Understanding the impacts of rural hospital closures: A scoping review

PURPOSE

Rural hospitals are closing at unprecedented rates, with hundreds more at risk of closure in the coming 2 years. Multiple federal policies are being developed and implemented without a salient understanding of the emerging literature evaluating rural hospital closures and its impacts. We conducted a scoping review to understand the impacts of rural hospital closure to inform ongoing policy debates and research.

METHODS

A comprehensive search strategy was devised by library faculty to collate publications using the PRISMA extension for scoping reviews. Two coauthors then independently performed title and abstract screening, full text review, and study extraction.

FINDINGS

We identified 5054 unique citations and assessed 236 full texts for possible inclusion in our narrative synthesis of the literature on the impacts of rural hospital closure. Twenty total original studies were included in our narrative synthesis. Key domains of adverse impacts related to rural hospital closure included emergency medical service transport, local economies, availability and utilization of emergency care and hospital services, availability of outpatient services, changes in quality of care, and workforce and community members. However, significant heterogeneity existed within these findings.

CONCLUSIONS

Given the significant heterogeneity within our findings across multiple domains of impact, we advocate for a tailored approach to mitigating the impacts of rural hospital closures for policymakers. We also discuss crucial knowledge gaps in the evidence base-especially with respect to quality measures beyond mortality. The synthesis of these findings will permit policymakers and researchers to understand, and mitigate, the harms of rural hospital closure.

Esophageal Adenocarcinoma Presenting as an Isolated Brain Lesion 6 Years After Treatment

Intracranial metastasis is a rare sequela of esophageal adenocarcinoma (EAC), typically presenting within the first 2 years after primary tumor detection. Our patient is a 72-year-old man diagnosed with an EAC in 2015 and presented with recurrence of a distant solitary brain lesion approximately 6 years after the initial diagnosis. Histological diagnosis was confirmed as EAC with all relevant indicators. In addition, we used genomic profiling to detect biomarkers that can be useful in the future for therapies.

Case report: Surgical resection of a retro-hepatic leiomyosarcoma involving atrial reconstruction, cardiopulmonary bypass, ex vivo tumor resection, and liver re-implantation

INTRODUCTION

Leiomyosarcomas (LMS) involving the inferior vena cava (IVC) is a clinically rare entity, accounting for approximately 0.5% of all adult sarcomas.

CASE PRESENTATION

A 67-year-old male presented to the emergency department with mild back and lower abdominal pain. During the workup, a computed tomography scan without contrast showed an area of decreased attenuation within the liver adjacent to the intrahepatic IVC. Magnetic resonance imaging confirmed the involvement of the retro-hepatic IVC; biopsy confirmed the diagnosis of LMS. Given the location of the involvement of the retro-hepatic IVC, liver explantation was deemed necessary for adequate tumor resection. The superior extension of the tumor toward the heart necessitated Cardio-Pulmonary (CPB). The patient successfully underwent a complex surgical procedure involving liver explantation with ex vivo back-table resection of the retro-hepatic LMS, replacement of the retro-hepatic vena cava with a ringed Gore-Tex graft, liver re-implantation, and hepatic vein-atrial reconstruction under cardiopulmonary bypass. There were no intraoperative or post-op complications.

DISCUSSION

The role of vascular reconstruction of the IVC varies depending on the level and extent of the tumor, with options ranging from primary repair, ligation, or reconstruction dictated. Surgical resection with negative margins remains the treatment of choice due to the lack of efficacy of adjuvant therapies. Importantly, liver explantation offers a chance for complete surgical resection and reconstruction. Similarly, the complex nature of the tumor necessitated a pioneering approach involving direct hepato-atrial venous anastomosis.

CONCLUSION

To the best of our knowledge, this is the first reported case in which the hepatic veins were anastomosed directly to the right atrium while also replacing the native vena cava with a separate graft.

Global oral health inequalities: challenges in the prevention and management of orofacial clefts and potential solutions

The birth prevalence of orofacial clefts, one of the most common congenital anomalies, is approximately one in 700 live births, but varies with geography, ethnicity, and socio-economic status. There is a variation in infant mortality and access to care both between and within countries, so some clefts remain unrepaired into adulthood. Quality of care also varies, and even among repaired clefts there is residual deformity and morbidity that significantly affects some children. The two major issues in attempts to address these inequalities are (a) etiology/possibilities for prevention and (b) management and quality of care. For prevention, collaborative research efforts are required in developing countries, in line with the WHO approach to implement the recommendations of the 2008 Millennium Development Goals (www.un.org/millenniumgoals). This includes the "common risk factor" approach, which analyzes biological and social determinants of health alongside other chronic health problems such as diabetes and obesity, as outlined in the Marmot Health inequalities review (2008) (www.ucl.ac.uk/gheg/marmotreview). Simultaneously, orofacial cleft research should involve clinical researchers to identify inequalities in access to treatment and identify the best interventions for minimizing mortality and residual deformity. The future research agenda also requires engagement with implementation science to get research findings into practice.

An unusual presentation of lipofibromatous hamartoma in an infant. A case report

Lipofibromatous hamartomas are rare benign tumors presenting in the third and fourth decades with a predilection for the upper extremity. We describe an unusual presentation of lipofibromatous hamartoma occurring in a one month old female child, where the lesion showed MR findings resembling that of a vascular malformation.

Use of distortions in the treatment of skin lesions of the face: the distorting excision

Reconstruction after excision of a cutaneous lesion of the face is done by various complex old and new flaps to avoid any distortion. The distortions following primary closure of defects in the face are given undue importance. We have observed and used the capacity of self-correction of these distortions, which is partially due to the muscular actions. We show our experience in various distorting reconstructions of the face in 36 patients. Because of our partial presence in a children's hospital, most of our patients were children.

Cutaneous expansion using enforced position in the treatment of large skin defects

This paper presents a new method of reconstruction of a large skin defect, e.g., following excision of a giant pigmented nevus. By taking advantage of the flexibility of the joints and the extensibility of skin in the children, the large defects were closed in one stage by an enforced position that allows an easy closure of the wound. The scar was protected against stretching for 6 weeks to obtain sufficient strength. Later, free movements across the joints were permitted to allow gradual tension to the skin surrounding the scar. The final result is a permanent gain of the tissue replacing the defect.

A general method for retrieving the components of a genetically engineered fusion protein

Escherichia coli expression vectors encoding an acid-labile aspartyl-proline (Asp-Pro) dipeptide bridging two protein sequences were constructed and used to synthesize two different bovine growth hormone (bGH) fusion proteins. The codons GAT-CCX coding for Asp-Pro are provided by the recognition site for Bam HI (GGATCC). Treatment of the bGH fusion proteins at low pH in the presence of guanidine hydrochloride releases the bGH moiety from the fusion protein. The release of the bGH from the fusion protein specifically requires the Asp-Pro dipeptide linking the bGH sequence to the fusion protein. The bGH released from the fusion protein retains anti-bGH immunoreactivity as well as the ability to bind to growth hormone receptor in vitro.