Search

Cardiac arrest guidelines recommend epinephrine every 3-5 minutes during cardiac arrest resuscitation. However, it is unclear if multiple epinephrine doses are associated with improved outcomes. The objective of this study was to determine if a single-dose epinephrine protocol was associated with improved survival compared to traditional multidose protocols.We conducted a pre-post study across five North Carolina EMS agencies from 11/1/2016 to 10/29/2019. Patients ≥18 years old with attempted resuscitation for non-traumatic prehospital cardiac arrest were included. Data were collected 1 year before and after implementation of the single-dose epinephrine protocol. Prior to implementation, all agencies used a multidose epinephrine protocol. The Cardiac Arrest Registry to Enhance Survival (CARES) was used to obtain patient outcomes. Study outcomes were survival to hospital discharge (primary) and return of spontaneous circulation (ROSC). Analysis was by intention to treat. Outcomes were compared pre- vs. post-implementation using generalized estimating equations to account for clustering within EMS agencies. Adjusted analyses included age, sex, race, shockable vs. non-shockable rhythm, witnessed arrest, automatic external defibrillator availability, EMS response interval, and bystander cardiopulmonary resuscitation.During the study period there were 1,690 encounters (899 pre- and 791 post-implementation). The population was 74.7% white, 61.1% male, and had a median age of 65 (IQR 53-76) years. Survival to hospital discharge was similar pre- vs. post-implementation [13.6% (122/899) vs. 15.4% (122/791); OR 1.19, 95%CI 0.89-1.59]. However, ROSC was more common post-implementation [42.3% (380/899) vs. 32.5% (257/791); OR 0.66, 95%CI 0.54-0.81]. After adjusting for covariates, the single-dose protocol was associated with similar survival to discharge rates (aOR 0.88, 95%CI 0.77-1.29), but with decreased ROSC rates (aOR 0.58, 95%CI 0.47-0.72).A prehospital single-dose epinephrine protocol was associated with similar survival to hospital discharge, but decreased ROSC rates compared to the traditional multidose epinephrine protocol.

Heart failure is a common, serious condition associated with frequent exacerbations and hospitalizations. Preventable causes of more than 70% of heart failure hospitalizations are attributable to ineffective heart failure self-care, including symptom recognition and interpretation, and delayed symptom reporting and treatment seeking. The social context in which illness symptoms occur is an important aspect of symptom self-management. Self-initiated medical and nonmedical treatments for symptom relief and engaging in lay consultations with persons in social networks for symptom evaluation are common. This article highlights socially delineated aspects of symptom self-management leading to hospitalization, many of which are amenable to nursing intervention.

Background Analysis of operative flow has been shown to improve efficiency in breast microsurgery. Both complex decision-making skills and technical mastery are required to overcome intraoperative challenges encountered during microsurgical reconstruction. Effects of intraoperative complications on operative time have not yet been reported. Methods A retrospective chart review of microsurgical breast reconstructions by three surgeons between 2013–2020 analyzed operative variables and duration. Intraoperative complications were determined from the operative report. Correlations between continuous variables were determined using Spearman correlation coefficients. Nonparametric testing was used when comparing operative duration between groups. Results Operative duration was analyzed for 547 autologous breast reconstruction cases; 210 reconstructions were unilateral and 337 were bilateral. Average operative duration was 471.2 SD 132.2 minutes overall (360.1 SD 100.5 minutes for unilateral cases and 530.5 SD 110.5 minutes for bilateral cases). Operative duration decreased with surgeon experience (r = -0.17, p< .001).Regarding intraoperative complications, difficult donor dissection was correlated with an average operative duration increase of 91.7 minutes (n = 43, 7.9%, p< .001), pedicle injury with an additional 67.7 minutes (n = 19, 3.5%, p = .02) and difficult recipient vessel dissection with an increase of 63.0 minutes (n = 35, 6.4%, p = .003). Complications with anastomosis also showed a statistically significant increase in operative duration, with arterial complications resulting in an increase of 104.3 minutes (n = 41, 7.5%, p< .001) and venous complications resulting in an increase in 78.8 minutes (n = 32, 5.8%, p< .001). Intraoperative thrombus resulted in an increase of 125.5 minutes (n = 20, 3.7%, p< .001), and requiring alternative venous outflow added an average of 193.7 minutes (n = 8, 1.5%, p< .001). Conclusion Intraoperative complications in autologous breast reconstruction significantly increase operative time. The greatest increase in operative time is seen with intraoperative thrombosis or requiring alternative venous outflow. As these complications are rarely encountered in breast microsurgery, opportunities for simulation and case-based practice exist to improve efficiency.

