bluuebunny/crossref_metadata_2025 huggingface dataset:
The Impact of Environmental Factors on Monogenic Mendelian Diseases
Authors: Tukker Anke M , Royal Charmaine D , Bowman Aaron B , McAllister Kimberly A
Published: February 2021

Environmental factors and gene-environment interactions modify the variable expressivity, progression, severity, and onset of some classic (monogenic) Mendelian-inherited genetic diseases. Cystic fibrosis, Huntington disease, Parkinson’s disease, and sickle cell disease are examples of well-known Mendelian disorders that are influenced by exogenous exposures. Environmental factors may act by direct or indirect mechanisms to modify disease severity, timing, and presentation, including through epigenomic influences, protein misfolding, miRNA alterations, transporter activity, and mitochondrial effects. Because pathological features of early-onset Mendelian diseases can mimic later onset complex diseases, we propose that studies of environmental exposure vulnerabilities using monogenic model systems of rare Mendelian diseases have high potential to provide insight into complex disease phenotypes arising from multi-genetic/multi-toxicant interactions. Mendelian disorders can be modeled by homologous mutations in animal model systems with strong recapitulation of human disease etiology and natural history, providing an important advantage for study of these diseases. Monogenic high penetrant mutations are ideal for toxicant challenge studies with a wide variety of environmental stressors, because background genetic variability may be less able to alter the relatively strong phenotype driving disease-causing mutations. These models promote mechanistic understandings of gene-environment interactions and biological pathways relevant to both Mendelian and related sporadic complex disease outcomes by creating a sensitized background for relevant environmental risk factors. Additionally, rare disease communities are motivated research participants, creating the potential of strong research allies among rare Mendelian disease advocacy groups and disease registries and providing a variety of translational opportunities that are under-utilized in genetic or environmental health science.
Leveraging Resources for Educational Equity to Promote Academic Success Among Underrepresented Nursing Students: An Integrative Review
Authors: Kirui Caroline , McGee Jerrihlyn
Published: February 2021

AIM

The aim of this study was to perform an integrative literature review to discover methods to foster academic success for underrepresented students pre- and postadmission to prelicensure nursing programs.

BACKGROUND

The US population is progressing to a minority–majority population. To effectively meet the needs of a diverse population, nursing recognizes the need to racially and ethnically diversify the workforce by increasing the diversity of students admitted to nursing schools. Although the need is widely known, minority groups remain underrepresented in nursing programs, and there is a need for sustainable recruitment and retention strategies.

METHOD

An integrative literature review on how to foster the success of underrepresented students was performed.

RESULTS

Proposed interventions include mentoring, financial support, academic and psychosocial support, and student success programs.

CONCLUSION

Tailoring interventions to specific student needs would be effective in enhancing student success.
Characteristics Associated With Treatment Failure 1 Year After Midurethral Sling in Women With Mixed Urinary Incontinence
Authors: Sung Vivian W. , Richter Holly E. , Moalli Pamela , Weidner Alison C. , Nguyen John N. , Smith Ariana L. , Dunivan Gena , Ridgeway Beri , Borello-France Diane , Newman Diane K. , Mazloomdoost Donna , Carper Benjamin , Gantz Marie G.
Published: February 2021

(Abstracted from Obstet Gynecol 2020;136:482–491)

Mixed urinary incontinence, including both stress urinary incontinence (SUI) and urgency urinary incontinence (UUI), occurs in up to 50% of women with urinary incontinence. Mixed incontinence is often considered more severe and more difficult to treat than either urinary condition alone.
Multiple Vitrification-Warming and Biopsy Procedures on Human Embryos: Clinical Outcome and Neonatal Follow-up of Children
Authors: De Vos Anick , Van Landuyt Lisbet , De Rycke Martine , Verdyck Pieter , Verheyen Greta , Buysse Andrea , Belva Florence , Keymolen Kathelijn , Tournaye Herman , Verpoest Willem
Published: February 2021

(Abstracted from Hum Reprod 2020;35(11):2488–2496)

Despite advances in preimplantation genetic testing (PGT), inconclusive diagnoses following aneuploidy screening, chromosomal rearrangement, or monogenic testing do occur regularly. With PGT these days shifting toward more and more trophectoderm (TE) biopsy, test failures inevitably involve a second round of biopsy and blastocyst vitrification.
Laparoscopic Major Vascular Injuries in Gynecologic Surgery for Benign Indications
Authors: King Nathan R. , Lin Emily , Yeh Chen , Wong Jacqueline M. K. , Friedman Jaclyn , Traylor Jessica , Tsai Susan , Chaudhari Angela , Milad Magdy P.
Published: February 2021

OBJECTIVE:

To identify the incidence, location, etiology, and mortality of major vascular injuries in gynecologic laparoscopy for benign indications.

DATA SOURCES:

A systematic review of PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov, and MEDLINE was conducted.

METHODS OF STUDY SELECTION:

One thousand ninety-seven studies were screened for inclusion with 147 full-text articles reviewed. Sixty-six studies published between 1978 and 2016 met inclusion criteria, representing 197,062 surgeries. Articles that were included reported the incidence of major vascular injuries during gynecologic laparoscopy for benign indications. Exclusion criteria included surgery for gynecologic malignancy, duplicated data, case series and reports, manuscripts not in English, and studies published only as abstracts.

