bluuebunny/crossref_metadata_2025 huggingface dataset:
Mechanism of posterior malleolar fracture of the ankle
Authors: Haraguchi Naoki , Armiger Robert S.
Published: April 2020

Objectives:

Ankle fracture treatment involves reduction of the bone fragments and stabilization of the joint by reversing the mechanics of injury. For posterior malleolar fracture however, the true mechanism is not understood, leading to a lack of consistent guidance on how to best treat this injury.

Methods:

Fifteen cadaver ankles were subjected to fracture loading that replicated the Lauge-Hansen pronation-external rotation mechanism. An axial load was applied to each specimen, which was mounted on a materials testing machine, and the foot was rotated externally to failure. Digital video cameras recorded the failure sequence of specific anatomic structures.

Results:

Posterior malleolar fracture occurred in 7 specimens. Of these, 1 was an intra-articular fracture, another was a fracture involving the entire posterior tibial margin consisting of 2 fragments: that of the posterior tubercle and that of the posteromedial margin of the tibial plafond, with the former judged to be a consequence of avulsion by the posterior inferior tibiofibular ligament and the latter a consequence of axial loading from the talus. In the remaining 5 specimens, the posterior malleolar fracture was a small extra-articular avulsion fracture.

Conclusions:

Fractures at the posterolateral corner of the distal tibia were shown to be avulsion fractures attributed to the posterior inferior tibiofibular ligament and produced by external rotation of the talus. A fracture involving the entire posterior tibial margin consisting of 2 fragments can be produced by a combination of avulsion by the posterior inferior tibiofibular ligament and axial loading from the talus.
The global burden of musculoskeletal injury in low and lower-middle income countries
Authors: Cordero Daniella M. , Miclau Theodore A. , Paul Alexandra V. , Morshed Saam , Miclau Theodore , Martin Claude , Shearer David W.
Published: April 2020

Background:

While the global burden of musculoskeletal injury is increasingly recognized, few epidemiologic studies have specifically recorded its incidence or prevalence, particularly in low- and middle-income countries. Understanding the burden of musculoskeletal injury relative to other health conditions is critical to effective allocation of resources to mitigate the disability that results from trauma. The current study aims to systematically review the existing primary literature on the incidence and prevalence of pelvic and appendicular fractures, a major component of musculoskeletal injury, in low- and lower-middle income countries (LMICs).

Methods:

This study conforms to the systematic review and traditional meta-analysis guidelines outlined in the PRISMA-P statement. Incidence rates were calculated as the occurrence of new fracture cases per 100,000 person-years, and prevalence as total fracture cases per population sample, reported as percentages.

Results:

The literature search yielded 3497 total citations. There were 21 full-text articles, representing 14 different countries, selected for data extraction. Included studies reported a wide range of incidence and prevalence rates, with an overall mean fracture incidence ranging from 779 (95% CI: 483.0–1188.7) to 1574 (95% CI: 1285.1–1915.1) per 100,000 person-years.

Conclusion:

Better understanding the unmet burden of musculoskeletal injury in LMICs is critical to effectively allocating resources and advocating for underserved populations. To address existing gaps and heterogeneity within the literature, future research should incorporate population-based sampling with broader geographic representation in LMICs to more accurately capture the burden of disease.
Does Pregnancy Predict Incisional Hernia Repair after Abdominally Based Autologous Breast Reconstruction? A Retrospective Review of 890 Free Flaps
Authors: Mauch Jaclyn T. , Kozak Geoffrey M. , Rhemtulla Irfan A. , Nathan Shelby L. , Tecce Michael , Broach Robyn B. , Serletti Joseph M.
Published: April 2020

Background:

The abdomen is a common donor site in autologous breast reconstruction. The authors aimed to determine whether pregnancy following autologous breast reconstruction increases the risk of incisional hernia repair.

Methods:

All women younger than 50 years who underwent abdominally based autologous breast reconstruction between 2005 and 2016 were identified. Patients with less than 20 months of follow-up were excluded. Demographics, operative details, outcomes, incisional hernia repair occurrence, and pregnancy history were analyzed.

