Hemodialysis Access: Initial Considerations and the Difficult Patient

The population requiring hemodialysis (HD) in the United States continues to grow, with recent studies reporting over 370,000 Americans with end stage renal disease (ESRD) who are HD-dependent. The creation of functional HD access is often the limiting step in utilization of renal replacement therapy (RRT). Since the 1960s, the creation of hemodialysis access has become one of the most commonly performed procedures in the United States with over 500,000 vascular access procedures performed per year. This represents approximately 8% of the annual Medicare budget allocated to patients with ESRD. The magnitude of the associated economic and human costs is further exemplified by the fact that up to 25% of patients with ESRD will die due to inadequate hemodialysis access. This clinical situation and societal burden makes understanding the basic management steps and options for hemodialysis access of key importance to all healthcare professionals involved in the care of patients who require HD

Surgical Education: Focus on Gender Equality in Academic Surgery and Related Areas

Despite progress and advancements made to achieve gender equality, a glass ceiling still exists for women in surgery. Women remain largely underrepresented in academic surgery, with appointments to only 18% of surgery program director roles and 6.3% of surgical chair positions in the United States as of 2018. Inequities across various surgical subspecialties are also significant, especially in the areas of neurosurgery, orthopedic surgery, otolaryngology, and plastic and reconstructive surgery. Additional barriers exist for women in academics, including lack of high-quality female mentorship, implicit bias within letters of recommendation, and a greater incidence of reported moral injury and burn-out. Further efforts to address these inequities are necessary to retain the talents and contributions of women in surgery. Interventions that may counterbalance the continued gender gap within surgical fields include the implementation of implicit bias training, increasing institutional support, establishing formal mentorship initiatives, the introduction of early exposure programs during medical training, transparent institutional promotion policies, childcare support, and accommodation of maternity leave. The purpose of this chapter is to educate the reader regarding gender inequality in surgery and related fields and to highlight key issues central to the propagation of gender biases specifically as they relate to female surgeons across various roles and responsibilities (e.g., clinical practice, education/training, and leadership) within the contemporary academic landscape

Patient Frailty: Key Considerations, Definitions and Practical Implications

By 2020, the elderly (≥65-year-old) world population is projected to exceed one billion individuals. This demographic megatrend has brought topics such as physiological age and frailty to the forefront of medical research efforts around the globe. The concept of frailty has evolved significantly since the mid-twentieth century. The outdated stereotype of a “thin, stooped, slow octogenarian” has transitioned to a more scientific and objective understanding of the problem. Still, a comprehensive and concise definition of “frailty” remains elusive. Until such a definition is firmly established and universally agreed upon, clinicians continue to rely on the somewhat subjective conceptual framework of today. In this chapter, the authors review key issues pertaining to clinical management of frail patients, including diagnosis/identification, preventive strategies, therapeutic approaches, and common pitfalls. The relationship between frailty, various domains of life, and functional status is also discussed. Finally, we will touch upon the concepts of end-of-life and goals of care, focusing on their relationship to frailty

International Health Security: A Summative Assessment by ACAIM Consensus Group

International health security (IHS) encompasses any natural or anthropogenic occurrence that can threaten the safety of human health and well-being. The American College of Academic International Medicine IHS Consensus Group (ACAIM-CG) developed a summative assessment highlighting the main issues that can impact IHS including emerging infectious diseases; chronic health conditions; bioterrorism; planetary changes (volcanic eruptions, earthquakes, wildfires, and climate change); nuclear incidents; information and cyber health; industrialization; globalization; pharmaceutical production; and communication platforms (social media). These concerns can directly and indirectly impact IHS both in the long and short term. When considering IHS, we aim to emphasize the utility of applying a predefined framework to effectively approach health security threats. This framework comprises of prevention, detection, assessment, reporting, response, addressing needs, and the perpetual repetition of the above cycle (inclusive of appropriate mitigation measures). It is hoped that this collective work will provide a foundation for further research within the redefined, expanded scope of IHS

Ultrasound-assisted musculoskeletal procedures: A practical overview of current literature

Traditionally performed by a small group of highly trained specialists, bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment. Due to this limitation, a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel. The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios. This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures. In-depth discussion of each ultrasound procedure including pertinent technical details, indications and contraindications is provided. Despite the limited amount of prospective, randomized data in this area, a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography

Rib fractures in the elderly: a marker of injury severity.

