bluuebunny/crossref_metadata_2025 huggingface dataset:
Contribution of Prepregnancy Obesity to Racial and Ethnic Disparities in Severe Maternal Morbidity
Authors: Siddiqui Ayesha , Azria Elie , Egorova Natalia , Deneux-Tharaux Catherine , Howell Elizabeth A.
Published: April 2021

OBJECTIVE:

To evaluate the role of prepregnancy obesity as a mediator in the association between race–ethnicity and severe maternal morbidity.

METHODS:

We conducted an analysis on a population-based retrospective cohort study using 2010–2014 birth records linked with hospital discharge data in New York City. A multivariable logistic regression mediation model on a subgroup of the sample consisting of normal-weight and obese women (n=409,021) calculated the mediation effect of obesity in the association between maternal race–ethnicity and severe maternal morbidity, and the residual effect not mediated by obesity. A sensitivity analysis was conducted excluding the severe maternal morbidity cases due to blood transfusion.

RESULTS:

Among 591,455 live births, we identified 15,158 cases of severe maternal morbidity (256.3/10,000 deliveries). The severe maternal morbidity rate among obese women was higher than that of normal-weight women (342 vs 216/10,000 deliveries). Black women had a severe maternal morbidity rate nearly three times higher than White women (420 vs 146/10,000 deliveries) and the severe maternal morbidity rate among Latinas was nearly twice that of White women (285/10,000 deliveries). Among women with normal or obese body mass index (BMI) only (n=409,021), Black race was strongly associated with severe maternal morbidity (adjusted odds ratio [aOR] 3.02, 95% CI 2.88–3.17) but the obesity-mediated effect represented only 3.2% of the total association (aOR 1.03, 95% CI 1.02–1.05). Latina ethnicity was also associated with severe maternal morbidity (aOR 2.01, 95% CI 1.90–2.12) and the obesity-mediated effect was similarly small: 3.4% of the total association (aOR 1.02, 95% CI 1.01–1.03). In a sensitivity analysis excluding blood transfusion, severe maternal morbidity cases found a higher mediation effect of obesity in the association with Black race and Latina ethnicity (15.3% and 15.2% of the total association, respectively).

CONCLUSION:

Our findings indicate that prepregnancy obesity, a modifiable factor, is a limited driver of racial–ethnic disparities in overall severe maternal morbidity.
Maternal Mortality in the United States
Authors: Joseph K. S. , Boutin Amélie , Lisonkova Sarka , Muraca Giulia M. , Razaz Neda , John Sid , Mehrabadi Azar , Sabr Yasser , Ananth Cande V. , Schisterman Enrique
Published: April 2021

Rigorous studies carried out by the National Center for Health Statistics show that previously reported increases in maternal mortality rates in the United States were an artifact of changes in surveillance. The pregnancy checkbox, introduced in the revised 2003 death certificate and implemented by the states in a staggered manner, resulted in increased identification of maternal deaths and in reported maternal mortality rates. This Commentary summarizes the findings of the National Center for Health Statistics reports, describes temporal trends and the current status of maternal mortality in the United States, and discusses future concerns. Although the National Center for Health Statistics studies, based on recoding of death certificate information (after excluding information from the pregnancy checkbox), showed that crude maternal mortality rates did not change significantly between 2002 and 2018, age-adjusted analyses show a temporal reduction in the maternal mortality rate (21% decline, 95% CI 13–28). Specific causes of maternal death, which were not affected by the pregnancy checkbox, such as preeclampsia, showed substantial temporal declines. However, large racial disparities continue to exist: Non-Hispanic Black women had a 2.5-fold higher maternal mortality rate compared with non-Hispanic White women in 2018. This overview of maternal mortality underscores the need for better surveillance and more accurate identification of maternal deaths, improved clinical care, and expanded public health initiatives to address social determinants of health. Challenges with ascertaining maternal deaths notwithstanding, several causes of maternal death (unaffected by surveillance artifacts) show significant temporal declines, even though there remains substantial scope for preventing avoidable maternal death and reducing disparities.
An advanced double intravenous vasopressor automated system to treat hypotension during spinal anaesthesia for caesarean section
Authors: Nagarajan Singaraselvan , Chan Jason Ju In , Tan Chin Wen , Al-Hashim Zainab Ghalib A. , Sultana Rehena , Sia Alex Tiong Heng , Sng Ban Leong
Published: April 2021

BACKGROUND

During spinal anaesthesia for caesarean section, haemodynamic instability may lead to maternal and foetal complications. We developed a novel advanced double intravenous vasopressor automated system (ADIVA) by using a continuous blood pressure and heart rate monitor. Treatment of hypotension was based on three criteria: the drug (phenylephrine or ephedrine) according to the heart rate; the dose of vasopressor determined by the degree of hypotension; a fast or slow bolus of vasopressor administered depending on whether there was a negative or positive gradient of SBP changes, respectively.

OBJECTIVE

The aim of this pilot study was to investigate the feasibility of the ADIVA algorithm.

DESIGN

A prospective pilot study.

SETTING

Single obstetrics and gynaecology centre in Singapore.

PATIENTS

Women undergoing elective caesarean delivery under spinal anaesthesia.

INTERVENTION

Automated administration of ephedrine or phenylephrine based on changes in blood pressure and heart rate (via the ADIVA algorithm) detected on continuous noninvasive haemodynamic monitoring using noninvasive continuous haemodynamic monitor (Nexfin).