Results:

Five hundred nineteen patients underwent autologous breast reconstruction with 890 free flaps [free transverse rectus abdominis musculocutaneous, n = 645 (72.5 percent); deep inferior epigastric perforator, n = 214 (24.0 percent); pedicled transverse rectus abdominis musculocutaneous, n = 18 (2.0 percent); and superficial inferior epigastric artery, n = 13 (1.5 percent)]. Average follow-up was 57.2 months (range, 9.5 to 312.8 months). Fourteen women became pregnant, with mean postpregnancy follow-up of 31.2 months (range, 5.4 to 70.8 months; pregnancies, n = 18). Age of nonpregnant patients (mean, 43.1 years; range, 20.6 to 50.0 years) was higher than that of pregnant patients (mean, 32.1 years; range, 27.1 to 37.9 years) (p < 0.0001); in univariate analysis, age was not associated with incisional hernia repair. Twelve pregnant patients (66.7 percent) underwent cesarean delivery. No statistically significant differences existed between groups regarding flap type and closure technique. Zero pregnant patients underwent incisional hernia repair, compared with a 6.1 percent incisional hernia repair rate in nonpregnant patients (p = 0.339). In multivariate analysis, prior incisional hernia, hematoma, fascial dehiscence, and reoperation predicted incisional hernia repair.

Conclusion:

The authors’ results demonstrate that there may not be an increased risk of incisional hernia repair associated with pregnancy following autologous breast reconstruction despite additional weakening of the abdominal wall.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, II.
Patient-Reported Outcomes after Irradiation of Tissue Expander versus Permanent Implant in Breast Reconstruction: A Multicenter Prospective Study
Authors: Yoon Alfred P. , Qi Ji , Kim Hyungjin M. , Hamill Jennifer B. , Jagsi Reshma , Pusic Andrea L. , Wilkins Edwin G. , Kozlow Jeffrey H.
Published: April 2020

Background:

Whether to irradiate the tissue expander before implant exchange or to defer irradiation until after exchange in immediate, two-stage expander/implant reconstruction remains uncertain. The authors evaluated the effects of irradiation timing on complication rates and patient-reported outcomes in patients undergoing immediate expander/implant reconstruction.

Methods:

Immediate expander/implant reconstruction patients undergoing postmastectomy radiation therapy at 11 Mastectomy Reconstruction Outcomes Consortium sites with demographic, clinical, and complication data were analyzed. Patient-reported outcomes were assessed with BREAST-Q, Patient-Reported Outcomes Measurement Information System, and European Organisation for Research and Treatment of Cancer Breast Cancer–Specific Quality-of-Life Questionnaire surveys preoperatively and 2 years postoperatively. Survey scores and complication rates were analyzed using bivariate comparison and multivariable regressions.

Results:

Of 317 patients who met inclusion criteria, 237 underwent postmastectomy radiation therapy before expander/implant exchange (before-exchange cohort), and 80 did so after exchange (after-exchange cohort). Timing of radiation had no significant effect on risks of overall complications (OR, 1.25; p = 0.46), major complications (OR, 1.18; p = 0.62), or reconstructive failure (OR, 0.72; p = 0.49). Similarly, radiation timing had no significant effect on 2-year patient-reported outcomes measured by the BREAST-Q or the European Organisation for Research and Treatment of Cancer survey. Outcomes measured by the Patient-Reported Outcomes Measurement Information System showed less anxiety, fatigue, and depression in the after-exchange group. Compared with preoperative assessments, 2-year patient-reported outcomes significantly declined in both cohorts for Satisfaction with Breasts, Physical Well-Being, and Sexual Well-Being, but improved for anxiety and depression.

Conclusions:

Radiation timing (before or after exchange) had no significant effect on complication risks or on most patient-reported outcomes in immediate expander/implant reconstruction. Although lower levels of anxiety, depression, and fatigue were observed in the after-exchange group, these differences may not be clinically significant.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, II.
Early Surgical Management of Medical Tourism Complications Improves Patient Outcomes
Authors: Adabi Kian , Stern Carrie S. , Kinkhabwala Corin M. , Weichman Katie E. , Garfein Evan S. , Tepper Oren M. , Conejero J. Alejandro
Published: April 2020

Background:

Complications from medical tourism can be significant, requiring aggressive treatment at initial presentation. This study evaluates the effect of early surgical versus conservative management on readmission rates and costs.