BACKGROUND: Enrollment in smoking cessation trials remain sub-optimal. The aim of this analysis was to determine the effectiveness of a modified Zelen’s design in engaging hospitalized patients who smoke in a pragmatic OPT-IN versus OPT-OUT tobacco treatment trial. METHODS: At bedside, clinical staff screened smokers for eligibility, randomized eligible into study arms, and delivered the appropriate treatment approach. Study staff called randomized patients at one-month post-discharge, debriefed patients on the study design, and collected consent to participate. We used frequencies and percentages for categorical variables and means and standard deviations for quantitative variables to describe the characteristics of those who consented and were enrolled versus those who did not enroll. We also compared the characteristics of participants who consented and those who were reached and explicitly refused consent at one-month follow-up. We used the Cohen’s d measure of effect size to evaluate differences. RESULTS: Of the 1,000 randomized, 741 (74.1%) consented to continue in the study at one-month follow-up. One hundred and twenty-seven (12.7%) refused consent and 132 (13.2%) were unreachable. Cohen’s d effect size differences between those who consented/enrolled (n = 741) and those who were not enrolled (n = 259) were negligible (

OBJECTIVE: Identify factors associated with perceived discrimination, including depression, body image satisfaction, Body Mass Index (BMI), social support, stress, and self-reported social status. PARTICIPANTS: 249 American Indian tribal college students METHODS: Students were recruited for an internet-based smoking cessation program. A total of 249 students answered the Everyday Discrimination Scale questions to assess perceived discrimination. We conducted bivariate analyses to determine potential significant associations between perceived discrimination and health outcomes at baseline. RESULTS: We found 63% of the sample reported racial discrimination. Among those who reported moderate/severe depression, 87% reported discrimination. Among those who were not satisfied with their body image, 70% reported racial discrimination. CONCLUSION: Reports of racial discrimination are highly prevalent among our participants. We found reports of discrimination are significantly associated with depression and dissatisfaction with body image. Our study highlights a high priority population that perceives racial discrimination, potentially increasing their risk for adverse health outcomes.

Although both high-frequency and burst spinal cord stimulation (SCS) have shown improved efficacy and patient satisfaction compared with conventional tonic stimulation, there are limited data directly comparing the two. This study aimed to compare both high-frequency 10,000 Hz and burst SCS in the same patients in terms of pain relief and satisfaction in those with axial back pain with or without leg pain.This prospective, single-blind, randomized controlled trial was conducted at an outpatient pain clinic within an academic medical center. Participants were randomly allocated to one of two groups in which they trialed either burst or high-frequency 10,000 Hz SCS over five days, followed by a 24- to 48-hour washout period with no stimulation, and the alternative therapy over the remaining four days. Visual analog scale (VAS) scores were collected immediately before and after both therapy trials. Secondary end points included percentage change in VAS score and patient preference.Of 25 participants, those receiving burst followed by high-frequency SCS (n = 11) had a mean VAS difference of 4.73 after the first trial period and 2.86 after the second. Of those receiving high-frequency followed by burst SCS (n = 14), mean VAS difference after the first trial period was 4.00 and 1.93 after the second trial period. Four participants were withdrawn owing to lead migration. Both therapies showed statistically significant differences in pre- minus post-VAS scores and percent relief. There were no significant differences in carryover or treatment effects between the two groups. There was a statistically significant association between trial sequence and stimulator type implanted because the first stimulator trialed was more likely to be chosen.There were no observed differences in VAS pain score decrease when comparing burst and high-frequency 10,000 Hz SCS programming therapies. Patient preference followed an order effect, favoring the first programming therapy in the trial sequence.

