A Narrative Review of Predictors of Adult Mental Health Emergency Department Return Visits and Interventions to Reduce Repeated Use.

BACKGROUND: Frequent utilizers of the emergency department (ED) are a minority of patients that account for a majority of visits to psychiatric emergency services and general EDs. OBJECTIVE: The primary aim of this narrative review is to synthesize the literature by describing patient characteristics correlated with adult mental health ED revisits and the efficacy of interventions for reducing frequent use. METHODS: A review of the literature was performed following a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocol checklist in PubMed, PsycINFO, and Google Scholar databases. RESULTS: Thirty-one articles, mostly retrospective cohort studies, met inclusion criteria. The most commonly studied sociodemographic and clinical characteristics associated with frequent users were age, homelessness, diagnosis of schizophrenia or a substance use/abuse disorder, and receipt of current psychiatric treatment. There were 7 different categories of interventions that were studied; only 2 demonstrated a significant reduction in revisits. CONCLUSIONS: Based on the current literature, high utilization of emergency mental health care is most strongly associated with financial and economic factors. These frequent users are also typically characterized as having substance use/abuse disorders, a diagnosis of schizophrenia, and current psychiatric treatment. Though most interventions have been unsuccessful in mitigating revisits, certain ED-based interventions that modified patient care based on the acute clinical needs demonstrated a significant reduction in repeated use. Further interventions should involve modifications to care at the level of the hospital, as well as the community and follow-up care.

Tie-Over Bolster Dressings vs Basting Sutures for the Closure of Full-Thickness Skin Grafts: A Review of the Literature.

BACKGROUND: Full-thickness skin grafting is a well-established technique in the reconstruction of various tissue defects and wounds. However, lack of uniformity in the procedure of closing and securing the grafts has led to a wide range of different techniques. OBJECTIVE: This article reviews the use of tie-over bolster dressings compared to basting sutures for the fixation and postsurgical immobilization of full-thickness skin grafts (FTSGs), discusses details of each method, and proposes a practice guideline for the closure of FTSGs. METHODS: A traditional review of the literature was performed through a search of PubMed using the following keywords: full-thickness skin graft, FTSG, closure, suture, tie-over bolster, quilting, and bolster. RESULTS: The current literature regarding tie-over bolster dressings does not demonstrate improved outcomes compared to quilting sutures. The 2 techniques appear equivalent in terms of utility and outcome, both possessing distinct advantages and disadvantages. CONCLUSION: Despite minimal head-to-head studies between tie-over bolsters and quilting, the best evidence from the literature appears to show comparable results regarding graft take, cosmetic outcomes, and postoperative complications. Ultimately, the choice of using a tie-over bolster technique or quilting sutures relies on surgeon preference and anatomic location.

Amyand's hernia with acute gangrenous appendicitis and cecal perforation: A case report and review of the literature.

INTRODUCTION: An Amyand's hernia is a heterogeneous clinical condition defined by the presence of the vermiform appendix within an inguinal hernia sac, which may or may not contain other abdominal contents or pathologic inflammatory changes. Herein we present an exceptionally rare case of an Amyand's hernia containing acute appendicitis and a perforated cecum. PRESENTATION OF CASE: A 46-year-old male with a right inguinal hernia of 2-3 year duration presented to our Emergency Department complaining of acute onset abdominal and groin pain. The patient was diagnosed with an incarcerated right inguinal hernia and underwent emergent surgical repair. Intraoperatively a reactive fluid was found within the hernia sac that prompted an exploratory laparotomy for suspected bowel perforation. The hernia was then found to contain an inflamed gangrenous appendix with an inflamed and perforated cecum. An ileocecectomy and enteroenterostomy was performed and the hernia defect was repaired without mesh. DISCUSSION: With an estimated incidence of only 1%, Amyand's hernias are rare and lack a clear evidence-based management scheme. Moreover, they can contain a diverse range of pathologic features and presentations that can complicate diagnosis and treatment. To avoid potential morbidity and mortality, the surgeon must consider an Amyand's hernia on his or her differential when operating on inguinal hernias and be aware of the associated presentations, complications, and management schemes. CONCLUSION: There is a paucity of reports describing simultaneous appendicitis and cecal perforation within an Amyand's hernia. In our case, ileocecectomy and Bassini hernia repair with close follow-up led to a favorable outcome.