MAIN OUTCOME MEASURES

The primary outcome was the incidence of hypotension, defined as SBP less than 80% of baseline. The secondary outcome measures were reactive hypertension, total vasopressor requirement, maternal and neonatal outcomes and system performance.

RESULTS

Forty-five women were recruited. Thirty-one women (69.9%) had at least one reading of hypotension. SBP was within ±20% of the baseline in a mean ± SD of 79.7 ± 17.6% of measurements. Forty-four (97.8%) women required phenylephrine before delivery, while 15 (33.3%) required ephedrine. No rescue medications were required. Three women (6.7%) had nausea and two (4.4%) vomiting. All neonates had APGAR scores of 9 at 5 min.

CONCLUSION

The ADIVA system, with noninvasive continuous haemodynamic monitoring, was able to maintain maternal SBP within ±20% of baseline for the vast majority of the measurements. This system had good maternal and foetal outcomes with minimal intervention from the attending anaesthetist.

TRIAL REGISTRATION

NCT03620942
Intra-operative nociceptive responses and postoperative major complications after gastrointestinal surgery under general anaesthesia
Authors: Ogata Hiroki , Matsuki Yuka , Okamoto Takuma , Ueki Ryusuke , Kariya Nobutaka , Tatara Tsuneo , Shigemi Kenji , Hirose Munetaka
Published: April 2021

BACKGROUND

Surgical procedures stimulate nociception and induce physiological responses according to the balance between nociception and antinociception. The severity of surgical stimuli is associated with major postoperative complications. Although an intra-operative quantitative index representing surgical invasiveness would be useful for anaesthetic management to predict and prevent major complications, no such index is available.

OBJECTIVES

To identify associations between major complications after gastrointestinal surgery and intra-operative quantitative values from intra-operative nociception monitoring.

DESIGN

A multi-institutional observational study.

SETTING

Two university hospitals.

PATIENTS

Consecutive adult patients undergoing gastrointestinal surgery under general anaesthesia.

MAIN OUTCOME MEASURES

Averaged values of nociceptive response index from start to end of surgery (mean NR index) and risk scores of the Surgical Mortality Probability Model (S-MPM) were calculated. Pre and postoperative serum C-reactive protein (CRP) levels were obtained. After receiver-operating characteristic (ROC) curve analysis, all patients were divided into groups with high and low mean nociceptive response index. Associations between mean nociceptive response index and postoperative major complications, defined as Clavien-Dindo grade at least IIIa, were examined using logistic regression analysis.

RESULTS

ROC curve analysis showed a nociceptive response index cut-off value for major complications of 0.83, and we divided patients into two groups with mean nociceptive response index less than 0.83 and at least 0.83. The incidence of major complications was significantly higher in patients with mean nociceptive response index at least 0.83 (23.1%; n = 346) than in patients with mean nociceptive response index less than 0.83 (7.7%; n = 443; P < 0.001). Multivariate analysis revealed emergency surgery, S-MPM risk score, mean nociceptive response index and postoperative CRP levels as independent risk factors for major complications.

CONCLUSION

Mean nociceptive response index during surgery likely correlates with major complications after gastrointestinal surgery.

TRIAL REGISTRATION

The current observational study had no intervention, and was therefore, not registered.
Intra-operative esmolol and pain following mastectomy
Authors: Mendonça Fabrício T. , Tramontini Alex J. , Miake Henrique I. , Seixas Luciano F. , de Carvalho Luiz Sergio F. , Sposito Andrei C.
Published: April 2021

BACKGROUND

Esmolol is a beta-1 selective blocker that has been shown to reduce postoperative pain. Its antinociceptive effects have not been tested following mastectomy.

OBJECTIVE

To evaluate the safety, efficacy and antinociception of intra-operative esmolol infusion after mastectomy.

DESIGN

Randomised, double-blinded, placebo-controlled trial.

SETTING

Tertiary referral centre, Brasília, Brazil. Recruitment: July 2015 to July 2017.

PATIENTS

Seventy women scheduled for mastectomy, ASA I to III, aged 18 to 75 years. Four were excluded.

INTERVENTIONS

All underwent general anaesthesia. The intervention group received a bolus of 0.5 mg kg−1 of esmolol over 10 min followed by a continuous infusion of 100 μg kg−1 min−1. The placebo group received saline.

MAIN OUTCOME MEASURES

The primary outcome was pain at rest 24 h after mastectomy as measured by a 0 to 10 numeric rating scale.

RESULTS

Pain scores at rest 24 h after mastectomy were lower in esmolol-treated patients compared with placebo (mean difference = −1.51, 95% confidence interval (CI), −2.36 to −0.65, P = 0.001). On arrival in the postanaesthesia care unit (PACU), the occurrence of pain was also lower in the esmolol group, at rest and on effort (P = 0.009 and P = 0.013, respectively), on discharge from PACU (P = 0.009 and P = 0.015), 12 h (P = 0.01 and P = 0.007) and on effort in the 24 postoperative hours (P = 0.003). Mean morphine consumption was reduced by 77% in the esmolol group compared with the placebo group (mean difference  = −2.52 mg, 95% CI = −3.67 to −1.38, P < 0.001). The length of hospital stay was shorter for the esmolol group (mean difference = −6.9 h, 95% CI, −13.4 to −0.31, P = 0.040).

CONCLUSION

Esmolol was well tolerated, allowed a notable reduction in the dose of rescue analgesics and demonstrated superior efficacy compared to placebo for pain management after mastectomy.

