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**Background**: Despite the theoretical and practical advantages of adjunct-based free flap failure detection, the introduction of ultrasonographic techniques has not changed free flap failures rates and their use remains secondary to clinical assessment. Our study aims to develop an educational framework to improve the confidence of nursing staff caring for free flaps, with an emphasis on early detection of flap failure, thereby improving postoperative outcomes. **Methods**: Nursing staff in intensive care units and surgical wards caring for free flaps completed standardised questionnaires either before or after an educational seminar detailing clinical and Doppler assessment of free flaps. Differences between cohorts were summarised descriptively with frequencies and percentages. Overall confidence scores for pre-education and post-education cohorts were compared. **Results**: Overall, 173 responses were collected. Most staff were from intensive care units (n = 114) and almost one-third completed surveys following the educational intervention (n = 51). Microsurgical ward staff had more experience in the postoperative care of free flaps than intensive care unit staff (29% vs 18% had experience caring for > 50 free flap cases). Confidence in assessing a free flap by clinical, implantable Doppler or external Doppler ultrasound was universally increased among ward staff compared to intensive care unit staff (*p* ≤ 0.007). Altogether, 51 per cent of intensive care unit staff had never identified a failing flap compared with 35 per cent of ward staff. Education increased confidence in managing and escalating failing flaps unanimously. Most failing flaps were identified by clinical assessment alone or combined with adjunct-based methods (94%). **Conclusion**: This study demonstrates that the provision of targeted education for nursing staff, both in intensive care units and on surgical wards, is useful for increasing confidence in the clinical assessment and early detection of free flap compromise. Increased confidence and improved clinical assessment may allow for early intervention and improved salvage rates for a threatened free flap, thereby improving patient outcomes.

Context: There are several procedures for surgical nodal staging in clinically node-negative (cN0) penile carcinoma., Objective: To evaluate the diagnostic accuracy, perioperative outcomes, and complications of minimally invasive surgical procedures for nodal staging in penile carcinoma., Evidence Acquisition: A systematic review of the Medline, Embase, and Cochrane controlled trials databases and ClinicalTrials.gov was conducted. Published and ongoing studies reporting on the management of cN0 penile cancer were included without any design restriction. Outcomes included the false negative (FN) rate, the number of nodes removed, surgical time, and postoperative complications., Evidence Synthesis: Forty-one studies were eligible for inclusion. Four studies comparing robot-assisted (RA-VEIL) and video-endoscopic inguinal lymphadenectomy (VEIL) to open inguinal lymph node dissection (ILND) were suitable for meta-analysis. A descriptive synthesis was performed for single-arm studies on modified open ILND, dynamic sentinel node biopsy (DSNB) with and without preoperative inguinal ultrasound (US), and fine-needle aspiration cytology (FNAC). DSNB with US + FNAC had lower FN rates (3.5-22% vs 0-42.9%) and complication rates (Clavien Dindo grade I-II: 1.1-20% vs 2.9-11.9%; grade III-V: 0-6.8% vs 0-9.4%) in comparison to DSNB alone. Favourable results were observed for VEIL/RA-VEIL over open ILND in terms of major complications (2-10.6% vs 6.9-40.6%; odds ratio [OR] 0.18; p < 0.01). Overall, VEIL/RA-VEIL had lower wound-related complication rates (OR 0.14; p < 0.01), including wound infections (OR 0.229; p < 0.01) and skin necrosis (OR 0.16; p < 0.01). The incidence of lymphatic complications varied between 20.6% and 49%., Conclusions: Of all the surgical staging options, DSNB with inguinal US + FNAC had the lowest complication rates and high diagnostic accuracy, especially when performed in high-volume centres. If DSNB is not available, favourable results were also found for VEIL/RA-VEIL over open ILND. Lymphatic-related complications were comparable across open and video-endoscopic ILND., Patient Summary: We reviewed studies on different surgical approaches for assessing lymph node involvement in cases with penile cancer. The results show that a technique called dynamic sentinel node biopsy with ultrasound guidance and fine-needle sampling has high diagnostic accuracy and low complication rates. For lymph node dissection in penile cancer cases, a minimally invasive approach may offer favourable postoperative outcomes., (Copyright © 2023. Published by Elsevier B.V.)