Given global trends in obesity and bariatric surgeries, there are an increasing number of women presenting for breast reconstruction after massive weight loss. There is a paucity of literature about breast reconstruction after mastectomy in patients with a history of massive weight loss. A literature review revealed 10 articles that discussed outcomes of different reconstruction techniques in patients with massive weight loss. Autologous reconstruction techniques and implant-based reconstruction techniques were assessed to evaluate the advantages, disadvantages, and indications of each approach specific to this unique patient population. This article provides a summary of expected outcomes, including complication profiles. Ultimately, consideration should be given for breast reconstruction of mastectomy defects in patients with a history of massive weight loss, as satisfactory results are demonstrated to be possible. Both autologous reconstruction and implant-based reconstruction present feasible options, although reconstruction in this patient population may be associated with increased need for revisions and a higher complication rate compared with patients without a history of massive weight loss. For this reason, it is imperative to appropriately manage preoperative expectations in patients with a history of massive weight loss.

Split-thickness skin grafts (STSG) are commonly required in reconstructive surgery but may cause significant pain. The goal of this investigator-initiated trial is to evaluate the effect of liposomal bupivacaine on donor site pain and opioid consumption. A parallel, randomized, controlled trial of adult acute burn patients with

Background: In Kenya, standard early infant diagnosis (EID) with polymerase chain reaction (PCR) testing at 6-week postnatal achieves early treatment initiation (

Background Radiation creates significant challenges for breast reconstruction. There is no consensus regarding optimal timing for autologous reconstruction following radiation. This study explores clearly defined, shorter time intervals between completion of radiation and reconstruction than previously reported. Methods A retrospective review was performed on patients who underwent autologous reconstruction by five microsurgeons at an academic institution from 2009 to 2020. Cohorts were selected by time elapsed between radiation and autologous reconstruction including 24 months. Analysis compared baseline characteristics, operative details, complications, revision rates, and BREAST-Q scores. Analysis of variance was used for continuous variables and chi-square for discrete variables. Results In total, 462 radiated patients underwent 717 flaps. There were 69 patients at 24 months (26.6%). Age, time from mastectomy, and failure of primary reconstruction were higher at >24 months (p Conclusion Reconstruction can be safely performed within 3 months after radiation without increases in intraoperative, acute, or late reconstructive complications.

Current rates of opioid prescribing and consumption in the United States have resulted in deleterious consequences for both patients and society. There has been a focus on opioid consumption and overprescribing, but the utility of patient education in reducing opioid consumption has only recently been explored. This randomized trial aimed to evaluate the effectiveness of a brief patient educational intervention in reducing pain and opioid consumption in patients undergoing mastectomy and breast reconstruction. A parallel, randomized, single-center trial of women undergoing mastectomy with immediate, implant-based breast reconstruction was completed to evaluate the utility of a patient educational instrument with information on multi-modal pain control. A questionnaire was administered postoperatively to collect data on pain control and opioid consumption. Fifty participants were randomized to each group preoperatively; 46 control (92%) and 39 intervention (78%) participants completed the postoperative questionnaire. Active tobacco use was more common in the control group (p = 0.04). There was a trend towards lower pain scores in the intervention group (3.0/10, SD 1.8 vs 3.6/10, SD 1.6, p = 0.06). Both groups were prescribed a median of 32.0 5-mg oxycodone tablets postoperatively. Participants in the intervention group consumed 33% fewer opioids than the control group (16.2 tablets, SD 16.4 vs 24.3 tablets, SD 21.8, p = 0.05). The use of a brief educational intervention provided at a preoperative appointment can reduce opioid consumption. We recommend the use of an educational intervention to decrease opioid consumption among breast surgery patients.

