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INTRODUCTION: Facial lacerations are a common reason for emergency department (ED) visits in the U.S. Proper laceration repair is imperative as poor wound management can lead to functional and aesthetic impairment and significantly impact patient quality of life. For the best outcomes and long-term scar reduction, treatment by and follow-up with a plastic surgeon or facial trauma specialist is recommended. The present study examines variations in facial trauma specialist consultation and referral by ED provider type for adult patients at hospitals within a large rural South Dakota health system. METHODS: Records for patients above the age of 18 who received treatment for facial lacerations between January 1, 2017 and January 1, 2022 were retrospectively reviewed across multiple hospitals in South Dakota, spanning a large rural catchment area. Multivariable logistic regression and Fisher's exact test were performed to examine the relationship between ED provider type and the probability of receiving specialty consult and/or referral. RESULTS: One hundred fifty-four ED visits were included in the analysis. Among these patients, 53 received specialty consult and/or follow-up referral and 101 were treated without consult or referral. ED provider type was significantly associated with the probability of having a specialty consult (OR = 5.11, 95% CI [1.05, 24.96]). When the patients had a certified nurse practitioner (CNP) as their ED provider, they had a significantly higher chance (40%) of receiving specialist consultation. CONCLUSION: For patients presenting to the ED with facial lacerations, facial trauma specialist consultation and referral for follow up varies based on provider type. CNPs placed specialist consultations more often than other ED provider types.
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Servicio de Urgencia en Hospital , Traumatismos Faciales , Laceraciones , Derivación y Consulta , Humanos , Derivación y Consulta/estadística & datos numéricos , Estudios Retrospectivos , Laceraciones/terapia , Laceraciones/diagnóstico , Traumatismos Faciales/terapia , Traumatismos Faciales/diagnóstico , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Masculino , Adulto , Persona de Mediana Edad , South Dakota , AncianoRESUMEN
Split-thickness skin grafts (STSG) are commonly used to treat soft-tissue defects. Harvesting a STSG creates an additional partial thickness wound at the donor site which must be managed. Many dressings are commercially available for the management of STSG donor sites; however, there is no evidence-based consensus on optimal dressing for site management. Urinary bladder matrix (UBM) is an extracellular matrix that acts as a structural support for tissue remodeling and provides molecular components for repair. Common clinical applications of UBM include coverage of deep wounds, burns, and irradiated skin. Skin grafting from the lower extremities poses a challenge due to the increased dermal tension. UBM-based reconstruction is an alternative method of managing lower extremity skin graft donor sites. This case study demonstrates the use of UBM in the reconstruction of a STSG donor site of the anterolateral thigh, which resulted in satisfactory healing, no pain, and excellent cosmetic and functional outcomes.
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When patients lack suitable superficial veins in the upper extremity to create an arteriovenous fistula, surgeons are faced with a decision between a synthetic graft or autologous fistula using deep veins, such as a brachial artery to brachial vein arteriovenous fistula. In patients with a high radial artery origin (or brachioradial artery) and inadequate superficial veins, arteriovenous fistula creation will be even more challenging. In the present report, we describe a technique used in three such patients who underwent successful staged brachioradial artery to brachioradial vein arteriovenous fistula creation.
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We compare herein polar processing diagnostics derived from the four most recent full-input reanalysis datasets: the National Centers for Environmental Prediction Climate Forecast System Reanalysis / Climate Forecast System, version 2 (CFSR/CFSv2), the European Centre for Medium-Range Weather Forecasts Interim Reanalysis (ERA-Interim), the Japanese Meteorological Agency's Japanese 55-year Reanalysis (JRA-55), and the National Aeronautics and Space Administration's Modern Era Retrospective-analysis for Research and Applications version 2 (MERRA-2). We focus on diagnostics based on temperatures and potential vorticity (PV) in the lower to middle stratosphere that are related to formation of polar stratospheric clouds (PSCs), chlorine activation, and the strength, size, and longevity of the stratospheric polar vortex. Polar minimum temperatures (Tmin) and the area of regions having temperatures below PSC formation thresholds (APSC) show large persistent differences between the reanalyses, especially in the southern hemisphere (SH), for years prior to 1999. Average absolute differences of the reanalyses from the reanalysis ensemble mean (REM) in Tmin are as large as 3 K at some levels in the SH (1.5 K in the NH), and absolute differences of reanalysis APSC from the REM up to 1.5% of a hemisphere (0.75% of a hemisphere in the NH). After 1999, the reanalyses converge toward better agreement in both hemispheres, dramatically so in the SH: Average Tmin differences from the REM are generally less than 1 K in both hemispheres, and average APSC differences less than 0.3% of a hemisphere. The comparisons of diagnostics based on isentropic PV for assessing