Context: Lymph node (LN) involvement in penile cancer is associated with poor survival. Early diagnosis and management significantly impact survival, with multimodal treatment approaches often considered in advanced disease., Objective: To assess the clinical effectiveness of treatment options available for the management of inguinal and pelvic lymphadenopathy in men with penile cancer., Evidence Acquisition: EMBASE, MEDLINE, the Cochrane Database of Systematic Reviews, and other databases were searched from 1990 to July 2022. Randomised controlled trials (RCTs), nonrandomised comparative studies (NRCSs), and case series (CSs) were included., Evidence Synthesis: We identified 107 studies, involving 9582 patients from two RCTs, 28 NRCSs, and 77 CSs. The quality of evidence is considered poor. Surgery is the mainstay of LN disease management, with early inguinal LN dissection (ILND) associated with better outcomes. Videoendoscopic ILND may offer comparable survival outcomes to open ILND with lower wound-related morbidity. Ipsilateral pelvic LN dissection (PLND) in N2-3 cases improves overall survival in comparison to no pelvic surgery. Neoadjuvant chemotherapy in N2-3 disease showed a pathological complete response rate of 13% and an objective response rate of 51%. Adjuvant radiotherapy may benefit pN2-3 but not pN1 disease. Adjuvant chemoradiotherapy may provide a small survival benefit in N3 disease. Adjuvant radiotherapy and chemotherapy improve outcomes after PLND for pelvic LN metastases., Conclusions: Early LND improves survival in nodal disease in penile cancer. Multimodal treatments may provide additional benefit in pN2-3 cases; however, data are limited. Therefore, individualised management of patients with nodal disease should be discussed in a multidisciplinary team setting., Patient Summary: Spread of penile cancer to the lymph nodes is best managed with surgery, which improves survival and has curative potential. Supplementary treatment, including the use of chemotherapy and/or radiotherapy, may further improve survival in advanced disease. Patients with penile cancer with lymph node involvement should be treated by a multidisciplinary team., (Copyright © 2023 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Context: Penile cancer is a rare disease but has a significant impact on quality of life. Its incidence is increasing, so it is important to include new and relevant evidence in clinical practice guidelines., Objective: To provide a collaborative guideline that offers worldwide physician and patient guidance for the management of penile cancer., Evidence Acquisition: Comprehensive literature searches were performed for each section topic. In addition, three systematic reviews were conducted. Levels of evidence were assessed, and a strength rating for each recommendation was assigned according to the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology., Evidence Synthesis: Penile cancer is a rare disease but its global incidence is increasing. Human papillomavirus (HPV) is the main risk factor for penile cancer and pathology should include an assessment of HPV status. The main aim of primary tumour treatment is complete tumour eradication, which has to be balanced against optimal organ preservation without compromising oncological control. Early detection and treatment of lymph node (LN) metastasis is the main determinant of survival. Surgical LN staging with sentinel node biopsy is recommended for patients with a high-risk (≥pT1b) tumour with cN0 status. While (inguinal) LN dissection remains the standard for node-positive disease, multimodal treatment is needed in patients with advanced disease. Owing to a lack of controlled trials and large series, the levels of evidence and grades of recommendation are low in comparison to those for more common diseases., Conclusions: This collaborative penile cancer guideline provides updated information on the diagnosis and treatment of penile cancer for use in clinical practice. Organ-preserving surgery should be offered for treatment of the primary tumour when feasible. Adequate and timely LN management remains a challenge, especially in advanced disease stages. Referral to centres of expertise is recommended., Patient Summary: Penile cancer is a rare disease that significantly impacts quality of life. While the disease can be cured in most cases without lymph node involvement, management of advanced disease remains challenging. Many unmet needs and unanswered questions remain, underlining the importance of research collaborations and centralisation of penile cancer services., (Copyright © 2023 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Context: The primary lesion in penile cancer is managed by surgery or radiation. Surgical options include penile-sparing surgery, amputative surgery, laser excision, and Moh's micrographic surgery. Radiation is applied as external beam radiotherapy (EBRT) and brachytherapy. The treatment aims to completely remove the primary lesion and preserve a sufficient functional penile stump., Objective: To assess whether the 5-yr recurrence-free rate and other outcomes, such as sexual function, quality of life, urination, and penile preserving length, vary between various treatment options., Evidence Acquisition: The EMBASE, MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane HTA, DARE, HEED), Google Scholar, and ClinicalTrials.gov were searched for publications from 1990 through May 2021. Randomized controlled trials, nonrandomized comparative studies (NRCSs), and case series (CSs) were included., Evidence Synthesis: The systematic review included 88 studies, involving 9578 men from 16 NRCSs and 72 CSs. The cumulative mean 5-yr recurrence-free rates were 82.0% for penile-sparing surgery, 83.9% for amputative surgery, 78.6% for brachytherapy, 55.2% for EBRT, 69.4% for lasers, and 88.2% for Moh's micrographic surgery, as reported from CSs, and 76.7% for penile-sparing surgery and 93.3% for amputative surgery, as reported from NRCSs. Penile surgery affects sexual function, but amputative surgery causes more appearance concerns. After brachytherapy, 25% of patients reported sexual dysfunction. Both penile-sparing surgery and amputative surgery affect all aspects of psychosocial well-being., Conclusions: Despite the poor quality of evidence, data suggest that penile-sparing surgery is not inferior to amputative surgery in terms of recurrence rates in selected patients. Based on the available information, however, broadly applicable recommendations cannot be made; appropriate patient selection accounts for the relative success of all the available methods., Patient Summary: We reviewed the evidence of various techniques to treat penile tumor and assessed their effectiveness in oncologic control and their functional outcomes. Penile-sparing as well as amputative surgery is an effective treatment option, but amputative surgery has a negative impact on sexual function. Penile-sparing surgery and radiotherapy are associated with a higher risk of local recurrence, but preserve sexual function and quality of life better. Laser and Moh's micrographic surgery could be used for smaller lesions., (© 2022 The Authors.)