American Indians have higher rates of smokeless tobacco (SLT) use than other racial/ethnic groups in the US, yet no efficacious cessation program exists for them. Because tobacco is a sacred plant to many American Indians, it is imperative that a program respect the scared nature of tobacco while encouraging quitting recreational use. All Nations Snuff Out Smokeless (ANSOS) was designed to help American Indian SLT users quit recreational tobacco use while still using it for traditional purposes. We pilot tested the ANSOS 6-month group-based counseling program (N = 48) and a shortened version consisting of a one-time education session (N = 80). Here, we discuss the tobacco characteristics of participants at baseline in both studies. Participants across studies were more likely to be male (74.2%) and have at least a college education (65%). Participants in the one-time education sessions were younger (age 35 vs age 39) and used SLT fewer days per week (4.9 vs 5.7). Two-thirds of those in the full program reported that they often substitute SLT in locations where smoking is not allowed compared to 26%. Participants in the education sessions were more likely to report daily use of traditional tobacco (20% versus 0%). Results suggest that dual use of SLT and cigarettes needs to be addressed, as does the use of SLT to circumvent public smoking rules. The role of traditional tobacco and its relationship to lower SLT use also warrants further investigation.

Purpose: Current rates of opioid prescribing and consumption in the United States have resulted in deleterious consequences for both patients and society. There has been a recent focus on opioid consumption and overprescribing, but little work has been done to evaluate the utility of patient education in opioid consumption. This study aimed to decrease opioid consumption in patients undergoing mastectomy and breast reconstruction through a patient education tool. Methods: Patients undergoing consultation for mastectomy and immediate, implant-based breast reconstruction between March, 2018 and January, 2019 were prospectively enrolled in a randomized control trial. Patients were randomized to standard of care or to receive a single-paged handout which included information on the pain scale, expectations for pain control, and examples of a multi-modal approach to pain control. A survey was administered at the preoperative and postoperative appointment to collect data on pain expectations and opioid use. A chart review was performed to obtain surgical information, patient comorbidities, and opioid prescription information. Results: Of 100 patients completing the preoperative survey, 97 patients (97.0%) underwent surgery and 85 patients (85.0%) completed the postoperative survey. Half of patients were randomized preoperatively to receive the intervention. Preoperatively, 27 patients (27.0%) had a history of a chronic pain syndrome, 34 (34.0%) of a mental health comorbidity, and 9 (9.0%) of both. Reconstruction was completed following bilateral mastectomy in 70.1% of patients (n=68) and unilateral mastectomy in 29.9% (n=29). A total of 85 tissue expander (87.6%) and 12 direct-to-implant (12.4%) reconstructions were completed. Patients were prescribed an average of 36.0 5mg-oxycodone tablets postoperatively. Patients in the intervention group consumed an average of 1/3 fewer opioids than patients in the control group (16.2 tablets, 121.5 MEE (SD=122.6) vs 24.3 tablets, 182.2 MEE (SD=181.9), p=0.03). Although not statistically significant, fewer patients in the intervention group required an opioid prescription refill (15.8% vs 21.7%). There was a trend towards lower pain scores in the intervention group (3.0/10 (SD=1.8) vs 3.6/10 (SD=1.6), p=0.06). Overall, patients reported consuming an average of 20.6 tablets postoperatively (154.5 MEE, SD=148.7), or 57.0% of the average prescription amount. The majority of patients (75.3%) reported taking an opioid less than once a day at the time of survey completion, and 24 patients (28.2%) reported that they had either not filled or had not used any of their opioid prescription postoperatively. Conclusions: Consistent with other studies of postoperative opioid consumption, patients undergoing mastectomy and implant-based breast reconstruction are prescribed nearly twice as many opioid tablets as consumed, and one in three patients report not using any opioids postoperatively. The amount of opioids prescribed in this population can be safely decreased. The results of this randomized controlled trial showed that through the use of a simple educational handout provided at a preoperative appointment, opioid consumption can be reduced by an additional 30% compared to patients receiving no intervention. Patients receiving an intervention are also less likely to require a refill. We recommend implementation of protocols related to opioid prescribing and the use of a simple educational tool to decrease opioid consumption among breast surgery patients. Citation Format: Katie Egan, Elizabeth Muenks, Niaman Nazir, Michelle De Souza, Richard Korentager. A brief intervention decreases opioid consumption following mastectomy with implant-based breast reconstruction [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-15-01.