TRIAL REGISTRATION

ClinicalTrials/NCT02466542
An Analysis of the Controversial Relationship Between Anencephaly, Brain Death, and Organ Donation
Authors: Stiekema Jennifer L.
Published: April 2021

Anencephaly is a congenital defect in which the neural tube fails to fully close during the fourth week of embryonic development (Obeidi, Russell, Higgins, & O'Donoghue, 2010). The Medical Task Force on Anencephaly (1990) defined it as a condition with the following four characteristics: (a) A large portion of the skull is absent, (b) the scalp is absent over the skull defect, (c) the exposed tissue is hemorrhagic and fibrotic, and (d) the cerebral hemispheres are indistinguishable. Approximately one in every 4,647 births is affected by anencephaly, with an estimated 847 anencephalic infants born each year (Centers for Disease Control and Prevention, 2020). It is estimated that around 65% of anencephalic fetuses will die in utero, whereas those that survive to birth typically die within a few hours or days of life (Medical Task Force on Anencephaly, 1990). Anencephalic infants who do survive beyond birth often exhibit irregular breathing, requiring the use of mechanical ventilation to be kept alive. For decades, anencephalic infants have been the topic of a highly controversial and heated debate with regard to their status and potential as organ donors. Currently, anencephalic infants are not used as organ donors because they do not meet the criteria for brain death. To some, this seems like the elimination of a vital pool of organ donors, whereas others view this as preservation of the sanctity and dignity of human life. This highly disputed issue of anencephaly and how it relates to both brain death and organ donation is the topic of this discussion.
Workflow and Throughput of Commercial Assays to Detect Mycoplasma genitalium and Macrolide Resistance–Mediating Mutations
Authors: Shah Anika , Jang Dan , Martin Irene , Speicher David J. , Lidder Ravinder , Clavio Avery , Ratnam Sam , Smieja Marek , Chernesky Max
Published: April 2021

Aptima Mycoplasma genitalium (MG) required the shortest and STD6 the longest time to detect MG in clinical samples. ResistancePlus MG detected MG and macrolide resistance–mediating mutations simultaneously. Times were influenced by specimen numbers. M. genitalium positives from the other 2 assays required increased time for macrolide resistance–mediating mutation sequencing.
Human Papillomavirus Vaccine to End Oropharyngeal Cancer. A Systematic Review and Meta-Analysis
Authors: Tsentemeidou Aikaterini , Fyrmpas Georgios , Stavrakas Marios , Vlachtsis Konstantinos , Sotiriou Elena , Poutoglidis Alexandros , Tsetsos Nikolaos
Published: April 2021

Oropharyngeal cancer (OPC) is currently the most frequent human papillomavirus (HPV)–related malignancy in high-income countries. Oral HPV16 infection is the cause of HPV-related OPC in more than 90% of cases and is primarily (90%) linked to oral sex. This systematic review and meta-analysis aimed at comparing the prevalence of oral vaccine–type HPV infection in individuals vaccinated with HPV vaccines and unvaccinated controls. Three databases (MEDLINE, ScienceDirect, and the Cochrane Library), as well as other sources, were searched by 2 independent reviewers. Controlled studies testing the efficacy or effectiveness of licensed HPV vaccines were included. The primary end point was multiple oral HPV infections in one individual with low-risk and high-risk types. Secondary end point was the number of oral HPV16 infections. Six studies—2 randomized controlled trials and 4 cross-sectional studies—with a total of 15,240 participants were included in a meta-analysis, which showed that vaccinated individuals were 46% (risk ratio, 0.54; 95% confidence interval, 0.32–0.91) less likely to develop oral vaccine–type HPV infection (P = 0.02). A second meta-analysis of 4 studies (1 randomized controlled trial and 3 cross-sectional studies) and 13.285 participants showed 80% (risk ratio, 0.20; 95% confidence interval, 0.09–0.43) less likelihood of oral HPV16 infection (P < 0.0001). This study suggests that HPV vaccines can protect against oral vaccine–type HPV infection including high-risk HPV16 infection, thus reducing the incidence of HPV-related OPC. Vaccination against HPV, especially in males, who are predominantly affected by HPV-related OPC, could result in the prevention of this disease.
Sexual Positioning Practices and Anal Human Papillomavirus Infection Among Young Men Who Have Sex with Men and Transgender Women—Chicago, Illinois, 2016–2018
Authors: Morgan Ethan , Meites Elissa , Markowitz Lauri E. , Xavier Hall Casey D. , Querec Troy D. , Unger Elizabeth R. , Crosby Richard A. , Newcomb Michael E. , Mustanski Brian
Published: April 2021

Background

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States; men who have sex with men (MSM) have higher prevalence of infection and related disease compared with other men. We assessed whether differences in HPV acquisition exist among MSM according to their sexual positioning practices, as well as self-reported receipt of HPV vaccination.

Methods

We enrolled young MSM and transgender women aged 18 to 26 years in Chicago, IL (N = 666). Participants self-reported their history of HPV vaccination and submitted self-collected anal swab specimens for type-specific HPV detection using an L1-consensus PCR assay. Multivariable logistic regression analyses were used to assess relationships between sexual positioning practices and detection of any HPV or quadrivalent HPV vaccine (4vHPV) types by vaccination status, defined as self-reported receipt of ≥1 HPV vaccine dose versus none.