Introduction: Although we have previously described the use of a novel polyurethane biodegradable dermal substitute in the reconstruction of 20 free flap donor sites, and extensive cutaneous defects, including a large area of exposed calvarium secondary to burn injury, our experience with this material now extends to 35 free flap donor site reconstructions and 13 major or complex burns. Methods: The polyurethane material (NovoSorb BTM; PolyNovo Biomaterials Pty Ltd, Port Melbourne, Victoria, Australia) was recently employed in another complex wound scenario, implanted into a large anterior cervical cutaneous and soft-tissue defect remaining after serial radical debridement for necrotizing fasciitis. Results: Implantation, integration, delamination, and split-skin graft application proceeded without complication, mirroring our previous experience in other wounds (including major burns). The result was a robust, supple, mobile, and well-contoured reconstruction over the deep tissues of the neck. The functional and cosmetic outcomes exceeded all expectation. Discussion: The wound environment created after necrotizing fasciitis infection and debridement is austere. In this particular case, reconstructive options were limited to large free flap repair, skin graft alone, and skin graft augmented by commercially available collagen/glycosaminoglycan dermal matrix. Each option was discarded for various reasons. Our previous success with NovoSorb BTM, developed at our center, prompted its use following regulatory approval. The patient was physiologically stronger after the temporization afforded by the biodegradable temporizing matrix over 4 weeks of integration. Conclusion: This is the first description of the successful use of an entirely synthetic biodegradable dermal substitute for the reconstruction of both necrotizing fasciitis and an anterior cervical defect.

