Citations

Objective Patients with heart failure (HF) perform a variety of self-care activities to control symptoms and minimise the risk of HF decompensations. The objective of this study was to understand how patients build capacity and manage the work of living with HF. Design A qualitative study using semi-structured telephone interviews. The interview guide was informed by the Cumulative Complexity Model, a conceptual framework that focuses on a patient’s workload and their capacity to manage that work. Interview transcripts were analysed using a mixed inductive and deductive coding approach with organisation into larger thematic categories. Setting Southeastern Minnesota USA (11 counties) with capture of data from local community healthcare providers under the auspices of the Rochester Epidemiology Project. Participants Intentional sampling of local patients with HF (n=24, median age 69.5 years, 54% women, 63% rural, 54% preserved ejection fraction) who reported high treatment burden and/ or poor health status on a questionnaire. Results Three major themes emerged: using capacity to manage workload, disruptions resulting in workload exceeding capacity and regaining workload-capacity balance. Participants described routinising the daily tasks associated with living with HF to minimise the associated burden and identified disruptions to their routines, including hospitalisations, emergency room visits, worsening health status and changes in healthcare access. To accommodate disruptions and regain workload-capacity balance, participants decreased workload and/or transferred tasks to others to maximise capacity. Conclusions Participants with HF described managing patient workload in times of stable health, but they sometimes struggled to accommodate disruptions and worsening health status. These findings can inform the design of interventions to minimise workload, maximise capacity and improve quality of life for patients with HF.

Context.— Morphologic evaluation of peripheral blood smears provides valuable information to diagnose and manage a variety of hematologic disorders. Objective.— To measure the competency of the technical staff in the morphologic evaluation of peripheral blood smears and provide performance trends. Design.— Participating technologists accessed 10 whole slide–imaged peripheral blood smears through a web-based imaging tool in 2 separate studies. Participants performed a 100-cell differential and morphologic evaluation for each slide image. Grading criteria, determined by 3 hematopathologists, were weighted according to their clinical significance (score range, 0–100 for each case). Each institution and participant answered a questionnaire to assess the impact of current practices and educational programs on competency scores. Results.— A total of 776 technologists from 92 institutions participated in study 1 and 1495 technologists from 179 institutions participated in study 2. Median performance scores for institutions were 78.9 and 87.6 for studies 1 and 2, respectively, encompassing a range of hematologic disorders. Based on results of the questionnaire for study 1, higher performance scores were seen when institutions required a specific number of continuing education credits per year through an agency ( P = .005). In study 2, institutions with remediation procedures following a failed competency demonstrated higher performance scores ( P = .03). Conclusions.— Medical technologist competency of peripheral blood smears improves with level of experience and is positively impacted through attending educational programs. Whole slide images offer a convenient means of assessing technical competence and provide data to allow institutions to appropriately focus their procedures and educational efforts.

Introduction: External ear malformations represent a spectrum of congenital anomalies that may involve the external auditory canal (EAC), tympanic membrane (TM), or associated structures. A rare anomaly, the EAC skin wedge, results from incomplete canalization during embryologic development. This report presents the clinical presentation, diagnostic evaluation, and surgical management of this condition. Objective: To detail the successful surgical management of an isolated EAC skin wedge and demonstrate the applicability of argon laser in treating these congenital anomalies. Methods: A 13-month-old female presented with recurrent otitis media and mild bilateral conductive hearing loss. Physical examination revealed a fan-like skin wedge spanning the EAC to the TM. Imaging with temporal bone computed tomography confirmed the extent of the anomaly. Under general anesthesia, the skin wedge was ablated using an argon laser, followed by antibiotic-soaked packing to prevent scarring and recurrence. Follow-up audiometry and endoscopic evaluations assessed outcomes. Results: The procedure was well-tolerated, with no intraoperative complications. At 3 weeks and 3 months postoperatively, no recurrence of the skin wedge was observed, and audiometry normalized. The patient demonstrated improved middle ear ventilation and resolution of conductive hearing loss. Conclusions: This case demonstrates the successful use of argon laser in the management of a rare congenital EAC anomaly. Argon lasers offer precise ablation and excellent hemostasis, making them a valuable option for similar cases. This report emphasizes the importance of tailored surgical approaches for rare pediatric ear malformations.

