Management of Discharge Instructions for Children With Medical Complexity: A Systematic Review.

CONTEXT: Children with medical complexity (CMC) are at risk for adverse outcomes after discharge. Difficulties with comprehension of and adherence to discharge instructions contribute to these errors. Comprehensive reviews of patient-, caregiver-, provider-, and system-level characteristics and interventions associated with discharge instruction comprehension and adherence for CMC are lacking. OBJECTIVE: To systematically review the literature related to factors associated with comprehension of and adherence to discharge instructions for CMC. DATA SOURCES: PubMed/Medline, Embase, Cochrane Central Register of Controlled Trials, PsycInfo, Cumulative Index to Nursing and Allied Health Literature, Web of Science (database initiation until March 2023), and OAIster (gray literature) were searched. STUDY SELECTION: Original studies examining caregiver comprehension of and adherence to discharge instructions for CMC (Patient Medical Complexity Algorithm) were evaluated. DATA EXTRACTION: Two authors independently screened titles/abstracts and reviewed full-text articles. Two authors extracted data related to study characteristics, methodology, subjects, and results. RESULTS: Fifty-one studies were included. More than half were qualitative or mixed methods studies. Few interventional studies examined objective outcomes. More than half of studies examined instructions for equipment (eg, tracheostomies). Common issues related to access, care coordination, and stress/anxiety. Facilitators included accounting for family context and using health literacy-informed strategies. LIMITATIONS: No randomized trials met inclusion criteria. Several groups (eg, oncologic diagnoses, NICU patients) were not examined in this review. CONCLUSIONS: Multiple factors affect comprehension of and adherence to discharge instructions for CMC. Several areas (eg, appointments, feeding tubes) were understudied. Future work should focus on design of interventions to optimize transitions.

Xanthogranulomatous cholecystitis mimicking gallbladder carcinoma: a case report.

Xanthogranulomatous cholecystitis (XGC) is an uncommon type of chronic cholecystitis. Clinical presentation, laboratory findings, and radiological analysis mimic gallbladder carcinoma. A definitive diagnosis is made by histological study. Cholecystectomy, along with adjuncts as required, is performed for management. Case Presentation: We present a case of a 67-year-old female who was planned for interval cholecystectomy for gallstone pancreatitis. Her clinical, laboratory and radiological findings were suggestive of cholelithiasis and was planned for laparoscopic cholecystectomy. Her intraoperative findings mimicked gallbladder carcinoma. The surgery was aborted, and a biopsy was sent for histopathological analysis. XGC was diagnosed, and the patient underwent laparoscopic cholecystectomy with no postoperative complications during the 6-month follow-up period. Discussion: XGC is a rare disorder resulting from chronic inflammation of the gallbladder. There is the presence of xanthogranuloma with predominant lipid-laden macrophages in the gallbladder wall along with fibrosis. Clinical presentation, laboratory findings, and radiological analysis mimic gallbladder carcinoma. Ultrasonography usually shows diffuse wall thickening of the gallbladder, intramural hypoechoic nodules, unclear liver and gallbladder interface, and the presence of gallstones. The final diagnosis is made by histopathological analysis. Laparoscopic or open cholecystectomy, along with adjuncts as required, is performed for management with a low postoperative complication rate. Conclusion: XGC is a rare, benign disease that is often confused with gallbladder cancer before histological analysis. XGC can be managed with laparoscopic cholecystectomy with minimal postoperative complications.

Developmental screening of full-term infants at 16 to 18 months of age after in-utero exposure to maternal SARS-CoV-2 infection.

OBJECTIVE: To screen for neurodevelopmental delays in a cohort of full-term infants born to mothers with SARS-CoV-2. STUDY DESIGN: This was a prospective, descriptive cohort study of full-term infants born to mothers with SARS-CoV-2 during pregnancy. Subjects underwent neurodevelopmental screening using the Ages and Stages Questionnaires®-Third Edition (ASQ®-3) at 16 to 18 months age. RESULTS: Of 51 subjects, twelve (24%) were below cutoff, and twenty-seven (53%) were either below or close to the cutoff in at least one developmental domain. Communication (29%), fine motor (31%), and problem-solving (24%) were the most affected domains. There were no differences in outcomes between infants born to asymptomatic and mildly symptomatic mothers. CONCLUSION: We observed increased risk of neurodevelopmental delays during screening of infants born at full-term to mothers with SARS-CoV-2 at 16 to 18 months age. These results highlight the urgent need for follow-up studies of infants born to mothers with SARS-CoV-2.

