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Objective: Since introducing new and alternative treatment options may increase decisional conflict, we aimed to describe the use of the decision support tool (DST) and its impact on treatment preference and decisional conflict., Background: For the treatment of appendicitis, antibiotics are an effective alternative to appendectomy, with both approaches associated with a different set of risks (eg, recurrence vs surgical complications) and benefits (eg, more rapid return to work vs decreased chance of readmission). Patients often have limited knowledge of these treatment options, and DSTs that include video-based educational materials and questions to elicit patient preferences about outcomes may be helpful. Concurrent with the Comparing Outcomes of Drugs and Appendectomy trials, our group developed a DST for appendicitis treatment ( www.appyornot.org )., Methods: A retrospective cohort including people who self-reported current appendicitis and used the AppyOrNot DST between 2021 and 2023. Treatment preferences before and after the use of the DST, demographic information, and Ottawa Decisional Conflict Scale (DCS) were reported after completing the DST., Results: A total of 8243 people from 66 countries and all 50 U.S. states accessed the DST. Before the DST, 14% had a strong preference for antibiotics and 31% for appendectomy, with 55% undecided. After using the DST, the proportion in the undecided category decreased to 49% ( P < 0.0001). Of those who completed the Ottawa Decisional Conflict Score (DCS; n = 356), 52% reported the lowest level of decisional conflict (<25) after using the DST; 43% had a DCS score of 25 to 50, 5.1% had a DCS score of >50 and 2.5% had and DCS score of >75., Conclusions: The publicly available DST appyornot.org reduced the proportion that was undecided about which treatment they favored and had a modest influence on those with strong treatment preferences. Decisional conflict was not common after use. The use of this DST is now a component of a nationwide implementation program aimed at improving the way surgeons share information about appendicitis treatment options. If its use can be successfully implemented, this may be a model for improving communication about treatment for patients experiencing emergency health conditions., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To compare secondary patient reported outcomes of perceptions of treatment success and function for patients treated for appendicitis with appendectomy vs. antibiotics at 30 days., Summary Background Data: The Comparison of Outcomes of antibiotic Drugs and Appendectomy trial found antibiotics noninferior to appendectomy based on 30-day health status. To address questions about outcomes among participants with lower socioeconomic status, we explored the relationship of sociodemographic and clinical factors and outcomes., Methods: We focused on 4 patient reported outcomes at 30 days: high decisional regret, dissatisfaction with treatment, problems performing usual activities, and missing >10 days of work. The randomized (RCT) and observational cohorts were pooled for exploration of baseline factors. The RCT cohort alone was used for comparison of treatments. Logistic regression was used to assess associations., Results: The pooled cohort contained 2062 participants; 1552 from the RCT. Overall, regret and dissatisfaction were low whereas problems with usual activities and prolonged missed work occurred more frequently. In the RCT, those assigned to antibiotics had more regret (Odd ratios (OR) 2.97, 95% Confidence intervals (CI) 2.05-4.31) and dissatisfaction (OR 1.98, 95%CI 1.25-3.12), and reported less missed work (OR 0.39, 95%CI 0.27-0.56). Factors associated with function outcomes included sociodemographic and clinical variables for both treatment arms. Fewer factors were associated with dissatisfaction and regret., Conclusions: Overall, participants reported high satisfaction, low regret, and were frequently able to resume usual activities and return to work. When comparing treatments for appendicitis, no single measure defines success or failure for all people. The reported data may inform discussions regarding the most appropriate treatment for individuals., Trial Registration: Clinicaltrials.gov Identifier: NCT02800785., Competing Interests: The authors report information from Price and Faine should read the remaining authors report no conflicts of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: To systematically review the published literature on the use of prophylactic mesh reinforcement of midline laparotomy closures for prevention of VIH., Summary of Background Data: VIH are common complications of abdominal surgery. Prophylactic mesh has been proposed as an adjunct to prevent their occurrence., Methods: PubMed, Embase, Scopus, and Cochrane were reviewed for RCTs that compared prophylactic mesh reinforcement versus conventional suture closure of midline abdominal surgery. Primary outcome was the incidence of VIH at postoperative follow-up ≥24 months. Secondary outcomes included surgical site infection and surgical site occurrence (SSO). Pooled risk ratios were obtained through random effect meta-analyses and adjusted for publication bias. Network meta-analyses were performed to compare mesh types and locations., Results: Of 1969 screened articles, 12 RCTs were included. On meta-analysis there was a lower incidence of VIH with prophylactic mesh [11.1% vs 21.3%, Relative risk (RR) = 0.32; 95% confidence interval (CI) = 0.19-0.55, P < 0.001), however, publication bias was highly likely. When adjusted for this bias, prophylactic mesh had a more conservative effect (RR = 0.52; 95% CI = 0.39-0.70). There was no difference in risk of surgical site infection (9.1% vs 8.9%, RR = 1.08, 95% CI = 0.82-1.43; P = 0.118), however, prophylactic mesh increased the risk of SSO (14.2% vs 8.9%, RR = 1.57, 95% CI = 1.19-2.05; P < 0.001)., Conclusion: Current RCTs suggest that in mid-term follow-up prophylactic mesh prevents VIH with increased risk for SSO. There is limited long-term data and substantial publication bias., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The purpose of this study is to determine whether there are radiographic and systemic clinical characteristics that can predict final visual outcomes in patients with indirect traumatic optic neuropathy (iTON)., Methods: This study is a retrospective, multicenter case series of adult patients with iTON treated initially at large, urban, and/or academic trauma centers with follow-up at an affiliated ophthalmology clinic. In addition to detailed cranial computed tomography characteristics, demographics, systemic comorbidities, coinjuries, blood products administered, and intracranial pressure, along with other factors, were gathered. LogMAR visual acuity (VA) at the initial presentation to the hospital and up to 12 months follow-up was collected., Results: Twenty patients met inclusion criteria; 16 (80%) were men with a mean age of 40.9 years (±20.9). Mean initial VA was 1.61 logMAR (∼20/800, ± 0.95), and final VA was 1.31 logMAR (∼20/400, ± 1.06). Three patients (4 eyes) had no light perception (NLP) VA at presentation and remained NLP at final follow-up. Of the predictors analyzed, only the initial VA was found to be a significant predictor of visual outcome. The presence of orbital fractures, intraconal and/or extraconal hemorrhage, as well as systemic comorbidities, were not found to significantly affect visual outcome., Conclusions: After evaluating multiple factors, initial VA was the only factor associated with visual prognosis in iTON. This knowledge may better enable clinicians to predict visual prognosis and set reasonable expectations with patients and families at the time of injury., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by North American Neuro-Ophthalmology Society.)

