Mind the Difference: Characterizing the Impact of Behavioral Health Disorders on Facial Trauma.

BACKGROUND: Patients with psychiatric diagnoses are at greater risk for traumatic injury than the general population. Current literature fails to characterize how premorbid behavioral health disorders (BHDs) complicate craniofacial trauma. This study aimed to describe the characteristics and outcomes of patients with premorbid BHD sustaining facial fractures. METHODS: All adults in the 2013-2016 Trauma Quality Improvement Program datasets with facial fractures were identified. Demographics, injury characteristics, fracture patterns, and in-hospital outcomes were compared in patients with and without premorbid BHDs. BHDs included major psychiatric illnesses, alcohol or drug use disorders, attention deficit hyperactivity disorder, or dementia. RESULTS: Twenty-five percent of the 240,104 subjects with facial fractures had at least one premorbid BHD. Assault (29.9% versus 23.9%, P< 0.001), self-inflicted injury (2.9% versus 1.2%, P< 0.001), and multiple facial fractures (40.2% versus 38.7%, P< 0.001) were more common among the BHD group. The BHD group displayed significantly higher rates of nearly all in-hospital complications, including pneumonia (4.3% versus 3.3%, P< 0.001), substance withdrawal (3.9% versus 0.3%, P< 0.001), unplanned intubation (1.5% versus 0.9%, P< 0.001) and unplanned transfer to the intensive care unit (ICU, 1.3% versus 0.8%, P< 0.001). BHD was strongly predictive of pneumonia, unplanned intubation, and unplanned ICU admission in multivariate analyses. CONCLUSIONS: Patients with BHD represent a subset of facial trauma characterized by different mechanisms and patterns of injury and premorbid health status. BHDs are associated with higher in-hospital complication rates and resource utilization. Understanding the relationship between craniofacial trauma and premorbid BHD creates opportunities to improve morbidity and resource utilization in this group.

Outcomes of Implant Removal and Capsulectomy for Breast Implant Illness in 248 Patients.

BACKGROUND: Breast implant illness (BII) is a term popularized by social media to describe systemic symptoms that patients ascribe to their breast implants. Though the concept of implants as an underlying cause for a systemic illness remains controversial, few studies have delineated the implant characteristics, capsular histology, and outcomes of patients who undergo explantation for BII. METHODS: We retrospectively reviewed the demographics, presenting symptoms, outcomes, capsular histology, and culture results of all women who presented to the senior author with symptoms attributed to BII and underwent breast implant removal with capsulectomy from August 2016 to February 2020. Chi-square and logistic regression analyses were performed to evaluate association between implant type, composition, and findings of inflammation on capsule pathology. RESULTS: Among 248 patients, 111 (23%) capsules demonstrated inflammatory changes on permanent pathology. Capsular inflammation was independently associated with silicone versus saline (right odds ratio [OR] = 2.18 [1.16-4.11], P = 0.016, left OR = 2.35 [1.08-5.12], P = 0.03) and textured versus smooth implants (right OR = 2.18 [1.16-4.11], P = 0.016, left OR = 2.25 [1.17-4.31], P = 0.01). Silicone material was present in the capsules of 12 patients (4.8%). Fourteen patients had positive cultures. There was one pneumothorax (0.4%), three hematomas requiring evacuation (1%), and two DVTs (0.8%). Of 228 patients, 206 (90.4%) reported high satisfaction with the outcome of the procedure. CONCLUSIONS: In a large cohort of BII patients, we found that capsular inflammation is significantly associated with silicone and textured implants. Implant removal with capsulectomy can be safely performed in patients with BII with a low complication rate and high patient satisfaction.

Secondary reduction mammaplasty: does initial pedicle design matter?

Reduction mammaplasty is one of the most common plastic surgical procedures performed in the United States. Occasionally patients will require a second reduction to address persistent or recurrent symptomatic macromastia. When the vascular pedicle of a primary breast reduction is unknown, there is uncertainty regarding how best to proceed with a secondary reduction. When the pedicle is known, we include at least the primary pedicle in our operative plan. When unknown, we performed a modified central mound (MCM) reduction technique. The MCM reduction respects the blood supply to the nipple-areolar complex (NAC) by preserving any remaining vascularity that is present within the central mound tissue while also maintaining superior and inferior vascular pedicles. We avoid using a free nipple graft.Thirty patients (60 breasts) underwent repeat breast reductions between 2009 and 2016. Patients were placed into two groups whether their primary vascular pedicle was known or unknown, and then further grouped based on the type of reduction they received. There was no significant difference in the complication rate between patients that underwent an MCM reduction versus those that underwent reduction with other techniques. Most patients maintained breast sensation and none required a free nipple graft.Patients can be offered repeat reduction mammaplasty with the possibility of nipple sensation preservation and a normal-appearing NAC regardless if the primary vascular pedicle is known. If the primary pedicle is unknown, the MCM technique is an excellent option.

Heart failure guidelines and implications for surgically treating heart failure.

In 2005, the American College of Cardiology and the American Heart Association released updated guidelines for the diagnosis and management of chronic heart failure in the adult, yielding new insights into the progression and treatment of this disease. Perioperative nurses need a working knowledge of these guidelines to provide optimal care when patients require surgical interventions for heart failure. This article provides an overview of the pathophysiology, classifications, and treatments for heart failure.

Fluid resuscitation therapy for hemorrhagic shock.

Hemorrhagic shock is a severe life-threatening emergency affecting all organ systems of the body by depriving tissue of sufficient oxygen and nutrients by decreasing cardiac output. This article is a short review of the different types of shock, followed by information specifically referring to hemorrhagic shock. The American College of Surgeons categorized shock into 4 classes: (1) distributive; (2) obstructive; (3) cardiogenic; and (4) hemorrhagic. Similarly, the classes of hemorrhagic shock are grouped by signs and symptoms, amount of blood loss, and the type of fluid replacement. This updated review is helpful to trauma nurses in understanding the various clinical aspects of shock and the current recommendations for fluid resuscitation therapy following hemorrhagic shock.