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A persistent challenge that has limited access and delivery of digit replantation surgery is timing, as ischemia time has traditionally been considered an important determinant of success. However, reports that the viability of amputated digits decreases after 6 hours of warm ischemia and 12 hours of cold ischemia are largely anecdotal. This review evaluates the quality and generalizability of available evidence regarding ischemia times after digit amputation and reported outcomes of “delayed” replantation. We identify substantial limitations in the literature supporting ischemia time cutoffs and recent evidence supporting the feasibility of delayed digit replantation. The current treatment approach for amputation injuries often necessitates transfers or overnight emergency procedures that increase costs and limit availability of digit replantation nationwide. Evidence-based changes to digit replantation protocols could lead to broader availability of this service, as well as improved care quality.

Background Split earlobe deformity typically results from earring-related trauma or, less commonly, from congenital malformation. Several surgical approaches to repair the earlobe have been described, with the goals of reconstructing normal contour of the earlobe, avoiding notching of the free margin, and minimizing scar visibility. Methods The authors reviewed 26 consecutive patients who underwent earlobe reconstruction using the senior author's novel technique, which involves anterior straight-line closure paired with a posterior Z-plasty. Baseline demographic characteristics, etiology of split earlobe, follow-up, outcomes, and rate of complications were analyzed. Results The median age at surgical repair was 8.04 (interquartile range, 4.53-12.84) years. Most patients had acquired split earlobe deformity secondary to trauma. Median follow-up was 86.5 (interquartile range, 29-385.5) days. Only 4 patients had less than satisfactory results, 3 having residual contour abnormality and 1 noting earlobe asymmetry. None of these patients desired revision. No keloid formation, dehiscence, or other postoperative complications were reported. Conclusions The authors describe a novel and effective surgical technique that successfully reconstructs split earlobe deformity. This technique minimizes visible scarring with an anterior straight-line repair combined with posterior Z-plasty to avoid notching.

BACKGROUND As the cost of health care continues to rise, the role of medical providers has evolved to include the duties of an operations manager. Two theories of operations management can be readily applied to health care-lean management, the process of identifying and eliminating waste; and Little's law, the idea that throughput is maximized by changing the capacity to host patients or the time they spend in the system. Equipped with theories of operations management, providers are better able to identify and address flow limitations in their own practices. METHODS Operations flow data were collected from three areas of care-clinic, surgical booking, and the operating room-for one provider. Variables of interest included visit or procedure characteristics and operations flow characteristics, such as different time points involved in the sector of care. RESULTS Clinic data were collected from 48 patients. Variables with a significant relationship to total clinic visit time included afternoon appointments (p = 0.0080) and visit type (p = 0.0114). Surgical booking data were collected for 127 patients. Shorter estimated procedure length (p = 0.0211) decreased time to surgery. Operating room data were collected for 65 cases. Variables with a significant relationship to total operating room time were patient age (p = 0.0325), Charlson Comorbidity Index (p = 0.0039), flap type (p = 0.0153), and number of flaps (p < 0.0001). CONCLUSIONS This brief single-provider study provides examples of how to apply operations management theories to each point of care within one's own practice. Although longitudinal data following patients through each point of care are the next step in operations flow analysis, this work lays the foundation for evaluation at each time point with the goal of developing practical strategies to improve throughput in one's practice.

To review the current literature regarding sexual dysfunction and interstitial cystitis/bladder pain syndrome (IC/BPS). Our goal was to review the epidemiology and overlap of these two conditions as well discuss the success of various IC/BPS treatment modalities with improving sexual function. Women with IC/BPS have a much higher incidence of sexual dysfunction as compared to controls, and this is often a significant predictor of poor quality of life. IC/BPS is thought to have various phenotypes and is associated with a number of overlapping chronic conditions which may contribute to sexual dysfunction thus making an accurate diagnosis imperative. Various treatments for IC/BPS may improve certain domains of sexual function. It is not surprising that IC/BPS, a chronic pelvic pain condition, negatively affects sexual function. More research is needed not just on the prevalence of sexual dysfunction in this patient population, but specifically on treatment options and ways to improve sexual function in these distressed patients.

