• Antifungal Prophylaxis for Adult Recipients of Veno-Venous Extracorporeal Membrane Oxygenation: A Cautionary Stance During the COVID-19 Pandemic

      Epelbaum, Oleg; Carmona, Eva M; Evans, Scott E; Hage, Chadi A; Jarrett, Benjamin; Knox, Kenneth S; Limper, Andrew H; Pennington, Kelly M; Division of Pulmonary and Critical Care Medicine, University of Arizona, College of Medicine-Phoenix (Lippincott Williams and Wilkins, 2021)
    • Facial Surgery in the Era of SARS-CoV-2 and Beyond: Challenges, Considerations, and Initiatives

      Dicaro, M.V.; Mintz, J.; Shir, S.; Muse, A.; Richards, J.; Shah, A.; Farber, S.; College of Medicine Tucson, University of Arizona (Lippincott Williams and Wilkins, 2020)
      The SARS-CoV-2 pandemic resulted in the implementation of healthcare practice regulations and restrictions across the United States. To facilitate safe patient management practices for facial plastic and reconstructive surgeons, appropriate guidelines and recommendations should be followed. Guidelines and recommendations should include a synthesis of the best evidence available from public health authorities and respected members in the surgery community. This review contains evidence-based suggestions that prioritize the safety of healthcare professionals and patients to help guide facial and reconstructive surgeons toward safe patient management. © 2020 The Authors. Published by Wolters Kluwer Health, Inc.
    • Gender Disparities in Cardiac Catheterization Rates Among Emergency Department Patients With Chest Pain

      Steenblik, Jacob; Smith, Alison; Bossart, Christopher S; Hamilton, David S; Rayner, Thomas; Fuller, Matthew; Carlson, Margaret; Madsen, Troy; Sarver Heart Center, University of Arizona (Lippincott Williams and Wilkins, 2021)
      Background: Previous studies have noted differences in rates of cardiac testing based on gender of patients. We evaluated cardiac catheterization rates for men and women presenting to the emergency department (ED) with chest pain, particularly among patients without a history of myocardial infarction (MI) or recent positive stress test. Methods: We performed a prospective evaluation of patients presenting to an urban, academic medical center for assessment of chest pain. We recorded baseline information, testing, and outcomes related to ED, observation unit, and inpatient stay. Primary outcomes included gender differences in cardiac catheterization and stenting rates among patients without an MI or positive stress test. Results: Over the 5.5 year study period, 2242 ED patients with chest pain participated in the study (45% male). Men and women had similar rates of cardiac stress testing (16.7% vs. 15.2%, P = 0.317) as well as similar rates of positive cardiac stress testing (2.9% vs. 1.9%, P = 0.116). Men were more likely to undergo cardiac catheterization (10.4% vs. 4.9%, P < 0.001). Men who had neither MI nor positive stress test were more likely than women to undergo cardiac catheterization: 5.8% versus 3.3%, P = 0.010. Similarly, men in this group were more likely to experience stent placement: 2.1% versus 0.7%, P = 0.003. Conclusions: Similar to previous studies, we noted disparities in cardiac testing by gender. Men were more likely to go to cardiac catheterization without an MI or a positive stress test. This disparity in a more aggressive strategy of cardiac catheterization in men may result in higher stenting rates in this group.
    • Managing acute uncomplicated appendicitis in frail geriatric patients: A second hit may be too much

