18-year-old woman • chest pain • shortness of breath • electrocardiogram abnormality • Dx?

► Chest Pain ► Shortness of breath ► Electrocardiogram abnormality.

An Enhanced Recovery after Surgery Pathway for Microvascular Breast Reconstruction Is Safe and Effective.

BACKGROUND: The aim of this study was to develop, implement, and evaluate a standardized perioperative enhanced recovery after surgery (ERAS) clinical care pathway in microsurgical abdominal-based breast reconstruction. METHODS: Development of a clinical care pathway was informed by the latest ERAS guideline for breast reconstruction. Key features included shortened preoperative fasting, judicious fluids, multimodal analgesics, early oral nutrition, early Foley catheter removal, and early ambulation. There were 3 groups of women in this cohort study: (1) traditional historical control; (2) transition group with partial implementation; and (3) ERAS. Narcotic use, patient-reported pain scores, antiemetic use, time to regular diet, time to first walk, hospital length of stay, and 30-day postoperative complications were compared between the groups. RESULTS: After implementation of the pathway, the use of parenteral narcotics was reduced by 88% (traditional, 112 mg; transition, 58 mg; ERAS, 13 mg; P < 0.0001), with no consequent increase in patient-reported pain. Patients in the ERAS cohort used less antiemetics (7.0, 5.3, 2.2 doses, P < 0.0001), returned to normal diet 19 hours earlier (46, 39, 27 hours, P < 0.0001), and walked 25 hours sooner (75, 70, 50 hours, P < 0.0001). Overall, hospital length of stay was reduced by 2 days in the ERAS cohort (6.6, 5.6, 4.8 days, P < 0.0001), without an increase in rates of major complications (9.5%, 10.1%, 8.3%, P = 0.9). CONCLUSIONS: A clinical care pathway in microsurgical breast reconstruction using the ERAS Society guideline promotes successful early recovery.

Anti-Inflammatory Diet in Clinical Practice: A Review.

Recently, there has been an increase in the research regarding the impact of acute and chronic inflammation on health and disease. Specific foods are now known to exert strong effects on inflammatory pathways within the body. Carefully selecting foods that are anti-inflammatory in nature while avoiding foods that are proinflammatory is central to an anti-inflammatory diet plan. Ultimately, the plan models a pattern of eating that (1) focuses on eating whole, plant-based foods that are rich in healthy fats and phytonutrients and (2) maintains a stable glycemic response.

A standardized operative team for major head and neck cancer ablation and reconstruction.

BACKGROUND: Prolonged procedure time in head and neck cancer ablation and free flap reconstruction cases has been shown to significantly increase perioperative complications. The authors' objective was to evaluate the effectiveness of a standardized surgical nursing team for head and neck cancer ablation and free flap reconstruction operations for reducing procedure time. METHODS: A retrospective cohort analysis of consecutive patients presenting for head and neck cancer ablation and free flap reconstruction between January 1, 2007, and September 1, 2010, was performed. A standardized head and neck surgical nursing team was introduced on May 1, 2009, at our center. Procedure time and case time were measured before and after the introduction of the team. Univariable analyses were performed to evaluate the difference in procedure and case time between the two cohorts. A multivariable linear regression model was developed to control for confounding variables. RESULTS: There were 52 cases before the team was introduced and 49 cases after. Mean procedure time was reduced by 47.1 minutes (p = 0.04) and mean case time was reduced by 68.9 minutes (p = 0.01) after team introduction. The multivariable linear regression analysis demonstrated a significant reduction in operative time after team introduction, controlling for confounding variables. CONCLUSIONS: The introduction of a standardized surgical nursing team led to a significant reduction in procedure and case time. A standardized team approach improves operating room efficiency in complex cases such as free flap reconstruction following tumor ablation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Outcomes from a medical weight loss program: primary care clinics versus weight loss clinics.

BACKGROUND: Few studies have focused on weight loss programs implemented in community-based primary care settings. The objective of this analysis was to evaluate the effectiveness of a weight loss program and determine whether physicians in primary care practices could achieve reductions in body weight and body fat similar to those obtained in weight loss clinics. METHODS: Analyses were performed on chart review data from 413 obese participants who underwent weight loss at a primary care (n=234) or weight loss (n=179) clinic. Participants received physician-guided behavioral modification sessions and self-selected a diet plan partially or fully supplemented by meal replacements. A repeated-measures analysis of covariance was conducted with age and sex serving as covariates; significance was set at P≤.05. RESULTS: In 178 subjects (43%) completing 12 weeks of the program, primary care clinics were as effective as weight loss clinics at achieving reductions in body weight (12.4 vs 12.1 kg) but better with regard to reduction in body fat percentage (3.8% vs 2.7%; P≤.05). Regardless of location, participants completing 12 weeks lost an average of 11.1% of their body weight. Participants selecting full meal replacement had greater reductions in weight and body fat percentage (12.7 kg, 3.5%) compared with participants selecting a partial meal replacement plan (8.3 kg, 2.3%). CONCLUSION: Primary care physicians can successfully manage and treat obese patients using behavioral modification techniques coupled with meal replacement diets.

