff creates a potential source for communication errors that can lead to near-miss and patient-harm events. We investigated the utility, efficacy, and trainee experience associated with implementation of a novel, standardized, electronic handoff system. Methods We conducted a prospective intervention study of trainee-trainee handoffs of inpatients undergoing complex general surgical oncology procedures at a large tertiary institution. Preimplementation data were measured using trainee surveys and direct observation and by tracking delinquencies in charting. A standardized electronic handoff tool was created in a research electronic data capture (REDCap) database using the previously validated I-PASS methodology (illness severity, patient summary, action list, situational awareness and contingency planning, and synthesis). Electronic handoff was augmented by direct communication via phone or face-to-face interaction for inpatients deemed “watcher” or “unstable.” Postimplementation handoff compliance, communication errors, and trainee work flow were measured and compared to preimplementation values using standard statistical analysis. Results A total of 474 handoffs (203 preintervention and 271 postintervention) were observed over the study period; 86 handoffs involved patients admitted to the surgical intensive care unit, 344 patients admitted to the surgical stepdown unit, and 44 patients on the surgery ward. Implementation of the structured electronic tool resulted in an increase in trainee handoff compliance from 73% to 96% ( P < .001) and decreased errors in communication by 50% ( P = .044) while improving trainee efficiency and workflow. Conclusion A standardized electronic tool augmented by direct communication for higher acuity patients can improve compliance, accuracy, and efficiency of handoff communication between surgery trainees. [ABSTRACT FROM AUTHOR]