      Chehab, Mohamad; Ditillo, Michael; Khurrum, Muhammad; Gries, Lynn; Asmar, Samer; Douglas, Molly; Bible, Letitia; Kulvatunyou, Narong; Joseph, Bellal; Division of Trauma, Critical Care, Burn, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona
      INTRODUCTION: Studies have proposed the use of antibiotics only in cases of acute uncomplicated appendicitis (AUA). However, there remains a paucity of data evaluating this nonoperative approach in the vulnerable frail geriatric population. The aim of this study was to examine long-term outcomes of frail geriatric patients with AUA treated with appendectomy compared with initial nonoperative management (NOP). METHODS: We conducted a 1-year (2017) analysis of the Nationwide Readmissions Database and included all frail geriatric patients(age, ≥65 years) with a diagnosis of AUA. Frailty was assessed using the five-factor modified frailty index. Patients were stratified into those undergoing appendectomy at index admission (operative management) versus those receiving antibiotics only without operative intervention (NOP). Propensity score matching in a 1:1 ratio was performed adjusting for patient- and hospital-related factors. RESULTS: A total of 5,562 frail geriatric patients with AUA were identified from which a matched cohort of 1,320 patients in each group was obtained. Patients in the NOP and operative management were comparable in terms of age (75.5 ± 7.7 vs. 75.5 ± 7.4 years; p = 0.882) and modified frailty index (0.4 [0.4-0.6] vs. 0.4 [0.4-0.6]; p = 0.526). Failure of NOP management was reported in 18% of patients, 95% of which eventually underwent appendectomy. Over the 6-month follow-up period, patients in the NOP group had significantly higher rates of Clostridium difficile enterocolitis (3% vs. 1%; p < 0.001), greater number of overall hospitalized days (5 [3-9] vs. 4 [2-7] days; p < 0.001), and higher overall costs (US $16,000 [12,000-25,000] vs. US $11,000 [8,000-19,000]; p < 0.001). Patients undergoing appendectomy after failed NOP had significantly higher rates of complications (20% vs. 11%; p < 0.001), mortality (4% vs. 2%; p = 0.019), and appendiceal neoplasm (3% vs. 1%; p = 0.027). CONCLUSION: One in six patients failed NOP within 6 months and required appendectomy with subsequent more complications and higher mortality. Appendectomy may offer better outcomes in managing AUA in the frail geriatric population. LEVEL OF EVIDENCE: Therapeutic, level IV. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
    • Predictors of pain severity among community-dwelling older adults with pain in the United States: Findings from a cross-sectional, retrospective study using 2017 Medical Expenditure Panel Survey

      Axon, D.R.; Le, D.; Department of Pharmacy Practice & Science, Center for Health Outcomes and Pharmacoeconomic Research, University of Arizona College of Pharmacy (Lippincott Williams and Wilkins, 2021)
      ABSTRACT: The purpose of this study was to determine predictors of pain severity among older United States (US) adults with pain.This cross-sectional, retrospective study utilized 2017 Medical Expenditure Panel Survey data. Eligible participants were alive for the calendar year, aged ≥50 years, and reported pain in the past 4 weeks. Hierarchical logistic regression models, adjusting for the survey design, were used to identify significant predictors of pain severity (i.e., extreme/quite a bit or moderate/little pain).An estimated 14,250,534 adults aged ≥50 with pain reported extreme/quite a bit of pain. Many variables were associated with extreme/quite a bit of pain, including: age 50 to 64 vs ≥65 years (adjusted odds ratio [AOR] = 1.49, 95% confidence interval [95% CI] = 1.22-1.82); males vs females (AOR = 0.80, 95% CI = 0.67-0.95); white race vs others (AOR = 0.75, 95% CI = 0.61-0.92); married vs other marital status (AOR = 1.31, 95% CI = 1.08-1.57); income <200% vs ≥200% federal poverty level (AOR = 1.30, 95% CI = 1.06-1.60); employed vs unemployed (AOR = 0.47, 95% CI = 0.37-0.60); limitation vs no limitation (AOR = 2.64, 95% CI = 2.09-3.33); 0, 1, 3, or 4 vs ≥5 chronic conditions (AOR ranged from 0.39 for 0 conditions to 0.77 for 4 conditions); excellent/very good or good vs fair/poor perceived physical health status (AOR ranged from 0.28 for excellent/very good to 0.40 for good); smokers vs non-smokers (AOR = 1.56, 95% CI = 1.27-1.93); exercise versus no exercise (AOR = 0.74, 95% CI = 0.62-0.88); and South vs West census region (AOR = 1.34, 95% CI = 1.04-1.74).This study found several characteristics could predict pain severity among older US adults who reported extreme/quite a bit of pain. These characteristics may guide specific areas of focus to improve patients' pain management. Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.
    • A Qualitative Study Describing Nurses' Experiences With Presenteeism

      Rainbow, Jessica G; Dudding, Katherine M; Bethel, Claire; College of Nursing, University of Arizona (Lippincott Williams and Wilkins, 31-03-20)
      OBJECTIVE: The aim of this study was to understand nurse awareness of coping and decision making regarding presenteeism and the consequences thereof. BACKGROUND: Nurses report high levels of presenteeism or not being able to fully function in the workplace, but we currently lack understanding of nurse perceptions of presenteeism and its consequences. METHODS: A qualitative descriptive method was used to evaluate the perceptions of nurses from medical surgical units at 2 different hospitals. FINDINGS: For purposes of the study, presenteeism was defined as being present at work when not fully engaged. Most respondents experienced presenteeism in the month before data collection. Five categories of themes were identified: 1) factors leading to presenteeism, 2) awareness and symptoms of presenteeism, 3) coping with presenteeism on and off shift, 4) decision making regarding presenteeism, and 5) consequences of presenteeism. CONCLUSIONS: Both personal and work factors contribute to presenteeism. To decrease presenteeism, healthcare leaders and systems should consider reviewing and changing sick/leave polices, unit cultures, and a lack of resources that contribute to and encourage an awareness of presenteeism, thereby decreasing nurse fatigue. Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
    • Recruiting Nurses Via Social Media for Survey Studies