Methods:

A single-center retrospective review was conducted from May of 2013 to May of 2017 of patients presenting with soft-tissue infections after cosmetic surgery performed abroad. Patients were categorized into two groups based on their management at initial presentation as either conservative or surgical. Demographic information, the procedures performed abroad, and the severity of infection were included. The authors’ primary outcome was the incidence of readmission in the two groups. International Classification of Diseases, Ninth Revision; International Classification of Diseases, Tenth Revision; and CPT codes were used for direct-billed cost analysis.

Results:

Fifty-three patients (one man and 52 women) presented with complications after procedures performed abroad, of which 37 were soft-tissue infections. Twenty-four patients with soft-tissue infections at initial presentation were managed conservatively, and 13 patients were treated surgically. The two groups were similar in patient demographics and type of procedure performed abroad. Patients who were managed conservatively at initial presentation had a higher rate of readmission despite having lower severity of infections (OR, 4.7; p = 0.037). A significantly lower total cost of treatment was shown with early surgical management of these complications (p = 0.003).

Conclusions:

Conservative management of complications from medical tourism has resulted in a high incidence of failure, leading to readmission and increased costs. This can contribute to poor outcomes in patients that are already having complications from cosmetic surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Docosahexaenoic Acid Improves Diabetic Wound Healing in a Rat Model by Restoring Impaired Plasticity of Macrophage Progenitor Cells
Authors: Jia Ya-Chao , Qiu Shuo , Xu Jia , Kang Qing-Lin , Chai Yi-Min
Published: April 2020

Background:

Chronic inflammation associated with delayed diabetic wound healing is induced by disturbed polarization of macrophages derived mainly from predisposed progenitor cells in bone marrow. Docosahexaenoic acid plays a critical role in regulating the function of macrophage progenitor cells. The authors evaluated whether docosahexaenoic acid accelerates diabetic wound healing in rats.

Methods:

Streptozotocin-induced diabetic rats divided into control and docosahexaenoic acid–treated groups (n = 10) were subjected to paired dorsal skin wounds. Docosahexaenoic acid (100 mg/kg per day) was orally supplemented 2 weeks before wounding until termination. The wound healing process was recorded 0, 7, and 14 days after wounding. At day 7, blood perfusion was measured by laser Doppler perfusion imaging; angiogenesis was compared using immunofluorescent CD31 and α-smooth muscle actin staining; macrophage polarization was detected using immunofluorescence for CD68, CD206, and inducible nitric oxide synthase. Hematoxylin and eosin staining was used to examine wound healing at day 14. Activation status of macrophages derived from bone marrow cells in normal, diabetic, and docosahexaenoic acid–treated diabetic rats was determined in vitro using Western blotting and enzyme-linked immunosorbent assay.

Results:

Docosahexaenoic acid significantly accelerated wound healing 7 and 14 days (p < 0.01) after wounding. Increased vessel densities (1.96-fold; p < 0.001) and blood perfusion (2.56-fold; p < 0.001) were observed in docosahexaenoic acid–treated wounds. Immunofluorescence revealed more CD206+ and fewer inducible nitric oxide synthase–positive macrophages (p < 0.001) in treated wounds. Furthermore, macrophages derived from diabetic rats expressed higher levels of inducible nitric oxide synthase and tumor necrosis factor-α and lower arginase-1 and interleukin-10 (p < 0.05).

Conclusion:

Docosahexaenoic acid accelerates diabetic wound healing at least in part by restoring impaired plasticity of macrophage progenitor cells.
Pediatric Skull Fracture Characteristics Associated with the Development of Leptomeningeal Cysts in Young Children after Trauma: A Single Institution’s Experience
Authors: Lopez Joseph , Chen Jennifer , Purvis Taylor , Reategui Alvaro , Khavanin Nima , Iyer Rajiv , Manson Paul N. , Dorafshar Amir H. , Cohen Alan R. , Redett Richard J.
Published: April 2020

Background:

Currently, the pathogenesis of leptomeningeal cysts, also known as growing skull fractures, is still debated. The purpose of this study was to examine the specific skull fracture characteristics that are associated with the development of growing skull fractures and describe the authors’ institutional experience managing this rare entity.