TABULATION, INTEGRATION, AND RESULTS:

Injuries to the aorta, inferior vena cava, iliac (common, external, or internal), and inferior epigastric vessels were recorded, as were injuries denoted as major but not otherwise specified. A total of 179 major vascular injuries were reported with an incidence of 0.09% (95% CI 0.08–0.10). The inferior epigastric vessels were the most commonly injured vessel (0.04%, 95% CI 0.03–0.05), comprising 48% (95% CI 40–55) of all injuries. The majority of injuries occurred during abdominal entry (82%, 95% CI 76–89), and the remainder occurred during surgical dissection (18%, 95% CI 11–24). Most injuries were recognized intraoperatively (93%, 95% CI 87–100), and approximately half (55%, 95% CI 46–63) required laparotomy for repair. Only two of the 179 major vascular injuries resulted in death, for an overall mortality rate from vascular injuries of 0.001% (95% CI 0.000–0.004).

CONCLUSION:

The incidence of major vascular injury during gynecologic laparoscopy found in this review is very low, and the vast majority of injuries did not result in death. Laparoscopy remains a safe surgical technique in relation to vascular injuries when performed for benign gynecologic disease.
Comparison of Plastic Surgeon and Spine Surgeon Closure in Revision Short Segment Thoracolumbar Spinal Fusions
Authors: Zhong Jack , Balouch Eaman , O’Malley Nicholas , Maglaras Constance , Stickley Carolyn , Leon Carlos , O’Connell Brooke , Fischer Charla R. , Protopsaltis Themistocles , Buckland Aaron J.
Published: February 2021

Study Design.

Retrospective cohort analysis.

Objective.

To compare outcomes of plastic versus spine surgeon wound closure in revision 1 to 4 level thoracolumbar fusions.

Summary of Background Data.

Plastic surgeons perform layered musculocutaneous flap closures in high-risk spine patients such as revision posterior spinal fusion and complex deformity correction surgeries. Few studies have assessed outcomes of revision fusion performed with plastic surgical closures, particularly in nondeformity thoracolumbar spinal surgery.

Methods.

A retrospective review of 1 to 4 level revision thoracolumbar fusion performed by Orthopedic or Neurosurgical spine surgeons. Patient charts were reviewed for demographics and perioperative outcomes. Patients were divided into two cohorts: wound closures performed by spine surgeons and those closed by plastic surgeons. Outcomes were analyzed before and after propensity score match for prior levels fused, iliac fixation, and levels fused at index surgery. Significance was set at P < 0.05.

Results.

Three hundred fifty-seven (87.3%) spine surgeon (SS) and 52 (12.7%) plastic surgeon (PS) closures were identified. PS group had significantly higher number of levels fused at index (PS 2.7 ± 1.0 vs. SS 1.8 ± 0.9, P < 0.001) and at prior surgeries (PS 1.8 ± 1.2 vs. SS 1.0 ± 0.9, P < 0.001), and rate of iliac instrumentation (PS 17.3% vs. SS 2.8%, P < 0.001). Plastics closure was an independent risk factor for length of stay  > 5 days (odds ratio 2.3) and postoperative seroma formation (odds ratio 7.8). After propensity score match, PS had higher rates of seromas (PS 36.5% vs. SS 3.8%, P < 0.001). There were no differences between PS and SS groups in surgical outcomes, perioperative complication, surgical site infection, seroma requiring aspiration, or return to operating room at all time points until follow-up (P > 0.05 for all).

Conclusion.

Plastic spinal closure for 1 to 4 level revision posterior thoracolumbar fusions had no advantage in reducing wound complications over spine surgeon closure but increased postoperative seroma formation.

Level of Evidence: 4
Therapeutic Efficacy of Transpedicular Impaction Bone Grafting with Long Segmental Posterior Instrumentation in Stage III Kümmell Disease
Authors: Zhu Yanyu , Zhang Zhenhui , Jiang Wentao , Su Kai , Wang Zhongwei , Wang Chunping , Wang Chunli , Wang Qingde
Published: February 2021

Study Design

A retrospective review of clinical and radiological parameters.

Objective

To evaluate the therapeutic efficacy of transpedicular impaction bone grafting (TIBG) with long segmental posterior instrumentation for the treatment of stage III Kümmell disease.

Summary of Background Data

The optimal treatment for stage III Kümmell disease remains controversial and unclear. Theoretically, transpedicular bone grafting can reconstruct anterior column support and reduce the failure of internal fixation, which is an intuitive method for the treatment of Kümmell disease. However, the use of this technique has rarely been reported for the treatment of this disease. This study reported the clinical and radiological results of TIBG with long segmental posterior instrumentation for the treatment of stage III Kümmell disease.

Methods

Between August 2011 and December 2017, we retrospectively analyzed 24 patients with stage III Kümmell disease who underwent TIBG with long segmental posterior instrumentation. Anterior vertebral heights, kyphotic Cobb angle, visual analog scale (VAS), Oswestry disability index (ODI), and American Spinal Injury Association (ASIA) impairment scale were used to evaluate the effects of surgery.

Results

The mean time to follow-up was 38.1 ± 10.2 months. The average operative duration was 136 ± 16.5 minutes, and the average intraoperative blood loss was 293 ± 41.3 mL. The VAS, ODI, anterior vertebral heights, and kyphotic Cobb angles were improved significantly at 1 week after surgery compared the preoperative examinations, and were well maintained at the final follow-up evaluation. Fourteen patients (58%) had mild neurological impairments before surgery, with neurological function returning to normal at the final follow-up evaluation. There was no instance of instrumentation failure.