BackgroundAdult immunization rates are belowHealthy People 2020targets. Our objective was to evaluate the effectiveness of a multicomponent intervention to improve adult immunization rates.MethodsThis prospective interventional before-and-after non-randomized study was conducted through the American Academy of Family Physicians National Research Network with 43 primary care physicians from a large multi-specialty healthcare organization (multicomponent intervention groupn = 23; comparator groupn = 20) in the United States. The multicomponent intervention included provider reminders, quarterly provider-level performance reports, provider education, patient visual aid materials, and standing orders on adult pneumococcal, influenza, and zoster immunizations. We assessed individual and comparative provider-level vaccination rates and missed opportunities detailing concordance with targets established by Healthy People 2020 for pneumococcal, influenza, and zoster immunizations.ResultsVaccination rates increased after 12 months in intervention and comparator groups respectively for: a). influenza from 44.4 ± 16.7 to 51.3% ± 12.9% (by 6.9 percentage points,p = 0.001) and from 35.1 ± 19.1 to 41.3% ± 14.2%, (by 6.2 percentage points,p = 0.01); b). pneumococcal vaccinations in older adults from 62.8 ± 17.6 to 81.4% ± 16.6% (by 18.6 percentage points, forp p p p = 0.001). Pneumococcal vaccinations in adults at risk did not change from baseline in intervention group (35.7 ± 19.6 to 34.5% ± 19.0%,p = 0.3) and improved slightly in comparator group (24.3 ± 20.1 to 28.2% ± 20.0%,p = 0.003). Missed opportunities reduced after 12 months, most noticeably, for: a). for influenza from 57.7 to 48.6% (by 9.1 percentage points,p p p p ConclusionsMulticomponent interventions show promise in improving vaccination rates and reducing missed opportunities in older adults for pneumococcal and zoster vaccines and vaccination against influenza. Provider reminders remain the most effective strategy when delivered either as a component of these interventions or alone.

Background Perforators are typically found in rows in the deep inferior epigastric perforator (DIEP) flap. As methods to assess flap perfusion continue to improve, surgeons may be more likely to select perforators traditionally avoided. The purpose of this article is to describe clinical outcomes based on row and number of perforators to reevaluate flap and abdominal donor site morbidity. Methods A retrospective analysis was performed on patients who underwent breast reconstruction with DIEP flaps by four microsurgeons from 2013 to 2020. The row and number of perforators were determined from operative reports. Chi-square and t-test or nonparametric Fisher's exact test and Wilcoxon two-sample test were used for discrete and continuous variable, respectively, as applicable. Logistic regression was used for multivariable analyses. Results Of 628 flaps, 305 were medial row (58.7%), 159 were lateral row (30.6%), and 55 had both rows (10.6%). Partial flap loss was higher in both rows (p = 0.003). Fat necrosis was higher with medial (p = 0.03) and both rows (p = 0.01) when compared with lateral using multivariable analysis. Hernia or bulge was higher in lateral row flaps (lateral: 8/157, 5.1%; medial, 5/299, 1.7%; both, 0/55; p = 0.05); however, mesh was more commonly used in both row flaps (p = 0.05). There was no difference in fat necrosis or abdominal morbidity between single and multiple perforators. Conclusion There was no difference in fat necrosis based on the number or row of perforators. The lateral row provides adequate perfusion but may be associated with an elevated risk of hernia or bulge. Patients may benefit from mesh, especially when both rows are dissected.

