Elective surgery in the time of COVID-19 Diaz, Adrian; Sarac, Benjamin A.; Schoenbrunner, Anna R. ...
The American journal of surgery,
06/2020, Letnik:
219, Številka:
6
Journal Article
Recenzirano
Odprti dostop
•The COVID-19 pandemic has placed a significant strain on the United States health care system.•Healthcare workers are rapidly altering their professional responsibilities to help meet hospital ...needs.•Surgeons have witnessed a dramatic change in their practices with rapidly decreasing elective surgery.•Surgical leaders should develop a framework to help make decisions around elective surgery as information is evolving.
The relationship between wound irrigation and healing has been recognized for centuries. However, there is little evidence and no official recommendations from any health care organization regarding ...best wound irrigation practices. This is the first review of wound irrigation that systematically summarizes the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and distills the evidence into a practical format. In this comprehensive review, the authors outline the irrigation fluids and delivery methods used in the identified studies, analyze reported treatment outcomes, summarize irrigation effectiveness, and propose evidence-based guidelines to improve wound healing outcomes and enhance the consistency of wound irrigation. Thirty-one high-quality studies with a combined total of 61,808 patients were included. Based on the current evidence provided by this review, the authors propose the following guidelines: (1) acute soft-tissue wounds should receive continuous gravity flow irrigation with polyhexanide; (2) complex wounds should receive continuous negative-pressure wound therapy with instillation with polyhexanide; (3) infected wounds should receive continuous negative-pressure wound therapy with instillation with silver nitrate, polyhexanide, acetic acid, or povidone-iodine; (4) breast implant wounds should receive gravity lavage with povidone-iodine or antibiotics; and (5) surgical-site infection rates can be reduced with intraoperative povidone-iodine irrigation.
BACKGROUND:Due to its strong antimicrobial activity, silver is a commonly used adjunct in wound care. However, it also has the potential to impair healing by exerting toxic effects on keratinocytes ...and fibroblasts. The published literature on the use of silver in wound care is very heterogeneous, making it difficult to generate useful treatment guidelines.
METHODS:A search of high-quality studies on the use of silver in wound care was performed on PubMed. A detailed qualitative analysis of published articles was performed to evaluate the evidence for the use of silver in infected wounds, clean wounds, burns, and over closed surgical incisions.
RESULTS:Fifty-nine studies were included in this qualitative analysis. We found that, overall, the quality of the published research on silver is poor. While there is some evidence for short-term use of dressings containing nanocrystalline silver in infected wounds, the use of silver-containing dressings in clean wounds and over closed surgical incisions is not indicated. Negative-pressure wound therapy accelerates the healing of contaminated wounds, especially when silver is used as an adjunct. For burns, silver sulfadiazine slows healing and should not be used. Instead, nanocrystalline silver, or alternatives such as octenidine and polyhexanide, lead to less infection and faster healing.
CONCLUSIONS:In infected wounds, silver is beneficial for the first few days/weeks, after which nonsilver dressings should be used instead. For clean wounds and closed surgical incisions, silver confers no benefit. The ideal silver formulations are nanocrystalline silver and silver-coated polyurethane sponge for negative-pressure wound therapy. Silver sulfadiazine impairs wound healing. Proper use of silver-containing dressings is essential to optimize wound healing.
Chronic migraines affect approximately 2 percent of the U.S. population and cost an estimated $17 billion per year. OnabotulinumtoxinA (botulinum toxin type A) is a U.S. Food and Drug ...Administration-approved prophylactic medication for chronic migraine headaches and is best injected in a targeted fashion into specific trigger sites. The purpose of this study was to determine the cost-effectiveness of long-term, targeted botulinum toxin type A versus peripheral trigger site deactivation surgery for the treatment of migraine headaches.
A Markov model was constructed to examine long-term, targeted botulinum toxin type A versus peripheral trigger site deactivation surgery. Costs, utilities, and other model inputs were identified from the literature. One-way and probabilistic sensitivity analyses were performed. An incremental cost-effectiveness ratio under $50,000 per quality-adjusted life-year was considered cost-effective.
The mean cost of peripheral trigger site deactivation surgery was $10,303, with an effectiveness of 7.06; whereas the mean cost of long-term, targeted botulinum toxin type A was $36,071, with an effectiveness of 6.34. Trigger-site deactivation surgery is more effective and less costly over the time horizon of the model. One-way sensitivity analysis revealed that surgery is the most cost-effective treatment in patients requiring treatment for greater than 6.75 years.
Based on this model, peripheral trigger site deactivation surgery is the more cost-effective option for treating refractory migraine headaches requiring treatment beyond 6.75 years. The model reveals that peripheral trigger-site deactivation surgery is more effective and less costly than long-term, targeted botulinum toxin type A over the course of a patient's lifetime.
The SARS-CoV-2 (COVID-19) pandemic has resulted in widespread cancellation of elective orthopaedic procedures. The guidance coming from multiple sources frequently has been difficult to assimilate as ...well as dynamic, with constantly changing standards. We seek to communicate the current guidelines published by each state, to discuss the impact of these guidelines on orthopaedic surgery, and to provide the general framework used to determine which procedures have been postponed at our institution.
An internet search was used to identify published state guidelines regarding the cancellation of elective procedures, with a publication cutoff of March 24, 2020, 5:00 P.M. Eastern Daylight Time. Data collected included the number of states providing guidance to cancel elective procedures and which states provided specific guidance in determining which procedures should continue being performed as well as to orthopaedic-specific guidance.