Conclusion

TIBG combined with long segmental posterior instrumentation is a safe and effective surgical option for stage III Kümmell disease.

Level of Evidence: 4
Cervical Disc Degeneration and Vertebral Endplate Defects After the Fused Operation
Authors: Leonova Olga , Baykov Evgenii , Sanginov Abdugafur , Krutko Aleksandr
Published: February 2021

Study Design.

Longitudinal study of cervical MR in patients with degenerative disc disease (DDD).

Objective.

To evaluate the evolution of the degenerative changes in the C2-D1 cervical segments and to assess the association magnetic resonance imaging (MRI) parameters with clinical symptoms after surgical treatment in patients with DDD.

Summary of Background Data.

The evolution of degenerative changes in the cervical spine is poorly understood. Endplate defects can be of great importance in progressive disc degeneration (DD). Clarification of this predictor may be important in determining the treatment tactics in patients with DDD.

Methods.

The study included patients who had 2-years’ follow-up after cervical fusion for spondylotic radiculo- with/without myelopathy. Demographic data (age, sex, surgical data) were assessed; clinical data (visual analogue scale [VAS] neck, VAS arm, Neck Disability Index [NDI]) and cervical MRI (DD grades by Pfirrmann, Modic changes (MC), total endplate scores (TEPS) were compared to preoperative data.

Results.

The median follow-up term was 26.5 (18.9–33.1) months. All patients reported a decrease neck pain and arm pain at follow-up (P < 0.001). There was observed the change in MC types (P < 0.001) and an increase of TEPS (P < 0.05). 71.7% discs remained unchanged during the follow-up, but a significant number of discs went from Grade 2 to Grade 3 and from Grade 3 to Grade 4 by Pfirrmann (P < 0.001). Clinical scores (VAS neck, VAS arm, NDI) had no correlation with MRI changes (P > 0.05). DD was associated with TEPS (odds ratio [OR] 2.05–5.47, P < 0.05) and patients’ age (OR 1.11–2.33, P < 0.05) at all cervical levels; with MC types, but only at C4-C5 and C6-C7 levels (OR = 2.91 and 2.79, respectively, P < 0.05). Receiver-operating characteristic analysis showed a TEPS threshold value of 7, above which the probability of DD significantly higher.

Conclusion.

During 2 years’ follow-up the significant increase of DD grades by Pfirrmann was observed at C4-C6 levels (P < 0.001). A significant association DD with TEPS and age at all cervical levels was determined.

Level of Evidence: 3
The Impact of Preintubation Noninvasive Ventilation on Outcomes in Pediatric Acute Respiratory Distress Syndrome*
Authors: Kopp Whitney , Gedeit Rainer G. , Asaro Lisa A. , McLaughlin Gwenn E. , Wypij David , Curley Martha A. Q.
Published: February 2021

OBJECTIVES:

There is evidence that noninvasive ventilation decreases the need for invasive mechanical ventilation. However, children with pediatric acute respiratory distress syndrome who fail noninvasive ventilation may have worse outcomes than those who are intubated without exposure to noninvasive ventilation. Our objective was to evaluate the impact of preintubation noninvasive ventilation on children with pediatric acute respiratory distress syndrome.

DESIGN:

Secondary analysis of data from the Randomized Evaluation of Sedation Titration for Respiratory Failure trial.

SETTING:

Thirty-one PICUs in the United States.

PATIENTS:

Children 2 weeks to 17 years old with pediatric acute respiratory distress syndrome receiving invasive mechanical ventilation, excluding those admitted with tracheostomies.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

Of 2,427 subjects receiving invasive mechanical ventilation, preintubation noninvasive ventilation was used in 995 (41%). Compared with subjects without preintubation noninvasive ventilation use, subjects with preintubation noninvasive ventilation use were more likely to have a history of seizures (10% vs 8%; p = 0.04) or cancer (11% vs 6%; p < 0.001) and have moderate or severe pediatric acute respiratory distress syndrome by the end of their first full day of invasive mechanical ventilation (68% vs 60%; p < 0.001). Adjusting for age, severity of illness on PICU admission, and baseline functional status, preintubation noninvasive ventilation use resulted in longer invasive mechanical ventilation duration (median 7.0 vs 6.0 d), longer PICU (10.8 vs 8.9 d), and hospital (17 vs 14 d) lengths of stay, and higher 28-day (5% vs 4%) and 90-day (8% vs 5%) inhospital mortalities (all comparisons p < 0.001). Longer duration of noninvasive ventilation before intubation was associated with worse outcomes.

CONCLUSIONS:

In children with pediatric acute respiratory distress syndrome, preintubation noninvasive ventilation use is associated with worse outcomes when compared with no preintubation noninvasive ventilation use. These data can be used to inform the design of clinical studies to evaluate best noninvasive ventilation practices in children with pediatric acute respiratory distress syndrome.
The Extent of Aspergillosis in Critically Ill Patients With Severe Influenza Pneumonia: A Multicenter Cohort Study
Authors: Coste Anne , Frérou Aurélien , Raute Anaïs , Couturaud Francis , Morin Jean , Egreteau Pierre-Yves , Blanc François-Xavier , Reignier Jean , Tadié Jean-Marc , Tran Adissa , Pronier Charlotte , Coste-Burel Marianne , Nevez Gilles , Gangneux Jean-Pierre , Le Pape Patrice , Ansart Séverine , Tonnelier Jean-Marie , Bretonnière Cédric , Aubron Cécile
Published: February 2021

OBJECTIVES:

To determine the frequency and prognosis of invasive pulmonary aspergillosis in critically ill patients with severe influenza pneumonia.