ImportanceTobacco use causes 7 million deaths per year; most national guidelines require people who use tobacco to opt in to care by affirming they are willing to quit. Use of medications and counseling is low even in advanced economy countries.ObjectiveTo evaluate the efficacy of opt-out care vs opt-in care for people who use tobacco.Design, Setting, and ParticipantsIn Changing the Default (CTD), a Bayesian adaptive population-based randomization trial, eligible patients were randomized into study groups, treated according to group assignment, and debriefed and consented for participation at 1-month follow-up. A total of 1000 adult patients were treated at a tertiary care hospital in Kansas City. Patients were randomized from September 2016 to September 2020; final follow-up was in March 2021.InterventionsAt bedside, counselors screened for eligibility, conducted baseline assessment, randomized patients to study group, and provided opt-out care or opt-in care. Counselors and medical staff provided opt-out patients with inpatient nicotine replacement therapy, prescriptions for postdischarge medications, a 2-week medication starter kit, treatment planning, and 4 outpatient counseling calls. Patients could opt out of any or all elements of care. Opt-in patients willing to quit were offered each element of treatment described previously. Opt-in patients who were unwilling to quit received motivational counseling.Main Outcomes and MeasuresThe main outcomes were biochemically verified abstinence and treatment uptake at 1 month after randomization.ResultsOf a total of 1000 eligible adult patients who were randomized, most consented and enrolled (270 [78%] of opt-in patients; 469 [73%] of opt-out patients). Adaptive randomization assigned 345 (64%) to the opt-out group and 645 (36%) to the opt-in group. The mean (SD) age at enrollment was 51.70 (14.56) for opt-out patients and 51.21 (14.80) for opt-out patients. Of 270 opt-in patients, 123 (45.56%) were female, and of 469 opt-out patients, 226 (48.19%) were female. Verified quit rates for the opt-out group vs the opt-in group were 22% vs 16% at month 1 and 19% vs 18% at 6 months. The Bayesian posterior probability that opt-out care was better than opt-in care was 0.97 at 1 month and 0.59 at 6 months. Treatment use for the opt-out group vs the opt-in group was 60% vs 34% for postdischarge cessation medication (bayesian posterior probability of 1.0), and 89% vs 37% for completing at least 1 postdischarge counseling call (bayesian posterior probability of 1.0). The incremental cost-effectiveness ratio was $678.60, representing the cost of each additional quit in the opt-out group.Conclusions and RelevanceIn this randomized clinical trial, opt-out care doubled treatment engagement and increased quit attempts, while enhancing patients’ sense of agency and alliance with practitioners. Stronger and longer treatment could increase cessation.Trial RegistrationClinicalTrials.gov Identifier: NCT02721082

Retrospective studies evaluating tissue oximetry in a more recent cohort have shown superiority in flap outcomes. This study compares the use of tissue oximetry in a historical cohort to clinical observation and handheld doppler in a more recent cohort. We hypothesize that there is no benefit to using tissue oximetry.A retrospective review was performed on patients who underwent abdominal-based autologous breast reconstruction by five microsurgeons at an academic institution from 2009 to 2020. Method of postoperative flap monitoring was determined then operative details and complications were analyzed.1367 flaps were reviewed; 740 flaps in 460 patients were monitored with clinical observation and tissue oximetry, and 627 flaps in 391 patients were monitored with clinical observation and handheld doppler. There were no statistical differences in ischemic (p = .59) or congestive complications (p = .41), flap salvage rates when exploring for venous or arterial compromise (p = .52), or early flap loss (p = .56). Although not significant, acute flap-related return to the operating room was lower in the doppler group (4.6%) compared to the oximetry group (6.1%; p = .22). Flaps monitored with tissue oximetry had a statistical increase in length of stay (4.8 ± 1.4 days vs. 3.8 ± 1.6 days; p ≤ .001). The rates of late partial flap loss and fat necrosis were significantly higher in the oximetry group (2.6%, 19/740 vs. 0.3%, 2/740; p = .04) and (18.2%, 135/740 vs. 13.6%, 85/627; p = .02), respectively.There is no statistical benefit to the use of tissue oximetry compared to handheld doppler in flap monitoring with regards to flap outcomes.

American Indians have the highest rates of smokeless tobacco (SLT) use of any racial/ethnic group in the United States, yet no proven effective cessation programs exist for them. Because tobacco is a sacred plant to many American Indians, cessation programs must not portray it in a completely negative manner. Based on our successful All Nations Breath of Life smoking cessation program, we developed and pilot-tested the All Nations Snuff Out Smokeless (ANSOS) program. Of 48 participants who began the program, 33 completed to six months (68.8% retention rate). Among participants who completed the program, 11 (34%) self-reported abstinence. When those lost to follow-up are considered current users, the cessation rate is 22.9%. An additional 14 individuals reported decreasing use (29.2% of all participants), with an average of 3.4 days per week decrease. All Nations Snuff Out Smokeless shows promise as a culturally appropriate SLT cessation program and is ready for efficacy testing.