Objective: This systematic review aims to assess what is known about convalescence following abdominal surgery. Through a review of the basic science and clinical literature, we explored the effect of physical activity on the healing fascia and the optimal timing for postoperative activity., Background: Abdominal surgery confers a 30% risk of incisional hernia development. To mitigate this, surgeons often impose postoperative activity restrictions. However, it is unclear whether this is effective or potentially harmful in preventing hernias., Methods: We conducted 2 separate systematic reviews using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The first assessed available basic science literature on fascial healing. The second assessed available clinical literature on activity after abdominal surgery., Results: Seven articles met inclusion criteria for the basic science review and 22 for the clinical studies review. The basic science data demonstrated variability in maximal tensile strength and time for fascial healing, in part due to differences in layer of abdominal wall measured. Some animal studies indicated a positive effect of physical activity on the healing wound. Most clinical studies were qualitative, with only 3 randomized controlled trials on this topic. Variability was reported on clinician recommendations, time to return to activity, and factors that influence return to activity. Interventions designed to shorten convalescence demonstrated improvements only in patient-reported symptoms. None reported an association between activity and complications, such as incisional hernia., Conclusions: This systematic review identified gaps in our understanding of what is best for patients recovering from abdominal surgery. Randomized controlled trials are crucial in safely optimizing the recovery period., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To establish a trauma preventable/potentially preventable death rate (PPPDR) within a heavily populated county in Texas., Summary: The National Academies of Sciences estimated the trauma preventable death rate in the United States to be 20%, issued a call for zero preventable deaths, while acknowledging that an accurate preventable death rate was lacking. In this absence, effective strategies to improve quality of care across trauma systems will remain difficult., Methods: A retrospective review of death-related records that occurred during 2014 in Harris County, TX, a diverse population of 4.4 million. Patient demographics, mechanism of injury, cause, timing, and location of deaths were assessed. Deaths were categorized using uniform criteria and recorded as preventable, potentially preventable or nonpreventable., Results: Of 1848 deaths, 85% had an autopsy and 99.7% were assigned a level of preventability, resulting in a trauma PPPDR of 36.2%. Sex, age, and race/ethnicity varied across preventability categories (P < 0.01). Of 847 prehospital deaths, 758 (89.5%) were nonpreventable. Among 89 prehospital preventable/potentially preventable (P/PP) deaths, hemorrhage accounted for 55.1%. Of the 657 initial acute care setting deaths, 292 (44.4%) were P/PP; of these, hemorrhage, sepsis, and traumatic brain injury accounted for 73.3%. Of 339 deaths occurring after initial hospitalization, 287 (84.7%) were P/PP, of these 117 resulted from sepsis and 31 from pulmonary thromboembolism, accounted for 51.6%., Conclusions: The trauma PPPDR was almost double that estimated by the National Academies of Sciences. Data regarding P/PP deaths offers opportunity to target research, prevention, intervention, and treatment corresponding to all phases of the trauma system.