DESIGN:

Retrospective multicenter cohort study.

SETTING:

Five French ICUs.

PATIENTS:

Patients with influenza admitted to ICU between 2009 and 2018.

MEASUREMENTS AND MAIN RESULTS:

Of the 524 patients admitted for severe influenza diagnosed with a positive airway reverse-transcriptase polymerase chain reaction test, 450 (86%) required mechanical ventilation. A lower respiratory tract sample yielded with Aspergillus (Asp+) in 28 patients (5.3%). Ten patients (1.9%) were diagnosed with putative or proven invasive pulmonary aspergillosis, based on the validated AspICU algorithm. A multivariate model was built to identify independent risk factors for Aspergillus-positive pulmonary culture. Factors independently associated with Aspergillus-positive culture were liver cirrhosis (odds ratio = 6.7 [2.1–19.4]; p < 0.01), hematologic malignancy (odds ratio = 3.3 [1.2–8.5]; p = 0.02), Influenza A(H1N1)pdm09 subtype (odds ratio = 3.9 [1.6–9.1]; p < 0.01), and vasopressor requirement (odds ratio = 4.1 [1.6–12.7]; p < 0.01). In-hospital mortality of Asp+ patients was 36% versus 21% in patients without Aspergillus-positive pulmonary culture (p = 0.09).

CONCLUSIONS:

In this large retrospective multicenter cohort of critically ill patients, putative invasive pulmonary aspergillosis according to AspICU algorithm was a relatively rare complication of influenza. Patients at higher risk of Aspergillus pulmonary colonization included those with liver cirrhosis, hematologic malignancy, H1N1pdm09 influenza A virus, and requiring vasopressors. Our results provide additional data on the controversial association between severe influenza and invasive pulmonary aspergillosis. Reaching a consensual definition of invasive pulmonary aspergillosis becomes mandatory and confers further prospective research.
Rationale, Methodological Quality, and Reporting of Cluster-Randomized Controlled Trials in Critical Care Medicine: A Systematic Review
Authors: Cook David J. , Rutherford William B. , Scales Damon C. , Adhikari Neill K. J. , Cuthbertson Brian H.
Published: February 2021

OBJECTIVE:

Compared with individual-patient randomized controlled trials, cluster randomized controlled trials have unique methodological and ethical considerations. We evaluated the rationale, methodological quality, and reporting of cluster randomized controlled trials in critical care studies.

DATA SOURCES:

Systematic searches of Medline, Embase, and Cochrane Central Register were performed.

STUDY SELECTION:

We included all cluster randomized controlled trials conducted in adult, pediatric, or neonatal critical care units from January 2005 to September 2019.

DATA EXTRACTION:

Two reviewers independently screened citations, reviewed full texts, protocols, and supplements of potentially eligible studies, abstracted data, and assessed methodology of included studies.

DATA SYNTHESIS:

From 1,902 citations, 59 cluster randomized controlled trials met criteria. Most focused on quality improvement (24, 41%), antimicrobial therapy (9, 15%), or infection control (9, 15%) interventions. Designs included parallel-group (25, 42%), crossover (21, 36%), and stepped-wedge (13, 22%). Concealment of allocation was reported in 21 studies (36%). Thirteen studies (22%) reported at least one method of blinding. The median total sample size was 1,660 patients (interquartile range, 813–4,295); the median number of clusters was 12 (interquartile range, 5–24); and the median patients per cluster was 141 (interquartile range, 54–452). Sample size calculations were reported in 90% of trials, but only 54% met Consolidated Standards of Reporting Trials guidance for sample size reporting. Twenty-seven of the studies (46%) identified a fixed number of available clusters prior to trial commencement, and only nine (15%) prespecified both the number of clusters and patients required to detect the expected effect size. Overall, 36 trials (68%) achieved the total prespecified sample size. When analyzing data, 44 studies (75%) appropriately adjusted for clustering when analyzing the primary outcome. Only 12 (20%) reported an intracluster coefficient (median 0.047 [interquartile range, 0.01–0.13]).

CONCLUSIONS:

Cluster randomized controlled trials in critical care typically involve a small and fixed number of relatively large clusters. The reporting of key methodological aspects of these trials is often inadequate.
Lambert–Eaton Myasthenic Syndrome and Dermatomyositis With Anti–TIF1-gamma Autoantibody: A Unique Association of Autoimmune Neuromuscular Conditions Without Malignancy
Authors: Isfort Michael , Mnatsakanova Diana , Oddis Chester , Lacomis David
Published: February 2021