We identified mortality predictors among HIV-exposed uninfected infants and infants living with HIV in Kenyan early infant diagnosis services between 2012 and 2017. Younger maternal age and absence of antenatal antiretroviral therapy among HIV-exposed uninfected infants (n = 2366) and travel time to hospital and delayed infant testing among infants living with HIV (n = 130) predicted mortality, highlighting the importance of supporting engagement in maternal/pediatric HIV services.

Background Inherited coagulopathies and previous thrombotic events are often considered relative contraindications to microvascular reconstruction. We hypothesize that with planning, head and neck microvascular reconstruction can be successfully performed in hypercoagulable individuals. Methods A retrospective review was conducted of subjects with coagulopathies or previous thrombotic events who underwent microvascular head and neck reconstruction. Outcomes studied were “flap-related complications” (arterial/venous compromise or flap loss) and “patient-related complications” (hematoma, deep venous thrombosis, pulmonary embolism, infection, stroke, or death). Results One hundred thirty-four microvascular flaps were performed in 117 subjects. Twenty-four subjects (20.5%) had a preoperative hypercoagulable condition and underwent 28 microvascular reconstructions. Twenty-three of 24 subjects had a previous thrombotic event, with five subjects identified with an inherited or acquired coagulopathy. All microvascular reconstructions were successful; however, complications occurred in 12 of 28 reconstructions (42.9%). Complications were “flap related” in four reconstructions (14.3%), “patient related” in nine reconstructions (32.1%), and both in one reconstruction (3.6%). Flap-related complications included small partial flap loss (n = 2), arterial compromise (n = 1), and venous compromise (n = 1), with all undergoing successful salvage. Patient-related complications included hematoma (n = 3), pulmonary embolism (n = 2), infection (n = 2), deep venous thrombosis (n = 1), and death (n = 1). Statistical analysis demonstrated that complications were more common in subjects with inferior vena cava filters (p = 0.06) and hematomas were associated with the use of therapeutic heparin infusion (p = 0.04). Conclusion Microvascular head and neck reconstruction can be successfully performed in hypercoagulable subjects. However, patient-related complications remain a concern in these subjects.

OBJECTIVE: To determine the prevalence and predictors of receiving a smoking cessation medication prescription at discharge. METHODS: Retrospective analysis of ongoing Human Studies Committee-approved clinical trial data at large tertiary care center, The University of Kansas Medical Center. Patients included were smokers over 18, either Spanish or English speaking, those admitted between October 1, 2016 through May 31, 2018. Other eligibility criteria include access to a telephone or mobile phone, not currently be pregnant or breastfeeding, have no significant co-morbidity that precludes participation (acute, life-threatening illness, and communication barriers such as tracheal tube or altered mental status). Those included in this analysis were those randomized into the trial who expressed interest in receiving a smoking cessation medication prescription at discharge. RESULTS: Two hundred fourteen patients were recommended a prescription by their smoking cessation counselor, 88 patients (41.12%) were approved a prescription at discharge. Out of those approved, 50.70 (14.05 SD) was the average age, 12.84 (8.47 SD) was the average number of cigarettes used per day, 47 patients (53.41%) were White, 49 patients (55.68%) were admitted through the emergency department, 55 patients (62.50%) had used smoking cessation medication in the past, 49 patients (55.68%) had used inpatient smoking cessation, 36 patients (40.91%) had Medicaid. A binary logistic regression determined to show insurance status (P = 0.042) and use of inpatient smoking cessation medication use (P < 0.001) as statistically significant predictors of receiving a prescription at discharge. CONCLUSION: It was determined that among the population recommended for medication, 41.12% actually received a prescription at discharge. The variables of “health insurance status” and “use of inpatient smoking cessation medication” demonstrated to be predictors of receiving a prescription. It is important to further study this as many patients rely on a prescription to afford these medications that are useful in a quit attempt.