Results

Among 666 participants, 400 (60.1%) had any anal HPV, and 146 (21.9%) had a 4vHPV type. Among vaccinated participants, 18, 36, and 177 reported exclusively insertive, exclusively receptive, or both sexual positioning practices, respectively. Compared with participants reporting exclusively insertive anal sex, odds of any HPV were significantly higher among participants engaging exclusively in receptive anal sex (adjusted odds ratio [aOR], 5.90; 95% confidence interval [CI], 2.52–13.78), as well as those engaging in both (aOR, 3.32; 95% CI, 1.71–6.44). Vaccinated participants, compared with unvaccinated participants, had lower odds of 4vHPV-type HPV regardless of sexual positioning practices (aOR, 0.56; 95% CI, 0.34–0.92).

Conclusions

Adult men and transgender women who practice anal receptive sex have high prevalence of infection with any HPV. Routine vaccination of all adolescents is expected to reduce HPV-related disease incidence among adult MSM and transgender women as vaccinated cohorts age.
Tubal Factor Infertility, In Vitro Fertilization, and Racial Disparities: A Retrospective Cohort in Two US Clinics
Authors: Anyalechi Gloria E. , Wiesenfeld Harold C. , Kirkcaldy Robert D. , Kissin Dmitry M. , Haggerty Catherine L. , Hammond Karen R. , Hook Edward W. , Bernstein Kyle T. , Steinkampf Michael P. , Geisler William M.
Published: April 2021

Background

Nearly 14% of US women report any lifetime infertility which is associated with health care costs and psychosocial consequences. Tubal factor infertility (TFI) often occurs as a result of sexually transmitted diseases and subsequent pelvic inflammatory disease. We sought to evaluate for and describe potential racial disparities in TFI and in vitro fertilization (IVF) prevalence.

Methods

Records of women aged 19 to 42 years in our retrospective cohort from 2 US infertility clinics were reviewed. We calculated TFI prevalence, IVF initiation prevalence, and prevalence ratios (PRs), with 95% confidence intervals (CIs) for each estimate, overall and by race.

Results

Among 660 infertile women, 110 (16.7%; 95% CI, 13.8–19.5%) had TFI which was higher in Black compared with White women (30.3% [33/109] vs 13.9% [68/489]; PR, 2.2 [95% CI, 1.5–3.1]). For women with TFI, IVF was offered to similar proportions of women by race (51.5% [17/33] vs 52.9% [36/68] for Black vs White women); however, fewer Black than White women with TFI started IVF (6.7% [1/15] vs 31.0% [9/29]; PR, 0.2 [95% CI, 0–1.0]), although the difference was not statistically different.

Conclusions

Tubal factor infertility prevalence was 2-fold higher among Black than White women seeking care for infertility. Among women with TFI, data suggested a lower likelihood of Black women starting IVF than White women. Improved sexually transmitted disease prevention and treatment might ameliorate disparities in TFI.
Subglottic Post-Extubation Upper Airway Obstruction Is Associated With Long-Term Airway Morbidity in Children
Authors: Green Jack , Ross Patrick A. , Newth Christopher J. L. , Khemani Robinder G.
Published: April 2021

OBJECTIVES:

Post-extubation upper airway obstruction is the most common cause of extubation failure in children, but there are few data regarding long-term morbidity. We aim to describe the frequency of long-term airway sequelae in intubated children and determine the association with post-extubation upper airway obstruction.

DESIGN:

Retrospective, post hoc analysis of previously identified prospective cohort of children in the pediatric/cardiothoracic ICU at Children’s Hospital Los Angeles from July 2012 to April 2015. A single provider blinded to the upper airway obstruction classification reviewed the electronic medical records of all patients in the parent study, before and after the index extubation (extubation during parent study), to identify pre-index and post-index upper airway disease. Primary outcomes were prevalence of newly diagnosed airway anomalies following index extubation.

SETTING:

Single center, tertiary, 391-bed children’s hospital.

PATIENTS:

From the parent study, 327 children younger than 18 years (intubated for at least 12 hr) were included if they received subsequent care (regardless of specialty) after the index extubation.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

New airway anomalies were identified in 40 of 327 children (12.2%). Patients labeled with subglottic upper airway obstruction at the index extubation were more likely to be diagnosed with new airway anomalies on subsequent follow-up, receive long-term Otolaryngology follow-up, or receive airway surgery (all p ≤ 0.006). In multivariable modeling, upper airway obstruction as the primary reason for initial intubation (odds ratio, 3.71; CI, 1.50–9.19), reintubation during the index ICU admission (odds ratio, 4.44; CI, 1.67–11.80), pre-index airway anomaly (odds ratio, 3.31; CI, 1.36–8.01), and post-extubation subglottic upper airway obstruction (odds ratio, 3.50; CI, 1.46–8.34) remained independently associated with the diagnosis of new airway anomalies.

CONCLUSIONS:

Post-extubation subglottic upper airway obstruction is associated with a three-fold greater odds of long-term airway morbidity. These patients may represent an at-risk population that should be monitored closely after leaving the ICU.
Assessment of Vocal Cord Motion Using Laryngeal Ultrasound in Children: A Systematic Review and Meta-Analysis
Authors: Hamilton Camille E. , Su Erik , Tawfik Daniel , Fernandez Ernesto , Veten Ahmed , Conlon Thomas , Ginsburg Sarah , Mariano Karley , Sidell Douglas , Haileselassie Bereketeab
Published: April 2021

OBJECTIVES:

Laryngeal ultrasound is a nonirradiating, noninvasive method for assessing the upper airway in children. This systematic review and meta-analysis examine available evidence for accuracy of laryngeal ultrasound in diagnosing vocal cord immobility in infants and children after surgery and trauma affecting the vocal cords.