Lambert–Eaton myasthenic syndrome (LEMS) is a presynaptic neuromuscular junction disorder, and dermatomyositis (DM) is an idiopathic inflammatory myopathy. LEMS and DM are uncommon conditions that can present similarly and are often associated with autoantibodies. Concomitant LEMS and DM have only been reported a few times, and most of those cases were paraneoplastic. We present the first reported case of a patient with antivoltage gated calcium channel antibody positive LEMS who subsequently developed DM with antitranscription intermediary factor 1-gamma (anti–TIF1-γ) antibodies. Interestingly, both conditions occurred without evidence of malignancy. This diagnosis of LEMS and DM with characteristic clinical, electrodiagnostic, and histopathological evidence led to a beneficial modification of the patient's therapeutic regimen. Due to the fact that overlapping concurrent neuromuscular conditions are rare, a high clinical suspicion is needed to identify, evaluate (including appropriate cancer screenings), and appropriately treat these patients.
Early Versus Traditional Oral Feeding Following Elective Colorectal Surgery
Authors: McAlee Anita , Allred Jacqueline
Published: February 2021

Traditional feeding protocols withhold oral intake until the return of bowel function for concern of postoperative complications following elective colorectal surgery. Implementation of early feeding into clinical practice challenges this conventional approach. The purpose of this literature review is to analyze the current evidence and compare the impact of traditional versus early oral feeding protocols on postoperative outcomes following elective colorectal resection. A literature search of PubMed, EMBASE, CINAHL, and Scopus was conducted. Outcomes of interest include the resolution of postoperative ileus, the incidence of anastomotic leakage, and length of hospital stay. Patients assigned to early oral feeding began oral caloric intake within 24 hours of surgery, whereas oral intake was withheld until the resolution of postoperative ileus for patients in the traditional oral feeding group. Five trials met the inclusion criteria for this review. All studies reported on the primary outcomes of interest. A P value less than .05 was considered significant. Results indicate that early oral feeding following elective colorectal surgery did not extend the duration of postoperative ileus as evidenced by shorter time to first flatus and defecation, did not increase the incidence of anastomotic leakage, and demonstrated shorter length of hospital stay when compared with traditional management.
Post–Sepsis Syndrome
Authors: Leviner Sherry
Published: February 2021

Sepsis is both common and costly. Successful implementation of guidelines in the acute care setting has decreased mortality and increased the number of sepsis survivors. However, patients returning to the community continue to experience complications related to sepsis and many are poorly prepared to manage these long-term complications. These long-term complications are collectively referred to as post–sepsis syndrome. The purpose of this review is to increase knowledge about post–sepsis syndrome and to compare post–sepsis syndrome with post–intensive care unit syndrome.
Workplace Violence Against Emergency Nurses
Authors: Ayasreh Ibrahim R. , Hayajneh Ferial A.
Published: February 2021

Violence against health care providers is one of the most pressing problems faced by health care systems around the world. Because of unpredictability and acuity of emergency cases, emergency nurses are more vulnerable to workplace violence. Violence against emergency nurses is a complex and multidimensional problem that has a devastating impact on the physical, psychological, and social well-being of nurse victims. The purpose of this review is to integrate evidence on manifestations, contributing factors, and consequences of workplace violence perpetrated by patients and/or their relatives against emergency nurses, in addition to behavioral responses of emergency nurse victims toward workplace violence. An integrative review was conducted by searching 3 main electronic databases: Web of Sciences, MEDLINE, and ScienceDirect. Eighteen studies met the inclusion criteria and were included in the final review process. The review identified the most common forms, contributing factors, unpleasant consequences of workplace violence, and behavioral reaction of nurse victims toward violence acts. Reporting rates of workplace violence among emergency nurses were found to be low. It is recommended to develop more effective workplace violence prevention and reporting programs.
Machine Learning for Causal Inference: On the Use of Cross-fit Estimators
Authors: Zivich Paul N. , Breskin Alexander
Published: February 2021

Background:

Modern causal inference methods allow machine learning to be used to weaken parametric modeling assumptions. However, the use of machine learning may result in complications for inference. Doubly robust cross-fit estimators have been proposed to yield better statistical properties.

Methods:

We conducted a simulation study to assess the performance of several different estimators for the average causal effect. The data generating mechanisms for the simulated treatment and outcome included log-transforms, polynomial terms, and discontinuities. We compared singly robust estimators (g-computation, inverse probability weighting) and doubly robust estimators (augmented inverse probability weighting, targeted maximum likelihood estimation). We estimated nuisance functions with parametric models and ensemble machine learning separately. We further assessed doubly robust cross-fit estimators.

Results:

With correctly specified parametric models, all of the estimators were unbiased and confidence intervals achieved nominal coverage. When used with machine learning, the doubly robust cross-fit estimators substantially outperformed all of the other estimators in terms of bias, variance, and confidence interval coverage.

Conclusions:

Due to the difficulty of properly specifying parametric models in high-dimensional data, doubly robust estimators with ensemble learning and cross-fitting may be the preferred approach for estimation of the average causal effect in most epidemiologic studies. However, these approaches may require larger sample sizes to avoid finite-sample issues.
Partial Ear Reconstruction with a Prelaminated Induced Expanded Radial Artery Flap
Authors: Flaherty Federico , Militelli Federico , Vizcay Macarena
Published: February 2021

A 76-year-old man underwent an extensive resection for squamous cell carcinoma 2 years before, resulting in the loss of the superior half of the right ear, without any attempt at reconstruction. The decision was to reconstruct with a combined suprafascial tissue expansion, an alloplastic framework fabricated with porous polyethylene, and a radial artery free flap. At 1-year follow-up, the patient was satisfied with the result. We believe this represents a novel approach to be considered for partial ear reconstruction.
Physician Burnout: Solutions for Individuals and Organizations
Authors: Carrau Diana , Janis Jeffrey E.
Published: February 2021