BACKGROUND Despite a heightened appreciation for wellness in medicine, there exists little information specific to plastic surgery. The purpose of this research was to assess happiness within the field of plastic surgery. METHODS A cross-sectional study was conducted in July of 2017 by distributing an American Society of Plastic Surgeons sponsored survey to a random cohort of current practicing American Society of Plastic Surgeons members, residents and fellows. In addition, the same survey was sent to medical students applying to integrated plastic surgery residency. Total happiness scores (Subjective Happiness Scale) were averaged and compared between and within surveyed groups. RESULTS A total of 595 individuals completed surveys, including 287 practicing surgeons, 116 residents, 12 fellows, and 180 medical students. Differences in happiness scores between the groups were statistically significant (P < 0.01). For practicing physicians, happiness scores were significantly greater for those more than 20 years out from training (P < 0.01). Furthermore, a significantly positive correlation was found between practice expectations coming out of residency and happiness scores (Pearson correlation coefficient, 0.2; P < 0.01). CONCLUSIONS Despite the prevalence of burnout and mental health disorders associated with a career in medicine, plastic surgeons and trainees report high levels of happiness. Practicing plastic surgeons report increased happiness further out from training and when meeting practice expectations coming out of training. Otherwise, there were no significant differences in happiness between groups. Regarding sex, it is encouraging to report no significant sex discrepancies with happiness in a field where women still face significant adversity.

Early infant diagnosis (EID) involves age-specific tracking and testing of HIV-exposed infants during the first 18 months of life and rapid initiation of life-saving treatment for those infected. In Kenya, pre-2013 data estimate EID lost to follow-up (LTFU) at 39–65%, yet no study has documented LTFU rates and predictors throughout the EID cascade since Option B+ fundamentally changed services by placing all HIV-positive expectant mothers on lifelong treatment. Using an explanatory mixed-method design, we assessed LTFU rates and predictors among 870 mother–infant dyads enrolled in EID in six urban/peri-urban Kenyan government hospitals. Mothers completed baseline surveys, and dyads were tracked through EID. We selected 12 baseline variables and modeled odds of LTFU at 9 and 18 months using mixed logistic regression. Qualitative interviews were conducted with 61 mothers to assess barriers and facilitators to completing EID. Thematically coded transcripts were used to interpret quantitative predictors of LTFU. By the 18-month test, 145 dyads (22%) were LTFU, with three-quarters of LTFU occurring between 9- and 18-month tests. Odds of LTFU at 18 months decreased by 10% for each additional year of maternal age and by 66% with HIV status disclosure. Qualitative data revealed how disclosure facilitated essential social support for EID completion and how older mothers attributed maturity and life experience to successful engagement in care. Findings suggest LTFU rates in Kenya have declined, but gaps remain in ensuring universal coverage. Efforts to improve retention should focus on increasing support for younger mothers and those who have not disclosed their HIV status.

Tobacco quitlines are effective, and work best for callers who receive three or more counseling sessions. Clinical settings are adopting quitline referral as a method for providing cessation support but little is known regarding enrollment and engagement following these referrals. We used data from quitline fax-back reports to describe enrollment and treatment engagement of 878 hospitalized patients who smoke who were referred via secure email to quitline at discharge. We compared patient demographics, tobacco characteristics, and treatment engagement between those enrolled and not enrolled. We conducted chi-square and t-tests to determine which variables should be included in a logistic regression to determine predictors of quitline enrollment. We did not receive fax-back reports for 25% (n = 221) of referred patients; these were excluded from all but the intent-to-treat analysis. Among patients for whom we received reports, 20.4% enrolled and accepted at least one service from the quitline. Among the 79.6% (n = 523) of patients who smoke not enrolled, most (78.3%; n = 410) were classified by the quitline as unreachable. Age (p = .006), smoking within 30 min of waking (p = .005), and interest in quitting (p = .008) were significant predictors of quitline enrollment. Using an intent to treat analysis, 11.4% (n = 100) of all referred patients were enrolled and accepted a single or multi-call programs; 4.2% (n = 37) of all referred patients enrolled and accepted a multi-call counseling program. Quitlines are a pillar of U.S. tobacco treatment. For quitlines to fulfill their potential, quitlines and hospitals must identify effective strategies for reaching and treating referred patients who smoke. Quitlines are effective and are readily available to many in advanced economy countries. Treatment engagement appears to be a barrier to quitline participation as we found few patients who were referred to the quitline actually enrolled in care. Quitlines should consider adopting alternative methods for reaching patients who smoke. Future research is warranted to determine effective solutions to breakdowns in transitions of care.