      Bethel, Claire; Rainbow, Jessica G; Dudding, Katherine M; The University of Arizona (Lippincott Williams and Wilkins, 2021)
      Background: Nurses are a difficult population to recruit for research. Barriers to recruitment of nurses include survey fatigue, hospital structures and institutional review boards as gatekeepers to accessing participants, and limited generalizability of findings. Social media present innovative opportunities to recruit participants for survey research. However, there is limited information about best practices for recruiting nurses through social media. Objectives: The aim of this report was to examine the advantages and disadvantages of and determine the best practices for recruiting nurses for survey studies via social media. Methods: We examined recruitment strategies of three survey studies involving nurse participants. Each study used social exchange theory and leverage-saliency theory to guide recruitment. The studies included were (a) the Travel Nurse Onboarding Study, which recruited participants from a single closed group on Facebook; (b) the Presenteeism and Nursing Study where participants were recruited using association listservs, healthcare organizations, and paid ads and postings on social media; and (c) the Pain and Nursing Study in which participants were recruited through social media, association listservs, and in person at conferences. Results: Social media offer accessible, low-cost, high-yield approaches to recruitment of nurses for survey studies. Discussion Useful strategies for crafting effective recruitment via social media are presented, including how, where, when, and how often to post. The generalizability of social media research is also discussed. Suggestions are provided for researchers using social media as well as guidelines for institutional review boards to address gray areas of social media research. Data integrity protection techniques are proposed to ensure social media survey data are not corrupted by malicious bots. This report outlines best practices for the recruitment of nurses for survey studies using social media. © 2020 Wolters Kluwer Health, Inc. All rights reserved.
    • Refining determinants of associations of visit-to-visit blood pressure variability with cardiovascular risk: results from the Action to Control Cardiovascular Risk in Diabetes Trial

      Nuyujukian, Daniel S; Zhou, Jin J; Koska, Juraj; Reaven, Peter D; Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona; College of Medicine-Phoenix, University of Arizona (Lippincott Williams and Wilkins, 2021)
      OBJECTIVES: As there is uncertainty about the extent to which baseline blood pressure level or cardiovascular risk modifies the relationship between blood pressure variability (BPv) and cardiovascular disease, we comprehensively examined the role of BPv in cardiovascular disease risk in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Trial. METHODS: Using data from ACCORD, we examined the relationship of BPv with development of the primary CVD outcome, major coronary heart disease (CHD), and total stroke using time-dependent Cox proportional hazards models. RESULTS: BPv was associated with the primary CVD outcome and major CHD but not stroke. The positive association with the primary CVD outcome and major CHD was more pronounced in low and high strata of baseline SBP (<120 and >140 mmHg) and DBP (<70 and >80 mmHg). The effect of BPv on CVD and CHD was more pronounced in those with both prior CVD history and low blood pressure. Dips, not elevations, in blood pressure appeared to drive these associations. The relationships were generally not attenuated by adjustment for mean blood pressure, medication adherence, or baseline comorbidities. A sensitivity analysis using CVD events from the long-term posttrial follow-up (ACCORDION) was consistent with the results from ACCORD. CONCLUSION: In ACCORD, the effect of BPv on adverse cardiovascular (but not cerebrovascular) outcomes is modified by baseline blood pressure and prior CVD. Recognizing these more nuanced relationships may help improve risk stratification and blood pressure management decisions as well as provide insight into potential underlying mechanisms.
    • Risk Factors Associated With Infection in Open Fractures of the Upper and Lower Extremities