There has been much confusion around the identity of Hypselobarbus pulchellus, an endemic large barb of the Western Ghats. Recent works highlighted the fact that it is likely that two similar-looking species have been considered as H. pulchellus. A genetic analysis helps differentiate the two forms: viz., H. pulchellus and a new species, here described as H. bicolor sp. nov. Hypselobarbus bicolor can be distinguished from all other species of Hypselobarbus based on a combination of the following characters: two pairs of barbels, lateral line complete, with 34-36+1-2 pored scales, ½6/1/3½ scales in the transverse row; 11-12 predorsal scales; last simple dorsal ray weak, dorsal fin with 9½ branched rays, gill rakers short and simple, 4-6+11-12 on first gill arch; proximal end of fifth ceratobranchial slightly curved, with 5+3+2 teeth; overall coloration dark grey with an ill-defined silver- or bronze-coloured band running along length of body, two scales high, on lateral-line scale-row and row above it; fins devoid of any markings; and small, closely-placed tubercles restricted to the tip of the snout in large males.

Fishes currently identified as Laubuka laubuca from the Cauvery River and its tributaries in the Western Ghats of India are shown to represent two different species: Laubuka trevori, sp. nov., and L. latens, sp. nov., distinguished from all species of Chela and Laubuka by possessing 7½ branched dorsal-fin rays; 14 precaudal vertebrae; 17-18 predorsal scales; 5 branched pelvic-fin rays and 5+4+2 teeth on the fifth ceratobranchial. Laubuka trevori is further distinguished from its congeners by possessing 14½-15½ branched anal-fin rays; ½6/1/1½ scales in transverse line on body; a short pelvic fin (10.1-16.3% SL) and two longitudinal stripes: a golden and a bluish-green stripe on the body, running from behind the opercle to the base of the caudal fin, the latter broken and less distinct in the anterior half of the body. Laubuka latens is further distinguished by its long pelvic fin (23.2-26.9% SL) and the absence of any markings on the side of the body other than a humeral spot and a caudal-peduncle spot.

The identities of Barilius canarensis and B. malabaricus have hitherto been confused. An attempt to resolve their identities by examining fresh collections from their respective type localities, i.e., southern Karnataka and northern Kerala, yielded a new species, which is herein described as B. ardens. The new species differs from B. canarensis and B. malabaricus by the presence of a row of 7-9 large vertically elongate blotches on the flank, in large adults the first three blotches broken into a smaller row of intercalate spots (vs. two rows of spots: the first consisting of 9-11oval spots, the second with 3-4 smaller spots); and 5+4+3 (vs. 5+4+2) pharyngeal teeth. The new species is distinguished from B. bakeri by having 5+4+3 (vs. 5+4+2) pharyngeal teeth; and the dorsal and anal fins margined with bright orange (vs. white). Barilius malabaricus (hitherto in the synonymy of B. canarensis) is shown to be a valid species distinguished from the latter by having 11½ (vs. 10½) branched dorsal-fin rays and 14½-15½ (vs. 13½) branched anal-fin rays; both species are redescribed.

Fishes currently assigned to Oreichthys cosuatis from the Western Ghats are shown to belong to a closely-related group of three valid species: Puntius coorgensis, which is raised from synonymy, and two new species, O. duospilus and O. incognito. Oreichthys coorgensis can be distinguished from its congeners by a combination of characters that include 22-23+1-2 scales in the longitudinal series with 5-8 pored scales; ½3/1/2½ scales in the transverse row; 6-7 predorsal scales and usually a faint blackish spot on the caudal-fin base. Oreichthys duospilus,  sp. nov., can be distinguished by possessing an almost complete lateral line with 11-21 pored scales and two black spots: one on the dorsal fin and the other on the anal fin. Oreichthys incognito,  sp. nov., can be distinguished by a lateral line with 5 pored scales; ½3/1/1½ scales in the transverse row; 8 predorsal scales and a vertical black bar on the dorsal fin.