BACKGROUND AND OBJECTIVES: The intraosseous subarcuate loop (SL) is a unique variant of the anterior inferior cerebellar artery (AICA), where a loop of the artery is trapped in the petrous bone's subarcuate fossa (SF). Recognizing this variant is crucial for planning cerebellopontine angle (CPA) surgeries; however, data regarding its frequency and management vary in the published literature. A cohort from a single center was studied using MRI to assess its prevalence, and the findings were compared with the existing literature. In addition, an intraoperative guide for mobilizing the intraosseous AICA's SL was provided through a detailed step-by-step cadaveric dissection. METHODS: Two hundred fifty-eight patients who had undergone MRI scans of the CPA (516 sides) were retrospectively reviewed. MRIs displaying vascular loops visible in the axial view were analyzed using multiplanar reconstruction, and the intraosseous loop frequency was evaluated. A scoping review was undertaken to provide an overview of previously published data on its prevalence. One embalmed and latex-injected specimen with intraosseous AICA's SL was dissected through a retrosigmoid approach, and 1 surgical case was detailed, describing the procedure to release it. RESULTS: Intraosseous AICA's SL mobilization involves the identification of its entry and exit points within the petrous bone, dural incision to expose the SF, SF drilling, subarcuate artery division, and detaching the vascular loop. Preservation of a dural cuff is crucial to prevent vascular injury. We analyzed 258 brain MRIs (mean age 55 years, 42% male). The intraosseous AICA's SL was present in 4 of 516 evaluated CPAs (0.8%). The prevalence of the vascular anomaly in the reviewed literature using different radiological modalities ranged from 0.2% to 1.6%. CONCLUSION: The intraosseous AICA's SL is an uncommon anatomic variation detectable by MRI, posing an added risk in CPA surgery. Identifying and properly mobilizing it is crucial for safe vascular preservation.

Background. The availability of in situ normothermic regional perfusion (NRP) or ex situ normothermic machine perfusion (NMP) has revolutionized donation after circulatory death (DCD) liver transplant (LT). While some have suggested that NRP and NMP may represent competing technologies for DCD LT, there are many scenarios where these technologies can function in a complementary manner. Methods. Between January 2022 and March 2024, 83 DCD LTs were performed using NRP (62 NRP alone and 21 NRP + NMP) and were compared with 297 static cold storage (SCS) DCD LTs. NRP + NMP was used in scenarios with (1) long travel distances, (2) complicated transplant recipients, or (c) the need for additional liver graft recovery in “marginal” cases. Results. Ischemic cholangiopathy was lower in the NRP alone group (0%) and the NRP + NMP group (0%) compared with the SCS group (16.8; P < 0.001 and P = 0.04, respectively). In addition, early allograft dysfunction, number of packed red blood cells transfused, and acute kidney injury were lower in the NRP alone and NRP + NMP groups compared with the SCS group. Graft survival was higher in cases where NRP was used than in cases where SCS was used ( P = 0.016). In all the cases where lactate remained elevated at the end of NRP (mean 8.2 ± 2.0), it ultimately normalized at the end of NMP (0.92 ± 0.56). Conclusions. The present study demonstrates lower rates of ischemic cholangiopathy and improved graft survival with NRP alone or NRP + NMP compared with SCS when using liver grafts from DCD donors. It also demonstrates that excellent outcomes can be achieved with sequential NRP + NMP in cases with prolonged travel distances, complicated recipients, or when there is a need for additional liver recovery in “marginal” cases.

ResumenLa tabaquera anatómica, una región triangular en la porción dorso-radial de la muñeca, es un punto de referencia anatómico clave. Está delimitada por los tendones del extensor largo del pulgar, extensor corto del pulgar y abductor largo del pulgar, y alberga la arteria radial y ramas nerviosas. Patologías como quistes sinoviales, fracturas y osteofitos pueden alterar su apariencia. Estudios sobre lesiones del ligamento escafolunar (SLL) muestran que el daño crónico provoca el desplazamiento dorso-radial del escafoides, iniciando un proceso degenerativo conocido como colapso avanzado escafolunar (SLAC). Esto a menudo resulta en la "desaparición" de la tabaquera anatómica, lo que facilita la identificación de pacientes con muñeca SLAC junto con síntomas como dolor y rigidez. La afección es impulsada por la formación de osteofitos, subluxación del escafoides y sinovitis, lo que conduce a inestabilidad articular y deformidad. Los tratamientos tradicionales, como la estiloidectomía, pueden no resolver completamente la inestabilidad. Nuevos enfoques que consideran la dinámica tridimensional de la muñeca podrían ser más efectivos para manejar el SLAC. Estudios biomecánicos sugieren que las lesiones del SLL, junto con la pérdida de estabilizadores secundarios, provocan que el escafoides se pronuncie y flexione, resultando en una proyección dorso-radial dentro de la fosa del escafoides. Sin tratamiento, esto puede progresar a SLAC, frecuentemente caracterizado por el "bulto dorso-radial de la muñeca".