Burnout in medicine has become a national epidemic, affecting greater than one third of physicians, and yet physicians, departments, and institutions remain ill equipped to address it. Burnout is a syndrome characterized by emotional exhaustion, depersonalization, and a reduced sense of accomplishment that occurs as a response to one’s environment. We have a moral and ethical imperative to address physician burnout, as it has immense implications within healthcare. Solutions have historically focused on changing the behavior of the individual, but research has demonstrated that long-lasting change is brought about by intervening at the organizational level, which requires that leadership champion these efforts. Departmental and hospital leadership play a critical role in addressing the drivers of burnout. Here, we outline evidence-based strategies to combat physician burnout at both the individual and organizational levels and review what has been explored within the field of plastic surgery.
Legislation, Market Size, and Access to Gender-affirming Genital Surgery in the United States
Authors: Dagi Alexander F. , Boskey Elizabeth R. , Nuzzi Laura C. , Kang Christine O. , Ganor Oren , Labow Brian I. , Taghinia Amir H.
Published: February 2021

Background:

The value of gender-affirming genital surgery (GAGS) has been established for certain transgender or gender non-conforming patients. This study aimed to determine the availability of GAGS by state and region in the United States, and to query possible associations of access to care with healthcare legislation and local market size.

Methods:

This was a cross-sectional study reporting on the distribution of hospitals and private practices offering GAGS in the United States. A list of prospective gender surgeons was compiled from 18 online databases. All surgeons were individually verified and were excluded if they did not perform phalloplasty, metoidioplasty, or vaginoplasty. Pertinent legislative and transgender or gender non-conforming population data were derived from the Movement Advancement Project and the Williams Institute.

Results:

Seventy-one practices in the United States offered GAGS in 2019. Forty-seven percent of states did not have a practice offering GAGS. A large prospective transgender or gender non-conforming market size increased the odds of GAGS availability in a state more than did local healthcare legislation supporting insurance coverage for gender-affirming care in 2019.

Conclusions:

Access to gender-affirming genital surgery was highly disparate in 2019. Factors that predicted access to care, including state healthcare legislation and prospective market sizes, may indicate strategies for overcoming disparities.
Post-Cesarean Section Pyoderma Gangrenosum Presenting with Vasopressor-dependent Shock: Long-term Follow-up after Delayed Primary Closure
Authors: Zolper Elizabeth G. , Harbour Patrick W. , Dekker Paige K. , Schwitzer Jonathan A. , Viramontes Ariel , Evans Karen K.
Published: February 2021

A 28-year-old woman with poor wound healing and surgical site pain presented 5 days post-cesarean section (post-CS) with vasopressor-dependent shock and was eventually diagnosed with postoperative pyoderma gangrenosum (PG). A worsening clinical picture consistent with presumed necrotizing infection necessitated surgical debridement. The patient was ultimately taken to the operating room 4 times with transient improvement after the operations when she received perioperative corticosteroids. We were unable to identify an infectious source and cultures revealed no microorganisms. Dermatopathology revealed neutrophilic infiltrate and focal necrosis without microorganisms. The biopsy site began to concurrently exhibit pathergic changes, leading to a diagnosis of PG. Twelve weeks later, she underwent DPC of her abdominal wound while maintained on an immunosuppressive regimen of cyclosporine and prednisone. Incisional negative pressure wound therapy with a small window was used in the immediate postoperative period to allow for direct visualization of the closed incision. She healed without issue and her immunosuppressive regimen was ultimately discontinued. Postoperative PG is an uncommon diagnosis with high risk of morbidity. It is often mistaken for necrotizing infection. We report a unique case of post-CS PG presenting as vasopressor-dependent shock that was successfully closed with incisional negative pressure wound therapy with a small window.
Immediate Lymphatic Reconstruction: Technical Points and Literature Review
Authors: Coriddi Michelle , Mehrara Babak , Skoracki Roman , Singhal Dhruv , Dayan Joseph H.
Published: February 2021

Recent studies have provided evidence that lymphovenous bypass—microsurgical re-routing of divided lymphatics to an adjacent vein—performed at the time of lymph node dissection decreases the rate of lymphedema development. Immediate lymphatic reconstruction in this setting is technically demanding, and there is a paucity of literature describing the details of the surgical procedure. In this report, we review the literature supporting immediate lymphatic reconstruction and provide technical details to demystify the operation for surgeons who wish to provide this option to their patients.
Targeted Muscle Reinnervation to Expendable Motor Nerves for the Treatment of Refractory Symptomatic Neuromas in Nonamputees
Authors: Chang Brian L. , Harbour Patrick , Mondshine Josh , Kleiber Grant M.
Published: February 2021