Methods:

A retrospective cohort study was performed that included all patients younger than 5 years presenting to a single institution with skull fractures from 2003 to 2017. Patient demographics, cause of injury, skull fracture characteristics (e.g., amount of diastasis, linear versus comminuted fracture), concomitant neurologic injuries, and management outcomes were recorded. Potential factors contributing to the development of a growing skull fracture and neurologic injuries associated with growing skull fractures were evaluated using univariate logistic regression.

Results:

A total of 905 patients met the authors’ inclusion criteria. Of these, six (0.66 percent) were diagnosed with a growing skull fracture. Growing skull fractures were more likely to be comminuted (83.3 percent versus 40.7 percent; p = 0.082) and to present with diastasis on imaging (100 percent versus 26.1 percent; p < 0.001; mean amount of diastasis, 7.1 mm versus 3.1 mm; p < 0.001). Univariate logistic regression analysis confirmed the role of a comminuted fracture pattern (OR, 7.572) and the degree of diastasis (OR, 2.081 per mm diastasis) as significant risk factors for the development of growing skull fractures.

Conclusions:

The authors’ analysis revealed that fracture comminution and diastasis width are associated with the development of growing skull fractures. The authors recommend dural integrity assessment, close follow-up, and early management in young children who present with these skull fracture characteristics.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, III.
Identifying Factors Most Important to Lower Extremity Trauma Patients: Key Concepts from the Development of a Patient-Reported Outcome Instrument for Lower Extremity Trauma, The LIMB-Q
Authors: Mundy Lily R. , Klassen Anne , Grier A. Jordan , Gibbons Christopher , Lane Whitney , Carty Matthew J. , Pusic Andrea L. , Hollenbeck Scott T. , Gage Mark J.
Published: April 2020

Background:

Severe lower extremity injuries are challenging to treat. The aspects of limb salvage and amputation most important to patients are not well-defined. This study’s aim is to develop a conceptual framework for a patient-reported outcome instrument for lower extremity trauma patients, by defining issues and concepts most important to this patient population.

Methods:

This is an interpretative description of transcripts collected from semistructured qualitative interviews at a single institution. High-energy lower extremity trauma patients were recruited by means of purposeful sampling to maximize variability. Thirty-three participant interviews were needed to reach content saturation. These participants were aged 19 to 79 years; 21 were men (63.6 percent); participation was after reconstruction [n= 15 (45.5 percent)], after amputation [n = 11 (33.3 percent)], or after amputation after failed reconstruction [n = 7 (21.2 percent)]. Interviews were recorded, transcribed, and coded line-by-line. Concepts were labeled with major and minor themes and refined through a process of constant comparison. Analysis led to the development of a conceptual framework and item pool to inform the development of a patient-reported outcome measure.

Results:

In total, 2430 unique codes were identified and used to generate the conceptual framework covering 10 major themes: appearance, environment, finances, physical, process of care, prosthesis, psychological, sexual, social, and treatment.

Conclusions:

This study establishes a comprehensive set of concepts, identifying what is most important to severe lower extremity trauma patients. These findings can be used to inform and focus research and clinical care, and provides the framework to develop a lower extremity trauma-specific patient-reported outcome instrument: the LIMB-Q.
Secondary Salvage of the Unsatisfactory Microtia Reconstruction
Authors: Reinisch John F. , van Hövell tot Westerflier Claire V. A. , Gould Daniel J. , Tahiri Youssef T.
Published: April 2020

Background:

Because auricular reconstruction is a complex and relatively uncommon procedure, there are many patients that have had disappointing reconstructions. This study describes the authors’ large experience with secondary procedures in patients with unsatisfactory or failed initial ear reconstruction.

Methods:

A prospectively maintained database of all consecutive patients who underwent secondary total ear reconstruction from March of 1991 to December of 2017 was reviewed. Demographic data and outcomes were assessed. Patients with acquired absence of the ear were not included.