DESIGN:

Medical subject heading terms were used to search MEDLINE, Embase, Google Scholar, Web of Science, and the Cochrane Library for relevant citations. Publications from January 1, 2000, to June 30, 2020 were included in the search strategy. Study inclusion criteria consisted of randomized control trials and nonrandomized retrospective or prospective observational studies where vocal cord motion was evaluated by laryngeal ultrasound and compared with a reference test. Studies were excluded if there was insufficient data to compute a sensitivity/specificity table. Case reports, case series less than 10, and manuscripts not published in English were also excluded.

PATIENTS:

Studies which included subjects younger than or equal to 18 years were considered for full article review.

SETTINGS:

No restrictions on study settings were imposed in this systematic review.

MEASUREMENTS AND MAIN RESULTS:

The initial search returned 1,357 citations. After de-duplication, abstract, and full review, eight citations were included in the final meta-analysis. A bivariate random-effects meta-analysis was performed, which revealed a pooled sensitivity for laryngeal ultrasound in detecting vocal cord immobility of 91% (95% CI, 83–95%), specificity of 97% (95% CI, 82-100%), diagnostic odds ratio 333.56 (95% CI, 34.00–3,248.71), positive likelihood ratio 31.58 (95% CI, 4.50–222.05), and negative likelihood ratio 0.09 (95% CI, 0.05–0.19).

CONCLUSIONS:

Laryngeal ultrasound demonstrates high sensitivity and specificity for detecting vocal cord motion in children in a wide range of clinical settings. Laryngeal ultrasound offers a low-risk imaging option for assessing vocal cord function in children compared with the current gold standard of laryngoscopy.
Point-of-Care Ultrasound–Guided Hematoma Block for Forearm Fracture Reduction
Authors: Singh Amar , Khalil Paul
Published: April 2021

Fractures of the radius and ulna are very common in pediatric patients. Procedural sedation or general anesthesia is typically required to perform orthopedic reductions. There are several studies in the adult literature that conclude that point-of-care ultrasound–guided hematoma blocks are faster and just as efficacious as procedural sedation for reducing fractures in the emergency department. There is currently no literature examining point-of-care ultrasound–guided hematoma blocks in pediatric patients. This case describes a pediatric patient with a distal radius fracture who underwent a hematoma block under ultrasound guidance and had a successful bedside reduction without the need for sedation.
Skin-Reducing Mastectomy with Immediate Prepectoral Reconstruction: Surgical, Aesthetic, and Patient-Reported Outcomes with and without Dermal Matrices
Authors: Safran Tyler , Al-Halabi Becher , Viezel-Mathieu Alex , Boileau Jean-François , Dionisopoulos Tassos
Published: April 2021

Background:

Prepectoral breast reconstruction is being increasingly popularized, largely because of technical advances. Patients with ptotic breasts and active cancer require mastectomies through a mastopexy excision pattern to achieve proper pocket control in a prepectoral single-stage operation. This article presents a single-surgeon experience with direct-to-implant, prepectoral reconstruction following skin-reducing mastectomies.

Methods:

A retrospective chart review identified all patients undergoing prepectoral, direct-to-implant breast reconstruction following Wise-pattern mastopexy from June of 2016 to June of 2018. Surgical and aesthetic outcomes, including capsular contracture and revision surgery, were measured. The BREAST-Q was administered preoperatively, 6 months postoperatively, and 1 year postoperatively.

Results:

Eighty-four patients (121 breasts) were included. A widely based inframammary fold adipodermal flap was used in all cases, with acellular dermal matrix used in 77 breasts (63.3 percent), free nipple grafts in 42 breasts (34.7 percent), and postmastectomy radiation therapy in 31 breasts (26.5 percent). Operative complications included nipple-areola complex necrosis in six (5.1 percent), hematoma in four (3.4 percent), seroma in four (3.4 percent), implant exposure in three (2.6 percent), and infection in one (0.9 percent). Minor complications included cellulitis in five (6.0 percent) and minor wound issues in five (4.3 percent). In aesthetic outcomes, only two nonirradiated breasts experienced a grade 3 to 4 or grade 4 capsular contracture requiring capsulectomy. Rippling was visible in four breasts (3.4 percent). The BREAST-Q showed good satisfaction with the technique, with no significant differences between nipple-areola complex techniques.

Conclusions:

This cohort represents the largest single-surgeon, Wise-pattern, direct-to-implant prepectoral database in the literature. This report showed that surgical and aesthetic complications did not differ in terms of acellular dermal matrix use. This technique has shown, through patient-reported outcomes, to yield good patient satisfaction.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Residual viremia in HIV-infected patients who continue a two-drug or switch to a three-drug integrase strand transfer inhibitor based regimen
Authors: Gianotti Nicola , Galli Laura , Poli Andrea , Torre Liviana Della , Vinci Concetta , Carini Elisabetta , Galli Andrea , Nozza Silvia , Spagnuolo Vincenzo , Muccini Camilla , Lazzarin Adriano , Castagna Antonella
Published: April 2021

In this randomized, single-centre, open-label, 96-week, superiority, controlled trial of 50 HIV-infected patients with HIV-RNA less than 50 copies/ml on a two-drug regimen based on dolutegravir as well as one reverse transcriptase inhibitor (RTI), switching to a single-tablet regimen of cobicistat, elvitregravir, emtricitabine along with tenofovir alafenamide did not appear to mitigate the burden of residual viremia, both at week 48 and at week 96. The immunological changes observed during follow-up and the safety of the two regimens were similar.
A decision analytics model to optimize investment in interventions targeting the HIV preexposure prophylaxis cascade of care
Authors: Jenness Samuel M. , Knowlton Gregory , Smith Dawn K. , Marcus Julia L. , Anderson Emeli J. , Siegler Aaron J. , Jones Jeb , Sullivan Patrick S. , Enns Eva
Published: April 2021

Objectives:

Gaps between recommended and actual levels of HIV preexposure prophylaxis (PrEP) use remain among MSM. Interventions can address these gaps but it is unknown how public health initiatives should invest prevention funds into these interventions to maximize their population impact.