      Tornetta, P., III; Della Rocca, G.J.; Morshed, S.; Jones, C.; Heels-Ansdell, D.; Sprague, S.; Petrisor, B.; Jeray, K.J.; Del Fabbro, G.; Bzovsky, S.; et al. (Lippincott Williams and Wilkins, 2020)
      INTRODUCTION: Open fractures are associated with a high risk of infection. The prevention of infection is the single most important goal, influencing perioperative care of patients with open fractures. Using data from 2,500 participants with open fracture wounds enrolled in the Fluid Lavage of Open Wounds trial, we conducted a multivariable analysis to determine the factors that are associated with infections 12 months postfracture. METHODS: Eighteen predictor variables were identified for infection a priori from baseline data, fracture characteristics, and surgical data from the Fluid Lavage of Open Wounds trial. Twelve predictor variables were identified for deep infection, which included both surgically and nonoperatively managed infections. We used multivariable Cox proportional hazards regression analyses to identify the factors associated with infection. Irrigation solution and pressure were included as variables in the analysis. The results were reported as adjusted hazard ratios (HRs), 95% confidence intervals (CIs), and associated P values. All tests were two tailed with alpha = 0.05. RESULTS: Factors associated with any infection were fracture location (tibia: HR 5.13 versus upper extremity, 95% CI 3.28 to 8.02; other lower extremity: HR 3.63 versus upper extremity, 95% CI 2.38 to 5.55; overall P < 0.001), low energy injury (HR 1.64, 95% CI 1.08 to 2.46; P = 0.019), degree of wound contamination (severe: HR 2.12 versus mild, 95% CI 1.35 to 3.32; moderate: HR 1.08 versus mild, 95% CI 0.78 to 1.49; overall P = 0.004), and need for flap coverage (HR 1.82, 95% CI 1.11 to 2.99; P = 0.017). DISCUSSION: The results of this study provide a better understanding of which factors are associated with a greater risk of infection in open fractures. In addition, it can allow for surgeons to better counsel patients regarding prognosis, helping patients to understand their individual risk of infection. Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.
    • Survey Outcomes of Lipedema Reduction Surgery in the United States

      Herbst, K.L.; Hansen, E.A.; Cobos Salinas, L.M.; Wright, T.F.; Larson, E.E.; Schwartz, J.S.; Department of Medicine, University of Arizona; TREAT Program, University of Arizona (Lippincott Williams and Wilkins, 2021)
      Background: Lipedema is a loose connective tissue disease affecting the limbs of women, that is difficult to lose by diet, exercise, or bariatric surgery. Publications from Europe demonstrate that lipedema reduction surgery improves quality of life for women with lipedema. There are no comparable studies in the United States (USA). The aim of this study was to collect data from women with lipedema in the USA who have undergone lipedema reduction surgery in the USA to determine if quality of life, pain, and other measures improved after lipedema reduction surgery. Methods: Subjects were recruited and consented online for a 166-item questionnaire in REDCap. In total, 148 women answered the questionnaire after undergoing lipedema reduction surgery in the USA. Significance set at P < 0.05 was determined by ANOVA, Tukey's multiple comparison test, or paired t-test. Results: Quality of life improved in 84% and pain improved in 86% of patients. Ambulation improved most in lipedema Stage 3 (96%). Weight loss occurred in all stages by 3 months after surgery. Complications included growth of loose connective tissue within and outside treated areas, tissue fibrosis, anemia, blood clots, and lymphedema. Conclusions: Women with lipedema noticed significant benefits after lipedema reduction surgery in the USA. Prospective studies are needed to assess benefits and complications after lipedema reduction surgery in the USA. © 2021 Lippincott Williams and Wilkins. All rights reserved.
    • Testing the Use of Natural Language Processing Software and Content Analysis to Analyze Nursing Hand-off Text Data

      Galatzan, Benjamin J; Carrington, Jane M; Gephart, Sheila; College of Nursing, University of Arizona (Lippincott Williams and Wilkins, 2021-05-10)
      Natural language processing software programs are used primarily to mine both structured and unstructured data from the electronic health record and other healthcare databases. The mined data are used, for example, to identify vulnerable at-risk populations and predicting hospital associated infections and complications. Natural language processing programs are seldomly used in healthcare research to analyze the how providers are communicating essential patient information from one provider to another or how the language that is used impacts patient outcomes. In addition to analyzing how the message is being communicated, few studies have analyzed what is communicated during the exchange in terms of data, information, and knowledge. The analysis of the "how"and "what"of healthcare provider communication both written and verbal has the potential to decrease errors and improve patient outcomes. Here, we will discuss the feasibility of using an innovative within-methods triangulation data analysis to uncover the contextual and linguistic meaning of the nurse-to-nurse change-of-shift hand-off communication. The innovative within-methods triangulation data analysis uses a natural language processing software program and content analysis to analyze the nursing hand-off communication.