Anaesthetic Effects of Ropivacaine and Bupivacaine on Onset, Duration of Block and Changes in Hemodynamic Parameters in Patients Undergoing Below Elbow Surgeries Under Ultrasound Guided Supraclavicular Brachial Plexus Block.

BACKGROUND: Supraclavicular brachial plexus block is commonly used regional anesthetic technique for below elbow upper limb surgeries. Ultrasound and nerve stimulator are used for higher success rates and fewer complications. Ropivacaine has been used as an alternative to Bupivacaine for rapid onset and longer duration along with lesser or no cardiac and neurotoxicity.The study was conducted with objective of assessing sensory and motor block characteristics of Bupivacaine and Ropivacaine in terms of onset, duration and adverse effects. METHODS: A prospective observational study lasting three month duration from 15th February, 2022 to 14th May, 2022 was conducted among 60 patients divided by convenient sampling method into 30 in Group R (0.2% Ropivacaine 30 ml) and 30 in Group B (0.2% Bupivacaine 30 ml) undergoing below elbow orthopedic surgery under ultrasound and peripheral nerve stimulator guided supraclavicular brachial plexus block. RESULTS: Block using Ropivacaine as compared to Bupivacaine had faster sensory onset in minutes (7±3.37 vs. 10.17±3.34; P value 0.0005), faster motor onset in minutes (10.17±5 vs. 22.33±5.04), shorter duration of sensory block in minutes (437.16±55.54 vs. 633.38±58.33), shorter duration of motor block in minutes (411±57.15 vs. 698.16±47.89), shorter time required for rescue analgesia in minutes (78.66±25.56 vs. 73.83±21.11) and no complications. CONCLUSIONS: 0.2% Ropivacaine can be used as an alternative to 0.2% Bupivacaine in below elbow upper limb orthopaedic surgeries under ultrasound and nerve stimulator guided supraclavicular brachial plexus block for rapid onset of sensory block and early regression of motor block.

Acute recurrent pancreatitis in a child with pancreatic divisum- A case report.

Introduction and importance: In children, acute recurrent pancreatitis is attributed to pancreato-biliary anomalies, hereditary pancreatitis and cystic fibrosis. Pancreatic divisum is a common congenital ductal anomaly that leads to recurrence of pancreatitis. Case presentation: A 13 years old female presented with clinical features of acute recurrent pancreatitis. After ruling out common causes, magnetic resonance cholangiopancreatography was done which showed pancreatic divisum. Her symptoms resolved following duodenum preserving pancreatic head resection. Discussion: Acute recurrent pancreatitis is attributed to raised intrapancreatic dorsal ductal pressure due to ductal anomalies especially pancreatic divisum (PD). It is the embryological failure in the fusion of the dorsal and ventral ductal system. PD is further classified into a classical subtype where there is complete failure of ductal fusion and an incomplete subtype where there is partial fusion of the ductal system. The diagnosis is commonly done through abdominal imaging with secretin enhanced magnetic resonance cholangiopancreatography being the choice of imaging modality. The initial approach is endoscopic intervention unless patients present with signs of pancreatic fibrosis where a duodenum preserving pancreatic head resection can be carried out. Conclusion: A keen suspicion should be given towards anatomical or structural variants in absence of common etiologies. Early identification and management of pancreatic divisum prevents the recurrence of pancreatitis.

A rare case of retroperitoneal extension in Fournier's gangrene: A case report and review of literature.