Background: Communication is the cornerstone of good multidisciplinary medical care, and the impact of conversations about diagnosis, treatment, and prognosis is indisputable. Healthcare providers must be able to have difficult conversations that accurately describe diagnostic procedures, treatment goals, and the benefits and/or risks involved., Methods: This paper reviews the literature about the importance of communication in delivering bad news, the status of communication training, communication strategies, and psychosocial interventions., Results: Although many published guidelines address difficult communication, communication training is lacking. Consequently, many clinicians may have difficulties with, or in the worst-case scenario, avoid delivering bad news and discussing end-of-life treatment. Clinicians also struggle with how to have the last conversation with a patient and how to support patient autonomy when they disagree with a patient's choices., Conclusion: There is a clinical imperative to educate physicians and other healthcare workers on how to effectively deliver information about a patient's health status, diagnostic avenues to be explored, and decisions to be made at critical health junctions. Knowing how to implement the most rudimentary techniques of motivational interviewing, solution-focused brief therapy, and cognitive behavioral therapy can help physicians facilitate conversations of the most difficult type to generate positive change in patients and families and to help them make decisions that minimize end-of-life distress.

Pethia rutila, a new species is described from Karnaphuli drainage, Mizoram, Northeast India. It is distinguished from its congeners in having a complete lateral line with 21-22 scales, an inconspicuous black humeral spot on the scale row below the 3rd and 4th lateral-line scales, a black blotch on the caudal peduncle centered above the insertion of the last anal-fin ray, overlapping lateral-line scales 16-18 or 17-19 and ½4/1/3½ scales in transverse line from dorsal-fin origin to pelvic-fin origin.

Knight et al. (2013a) clarified the identity of Barbus mussullah Sykes, the type species of Hypselobarbus Bleeker, showing it to represent a lineage clearly distinct from Tor Gray (type species Tor hamiltonii Gray (= Cyprinus tor Hamilton)). They showed the two species to be distinguished by a suite of characters, with Hypselobarbus lacking the distinctive median fleshy lobe of the lower lip (present in T. tor), having the last simple ray of the dorsal fin weak (vs. strong, 'osseous'), gill rakers long and branched (vs. short and simple, unbranched) on first gill arch, and the proximal end of the fifth ceratobranchial hooked (vs. only slightly curved). Nevertheless, some subsequent authors (e.g., Ambili et al. 2014; Khare et al. 2014) have persisted in referring Barbus mussullah to Tor, in effect synonymyzing Hypselobarbus (in which 12 species are currently recognized) with Tor and thereby causing confusion with regard to the identities of these groups of fishes which, being large and relatively common cyprinids, are of significant economic importance.

The identity and generic placement of Barbus mussullah Sykes, the type species of Hypselobarbus Bleeker, have for long been unclear, variously having been considered a synonym of Cyprinus curmuca Hamilton or a species of Tor Gray or Gonoproktopterus Bleeker. Here, through a re-examination of the original descriptions and the examination of specimens from western peninsular India, we redescribe H. mussullah and show that Hypselobarbus is a valid genus, of which Gonoproktopertus is a junior synonym. Hypselobarbus mussullah is distinguished from all other species of Hypselobarbus by possessing both rostral and maxillary barbels; having the last simple dorsal-fin ray weak and smooth; the lateral line complete, with 41 +1 pored scales; 9/1/4 scales in transverse line between origins of dorsal and pelvic fins; and 5½ scales between lateral line and anal-fin origin. Species of Hypselobarbus are distinguished from other genera of Cyprinidae by possessing long, branched gill rakers and the anal fin distally rounded in adults. Hypselobarbus canarensis was found to be a valid species and H. kurali is considered its synonym. Hypselobarbus canarensis can be distinguished from all congeners by possessing both rostral and maxillary barbels; having the last simple dorsal-fin ray weak and smooth; the lateral line complete, with 40-42+1 pored scales; ½7-½8/1/3½ scales in transverse line from dorsal-fin origin to pelvic-fin origin; 4½ scales between lateral line and anal-fin origin. Hypselobarbus kolus is considered a synonym of H. curmuca, which is redescribed: it is distinguished from all congeners by possessing maxillary barbels only; the last simple dorsal-fin ray weak and smooth; 41-43+1 lateral-line scales; 9-10/1/4½-5 scales in transverse line between origins of dorsal and pelvic fins; and 5½-6 scales between lateral line and anal-fin origin.