Results:

There were 144 microtia patients that met the inclusion criteria. Patient age at the time of the secondary reconstruction ranged from 3 to 59 years. Follow-up duration ranged from 1 to 21 years. Primary reconstruction was performed with rib cartilage in 91 patients, porous polyethylene implant in 47 patients, prosthesis in four patients, and irradiated cadaver rib cartilage in two patients. All secondary reconstructions were performed with porous polyethylene implants. The alloplastic framework was covered with a temporoparietal fascia flap in 76 patients, an occipital fascia flap in 64 patients, and a free fascia flap in four patients (two radial forearm flaps in the same patient, one contralateral temporoparietal fascia flap, and one lateral arm flap). Fourteen patients (10 percent) had complications requiring revision surgery. Secondary surgery was successful in all but one patient.

Conclusions:

These data represent the largest series of secondary total ear reconstructions. The use of a porous polyethylene implant is an ideal method for these patients because of its minimal morbidity and relatively low complication rate.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
No-Touch Technique of Mesh Placement in Ventral Hernia Repair: Minimizing Postoperative Mesh Infections
Authors: Schneeberger Steven J. , Kraft Casey T. , Janis Jeffrey E.
Published: April 2020

Synthetic mesh is commonly used in ventral hernia repairs to reinforce the abdominal closure and minimize hernia recurrence rates. However, the use of synthetic mesh is associated with certain risks, most notably infection requiring explantation. This study sought to evaluate the use of a “no-touch” technique with antibiotic solution during synthetic mesh placement in ventral hernia repairs and its impact on complication/infection rates. The authors retrospectively reviewed a prospectively maintained database of patients undergoing abdominal wall reconstruction with synthetic mesh from 2013 to 2018 by a single surgeon with a minimum 1-year follow-up. Data collected included demographic data, medical comorbidities, hernia history, and the type of antibiotics used in the no-touch technique. Complications were stratified into short-term (<30 days), medium-term (30 to 90 days), and long-term (91 to 365 days) complications. Results were compared to previously published rates in the literature. Eighty-eight patients met inclusion criteria. Fourteen patients (15.9 percent) experienced postoperative complications (two patients had multiple complications); six of these patients (6.8 percent) were readmitted to the hospital for management. Subsequently, three of the readmitted patients (3.4 percent) required reoperations related to abdominal infection and required removal of the synthetic mesh. A total of 16 complication events occurred in the cohort: 13 short-term complications (81.3 percent), three medium-term complications (18.7 percent), and zero long-term complications. The authors conclude that the no-touch technique for mesh placement in ventral hernia repairs appears to be efficacious in minimizing infectious complications with mesh placement, although further prospective studies are required to further define this relationship.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Direct-to-Implant Breast Reconstruction with Simultaneous Nipple-Sparing Mastopexy Utilizing an Inferiorly Based Adipodermal Flap: Our Experience with Prepectoral and Subpectoral Techniques
Authors: Mosharrafa Ali M. , Mosharrafa Tamir M. , Zannis Victor J.
Published: April 2020

Background:

Direct-to-implant breast reconstruction continues to grow in popularity among reconstructive breast surgeons and patients alike. Women with large breasts and ptosis are often thought not to be candidates for nipple sparing or direct-to-implant reconstruction. The authors utilized a single-stage, nipple-sparing, direct-to-implant reconstruction with simultaneous mastopexy, while the nipple-areolar complex was kept viable on an inferiorly based adipodermal flap in a single stage. They report their experience and outcomes using this approach in women with breast ptosis and/or macromastia.

Methods:

The authors reviewed all direct-to-implant reconstructions with simultaneous nipple-sparing mastopexies performed from June of 2015 to March of 2019. Sixty-five patients and 125 breast reconstructions were analyzed.

Results:

Among the 65 patients (125 breast reconstructions), 15 (23 percent) had implants placed in the prepectoral space, and 50 (77 percent) had them placed subpectorally. Forty-seven patients (72 percent) had acellular dermal matrix used. Partial nipple-areolar complex necrosis occurred in six patients (9 percent). Other complications included partial mastectomy flap necrosis (n = 8 patients, 12 percent), implant exposure (n = 3, 4 percent), infection (n = 1, 1 percent), capsular contracture (n = 4, 6 percent), and reoperation (n = 11, 16 percent). Mean follow-up was 17 months (range, 3 to 47 months). There have been no cancer recurrences reported in any participants to date.