Introduction and importance: Retroperitoneal extension is a rare and fatal complication of Fournier's gangrene (FG) which mandates immediate surgical intervention for better outcome. Case presentation: A 70-year-old male presented to the emergency department with a history of bilateral painful scrotal swelling for 7 days with fever and abdominal pain for 3 days. On his general examination, he was septic with necrotic patches in the perineum and bilateral scrotum. Imaging revealed soft tissue gas and collections in scrotum extending to the right retroperitoneum with massive collection suggestive of retroperitoneal abscess. Following resuscitation and intravenous antibiotics, immediate exploratory laparotomy was done to drain the retroperitoneal abscess followed by debridement of Fournier's gangrene. The patient remained well on follow up. Clinical discussion: Fournier gangrene is a fulminant polymicrobial infection of the perineum, scrotum and penis which when complicated by retroperitoneal extension, has a very high mortality. Majority of patients have an immunocompromised condition. Early diagnosis with prompt surgical drainage and debridement (within 6 hours) significantly reduces the mortality. Conclusion: High index of suspicion, careful clinical examination and timely use of imaging is crucial for early diagnosis of this rare but fatal complication of FG. Furthermore, adequate resuscitation with prompt surgical intervention is the key for a favorable outcome.

Subarachnoid Block in Prone Position for lower limb surgery.

Subarachnoid block is a safe and effective regional anesthesia technique. It is usually carried out in sitting or lateral position but it can also be performed in prone position. Here we report two cases of flame burn over bilateral gluteal region extending to the posterior and lateral aspect of both thighs, who were planned for debridement and split skin grafting. Both patients had difficulty in siting and lying on either side of lateral position. We had administered subarachnoid block in prone position taking into consideration of patient's comfort and the nature of the procedure. Both patients remained hemodynamically stable throughout the procedure and their post-operative periods were uneventful. Keywords: Burn; prone position; subarachnoid block.

Strategic Operational Redesign for Successfully Navigating Prior Authorization Barriers at a Large-Volume Proton Therapy Center.

PURPOSE: Prior authorization (PA) can be a resource-intensive barrier to oncologic care. To improve patient access and reduce delays at our large, academic proton therapy center, we implemented a novel payor-focused strategy to efficiently navigate the PA process while eliminating physician burden and reducing inappropriate denials. METHODS: In 2017, business operations were redesigned to better reflect the insurance process: (1) certified medical dosimetrists (CMDs), with their unique treatment expertise, replaced our historical PA team to function as an effective interface among physicians, patients, and payors; (2) a structured, tiered timeline was implemented to hold payors accountable to PA deadlines; and (3) our PA team provided administrative leadership with requisite insurance knowledge. PA outcomes were compared 6 months before and after the intervention. RESULTS: After implementation of this multifaceted strategy, the median time to successful appeal (after initial denial of coverage) decreased from 30 to 18 days (P < .001), and the total number of overturned denials increased by 56%. Because of the efficiency of the CMDs, full-time equivalents on the PA team actually decreased by 44%, translating to a 34% reduction in team personnel expenses. Internal referrals increased by 29%, attributable to optimized communication and diminished administrative burden for providers. New treatment starts also increased, resulting in a 37% larger patient census on treatment. CONCLUSION: Incorporating payor-focused strategies can improve patient access in a cost-effective manner while decreasing time and administrative burden associated with the PA process. These operational concepts can be adapted for other oncologic practice settings facing analogous PA-related obstacles.

Three-Year Results of a Prospective Statewide Insurance Coverage Pilot for Proton Therapy: Stakeholder Collaboration Improves Patient Access to Care.