Design:

We used a stochastic network-based HIV transmission model for MSM in the Atlanta area paired with an economic budget optimization model.

Methods:

The model simulated MSM participating in up to three real-world PrEP cascade interventions designed to improve initiation, adherence, or persistence. The primary outcome was infections averted over 10 years. The budget optimization model identified the investment combination under different budgets that maximized this outcome, given intervention costs from a payer perspective.

Results:

From the base 15% PrEP coverage level, the three interventions could increase coverage to 27%, resulting in 12.3% of infections averted over 10 years. Uptake of each intervention was interdependent: maximal use of the adherence and persistence interventions depended on new PrEP users generated by the initiation intervention. As the budget increased, optimal investment involved a mixture of the initiation and persistence interventions but not the adherence intervention. If adherence intervention costs were halved, the optimal investment was roughly equal across interventions.

Conclusion:

Investments into the PrEP cascade through initiatives should account for the interactions of the interventions as they are collectively deployed. Given current intervention efficacy estimates, the total population impact of each intervention may be improved with greater total budgets or reduced intervention costs.
Association of epicardial fat with noncalcified coronary plaque volume and with low attenuation plaque in people with HIV
Authors: Sadouni Manel , Durand Madeleine , Boldeanu Irina , Danieli Coraline , Bodson-Clermont Paule , Mansour Samer , Baril Jean-Guy , Trottier Benoit , Tremblay Cécile , Chartrand-Lefebvre Carl
Published: April 2021

Objectives:

People with HIV are exposed to a higher risk of coronary artery disease (CAD) compared with the general population. Epicardial fat may play a unique role in promoting coronary atherosclerosis. We measured epicardial fat in participants living with HIV and controls and investigated its association with coronary plaque volume and low attenuation plaque, a marker of plaque vulnerability.

Design:

This is a cross-sectional study, nested in the Canadian HIV and Aging Cohort Study, a large prospective cohort actively following participants with HIV and controls. Participants with low/intermediate cardiovascular risk without symptoms/history of CAD were invited to undergo cardiac computed tomography (CT).

Methods:

Volume of epicardial fat, coronary plaque and low attenuation component of the plaque were measured. Association between epicardial fat, coronary plaque volume and low attenuation component was tested using adjusted regression analysis.

Results:

A total of 169 participants with HIV and 81 controls underwent cardiac CT. Participants with HIV had a greater epicardial fat volume compared with controls (P = 0.019). In participants with HIV, epicardial fat volume was positively associated with duration of nonnucleoside reverse transcriptase inhibitors (NNRTI) (β=2.19, P = 0.004). After adjustment for cardiovascular risk factors, epicardial fat volume was positively associated to noncalcified plaque volume [odds ratio (OR) = 1.09, P = 0.028] and to the low-attenuation plaque component portion (β=0.38, P = 0.026).

Conclusion:

The association of epicardial fat volume to noncalcified plaque volume and to low attenuation component plaque may suggest a potential mechanism by which epicardial fat could be a silent driver of CAD in the HIV population.
The Adrenergic System in Plastic and Reconstructive Surgery
Authors: Fahy Evan J. , Griffin Michelle , Lavin Christopher , Abbas Darren , Longaker Michael T. , Wan Derrick
Published: April 2021

The primary organ systems and tissues concerning plastic and reconstructive surgery include the integument, vasculature, subcutis, and peripheral nerves, because these may individually or collectively be injured requiring reconstruction, or indeed be used in reconstruction themselves through grafts, flaps, or anastomoses. Adrenergic receptors are present throughout these anatomic components on the vasculature, adipose, platelets, immune cells, keratinocytes, melanocytes, fibroblasts, peripheral nerves, and tendons. Herein, the influence of adrenergic signaling on the physiology of anatomic components related to plastic surgery is discussed, along with clinical considerations of this systems involvement in procedures, such as free flap reconstruction, skin grafting, fat grafting, and other areas relevant to plastic and reconstructive surgery. Current evidence as well as potential for further investigation is discussed.
Modified Posterior Arm Flap for Axillary Hidradenitis Suppurativa
Authors: Thomson David R. , Saltrese Songtum , Mehdi Syed
Published: April 2021

Introduction

Hidradenitis suppurativa (HS) is a chronic, inflammatory condition of the apocrine sweat glands present in 1% to 4% of the adult population, with twice greater prevalence in females. Surgical excision is the criterion-standard treatment for advanced, grade III disease, characterized by extensive and recurrent abscesses and interconnected sinus tracts. Numerous reconstructive methods have been used to cover the resulting defects, including secondary intention healing, use of skin grafts, and a wide range of locoregional flaps.

Methods

The modified posterior arm flap has been developed for reconstruction of axillary defects after radical excision of HS. Based on perforating vessels from the axillary artery first identified by Masquelet, a brachioplasty-like incision is used to keep the donor site closure relatively hidden on the posteromedial aspect of the inner arm.

