• Development and Internal Validation of Novel Risk Tools to Predict Subsequent Shoulder Surgery After Proximal Humerus Fractures

      Nowak, Lauren L.; Hall, Jeremy; Davis, Aileen M.; McKee, Michael D.; Mamdani, Muhammad; Beaton, Dorcas; Schemitsch, Emil H. (Ovid Technologies (Wolters Kluwer Health), 2022-06)
      OBJECTIVE: To (1) identify predictors of subsequent surgery after initial treatment of proximal humerus fractures (PHFs) and (2) generate valid risk prediction tools to predict subsequent surgery. METHODS: We identified patients ≥50 years with PHF from 2004 to 2015 using health data sets in Ontario, Canada. We used procedural codes to classify patients into treatment groups of (1) surgical fixation, (2) shoulder replacement, and (3) conservative. We used procedural and diagnosis codes to capture subsequent surgery within 2 years after fracture. We developed regression models for two-thirds of each group to identify predictors of subsequent surgery and the regression equations to develop risk tools to predict subsequent surgery. We used the final third of each cohort to evaluate the discriminative ability of the risk tools using c-statistics. RESULTS: We identified 20,897 patients with PHF, 2414 treated with fixation, 1065 with replacement, and 17,418 treated conservatively. Predictors of reoperation after fixation included bone grafting and nail or wire fixation versus plate fixation, whereas poor bone quality was associated with reoperation after initial replacement. In conservatively treated patients, more comorbidities were associated with subsequent surgery, whereas age 70+ and discharge home after presentation lowered the odds of subsequent surgery. The risk tools were able to discriminate with c-statistics of 0.75-0.88 (derivation) and 0.51-0.79 (validation). CONCLUSIONS: Our risk tools showed good to strong discriminative ability for patients treated conservatively and with fixation. These data may be used as the foundation to develop a clinically informative tool. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
    • Mercurial Metastatic Merkel Cell Carcinoma: A Case of Colonic Involvement

      Liu, Margaret C.; Ahmed, Shifat; Mehta, Shivang; Univ Arizona, Coll Med (Ovid Technologies (Wolters Kluwer Health), 2019-06)
      Merkel cell carcinoma (MCC) is a neuroendocrine skin cancer that typically presents as a painless erythematous nodule on body surfaces visible to the sun. Metastatic disease is typical to the lymph nodes, liver, and lungs. There are previous case reports of patients with metastases to the gastrointestinal tract including the stomach, small intestine, and pancreas. To our knowledge, there are only rare occurrences of metastases to the colon. We report a patient with a history of MCC treated with chemotherapy who presented with hematochezia and underwent a colonoscopy that showed a partially obstructing, edematous, friable 7-cmcircumferential mass in the transverse colon. Biopsy confirmed the diagnosis of MCC that metastasized to the transverse colon.
    • Stroke-Specific Refinements to Naylor's Transitional Care Model to Address the Storm of Uncertainty and Unmet Survivor and Caregiver Needs

      Laws, Lorre; Ritter, Leslie; Loescher, Lois; McEwen, Marylyn; College of Nursing, The University of Arizona (Ovid Technologies (Wolters Kluwer Health), 2021-12-09)
      BACKGROUND: By 2030, there will be approximately 7.6 million stroke survivors (SSs) in the United States, yet comprehensive transitional care (TC) for stroke is not widely available. Stroke strikes without warning and leaves in its wake a "storm"of uncertainty for SSs and caregivers (CGs) as they encounter a myriad of unmet physical, mental, emotional, and financial needs that are not wholly addressed by passive healthcare delivery systems. Needed is a stroke-specific TC model that bridges this stormto active delivery of SS and CG postacute care. Naylor's Transitional Care Model (NTCM) has not been examined for how it can frame comprehensive stroke care. The purpose of this study was to solicit SS and CG descriptions of TC experiences to inform the NTCM with refined operational definitions and exemplars specific to stroke. METHODS: Focus groups conducted for this qualitative descriptive study were guided by interview questions based on the 8 NTCM operational definitions. Data were analyzed using inductive and deductive qualitative content analysis methods. RESULTS: Post-acute-stroke care does not comprehensively meet the needs of SSs and CGs. Participants described TC deficits across all 8 NTCM components. Two new subcomponents that could be applied for a stroke-specific NTCM emerged: Psychological and transportation challenges. CONCLUSION: Unmet needs identified by SSs and CGs were used to extend NTCM specific to the stroke population and to develop the Recommendations and Exemplars for Stroke Specific Comprehensive Transitional Care Delivery (see Supplementary Digital Content, available at http://links.lww.com/JNN/A385). Researchers and practitioners can use the findings to develop and deliver more comprehensive TC to SSs and CGs.