PURPOSE: Proton therapy is increasingly prescribed, given its potential to improve outcomes; however, prior authorization remains a barrier to access and is associated with frequent denials and treatment delays. We sought to determine whether appropriate access to proton therapy could ensure timely care without overuse or increased costs. METHODS: Our large academic cancer center collaborated with a statewide self-funded employer (n = 186,000 enrollees) on an insurance coverage pilot, incorporating a value-based analysis and ensuring preauthorization for appropriate indications. Coverage was ensured for prospective trials and five evidence-supported anatomic sites. Enrollment initiated in 2016 and continued for 3 years. Primary end points were use, authorization time, and cost of care, with case-matched comparison of total charges at 1 month pretreatment through 6 months posttreatment. RESULTS: Thirty-two patients were approved over 3 years, with only 22 actually receiving proton therapy, versus a predicted use by 120 patients (P < .01). Median follow-up was 20.1 months, and average authorization time decreased from 17 days to < 1 day (P < .01), significantly enhancing patient access. During this time, 25 patients who met pilot eligibility were instead treated with photons; and 17 patients with > 6 months of follow-up were case matched by treatment site to 17 patients receiving proton therapy, with no significant differences in sex, age, performance status, stage, histology, indication, prescribed fractions, or chemotherapy. Total medical costs (including radiation therapy [RT] and non-RT charges) for patients treated with PBT were lower than expected (a cost increase initially was expected), with no significant difference in total average charges (P = .82), in the context of overall ancillary care use. CONCLUSION: This coverage pilot demonstrated that appropriate access to proton therapy does not necessitate overuse or significantly increase comprehensive medical costs. Objective evidence-based coverage polices ensure appropriate patient selection. Stakeholder collaboration can streamline patient access while reducing administrative burden.

The Insurance Approval Process for Proton Radiation Therapy: A Significant Barrier to Patient Care.

PURPOSE: Proton therapy is increasingly prescribed for cancer treatment, given its potential for improvements in clinical outcomes and toxicity reduction; however, insurance coverage continues to be a barrier to patient access. This study examined insurance approval and appeal outcomes at a large-volume proton therapy center to clarify the process and identify areas for improvement. METHODS AND MATERIALS: In 2013 to 2016, 1753 patients with thoracic or head and neck cancer were considered for proton therapy; 903 (553 thoracic, 350 head and neck) entered the insurance process. Rates of and times to approval and successful appeal after initial denial were calculated. Clinical factors were evaluated for association with insurance outcomes via logistic regression. RESULTS: Approval rates by Medicare (n = 538) and private insurance (n = 365) were 91% and 30% on initial request, at a median 3 days and 14 days from inquiry to determination. Of the 306 patients initially denied coverage, 276 appealed the decision, and denial was overturned for 189 patients (68%; median time, 21 days from initial inquiry). On multivariable analysis, Medicare (odds ratio [OR], 14.20; P < .001) was the strongest predictor of initial approval. Approval rates decreased from 2013 to 2014 versus 2015 to 2016 (OR 0.54; P = .001). For patients who appealed denial, multivariable analysis found no associations between approval and trial enrollment or tumor type. Submission of a comparison treatment plan (proton vs photon) indicating dosimetric advantage to normal tissues was associated with decreased likelihood of approval (OR 0.43; P = .006), as was a prescribed dose of ≥66 Gy (OR 0.48; P = .019). CONCLUSIONS: Despite an 87% ultimate approval rate for proton therapy, the insurance process is a resource-intensive barrier to patient access associated with significant time delays to cancer treatment. These findings, plus the lack of clinical correlates with insurance outcomes, highlight a need for increased efficiency, transparency, and collaboration among stakeholders to promote timely patient care and research.

Variations in human pulmonary fissures and lobes: a study conducted in nepalese cadavers.

The fissures of lungs are embryologically separating the bronchopulmonary segments, which later on persist in interlobar planes of fully developed lung. Fifty lungs (23 right side and 27 left side), obtained during routine dissection and preserved in formalin constituted the material for present study. In them, variations in fissures and lobes of lung were observed and compared with the previous studies. Seven right sided and 14 left sided lungs showed incomplete oblique fissure. Incomplete horizontal fissure of right lung was observed in eight lungs while it was completely missing in three specimens. A right lung with "lobe of the azygos vein" separated by a supernumerary fissure in medial surface was found. One of the right lung had both superior accessory fissure and inferior accessory fissure and four other right lungs and one left lung presented only with inferior accessory fissure. A vertical notch was found in middle lobe of one right lung. Eight left lungs exhibited with left minor fissure among them two lungs had lingula appearing as a separate lobe. Knowledge of variations in fissures and lobes is of interest to all medical professionals to exactly interpret radiographs, computed tomography scans, to diagnose, plan and modify a surgical procedure depending on the merit of the case and also in certain classical clinical cases pertaining to lung pathologies.