Symptomatic neuromas can cause debilitating pain, significantly impairing patients’ quality of life. There are numerous medical and surgical options for management. Targeted muscle reinnervation (TMR) is a nerve transfer procedure that is now commonly used to prevent or treat symptomatic neuromas or phantom limb pain in amputees. There are a few reports in the current literature about performing TMR in the nonamputee, but no cohort studies to date that report pain outcomes. This study evaluates TMR to treat symptomatic neuromas in nonamputee patients. This is a retrospective cohort study of all patients with symptomatic neuromas treated with TMR over a 1-year period from January 1,2019, to January 1, 2020, at MedStar Georgetown University Hospital. The neuromas are excised to healthy nerve fascicles, and a redundant donor motor fascicle is selected for nerve transfer. Patients were asked in clinic or via telephone about their preoperative and postoperative pain, function, and quality of life, and postoperative clinic notes were reviewed for complications and motor deficits. Fifteen patients were included in this study. Patients had symptomatic neuromas involving the upper extremity, lower extremity, and trunk. Pain frequency decreased from 6.7 times per week to 3.9 (P < 0.01) and from 9.1 times per day to 5.1 (P < 0.01). Pain severity decreased from an average of 7.9/10 to 4.3/10 (P < 0.01). Overall physical function increased from 3.7/10 to 5.8/10 (P = 0.01), and overall quality of life increased from 4.9/10 to 7.0/10 (P < 0.01). No patients had demonstrable weakness of the motor function of the donor nerve. Targeted muscle reinnervation is a viable surgical option for the treatment of symptomatic neuromas, particularly in those patients who have previously failed prior neuroma excisions.
SURGICAL OUTCOMES OF VITREOMACULAR TRACTION TREATED WITH FOVEAL-SPARING PEELING OF THE INTERNAL LIMITING MEMBRANE
Authors: Morescalchi Francesco , Russo Andrea , Semeraro Francesco
Published: February 2021

Purpose:

To compare sensitivity of the retina after complete internal limiting membrane (ILM) peeling versus foveal-sparing ILM peeling in vitrectomy for vitreomacular traction syndrome.

Methods:

This was a randomized, prospective, comparative study. Thirty-four eyes were randomized to undergo peeling with foveal sparing of the ILM (FS group) or complete peeling group. Foveal and perifoveal retinal sensitivity, visual acuity, and central macular thickness were the main outcome measures.

Results:

Parafoveal retinal sensitivity exhibited a significant improvement in both the FS and complete peeling groups (+2.43 ± 0.82 dB and +1.79 ± 0.86 dB, respectively; P = 0.037). Significant improvements were observed in both visual acuity and central macular thickness in both groups. No cases of epiretinal membrane recurrence were observed in the FS group.

Conclusion:

Both the FS and complete peeling surgical techniques are safe and yielded good anatomical and functional results; however, a significant difference in favor of FS was found in relation to the best-corrected visual acuity and perifoveal retinal sensitivity. Preservation of the foveal ILM disc allowed the anatomical restoration of the foveal architecture in most vitreomacular traction syndrome cases without signs of stiffening or ILM fibrosis over a follow-up period of 1 year.
Bacterial Meningitis in the Absence of Pleocytosis in Children
Authors: Zimmermann Petra , Curtis Nigel
Published: February 2021

One of the main features of bacterial meningitis is pleocytosis. However, when children with meningitis present within hours of onset of symptoms, there is the possibility that the meninges are not yet sufficiently inflamed to lead to a raised cerebrospinal fluid (CSF) white blood cell count. A systematic search was done to identify published studies reporting children with culture- or polymerase chain reaction-proven bacterial meningitis in the absence of pleocytosis. We identified 26 studies describing 62 children (18 neonates). In those in whom fever duration was specified, 32 (80%) of 40 had a fever for less than or equal to 24 hours before lumbar puncture (LP). In those in whom the glucose level was reported, it was normal in 14 (82%) of 17 neonates and 33 (80%) of 41 older infants and children. The protein level was normal in 8 (44%) of 17 neonates and 32 (80%) of 40 older infants and children. Twelve of the 62 children had a Gram stain of their CSF and this was positive in 2 (17%). Simultaneous blood cultures were positive in 5 (28%) of 18 neonates and 21 (68%) of 31 older infants and children. There was no association between the absence of pleocytosis and particular bacteria. All of the 10 children who had a second LP had an abnormal CSF including pleocytosis. These findings indicate that the absence of pleocytosis does not exclude bacterial meningitis reliably and should be interpreted in the context of the duration of illness. CSF samples, particularly those from cases with relatively short symptom duration, should be cultured even when the cell count and biochemistry are normal. A second LP can be helpful when bacterial meningitis is suspected despite a normal initial CSF.
Transient Severe Liver Injury: A Unique Presentation of COVID-19 Disease in a Pediatric Patient
Authors: Sgouropoulou Vasiliki , Vargiami Euthymia , Kyriazi Maria , Papadimitriou Eleni , Agakidis Charalambos , Zafeiriou Dimitrios
Published: February 2021

Liver dysfunction is highlighted by several studies as a relevant complication in the context of coronavirus disease 2019 (COVID-19). We present a pediatric patient with mild phenotype but transient severe liver injury. Hepatic damage should be considered even in mild cases of the disease to ensure prompt recognition and management.
Multidisciplinary Management of Orbital Metastasis and Survival Outcomes
Authors: El-Hadad Christian , Koka Kirthi , Dong Wenli , Do Thai , Haider Maryam , Ursua Jocelyn D. , Ning Jing , Debnam James Matthew , Esmaeli Bita
Published: February 2021

Purpose:

To study the multidisciplinary management and survival outcomes of orbital metastasis (OM).

Methods:

All patients with a diagnosis of OM treated during 1999–2019 were included. Clinical data were retrospectively collected and analyzed.