The existing literature on preoperative spine tumor embolization is limited in size of patient cohorts and diversity of tumor histologies. This report presents our experience with preoperative embolization of hypervascular thoracic, lumbar, and sacral spinal column tumors in the largest series to date. We conducted a retrospective review of 228 angiograms and 188 pre-operative embolizations for tumors involving thoracic, lumbar and sacral spinal column. Tumor vascularity was evaluated with conventional spinal angiography and was graded from 0 (same as normal adjacent vertebral body) to 3 (severe tumor blush with arteriovenous shunting). Embolic materials included poly vinyl alcohol (PVA) particles and detachable platinum coils and rarely, liquid embolics. The degree of embolization was graded as complete, near-complete, or partial. Anesthesia records were reviewed to document blood loss during surgery. Renal cell carcinoma (44.2%), thyroid carcinoma (9.2%), and leiomyosarcoma (6.6%) were the most common tumors out of a total of 40 tumor histologies. Hemangiopericytoma had the highest mean vascularity (2.6) of all tumor types with at least five representative cases followed by renal cell carcinoma (2.0) and thyroid carcinoma (2.0). PVA particles were used in 100% of cases. Detachable platinum coils were used in 51.6% of cases. Complete, near-complete, and partial embolizations were achieved in 86.1%, 12.7%, and 1.2% of all cases, respectively. There were no new post-procedure neurologic deficits or other complications with long-term morbidity. The mean intra-operative blood loss for the hypervascular tumors treated with pre-operative embolization was 1745 cc. Preoperative embolization of hypervascular thoracic, lumbar, and sacral spine tumors can be performed with high success rates and a high degree of safety at high volume centers.

Fishes currently assigned to Pethia gelius Hamilton from West Bengal are shown to belong to a closely-related group of three species: P gelius, its erstwhile synonym P canius Hamilton and a new species, P aurea. The three species are distinguished from all other species of Pethia by having the lateral line incomplete, with 3-4 pored scales; 20-26 scales in lateral series on body; ½4-5/l/2-3½ scales in transverse line on body; 8-9 predorsal scales; barbels absent and by a unique colour pattern consisting of two or three black blotches on the body (which, however, fade on preservation), the first behind the opercle, the second beneath the origin of the dorsal fin, extending to the mid-lateral region, and the third above the origin of the anal fin. A black spot is also present at the base of the dorsal and anal fins. Additionally, P gelius is distinguished by having the last unbranched dorsal-fin ray thick, straight, serrated, with 20-25 serrae on its posterior margin; a snout length of 6.1-8.4% standard length (SL); a body depth of 32.6-37.7% SL; and a dorsal-fin height of 19.4-22.8% SL. Pethia canius is additionally distinguished by having a snout length of 8.9-11.8% SL; a body depth of 28.1-32.2% SL; and dorsal-fin height of 26.9-32.8% SL. Pethia aurea, new species, is additionally distinguished from all its congeners by having ½5/1/3-3½ scales in transverse line on body; 9 pre-dorsal scales; and last unbranched dorsal-fin ray slender, serrated, with 19-22 serrae on posterior margin.

Objectives: To retrospectively collect data on patients with burn injury due to hot depilatory wax. To investigate the effect of varying microwave output power on wax temperature. To determine whether instructions provided by manufacturers allow safe domestic use., Methods: Data from the RAH burns database was collected for patients with wax-induced burns between January 1991 and January 2010. Wax temperatures were tested in a pilot study (4 wax products heated in microwave with power outputs of 800 W, 900 W, and 1100 (W) and a definitive study (5 wax products, 3 of each, heated in microwave with power outputs of 800 W, 1000 W, and 1200 (W). A number of different heating regimens were employed and temperatures were recorded using an infrared thermometer., Results: Twenty-one patients were studied. Mean age was 26.5 years. The majority of burns were superficial (33.3%) or partial thickness (25.8%). The right hand was most commonly affected (38.1%), the mean total body surface area was 1%. The pilot study revealed an increase in wax temperature with the number of times the wax was heated. During definitive wax temperature testing, the maximum wax temperature recorded was 108.5°C. Seventeen of 60 wax surface temperatures recorded exceeded 90°C, 9 exceeded 100°C. Ninety-three percent of the stirred wax temperatures showed an increase in wax temperature with an increase in microwave power output., Conclusion: Microwave-heated hair-removal wax has the potential to reach unsafe temperatures and cause burn injury, even when manufacture's heating instructions are followed. Safe use in domestic setting requires improvements in instructions provided by the manufacturer.