The "Hitch Stitch": An Effective Method of Preventing Migration in High Tracheal Stenosis.

BACKGROUND: The incidence of caudal stent migration in high tracheal stenting is 13-21% and is common with silicone stents. This can lead to major problems, including emergency repeat procedures. Several antimigration methods are described, but have limitations in terms of their success rate, availability, cost or ease of the procedure. OBJECTIVES: We describe an innovative method of stent migration prevention using a simple percutaneous anchoring "hitch stitch", validated in a large series. METHODS: After tracheal stent placement, an Ethilon suture was passed into the stent lumen through an 18-G needle. To take this suture back to the exterior to complete the stitch, a retrieval loop was passed through another 14-G percutaneous cannula inserted into the stent lumen. Bronchoscopically, using a forceps the first suture was pulled inside the loop, the loop was retracted, the suture was exteriorized, and the knot was completed and embedded subcutaneously. While removing the stent, an endoscopic scissor was used to cut the stitch to free the stent. RESULTS: A total of 42 "hitch stitches" were done in 29 patients over 5 years, predominantly for silicone stents. Indications for stenting included postintubation tracheal stenosis (83.3%), malignancy (11.9%) and tracheoesophageal fistula (4.8%, metal stents). The procedure was successful in 41/42 (97.6%) patients. Stitch removal was uncomplicated. CONCLUSION: This is the largest series of an external stent anchoring procedure as a migration prevention strategy in high tracheal stenting, applicable to both silicone and metal stents. Stent migration prevention using this "hitch stitch" is simple, safe and successful, without any complications during stent removal.

Laparoscopic excision of large lower rectal gastrointestinal stromal tumour (GIST): A case report.

Gastrointestinal stromal tumour (GIST) involving rectum is rare. No definite method of treatment has been established because of a small number of cases being reported. It is usually managed with invasive or ablative surgery, such as abdominoperineal resection (APR). The acceptance of minimally invasive (laparoscopic) surgery in colorectal disease plays a pivotal role in improving the postoperative quality of life. We report a case of a large lower rectal GIST who underwent laparoscopic excision of tumour through a subserosal approach whilst preserving the anal sphincter and without any rectal resection.

Chemical rescue of ΔF508-CFTR in C127 epithelial cells reverses aberrant extracellular pH acidification to wild-type alkalization as monitored by microphysiometry.

Cystic fibrosis (CF) is caused by mutations in the gene for CFTR, a cAMP-activated anion channel expressed in apical membranes of wet epithelia. Since CFTR is permeable to HCO3(-), and may regulate bicarbonate exchangers, it is not surprising evidence of changes in extracellular pH (pHo) have been found in CF. Previously we have shown that tracking pHo can be used to differentiate cells expressing wild-type CFTR from controls in mouse mammary epithelial (C127) and fibroblast (NIH/3T3) cell lines. In this study we characterized forskolin-stimulated extracellular acidification rates in epithelia where chemical correction of mutant ΔF508-CFTR converted an aberrant response in acidification (10%+ increase) to wild-type (25%+ decrease). Thus treatment with corrector (10% glycerol) and the resulting increased expression of ΔF508-CFTR at the surface was detected by microphysiometry as a significant reversal from acidification to alkalization of pHo. These results suggest that CFTR activation as well as correction can be detected by carefully monitoring pHo and support findings in the field that extracellular pH acidification may impact the function of airway surface liquid in CF.

De garengeot hernia: a case report and review of literature.

Femoral Hernia constitutes a small percentage of groin herniae,but have always been associated with significantly high morbidity.This is partly due to the difficulties in diagnosing the hernia and also due to its propensity for incarceration because of its anatomy. We report a rare case of De Garengeot Hernia which is the herniation of the appendix into a femoral hernia.While this is rare in itself,acute appendicitis in a strangulated femoral hernia is even more uncommon.

Tumor-induced osteomalacia caused by primary fibroblast growth factor 23 secreting neoplasm in axial skeleton: a case report.