Purpose of Review: Within the last decade, it was realized that during and after long-duration spaceflight, some astronauts experience ophthalmic abnormalities including refractive changes, optic disc edema, globe flattening, choroidal folds, and cotton wool spots. Much research has been initiated and conducted, but little evidence is available to differentiate affected crewmembers., Recent Findings: The first published data to distinguish between affected and nonaffected crewmembers identified biochemical differences in affected astronauts: one-carbon pathway metabolite concentrations were higher in these individuals than in nonaffected astronauts, even before flight. These data led to findings that genetics and B-vitamin status were predictors of the incidence of the ophthalmic abnormalities. A multihit hypothesis was developed, with genetics and B-vitamin status as two of several important elements that all contribute to endothelial dysfunction and ultimately to ophthalmic changes after flight. One of these contributing factors - response to carbon dioxide exposure - was recently documented to be affected by the same one-carbon pathway genetics., Summary: This line of research may help identify which astronauts are at risk of these ophthalmic changes, and allow targeted treatment. This research may have implications for clinical populations, including patients with polycystic ovary syndrome, that have similar biochemical, endocrine, and genetic characteristics, and it may shed light on why links between cardiovascular disease and the metabolites homocysteine and folate have been elusive and confounded.

Older adults comprise approximately 50% of patients admitted to critical care units in the United States. This population is particularly susceptible to multiple morbidities that can be exacerbated by confounding factors like age-related safety risks, polypharmacy, poor nutrition, and social isolation. The elderly are particularly vulnerable to health conditions (heart disease, stroke, and diabetes) that put them at greater risk of morbidity and mortality. When an older adult presents to the emergency department with 1 or more of these life-altering diagnoses, an admission to the intensive care unit is often inevitable. Pain is one of the most pervasive manifestations exhibited by intensive care unit patients. There are myriad challenges for critical care nurses in caring for patients experiencing pain-inadequate communication (cognitively impaired or intubated patients), addressing the concerns of family members, or gaps in patients' knowledge. The purpose of this article was to discuss the multidimensional nature of pain and identify concepts innate to pain homeostenosis for elderly patients in the critical care setting. Evidence-based strategies, including an interprofessional team approach and best practice recommendations regarding pharmacological and nonpharmacological pain management, are presented.