Background: Nurses in hospital administration and management positions may experience workplace stress, which can have important consequences on the health and well-being., Purpose: The aim of this study was to examine the effects of perceived stress on nursing hospital management and administrative employees of a large health care organization before and after a review by The Joint Commission on the Accreditation of Healthcare Organizations., Methods: A total of 100 hospital employees were randomly selected to complete questionnaires assessing their perception of stress and its effect on their well-being before and after the site review. They were also asked to rate their subjective experience of sleep, anxiety, depression, and job satisfaction., Results: Perceived stress was significantly related to employees' increased health concerns, symptoms of depression and anxiety, interpersonal relationships, and job satisfaction (p = .003)., Conclusions: Hospital accreditation reviews may increase perceived stress and appears to be related to emotional and physical well-being., Application: The implications include evidence there is a need for organizations to initiate corrective action to help nurses in administrative roles to cope with increased levels of job strain, minimize potential psychological and physiological consequences, and preserve job satisfaction.

Object: The object of this study was to identify characteristic preoperative angiographic and MR imaging features of safely resectable insular gliomas and describe the surgical techniques and postoperative clinical outcomes., Methods: Thirty-eight patients with insular gliomas underwent transsylvian resection between 1995 and 2007. Patient demographics, presenting symptoms, pathological findings, and neurological outcomes were retrospectively reviewed. Preoperative MR imaging-defined tumor volumes were superimposed onto the preoperative stereotactic cerebral angiograms to determine whether the insular tumor was confined lateral to (Group I) or extended medially around (Group II) the lenticulostriate arteries (LSAs)., Results: Twenty-five patients (66%) had tumors situated lateral to the LSAs and 13 (34%) had tumors encasing the LSAs. Insular gliomas situated lateral to the LSAs led to significant medial displacement of these vessels (161 +/- 39%). In 20 (80%) of these 25 cases the boundaries between tumor and brain parenchyma were well demarcated on preoperative T2-weighted MR images. In contrast, there was less displacement of the LSAs (130 +/- 14%) in patients with insular gliomas extending around the LSAs on angiography. In 11 (85%) of these 13 cases, the tumor boundaries were diffuse on T2-weighted MR images. Postoperative hemiparesis or worsening of a preexisting hemiparesis, secondary to LSA compromise, occurred in 5 patients, all of whom had tumor volumes that extended medial to the LSAs. Gross-total or near-total resection was achieved more frequently in cases in which the insular glioma remained lateral to the LSAs (84 vs 54%)., Conclusions: Insular gliomas with an MR imaging-defined tumor volume located lateral to the LSAs on stereotactic angiography displace the LSAs medially by expanding the insula, have well-demarcated tumor boundaries on MR images, and can be completely resected with minimal neurological morbidity. In contrast, insular tumors that appear to surround the LSAs do not displace these vessels medially, are poorly demarcated from normal brain parenchyma on MR images, and are associated with higher rates of neurological morbidity if aggressive resection is pursued. Preoperative identification of these anatomical growth patterns can be of value in planning resection.

Bariatric surgery is performed to alleviate the major health problems associated with morbid obesity. However, after surgery, patients must learn to deal with new self-images and old behavior patterns that may precipitate a return to the pre-surgery status. Thus, long-term follow-up and continued emotional support are essential ingredients for a successful bariatric surgery outcome. Patients who attend group meetings regularly, tend to lose more weight. Patients are encouraged to participate in a structured support group both before and after bariatric surgery. The current model of the group incorporates self-responsibility, aspects of the "relapse prevention" model, and group therapy processes. Additionally the group is flexible, to adapt to the needs of the evolving group membership.