OBJECTIVES: To examine the relationship between the number of rib fractures (RIBFs) and mortality, injury severity, and resource consumption in elderly patients admitted to trauma centers. DESIGN: Thirteen-year retrospective statewide database analysis. SETTING: Participating trauma centers in Pennsylvania. PARTICIPANTS: A total of 27,855 trauma patients, including 8,648 elderly patients, admitted to a trauma center with more than one RIBF. MEASUREMENTS: Patient demographics, number of RIBFs, Injury Severity Score, complications, patient mortality, preexisting conditions (PECs), and hospital and intensive care unit length of stay. RESULTS: Mortality for elderly patients (aged\u3e/=65) with RIBFs was greater than for patients younger than 65 (20.1% vs 11.4%, P CONCLUSION: Overall trauma-related mortality is higher in elderly patients with RIBFs than younger patients with RIBFs. Mortality rates rise with increasing number of RIBFs. The number of RIBFs is easy to quantify and may be a useful predictor of overall injury severity and outcome for elderly trauma patients

Adrenal gland trauma is associated with high injury severity and mortality.

PURPOSE: To review a statewide experience of adrenal gland trauma (AGT), incidence, demographics, associated injuries, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), mechanisms of injury, and complications, associated with AGT. METHODS: A retrospective analysis of patients admitted to accredited trauma centers in the Commonwealth of Pennsylvania who sustained AGT from January 1, 1989 to December 31, 2000. RESULTS: Adrenal trauma was found in 322 of 210,508 cases (0.15%). There were 76.4% men and 23.6% women. Seventy-one percent of patients had an ISS greater than 20. The overall mortality was 32.6%. The mechanism of injury was blunt in 81.4% of the cases and penetrating in 18.6%. Vehicular accidents constituted 48.8% of the cases. Younger age was associated with male predominance and greater proportion of penetrating injuries. Although exact indications are not known, advanced imaging studies were done in 163 of 322 (50.6%) patients: computed tomography in 133 (41.3%), ultrasound in 26 (8.1%), and angiography in 4 cases (1.2%). Exploratory laparotomy was done in 60 (18.6%), splenectomy in 25 (7.8%), nephrectomy in 14 (4.3%), and adrenalectomy in 8 (2.5%). Penetrating injuries had a 43.8% rate of exploratory laparotomy, whereas it was 12.4% in blunt trauma. Associated injuries included liver injury (57.8%), rib fractures (50.9%), kidney injury (41.3%), and spleen injury (32.9%). Pulmonary complications were most common, followed by infection/sepsis, and cardiovascular. Nearly 45% of patients were discharged home, 17% of patients were discharged to a rehabilitation facility, and 3.4% to nursing homes. CONCLUSIONS: Adrenal gland trauma is a rare and largely coincidental finding diagnosed either during an initial radiologic examination or surgical exploration for other injuries. Surgical exploration was carried out in 21.4% of patients, with adrenalectomy in 2.5% of cases and nephrectomy in 4.3% of cases. Adrenal injury is associated with high injury severity, and with mortality rates up to 5 times higher than non-AGT trauma

Human immunodeficiency virus infection in trauma patients: where do we stand?

OBJECTIVE: The human immunodeficiency virus (HIV) epidemic is a growing health care problem. The purpose of this study was to examine the relationship between HIV infection and trauma patient treatment, complications, and mortality. METHODS: The Pennsylvania Trauma Outcome Study database was used to identify trauma patients with known HIV-positive status (HP) and randomly selected age-matched controls (CL). Demographics, Injury Severity Score, Glasgow Coma Scale score, mechanism of injury, preexisting conditions, complications, mortality, hospital length of stay (HLOS), intensive care unit length of stay (ILOS), and operative interventions were compared. RESULTS: Demographics, vital signs on presentation, and Injury Severity Score were similar between the HP and CL groups. There was no difference in mortality between the two groups (3.6% vs. 3.1%, p = 0.6447). HP patients were more likely to present with penetrating injuries (22.6% vs. 15.8%, p \u3c 0.0031) and had significantly fewer major orthopedic injuries than CL patients (p \u3c 0.01). HP patients were more likely to have a history of a neurologic condition; chronic drug/alcohol use; psychiatric diagnosis; or liver, pulmonary, and/or renal disease (all p \u3c 0.01). HP patients had more pulmonary complications (12.3% vs. 4.1%), renal complications, and infectious/septic complications (all p \u3c 0.01) than controls. Infection/sepsis and pulmonary complications were associated with significant mortality in HP patients. HP patients underwent more thoracostomies (7.5% vs. 4.4%, p = 0.0235) and exploratory laparotomies (7.0% vs. 2.4%, p = 0.0002). HLOS (10.2 +/- 10 vs. 6.8 +/- 8.6 days, p = 0.001) and ILOS (2.3 +/- 7.2 vs. 1.5 +/- 4.9 days, p = 0.0178) were greater for HP patients. HP patients were less likely than controls to be discharged directly to home (67.8% vs. 82.7%, p = 0.0001). CONCLUSION: HP patients had more preexisting conditions and complications than controls. There was no difference in overall mortality between the two groups. However, pulmonary/infectious complications were associated with significant mortality in HP patients. HP patients consumed more health care resources than controls, as exemplified by greater ILOS and HLOS and more operative procedures