Objectives: To determine to what extent RNs in an acute care multihospital system used research findings in their practice; what types of knowledge they used in their practice; and what personal, professional, and organizational factors enhanced or hindered their research utilization., Methods: A cross-sectional, descriptive, online survey design was used. The survey, which asked about use of research findings in practice and evidence-based practice (EBP) participation, was placed on the hospital system intranet. Of the 2,900 RNs invited to participate, 1,112 nurses completed usable surveys, for a response rate of 38%. This article reports findings for 794 of the staff nurses who responded to the survey., Results: The forms of knowledge that staff nurses reported relying on most were their personal experience with patients, conferences, hospital policies and procedures, physician colleagues, and nursing peers. Although a variety of resources were available for nurses to use in locating research and implementing EBP, respondents reported many of the same barriers that have been reported in other studies over the last two decades: lack of time, lack of resources, and lack of knowledge. Although their attitudes about research utilization and EBP were positive overall, respondents expected unit-based educators and clinical nurse specialists to collect and synthesize the research for them., Conclusions: These findings are similar to those of other recent studies regarding nurses' research utilization and EBP. A great deal of work remains to be done if we are to inform, educate, and assist staff nurses in using research and implementing EBP. It may be unrealistic to expect bedside nurses to add these activities to their duties unless they are compensated for the time and have the support of master's or doctorally prepared nurses to serve as EBP coaches and champions.

A mathematical model, which describes the dynamics of acutely irradiated skin epidermal epithelium in swine, is developed. This model embodies the key mechanisms of regulation of skin epidermal epithelium and the principal stages of development of its cells (basal, prickle, and corneal). The model is implemented as a system of nonlinear ordinary differential equations, whose variables and parameters have clear biological meaning. The modeling results for the dose- and time-dependent changes in basal and prickle cell populations are in a good agreement with relevant experimental data. The correlation between the experimental data on the dynamics of moist reaction in acutely irradiated swine skin epidermal epithelium and the corresponding modeling results on the dynamics of corneal cells is revealed. Proceeding from this, the threshold level of corneal cells, which indicates the appearance of the moist reaction, is found. All this bears witness to the validity of employment of the developed model, after appropriate identification, in the investigation and prediction of radiation effects on skin epidermal epithelium in humans.

Cigarette smoking, which is presently associated with more than 20% of adult deaths in the United States, is a large confounder to radiation risk estimates derived from epidemiology data. Astronauts and other exposed groups are classified as never-smokers (NS), defined as lifetime use of less than 100 cigarettes. In the past, radiation risk estimates have been made using average U.S. population rates for cancer and all causes of death, which may lead to overestimation of radiation risks for NS. In this report, age- and gender-specific radiation carcinogenesis risk calculations for NS and the average U.S. population are compared. Lung is the major tissue site for smoking and radiation-related cancer. However, other radiogenic cancers where tobacco has been shown to increase population cancer rates are esophagus, oral cavity, salivary gland, bladder, stomach, liver, colorectal, and leukemia. After adjusting U.S. cancer rates to remove smoking effects, radiation risks for lung and other cancers were estimated using the multiplicative risk model and a mixture model, with weighted contributions for additive and multiplicative risk transfer. Radiation mortality risks for NS were reduced compared to the average U.S. population by more than 20% and 50% in the mixture model and multiplicative transfer models, respectively. The authors discuss possible mechanisms of cancer risks from radiation and tobacco that suggest multiplicative effects could occur. These results suggest that improved understanding of possible synergisms between cancer initiators and promoters, such as radiation and tobacco, would greatly improve risk estimates and reduce uncertainties for differentially exposed groups, including NS.

A consistent pulmonary artery wedge pressure measurement is vital to insure that patients have the proper fluid balance and that the healthcare team obtain accurate information on the patients' ventricular function. This article discusses how guidelines for pulmonary artery wedge pressure measurement were developed and implemented at one facility. To implement and ensure that the guidelines were effective, nurses received a copy of guidelines for pulmonary artery wedge pressure measurement and they were posted in the intensive care unit. A pretest was completed before nurses were given the guidelines, and a posttest was completed after nurses reviewed the guidelines. This fast and simple method of education was found to increase nurses' knowledge of how to measure pulmonary artery wedge pressure. These results are encouraging and warrant extending the teaching techniques to other nurses caring for critically ill patients.