Results

Eight modified posterior arm flaps have been undertaken in 6 patients, all women (mean age, 35 years; range, 22–51 years) from 2014 to 2019. All patients had complete resolution of their HS symptoms with no incidences of recurrence at mean follow-up of 15 months. All reported satisfaction with the aesthetic and functional outcomes of the procedure

Discussion

We present a novel modification of the posterior arm flap for the treatment of advanced axillary HS with good functional and aesthetic outcomes and no incidences of recurrence.
Routine Postoperative Antibiotics After Tissue Expander Placement Postmastectomy Does Not Improve Outcome
Authors: Yamin Feras , Nouri Andrew , McAuliffe Phoebe , Vasilakis Vasileios , Ganz Jason , Khan Sami , Huston Tara , Dagum Alexander , Bui Duc
Published: April 2021

Purpose

In an attempt to reduce the incidence of infectious complications after tissue expander–based breast reconstruction, the routine administration of postoperative antibiotics regimen is common in many practices. In recent years, there has been a plethora of reports scrutinizing the prophylactic use of postoperative antibiotics in this setting. The aim of this study was to determine the efficacy of prolonged administration of postoperative antibiotics compared with perioperative-only antibiotic administration for prophylaxis after tissue expander placement for immediate mastectomy reconstruction.

Methods and Materials

A retrospective chart review of all patients who underwent immediate tissue expander placement after mastectomy at our institution from June 2005 to September 2018 was performed. All patients in the study received perioperative intravenous antibiotics 30 to 60 min preoperatively and for 24 hours postoperatively. Patients were divided into 2 groups. Patients in group A did not receive antibiotics beyond the perioperative period. Patients in group B received oral antibiotics for at least 7 days postoperatively in addition to the perioperative intravenous antibiotics. The 2 groups were compared for demographics and prevalence of risk factors such as radiation, chemotherapy, smoking, and diabetes. The incidence of complications such as infection, wound complications, hematoma, seroma, capsular contracture, loss of tissue expander, and reoperations was assessed.

Summary of Results

A total of 529 patients were included in the study, of which 241 were in group A and 288 were in group B. The total number of breasts reconstructed in group A was 398, whereas in group B, it was 466 breasts. Patients were followed up to 5 months postoperatively in each group. There were no statistically significant differences in the demographic and patient characteristics among the 2 groups. The incidence of infection in group A was 23.24% and in group B was 21.53% (P = 0.412). The incidence of other complications follows the same trend when comparing group A versus B.

Conclusions

This retrospective study shows that the routine use of postoperative antibiotics after tissue expander placement for immediate mastectomy reconstruction does not result in reduction in the incidence of common complications or improvement of clinical outcomes.
Targeting T Follicular Helper Cells to Control Humoral Allogeneic Immunity
Authors: Louis Kevin , Macedo Camila , Metes Diana
Published: April 2021

Humoral allogeneic immunity driven by anti-HLA donor-specific antibodies and antibody-mediated rejection (AMR) significantly impede prolonged survival of organ allografts after transplantation. Although the importance of T follicular helper (TFH) cells in controlling antibody responses has been long established, their role in directing donor-specific antibody generation leading to AMR was only recently appreciated in the clinical setting of organ transplantation. In this review, we provide a comprehensive summary of the current knowledge on the biology of human TFH cells as well as their circulating counterparts and describe their pivotal role in driving humoral alloimmunity. In addition, we discuss the intrinsic effects of current induction therapies and maintenance immunosuppressive drugs as well as of biotherapies on TFH cells and provide future directions and novel opportunities of biotherapeutic targeting of TFH cells that have the potential of bringing the prophylactic and curative treatments of AMR toward personalized and precision medicine.
Elizabethkingia argenteiflava sp. nov., isolated from the pod of soybean, Glycine max
Authors: Hwang Jun-Hee , Kim Jihyeon , Kim Jae-heon , Mo SangJoon
Published: April 2021

Soybean pods, separated and enclosed from the outside environment, are considered a suitable place to find new microbes. A Gram-stain-negative, aerobic bacterium, bacterial strain (YB22T) was isolated from the pod of Glycine max (soybean) collected from a rural area in Republic of Korea and characterized by using polyphasic taxonomy. Cells of the strain were rod-shaped (approximately 0.4–0.6 µm wide and 4.0–5.0 µm long), non-flagellated and formed silver-yellow colonies. Cells grew at 25–35 °C (optimum, 28–30 °C), at pH 5.0–9.0 (optimum, pH 7.0) and with 0–2.0% NaCl (optimum, 0 % NaCl). 16S rRNA gene sequencing showed that strain YB22T was phylogenetically closest to the genus

Elizabethkingia

, and showed highest similarities to

Elizabethkingia occulta

G4070T (96.7 %),

Elizabethkingia meningoseptica

ATCC 13253T (96.7 %),

Elizabethkingia miricola

DSM 14571T (96.6 %),

Elizabethkingia bruuniana

G0146T (96.5 %),

Elizabethkingia ursingii

G4122T (96.4 %) and

Elizabethkingia anophelis

R26T (96.2 %). Average amino acid identity values between strain YB22T and other taxa in the genus