We report the case of a 66-year-old woman with tumor-induced osteomalacia (TIO) caused by fibroblast growth factor 23 (FGF-23) secreting mesenchymal tumor localized in a lumbar vertebra and review other cases localized to the axial skeleton. She presented with nontraumatic low back pain and spontaneous bilateral femur fractures. Laboratory testing was remarkable for low serum phosphorus, phosphaturia, and significantly elevated serum FGF-23 level. Magnetic resonance imaging (MRI) of the lumbar spine showed a focal lesion in the L-4 vertebra which was hypermetabolic on positron emission tomography (PET) scan. A computed tomography (CT) guided needle biopsy showed a low grade spindle cell neoplasm with positive FGF-23 mRNA expression by reverse transcriptase polymerase chain reaction (RT-PCR), confirming the diagnosis of a phosphaturic mesenchymal tumor mixed connective tissue variant (PMTMCT). The patient elected to have surgery involving anterior resection of L-4 vertebra with subsequent normalization of serum phosphorus. Including the present case, we identified 12 cases of neoplasms localized to spine causing TIO. To our knowledge, this paper represents the first documented case of lumbar vertebra PMT causing TIO. TIO is a rare metabolic bone disorder that carries a favorable prognosis. When a lesion is identifiable, surgical intervention is typically curative.

Effect of ultrasonic capillary dynamics on the mechanics of thermosonic ball bonding.

Microelectronic wire bonding is an essential step in today's microchip production. It is used to weld (bond) microwires to metallized pads of integrated circuits using ultrasound with hundreds of thousands of vibration cycles. Thermosonic ball bonding is the most popular variant of the wire bonding process and frequently investigated using finite element (FE) models that simplify the ultrasonic dynamics of the process with static or quasistatic boundary conditions. In this study, the ultrasonic dynamics of the bonding tool (capillary), made from Al(2)O(3), is included in a FE model. For more accuracy of the FE model, the main material parameters are measured. The density of the capillary was measured to be rho(cap) = 3552 +/- 100 kg/m(3). The elastic modulus of the capillary, E(cap) = 389 +/- 11 GPa, is found by comparing an auxiliary FE model of the free vibrating capillary with measured values. A capillary "nodding effect" is identified and found to be essential when describing the ultrasonic vibration shape. A main FE model builds on these results and adds bonded ball, pad, chip, and die attach components. There is excellent agreement between the main model and the ultrasonic force measured at the interface on a test chip with stress microsensors. Bonded ball and underpad stress results are reported. When adjusted to the same ultrasonic force, a simplified model without ultrasonic dynamics and with an infinitely stiff capillary tip is substantially off target by -40% for the maximum underpad stress. The compliance of the capillary causes a substantial inclination effect at the bonding interface between wire and pad. This oscillating inclination effect massively influences the stress fields under the pad and is studied in more detail. For more accurate results, it is therefore recommended to include ultrasonic dynamics of the bonding tool in mechanical FE models of wire bonding.

Impact of treating the metabolic syndrome on chronic kidney disease.

The metabolic syndrome is defined by the concurrent presence of at least three metabolic disorders that are associated with an increased risk of cardiovascular disease and diabetes. Results from prospective and cross-sectional studies also point to an association between the metabolic syndrome and chronic kidney disease. Visceral obesity and insulin resistance are two important features of the metabolic syndrome that might explain renal injury. We reviewed the literature to examine whether treatment of the metabolic syndrome can favorably influence renal outcomes. Weight loss, regular exercise, and a low-calorie, low-fat diet are first-line treatments of the metabolic syndrome, yet few data are available to indicate that such lifestyle interventions can prevent or reverse renal damage. Similarly, results from few studies show little or no beneficial effect of blood pressure control, use of statins, fibrates, thiazolidinediones or metformin on renal parameters in patients with metabolic syndrome. The reasons for the lack of trials in this research field are also discussed. This Review identifies the need to improve understanding of the role of metabolic syndrome in chronic kidney disease, define consistent criteria for metabolic syndrome and perform clinical trials that analyze renal outcomes as primary end points.