Results:

The study included 118 patients, 71 females and 47 males, with a median age of 61 years. The most common primary tumor types were breast carcinoma (43 patients), melanoma (17), and lung (13), thyroid (7), renal cell (6), and neuroendocrine carcinoma (6). Ninety-six patients had a known history of cancer at OM diagnosis. The median time from diagnosis of primary cancer to OM was 31 months (range, 0–304). In 22 patients, OM was the first sign of cancer. In 47 patients, the orbit was the only site of metastasis. The most common presenting features were restricted by extraocular motility (77 patients) and proptosis (61). Eight patients had enophthalmos. OM was diagnosed based on clinical history and imaging studies in 81 patients and orbital biopsy in 37. One hundred nine patients were treated with chemotherapy and immunotherapy, 75 with radiation, and 21 with palliative surgical resection. Eighty-two patients died during follow up. The median overall survival (OS) time after diagnosis of OM was 17 months (95% CI: 12–28). OM from renal cell carcinoma was associated with the best and OM from thyroid cancer with the worst OS. Patients with breast cancer had longer median survival (28 months; 95% CI: 15–60) than patients with lung, melanoma, neuroendocrine, or thyroid cancer.

Conclusion:

In this large series, breast cancer and melanoma were the most common causes of OM. Most patients had a known history of cancer at OM diagnosis and did not require orbital biopsy to confirm the diagnosis. Patients with renal cell carcinoma and breast carcinoma had the best prognosis after diagnosis of OM.
Conjunctival Actinic Granuloma: A Clinicopathological and Immunohistochemical Study With a Review of the Literature and a Differential Diagnosis
Authors: Neerukonda Vamsee , Jakobiec Frederick A. , Barrantes Paula Cortes , Campbell Douglas , Stagner Anna M.
Published: February 2021

Purpose:

To document a case of actinic granuloma (AG) of the conjunctiva, provide an extensive histopathologic and immunohistochemical description, review previously reported cases, and supply a differential diagnosis.

Methods:

Both a retrospective chart review and comprehensive literature review were performed. The distinctive histopathologic pattern of the current case was defined with histochemical and immunohistochemical stains (CD163, p63, and a Verhoeff–Van Gieson elastic stain). Clinical follow up was obtained.

Results:

A granulomatous process composed of CD163-positive mononuclear epithelioid cells and multinucleated giant cells was characterized by displaced extracellular actinic-related elastic fibers to the base of the lesion. Small elastic fibers were phagocytosed in epithelioid cells. Pseudoepitheliomatous hyperplasia of the overlying squamous epithelium was present; p63 assisted in defining the squamous proliferation and highlighted its noninvasive nature. Conjunctival AGs, according to the literature review, occur almost exclusively in young females, clinically manifest as nodular foci with painless injection over the course of weeks, and histologically featured granulomatous inflammation and elastophagocytosis. The etiology of this entity is likely multifactorial, but its genesis revolves around actinic injury.

Conclusion:

AGs of the conjunctiva have likely been an underreported entity in the past. The authors’ review underscores the importance of including conjunctival AGs in the differential diagnosis of painless, subacute injected masses of the perilimbal conjunctiva. While it is benign, histopathologically separating AGs from neoplasia and other mimickers such pinguecula, foreign body granulomas, allergic, or rheumatoid nodules is essential for optimal management.
Clinical Pathway for Vaso-Occlusive Pain Reduces Hospital Admissions
Authors: Jones Wallace , Jang Albert , Myers Leann , Dasgupta Aditi , DeBord Jessica
Published: February 2021

Background:

Vaso-occlusive pain leads to high acute care utilization among patients with sickle cell disease (SCD). Data suggest that clinical pathways (CPWs) reduce variation in the management of vaso-occlusive pain and improve clinical outcomes.

Methods:

We implemented and evaluated a CPW for vaso-occlusive pain at our institution using a before and after study design. The primary objective was to decrease acute care utilization among patients with SCD, which was assessed by the primary outcome measures of hospital length of stay (LOS), 30-day readmission rate, and total hospitalizations annually per patient. Secondary outcome measures were packed red blood cell transfusions, and acute chest syndrome incidence. Patient-controlled analgesia use and promethazine use were assessed to estimate CPW use.

Results:

Three hundred fourty-four admissions in 112 patients were analyzed, of which 193 admissions occurred pre-CPW and 151 admissions occurred post-CPW implementation. Post-CPW implementation, we observed a significant decrease in hospital admissions annually per patient, an increase in patient-controlled analgesia use, and a decrease in intravenous promethazine use. We observed trends toward decreased 30-day readmission rate and increased acute chest syndrome incidence, which were not statistically significant. No effect was found on hospital LOS.

Conclusions:

Clinical pathway implementation at our institution reduced variation in management and decreased hospital admissions for vaso-occlusive pain.
A Review of Chronic Comorbidities in Adults Living With HIV: State of the Science
Authors: Webel Allison R. , Schexnayder Julie , Cioe Patricia A. , Zuñiga Julie A.
Published: February 2021

People living with HIV are living longer, high-quality lives; however, as they age, this population is at increased risk for developing chronic comorbidities, including cardiovascular disease, certain types of cancer (e.g., lung, anal, and liver), and diabetes mellitus. The purpose of this state-of-the-science review is to provide an evidence-based summary on common physical comorbidities experienced by people living and aging with HIV. We focus on those chronic conditions that are prevalent and growing and share behavioral risk factors that are common in people living with HIV. We will discuss the current evidence on the epidemiology, physiology, prevention strategies, screening, and treatment options for people living with HIV across resource settings.