Actuation of mobility intentions among the young-old: an event-history analysis.

PURPOSE: Although migration decision making is central to understanding later-life migration, the critical step between migration intentions and mobility outcomes has received only limited empirical attention. We address two questions: How often are intended moves actuated? What factors condition the likelihood that mobility intentions will be actuated? DESIGN AND METHODS: We employ data from the 1994-2002 Health and Retirement Study, which is a nationally representative panel targeting households containing persons aged 53 to 63 years at baseline. Event-history techniques are used to examine the link between reported mobility intentions at baseline and mobility outcomes across the study period, net of relevant controls. We conduct separate household-level analyses for couple and noncouple households and recognize three types of moves: local, family oriented, and nonlocal. RESULTS: Findings confirm the utility of mobility expectations as a predictor of future mobility. More importantly, results highlight the complex nature of later-life mobility. The actuation of mobility intentions appears to operate differently in couple than in noncouple households. Moreover, our findings suggest that the role of several key variables depends on the type of move under consideration. IMPLICATIONS: The ability to identify potential "retirement migrants" may be of practical importance for state and local government officials as well as developers interested in recruiting or retaining young-old residents. Our study offers insight on the interpretation of stated mobility intentions. Moreover, consistent with early theoretical work in the field, our analysis suggests that empirical studies must account for heterogeneity among older movers in order to avoid misleading results.

Predictors of non-local moves among older adults: a prospective study.

OBJECTIVES: The goal of this article was to test a series of established predictors of the hazard of moving for persons primarily in their 50s and 60s. We tested demographic covariates, resources, travel experience, and community and person ties using a prospective design. METHODS: We employed data from the Health and Retirement Study, 1994 to 2002, based on a representative sample of households containing at least one member aged 51 to 61 in 1992. We employed measures available in the Health and Retirement Study to construct a series of Cox proportional hazards models that examined the causes of non-local moves. RESULTS: Community and person ties emerged as important predictors of non-local moves. DISCUSSION: Travel experience, when measured by regular vacationing and second homes, may increase community ties to a destination. The life-course model must be modified in its explanation of the importance of community and person ties, and of life transitions, as motivators of migration.

In retirement migration, who counts? A methodological question with economic policy implications.

PURPOSE: We examine the methodological and economic policy implications of three operations of retirement migration. DESIGN AND METHODS: We compared the traditional age-based definition of retirement migration and two retirement-based definitions, based on degree of labor-force participation and retirement income, by using the 2000 U.S. Census Public Use Microdata Sample. RESULTS: The age-based definition overestimated the number of retired migrants, although the ranking of host and donor states remained relatively stable; nevertheless, states revealed different rates of change in inmigration and outmigration and income streams declined. IMPLICATIONS: Retirement-based definitions are more useful and precise for those researchers considering the economic implication of retirement migration.

Electrosurgery in patients with pacemakers/implanted cardioverter defibrillators.

Despite improved protective mechanisms, pacemakers and implanted cardioverter defibrillators are subject to interference from various sources. An effective means of hemostasis, electrocautery generates electromagnetic interference and may be problematic in this patient population. Reported complication rates are low, but the consequences can be serious. Recommendations regarding the management of patients with implanted cardiac devices become increasingly significant both as the number of patients with devices increases and the number of out-of-hospital/minor surgery procedures performed increases. This article provides surgeons and anesthetists with practical recommendations for use of electrocautery in patients with pacemakers or implantable cardiac defibrillators.

Bear maulings treated in Calgary, Alberta: Their management and sequelae.

BACKGROUND: Between 1994 and 2005, seven patients underwent surgery at the Foothills Medical Centre, Calgary, Alberta, for injuries sustained in bear maulings. The purpose of the present study was to document these cases and add to the literature on the management and the potential complications of bear attacks. METHODS: Data were collected retrospectively from charts. RESULTS: Seven patients were treated for injuries ranging from lacerations and puncture wounds to fractures and avulsed tissue. On average, patients underwent three operations and spent 22 days in hospital. Mean time from attack to arrival at the trauma centre was 19 h. Irrigation, debridement and intravenous antibiotics did not prevent wound infections in two patients. Six of seven patients developed acute stress disorder, and one of these patients went on to suffer from post-traumatic stress disorder. Complications ranged from infection to pulmonary embolism. CONCLUSIONS: Bear attacks result in a spectrum of injuries. Infections and psychiatric disorders are common sequelae.