Conclusions:

Nipple-sparing mastectomy with mastopexy and immediate direct-to-implant reconstruction dramatically improved the authors’ results for implant-based breast reconstruction patients. The higher than expected explantation rate of 7 percent early in the study has since improved. This approach provides an opportunity to expand indications for nipple-sparing mastectomy and direct-to-implant reconstruction to women with breast ptosis and/or macromastia.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Activation Status of NLRP3 Inflammasome in Peripheral Blood Mononuclear Cells From Patients With Gout Flare
Authors: Amezcua-Castillo Luis M. , Juárez-Vicuña Yaneli , Márquez-Velasco Ricardo , Amezcua-Guerra Luis M.
Published: April 2020

Background/Objective

Although gout flares are featured by systemic signs of inflammation, cellular sources of inflammatory mediators are not yet properly characterized. Our objective was to evaluate serum levels and gene expression in peripheral blood mononuclear cells (PBMCs) of several molecules associated with the activation of NLRP3 inflammasome.

Methods

Fifteen patients with gout flare and 15 individuals with asymptomatic hyperuricemia were cross-sectionally studied. Serum levels of interleukin 1β (IL-1β), IL-18, monocyte chemoattractant protein 1/chemokine (C-C motif) ligand 2 (CCL2), and vascular cell adhesion molecule 1 were measured as a reflection of systemic inflammation, whereas the expression of NLRP3, CASP1, IL18, and CCL2 genes was measured to assess the inflammatory characteristics of PBMCs.

Results

Serum levels of IL-1β (1.27 [0.07–1.99] pg/mL vs. 0 [0–0.82] pg/mL, p = 0.032) and vascular cell adhesion molecule 1 (606 [435–748] pg/mL vs. 349 [305–422] pg/mL, p = 0.014) were significantly higher in patients with gout flare than in individuals with asymptomatic hyperuricemia, whereas differences in IL-18 and monocyte chemoattractant protein 1/CCL2 were not found. Notably, no differences were observed in the expression of NLRP3, CASP1, IL18, or CCL2 in PBMCs from individuals of one or another group.

Conclusions

Systemic inflammation during gout flares does not appear to be associated with NLRP3 inflammasome activation in PBMCs, suggesting that it may represent the systemic spread of local (synovial) inflammation to monosodium urate crystals, which provides a rationale for redirecting anti-inflammatory therapy from a systemic approach to one centered on the inflamed joint.
Pearls and Pitfalls in Interpretation of 68Ga-DOTATOC PET Imaging
Authors: Bashir Asma , Broholm Helle , Clasen-Linde Erik , Vestergaard Mark B. , Law Ian
Published: April 2020

DOTA-D-Phe1-Tyr3-octreotide labeled with 68Ga (68Ga-DOTATOC) is the commonly used PET tracer for imaging meningioma because of its high affinity to somatostatin receptor subtype 2 (SSTR2) and an established imaging modality for planning radiation and radionuclide therapy. However, SSTR2 is not an exclusive marker for meningioma, and not all meningiomas express high levels of SSTR2. The SSTR2 expression has been reported in other intracranial tumors, for example, glioma, pituitary adenoma, medullablastoma, primitive neuroectodermal tumors, and hemangioblastoma leading to a significant risk of misinterpretation of PET/CT findings. We present 2 cases with similar 68Ga-DOTATOC uptakes in 2 distinct etiologies, for example, cerebral lymphoma and meningioma.
Extrastriatal Peri-infarct Accumulation of 99mTc-TRODAT
Authors: ArunRaj S. T. , Tripathi Madhavi , Tripathi Manjari , Sachani Hemant , Singh Roma , Jaleel Jasim , Shaikh Raja Gulfam , Bal Chandrasekhar
Published: April 2020

We describe the extrastriatal accumulation of dopamine transporter imaging agent 99mTc-TRODAT in the peri-infarct area in a 75-year-old man referred for dopamine transporter SPECT imaging with a suspicion of idiopathic Parkinson disease.
Real-Time DMSA-SPECT/US Fusion Imaging Revealing Nonscarring Loss of Function After Pyelonephritis
Authors: Freesmeyer Martin , Weigel Friederike , John Ulrike , Mentzel Hans-Joachim , Gühne Falk
Published: April 2020