Background: Ultrasound imaging is a successful modality in a broad variety of diagnostic applications including trauma. Ultrasound has been shown to be accurate when performed by non-radiologist physicians; recent reports have suggested that non-physicians can perform limited ultrasound examinations. A multipurpose ultrasound system is installed on the International Space Station (ISS) as a component of the Human Research Facility (HRF). This report documents the first ocular ultrasound examination conducted in space, which demonstrated the capability to assess physiologic alterations or pathology including trauma during long-duration space flight., Methods: An ISS crewmember with minimal sonography training was remotely guided by an imaging expert from Mission Control Center (MCC) through a comprehensive ultrasound examination of the eye. A multipurpose ultrasound imager was used in conjunction with a space-to-ground video downlink and two-way audio. Reference cards with topological reference points, hardware controls, and target images were used to facilitate the examination. Multiple views of the eye structures were obtained through a closed eyelid. Pupillary response to light was demonstrated by modifying the light exposure of the contralateral eye., Results: A crewmember on the ISS was able to complete a comprehensive ocular examination using B- and M-mode ultrasonography with remote guidance from an expert in the MCC. Multiple anteroposterior, oblique, and coronal views of the eye clearly demonstrated the anatomic structures of both segments of the globe. The iris and pupil were readily visualized with probe manipulation. Pupillary diameter was assessed in real time in B- and M-mode displays. The anatomic detail and fidelity of ultrasound video were excellent and could be used to answer a variety of clinical and space physiologic questions., Conclusions: A comprehensive, high-quality ultrasound examination of the eye was performed with a multipurpose imager aboard the ISS by a non-expert operator using remote guidance. Ocular ultrasound images were of diagnostic quality despite the 2-second communication latency and the unconventional setting of a weightless spacecraft environment. The remote guidance techniques developed to facilitate this successful NASA research experiment will support wider applications of ultrasound for remote medicine on Earth including the assessment of pupillary reactions in patients with severe craniofacial trauma and swelling.

Objective: To assess the value of clinical and/or radiographic prognostic indices in predicting the clinical course and outcome of patients with acute pancreatitis, in the intensive care unit., Design: Retrospective, single institution review., Setting: An adult medical and surgical intensive care unit in a public, urban teaching hospital., Patients: Patients with acute pancreatitis requiring intensive care unit admission between January 1, 1997 and June 30, 2000., Interventions: Standard care., Measurements and Main Results: A total of 477 patients were hospitalized with the diagnosis of acute pancreatitis. Of these, 28 patients (6%) were admitted to the intensive care unit. Ranson's, Imrie scores, Acute Physiologic and Chronic Health Evaluation (APACHE) II and III scores, simplified acute physiology scores, and multiple organ dysfunction scores were tabulated at 1, 2, 3, 7, and 14 days after intensive care unit admission. Abdominal computed tomography was available for review for 24 of the 28 patients (86%), where the mean Balthazar's computed tomography index was 4.5 +/- 0.4 (range = 2 to 10). Hospital mortality rate for the intensive care unit patients was 14% (4 of 28). The intensive care unit length of stay ranged from 1 to 79 days (mean 15 days, median 5 days). Fifty-seven percent of the patients developed organ dysfunction, and 36% of the patients required mechanical ventilatory support, ranging in duration from 1 to 70 days. Infectious morbidity occurred in 43% of patients. Thirty-six percent of the patients required operative intervention for intraabdominal complications. APACHE II scores at 7 days after intensive care unit admission correlated closely with ventilator days (r2 =.90; p =.003) and correlated with the occurrence of infectious complications (r2 =.71; p =.02). Patient age, APACHE III, simplified acute physiology scores, multiple organ dysfunction scores, Ranson, Imrie, computed tomography, and APACHE II scores before day 7 did not closely correlate with the occurrence of adverse clinical outcome., Conclusions: The clinical course and outcomes of intensive care unit patients with acute pancreatitis can be highly variable. An APACHE II score <10 during the initial 48 hrs correlated with mild pancreatitis and uncomplicated intensive care unit course; however, multifactorial prognosticators were not useful for the early identification of patients who developed complications or required extended intensive care unit care.