Thirty states published guidance regarding the discontinuation of elective procedures, and 16 states provided a definition of "elective" procedures or specific guidance for determining which procedures should continue to be performed. Only 5 states provided guidelines specifically mentioning orthopaedic surgery; of those, 4 states explicitly allowed for trauma-related procedures and 4 states provided guidance against performing arthroplasty. Ten states provided guidelines allowing for the continuation of oncological procedures.
Few states have published guidelines specific to orthopaedic surgery during the COVID-19 outbreak, leaving hospital systems and surgeons with the responsibility of balancing the benefits of surgery with the risks to public health.
Pain is an unpleasant experience resulting from either tissue damage or insults to the somatosensory system. Approaches to pain management evolve as we better understand both pain pathways and the ...tools available to interrupt these. The interest surrounding botulinum neurotoxin as a chemodenervating agent has expanded to include its potential applications in painful pathologies, both within and beyond the confines of plastic surgery. In this article, the authors discuss botulinum neurotoxin's mechanism of action as it pertains to both muscular paralysis and its interplay in the modulation of proinflammatory pain mediators. In addition, the authors review evidence supporting the use of botulinum neurotoxin in common painful conditions, in order to prepare the readership to aptly provide their patients with evidence-based recommendations. After reading this article, the participant should be able to discuss both mechanism of action and common applications of botulinum neurotoxin in painful conditions.
As more of the world's resources are directed toward improving patient access to safe surgical and anesthesia care, there is a growing concern that volunteer surgeons' "desire to help" has numerous ...unintended consequences. The purpose of this study was to ask in-country, local surgeons and visiting volunteer plastic surgeons about the frequency of ethical dilemmas for different types of global surgery collaborations and to assess their perception of compliance with the concepts of autonomy, beneficence, nonmaleficence, and justice.
A cross-sectional email survey tool was sent to a representative sample of domestic American Society of Plastic Surgeons members, all international members of the American Society of Plastic Surgeons, and international partners of the Volunteers in Plastic Surgery committee of the Plastic Surgery Foundation. The survey response rate was 7.7 percent, with 356 respondents from 65 countries.
This survey data showed a statistically significant divergence of perspectives between local and visiting surgeons in regard to scope of practice, quality of patient care, impact on local health care systems, perception of the quality of care by local providers, the integrity of the informed consent process, and photography in global plastic surgery collaborations. Though the short-term mission trip model was particularly polarizing when comparing the responses of local and visiting surgeons, educational and research exchanges may also significantly interrupt local health care and incite ethical lapses.
This survey provides quantitative insight into the impact of current global plastic surgery collaborations and highlights ethical areas of disagreement between local and visiting surgeons.
BACKGROUND:The coronavirus disease 2019 (COVID-19) pandemic led to a drastic decline in the number of elective surgeries performed in the United States. Many national societies and local governments ...provided recommendations for surgeons to initially suspend and progressively resume elective surgery. The authors used a survey to the American Council of Academic Plastic Surgeons (ACAPS) to assess the effect on plastic surgeons.
METHODS:An electronic survey questionnaire was distributed to 532 members of ACAPS. Data on individual and plastic surgery practice demographics, COVID-19 prevention measures, and procedures or services that were being performed or delayed were collected and analyzed.
RESULTS:An estimated 161 members (30.2%) completed the survey. Changes in hospital policy were cited as the most common reason (89%) for determining which procedures were currently offered. Results vary by specialty. Notably, <10% of respondents who normally offered aesthetic procedures currently offered any procedures during the survey. Subspecialty-specific results and prevention measures when seeing clinic patients are further summarized and discussed.
CONCLUSIONS:Plastic surgeons have seen a drastic decrease in the variety of procedures and services they are allowed to offer during the COVID-19 pandemic. To help plan a return to normalcy, surgeons should create and implement plans to protect patients and staff from coronavirus transmission, assure financial solvency, and consider the effects of delayed surgeries on both the physical and mental health of their patients. In doing so, surgeons and their patients will be better prepared in the event of a resurgence of the virus.
Philanthropy in plastic surgery supports research, clinical care, academic infrastructure, and education in the United States and internationally. Plastic surgeons have opportunities to innovatively ...address unmet needs in their local and global communities by forming philanthropic nonprofit organizations.
The authors queried three national philanthropic databases (Charity Navigator, Guidestar, and ProPublica) for Internal Revenue Service 990 form tax return information related to philanthropic plastic surgery organizations. The authors analyzed the financial information publicly available about current plastic surgery philanthropic organizations and their funding sources.
Seventy-three federally tax-exempt groups identified plastic surgery as their primary area of work to the Internal Revenue Service in 2019, and 52 of those organizations said they engaged in clinical and/or educational philanthropy.3 In 2017, a total of $158.5 million was donated to these groups in cash and noncash donations including equipment and time. Analyses of 6 years (2013 to 2018) of tax records from groups that provide plastic surgery clinical, research, or educational philanthropy reveal that government grants provide very little funding for this work. Eighty-six percent of money raised for these groups in 2017 was collected by means of direct donations. Money obtained from fundraising events contributed 2 percent to their total monies raised in 2017 on average and 8 percent came from noncash gifts.
A broad body of academic research is reviewed here that guides best practices and measuring a group's impact and outcomes. The details of a philanthropic group's organization and finances directly influence the impact of their work and, as such, are worthy of our sustained attention.
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