Elizabethkingia

were all above the threshold range of genus determination. Average nucleotide identity and digital DNA–DNA hybridization values between strain YB22T and other phylogenetic relatives were all found to be below the threshold range for species determination. The respiratory quinone of strain YB22T was menaquinone 6 (MK-6) and the predominant cellular fatty acids were iso-C15 : 0 (47.8 %) and iso-C17 : 0 3-OH (18.5 %). The major polar lipids were phosphatidylethanolamine, four unidentified aminolipids and three unidentified polar lipids. The phylogenetic analysis and physiological and biochemical data showed that strain YB22T should represent a novel species in the genus

Elizabethkingia

, for which the name Elizabethkingia argenteiflava sp. nov. is proposed. The type strain for this novel species is YB22T (=KCCM 43263T=JCM 32097T).
Reclassification of Haloactinobacterium glacieicola as Occultella glacieicola gen. nov., comb. nov., of Haloactinobacterium album as Ruania alba comb. nov, with an emended description of the genus Ruania, recognition that the genus names Haloactinobacterium and Ruania are heterotypic synonyms and description of Occultella aeris sp. nov., a halotolerant isolate from surface soil sampled at an ancient copper smelter
Authors: Schumann Peter , Kalensee Franziska , Cao Jialan , Criscuolo Alexis , Clermont Dominique , Köhler Johann Michael , Meier-Kolthoff Jan P. , Neumann-Schaal Meina , Tindall Brian J. , Pukall Rüdiger
Published: April 2021

In the course of screening the surface soils of ancient copper mines and smelters (East Harz, Germany) an aerobic, non-motile and halotolerant actinobacterium forming small rods or cocci was isolated. The strain designated F300T developed creamy to yellow colonies on tryptone soy agar and grew optimally at 28 °C, pH 7–8 and with 0.5–2 % (m/v) NaCl. Its peptidoglycan was of type A4α l-Lys–l-Glu (A11.54). The menaquinone profile was dominated by MK-8(II, III-H4) and contained minor amounts of MK-8(H2), MK-8(H6) and MK-9(H4). The polar lipids comprised diphosphatidylglycerol, phosphatidylglycerol, phosphatidylinositol, mono and diacylated phosphatidylinositol dimannosides, and components that were not fully characterized, including two phospholipids, two glycolipids and an uncharacterized lipid. Major whole-cell sugars were rhamnose and ribose. The fatty acid profile contained mainly iso and anteiso branched fatty acids (anteiso-C15 : 0, iso-C14 : 0) and aldehydes/dimethylacetals (i.e. not fatty acids). Sequence analysis of its genomic DNA and subsequent analysis of the data placed the isolate in the group currently defined by members of the genera

Ruania

and

Haloactinobacterium

(family

Ruaniaceae

, order

Micrococcales

) as a sister taxon to the previously described species

Haloactinobacterium glacieicola

, sharing an average nucleotide identity and average amino acid identity values of 85.3 and 85.7 %, respectively. Genotypic and chemotaxonomic analyses support the view that strain F300T (=DSM 108350T=CIP 111667T) is the type strain of a new genus and new species for which the name Occultella aeris gen. nov., sp. nov. is proposed. Based on revised chemotaxonomic and additional genome based data, it is necessary to discuss and evaluate the results in the light of the classification and nomenclature of members of the family

Ruaniaceae

, i.e. the genera

Haloactinobacterium

and

Ruania

. Consequently, the reclassification of

Haloactinobacterium glacieicola

as Occultella glacieicola comb. nov. and

Haloactinobacterium album

as Ruania alba comb. nov., with an emended description of the genus

Ruania

are proposed.
Effects of repeated injection of 1% lidocaine vs. radial extra-corporeal shock wave therapy for treating myofascial trigger points: a randomized controlled trial
Authors: Suputtitada Areerat , Chen Carl P.C. , Ngamrungsiri Narin , Schmitz Christoph
Published: April 2021

Background and Objectives

This study tested the hypothesis that treatment of myofascial trigger points (MTrPs) in the upper trapezius muscle (UTM) with repeated injection of 1% lidocaine results in better alleviation of muscular stiffness and soreness as well as improved metabolism in the hypercontracted MTrP area than treatment with radial extracorporeal shock wave therapy (rESWT).

Materials and Methods

A single-blinded, prospective, randomized controlled trial was conducted on patients suffering from MTrPs in the UTM. Thirty patients were treated with repeated injection of 2 ml of 1% lidocaine (three injections; one injection per week). Another 30 patients were treated with rESWT (three treatment sessions; one treatment session per week; 2000 radial extracorporeal shock waves per treatment session; positive energy flux density = 0.10 mJ/mm2). The primary outcome measure was pain severity using the VAS score. The secondary outcome measures included muscle elasticity index, pressure pain threshold and neck disability index. Evaluation was performed at baseline (T1), 15-30 minutes after the first treatment in order to register immediate treatment effects (T2), before the second treatment (i.e., one week after baseline) (T3) and one week after the third treatment (i.e., four weeks after baseline) (T4).

Results

There were no statistically significant differences in the primary and secondary outcome measures between the patients in the lidocaine arm and the patients in the rESWT arm at T1 and T4. Within the arms, the mean differences of all outcomes were statistically significant (P < 0.001) when comparing the data obtained at T1 with the data obtained at T3 and the data obtained at T4.

Conclusions

The results of this pilot study suggest that the use of rESWT in patients with MTrPs in the UTM is safe and leads to reduced pain and improved muscle elasticty, pressure pain threshold and neck disability index, without adverse effects. Larger trials are necessary to verify this. Clinicians should consider rESWT instead of injections of lidocaine in the treatment of MTrPs in the UTM.