polar vortex characteristics, including maximum PV gradients (MPVG) and the area of the vortex in sunlight (or sunlit vortex area, SVA), show more complex behavior: SH MPVG showed convergence toward better agreement with the REM after 1999, while NH MPVG differences remained largely constant over time; differences in SVA remained relatively constant in both hemispheres. While the average differences from the REM are generally small for these vortex diagnostics, understanding such differences among the reanalyses is complicated by the need to use different methods to obtain vertically-resolved PV for the different reanalyses. We also evaluated other winter season summary diagnostics, including the winter mean volume of air below PSC thresholds, and vortex decay dates. For the volume of air below PSC thresholds, the reanalyses generally agree best in the SH, where relatively small interannual variability has led to many winter seasons with similar polar processing potential and duration, and thus low sensitivity to differences in meteorological conditions among the reanalyses. In contrast, the large interannual variability of NH winters has given rise to many seasons with marginal conditions that are more sensitive to reanalysis differences. For vortex decay dates, larger differences are seen in the SH than in the NH; in general the differences in decay dates among the reanalyses follow from persistent differences in their vortex areas. Our results indicate that the transition from the reanalyses assimilating Tiros Operational Vertical Sounder (TOVS) data to Advanced TOVS and other data around 1998 - 2000 resulted in a profound improvement in the agreement of the temperature diagnostics presented (especially in the SH) and to a lesser extent the agreement of the vortex diagnostics. We present several recommendations for using reanalyses in polar processing studies, particularly related to the sensitivity to changes in data inputs and assimilation. Because of these sensitivities, we urge great caution for studies aiming to assess trends derived from reanalysis temperatures. We also argue that one of the best ways to assess the sensitivity of scientific results on polar processing is to use multiple reanalysis datasets.
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The representation of upper tropospheric/lower stratospheric (UTLS) jet and tropopause characteristics is compared in five modern high-resolution reanalyses for 1980 through 2014. Climatologies of upper tropospheric jet, subvortex jet (the lowermost part of the stratospheric vortex), and multiple tropopause frequency distributions in MERRA (Modern Era Retrospective Analysis for Research and Applications), ERA-I (the ECMWF interim reanalysis), JRA-55 (the Japanese 55-year Reanalysis), and CFSR (the Climate Forecast System Reanalysis) are compared with those in MERRA-2. Differences between alternate products from individual reanalysis systems are assessed; in particular, a comparison of CFSR data on model and pressure levels highlights the importance of vertical grid spacing. Most of the differences in distributions of UTLS jets and multiple tropopauses are consistent with the differences in assimilation model grids and resolution: For example, ERA-I (with coarsest native horizontal resolution) typically shows a significant low bias in upper tropospheric jets with respect to MERRA-2, and JRA-55 a more modest one, while CFSR (with finest native horizontal resolution) shows a high bias with respect to MERRA-2 in both upper tropospheric jets and multiple tropopauses. Vertical temperature structure and grid spacing are especially important for multiple tropopause characterization. Substantial differences between MERRA and MERRA-2 are seen in mid- to high-latitude southern hemisphere winter upper tropospheric jets and multiple tropopauses, and in the upper tropospheric jets associated with tropical circulations during the solstice seasons; some of the largest differences from the other reanalyses are seen in the same times and places. Very good qualitative agreement among the reanalyses is seen between the large scale climatological features in UTLS jet and multiple tropopause distributions. Quantitative differences may, however, have important consequences for transport and variability studies. Our results highlight the importance of considering reanalyses differences in UTLS studies, especially in relation to resolution and model grids; this is particularly critical when using high-resolution reanalyses as an observational reference for evaluating global chemistry climate models.
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Researchers have documented an intriguing phenomenon whereby simply walking through a doorway causes forgetting (the location updating effect). The Event Horizon Model is the most commonly cited theory to explain these data. Importantly, this model explains the effect without invoking the importance or reliance upon perceptual information (i.e., seeing oneself pass through the doorway). This generates the intriguing hypothesis that the effect may be demonstrated in participants who simply imagine walking through a doorway. Across two experiments, we explicitly test this hypothesis. Participants familiarised themselves with both real (Experiment 1) and virtual (Experiment 2) environments which served as the setting for their mental walk. They were then provided with an image to remember and were instructed to imagine themselves walking through the previously presented space. In both experiments, when the mental walk required participants to pass through a doorway, more forgetting occurred, consistent with the predictions laid out in the Event Horizon Model.