Pseudohyperaldosteronism, or Liddle syndrome, is a rare, autosomal dominant condition characterized by early-onset hypertension, often associated with hypokalemia and metabolic alkalosis. Martorell hypertensive ischemic leg ulcer is a rare, underdiagnosed ulcer characterized by subcutaneous arteriolosclerosis, classically appearing over the dorsolateral lower extremity or Achilles tendon in patients with hypertension and diabetes. It presents an important diagnostic challenge because it can appear grossly similar to other entities such as pyoderma gangrenosum or venous stasis ulcers, but requires surgical intervention. This article presents a case study of surgical management of a Martorell ulcer in a 69-year-old woman with Liddle syndrome. To the authors' knowledge, this is the first case reported in the literature of this rare ulcer occurring secondary to this rare cause of hypertension.

Summary Bowel and bladder dysfunction (BBD) refers to a heterogeneous group of voiding disorders, accounting for an estimated 40% of pediatric urology visits. Symptoms of BBD include enuresis, urgency, and urinary retention, often accompanied by constipation. The aim of this pilot study was to explore whether a pupillary response can be characterized for BBD, by examining the pupillary light reflex (PLR) before and after voiding among patients with BBD. A total of 28 patients aged from 7 to 21 years were recruited from the Wetting, Infections, and Stooling Help clinic at Children's National Medical Center. An infrared pupilometer was used to assess the PLR. Both baseline static and dynamic pupillometry assessments were obtained before and after voiding. Measurements were also taken after 5 min in the supine position, followed by 5 min standing to induce an orthostatic stressor. Visual inspection of the graphed data revealed a characteristic shape in 11 of 28 patients with voiding symptoms. In these 11 patients, the redilation arm of the PLR shows a ‘notch,’ or a brief reconstriction of the pupil before resting pupil size is reestablished (figure). This feature of the PLR has not been seen in previous and parallel studies using pupillometry to evaluate other populations. The results of this study suggest that a subset of patients with BBD may have a significant perturbation of autonomic regulation, identifiable through analysis of the PLR. To our knowledge, this ‘notch’ during redilation has not been previously described or seen in other patient populations and may represent a distinctive and readily identifiable physiologic marker of disease. These results are broadly aligned with results of other studies that have examined ANS activity in patients with BBD, although further study is needed to confirm the results of this pilot study and to assess relative contributions of sympathetic and parasympathetic function in producing pupillary abnormalities. This study has several limitations, including the small sample size, the absence of data on severity and duration of symptoms, and the absence of a control group of patients without any voiding symptoms. A simple tool for diagnosing BBD and for monitoring response to treatment could significantly improve the quality of treatment for one of the most common pediatric urologic complaints. Given the heterogeneity of symptoms under the BBD umbrella, pupillometric data could guide selection of treatment options, as well as assess adequacy of response to pharmacologic therapy. Download : Download high-res image (178KB) Download : Download full-size image Summary Figure . Aberrant pupillary response (right) versus normal response (left). Arrow indicates a ‘notch,’ or a transient reconstriction during redilation arm of the pupillary response curve.

Thousands of measures are in use today to assess health and health care in the United States. Although many of these measures provide useful information, their usefulness in either gauging or guiding performance improvement in health and health care is seriously limited by their sheer number, as well as their lack of consistency, compatibility, reliability, focus, and organization. To achieve better health at lower cost, all stakeholders-including health professionals, payers, policy makers, and members of the public-must be alert to what matters most. What are the core measures that will yield the clearest understanding and focus on better health and well-being for Americans? Vital Signs explores the most important issues-healthier people, better quality care, affordable care, and engaged individuals and communities-and specifies a streamlined set of 15 core measures. These measures, if standardized and applied at national, state, local, and institutional levels across the country, will transform the effectiveness, efficiency, and burden of health measurement and help accelerate focus and progress on our highest health priorities. Vital Signs also describes the leadership and activities necessary to refine, apply, maintain, and revise the measures over time, as well as how they can improve the focus and utility of measures outside the core set.If health care is to become more effective and more efficient, sharper attention is required on the elements most important to health and health care. Vital Signs lays the groundwork for the adoption of core measures that, if systematically applied, will yield better health at a lower cost for all Americans.