Objective: To assess the utility of triage guidelines for patients with cholelithiasis and suspected choledocholithiasis, incorporating selective use of magnetic resonance cholangiography (MRC) and endoscopic retrograde cholangiopancreatography (ERCP) before laparoscopic cholecystectomy (LC)., Summary Background Data: ERCP is the most frequently used modality for the diagnosis and resolution of choledocholithiasis before LC. MRC has recently emerged as an accurate, noninvasive modality for the detection of choledocholithiasis. However, useful strategies for implementing this diagnostic modality for patient evaluation before LC have not been investigated., Methods: During a 16-month period, the authors prospectively evaluated all patients before LC using triage guidelines incorporating patient information obtained from clinical evaluation, serum chemistry analysis, and abdominal ultrasonography. Patients were then assigned to one of four groups based on the level of suspicion for choledocholithiasis (group I, extremely high; group 2, high; group 3, moderate; group 4, low). Group 1 patients underwent ERCP and clearance of common bile duct stones; group 2 patients underwent MRC; group 3 patients underwent LC with intraoperative cholangiography; and group 4 patients underwent LC without intraoperative cholangiography., Results: Choledocholithiasis was detected in 43 of 440 patients (9.8%). The occurrence of choledocholithiasis among patients in the four groups were 92.6% (25/27), 32.4% (12/37), 3.8% (2/52), and 0.9% (3/324) for groups 1, 2, 3, and 4, respectively (P <.001). MRC was used for 8.4% (37/440) of patients. Patient triage resulted in the identification of common bile duct stones during preoperative ERCP in 92.3% (36/39) of the patients. Unsuspected common bile duct stones occurred in six patients (1.4%)., Conclusions: The probability of choledocholithiasis can be accurately assessed based on information obtained during the initial noninvasive evaluation. Stratification of risks for choledocholithiasis facilitates patient management with the most appropriate diagnostic studies and interventions, thereby improving patient care and resource utilization.

We report a case of pseudosarcomatous fibromyxoid tumor of the bladder in a 23-year-old man with a 2 month history of painless gross hematuria, which was studied by biphasic contrast-enhanced helical CT. CT demonstrated a 2 cm diameter polypoid enhancing mass in the anterior bladder wall. The lesion measured 103 and 91 HU on early and delayed images, respectively. Increased contrast enhancement was attributed to a histologically highly vascular myxoid stroma.

Objective: To determine whether prophylactic doxycycline at suction curettage for incomplete abortion decreases the rate of postoperative pelvic infection., Methods: We randomized 240 patients to receive intravenous doxycycline or placebo at curettage. Cervical specimens for gonorrhea and chlamydia were obtained preoperatively. Two weeks post-procedure, we evaluated all patients for infectious morbidity and repeated gonorrhea and chlamydia cultures. Statistical analysis used Mann-Whitney U test, McNemar test, or Fisher exact test, as appropriate., Results: There were no statistically significant differences in age, parity, gestational age, history of sexually transmitted disease, pelvic inflammatory disease, or multiple sex partners between the doxycycline and placebo groups. Preoperative gonorrhea or chlamydia isolates were positive in five (4.2%) and six (5%) of 120 doxycycline patients and four (3.3%) and eight (6.6%) of 120 controls (not significant). All preoperative gonorrhea isolates remained positive postoperatively. Seven (5.8%) controls had positive postoperative chlamydia isolates, as did one (0.8%) in the doxycycline group (P = .06). We diagnosed eight (6.6%) of 120 doxycycline patients and seven (5.8%) of 120 controls with infectious morbidity (not significant)., Conclusion: In our population of patients with incomplete abortion, the prevalence of gonorrhea and chlamydia was low, and prophylactic doxycycline did not decrease the rate of postoperative febrile morbidity.

Background: Septic pelvic thrombophlebitis is a major complication of endometritis. The thrombi commonly occur in the uterine and/or ovarian veins and may extend into the inferior vena cava., Case: Following vaginal delivery, a 19-year-old woman, gravida 2, developed postpartum septic pelvic thrombophlebitis extending from the right ovarian vein up to the diaphragm and down to the femoral vein. The patient was treated successfully with heparin and antibiotics, and eventually was discharged on oral anticoagulants for an extended period. Follow-up revealed complete resolution of the thrombus., Conclusion: Septic pelvic thrombophlebitis is not limited to the pelvis and lower abdominal vessels.

We report a patient with supralethal magnesemia of 38.7 mg/dL who survived. Our treatment consisted of assisted ventilation with intubation, accompanied by calcium chloride infusion and forced diuresis with mannitol.