Using real-time SPECT/US fusion imaging, the localization of an uptake defect in DMSA scan could be identified unambiguously after being uncertain in ultrasound alone. Thereby, a localized functional loss, due to history of pyelonephritis, without scarring, but reduced cortical thickness could be verified. DMSA-SPECT/US primarily demonstrates its utility in depiction of renal pathologies and may be a descriptive tool in equivocal constellation of findings.
Colon Adenocarcinoma Associated With Clostridium Septicum Endophthalmitis Detected on 18F-FDG PET/CT
Authors: Plouznikoff Nicolas , Artigas Carlos , Woff Erwin , Ene Diana , Flamen Patrick
Published: April 2020

Endogenous Clostridium septicum endophthalmitis is a rare and fulminant ocular infection, usually encountered in immunocompromised or diabetic patients. It is also highly associated with both gastrointestinal and hematologic malignancies. We describe herein the detection of an adenocarcinoma of the cecum on PET/CT with 18F-FDG in a patient with an active endogenous C. septicum endophthalmitis of the right eye. FDG PET/CT should be considered for all patients with endogenous endophthalmitis to exclude an occult malignancy, especially colorectal cancer.
99mTc-Besilesomab Scintigraphy in Soft Tissue Infections of the Lower Limbs
Authors: Barros Gouveia Patrícia , Valpaços Teixeira Ricardo Jorge , Alves de Sá Lemos Pinto Adriana , Amorim Maria Inês
Published: April 2020

Only a few studies and images of 99mTc-besilesomab scintigraphy are documented in the literature. We present a 99mTc-besilesomab image consistent with soft tissue infection of the lower limbs in a febrile 67-year-old man.
Hypoxia and Amino Acid Imaging of High-Grade Glioma
Authors: Mapelli Paola , Fallanca Federico , Scifo Paola , Barbera Maurizio , Castellano Antonella , Bettinardi Valentino , Incerti Elena , Gianolli Luigi , Anzalone Nicoletta , Picchio Maria
Published: April 2020

In the present case, we report the first experience of a patient with high-grade glioma who underwent dual 18F-FAZA PET/CT imaging for intratumoral hypoxia assessment, before treatment, and for therapy monitoring in the suspicious of recurrence, as part of a clinical research protocol. In addition, despite the diagnosis of glioblastoma, the patient at 3 years from diagnosis was alive and underwent 11C-methionine simultaneous PET/MRI for disease monitoring after treatment, showing stability of disease. The multitracer capability of PET in assessing different and complementary metabolic features along with the use of a last-generation scanner as PET/MRI in brain oncology are here enlighten.
Clinical Implications of 18F-FDG PET/CT in Malignant Glomus Tumors of the Esophagus
Authors: Seban Romain-David , Bozec Laurence , Champion Laurence
Published: April 2020

The majority of glomus tumors are localized to cutaneous sites and are benign. However, extracutaneous malignant glomus tumors have been reported and are aggressive. Here, we report a case of a 45-year-old man who presented severe dysphagia, diagnosed with malignant glomus tumor of the esophagus. 18F-FDG PET/CT played a decisive role in several phases of the patient management offering previously unknown accuracy. It was first performed in the initial staging of local tumor extent before surgery. A year and a half after, 18F-FDG PET/CT helped to detect recurrence and, finally, was performed for response evaluation of several systemic therapies.
Rib Plasmacytoma With Unusual Sunburst Periosteal Reaction
Authors: Singh Vijay , Suraj Ajay Kumar , Mishra Vineet , Ora Manish , Gambhir Sanjay
Published: April 2020

A 39-year-old man presented with progressive painful swelling on the left chest since 6 months. Examination revealed osseous consistency mass. CT of the thorax suggested mass arising from left fourth rib with intrathoracic and extrathoracic soft tissue components. It had extensive sunburst periosteal reaction consistent with primary malignant bone tumor. True cut biopsy revealed plasmacytoma. Routine hematological, biochemical, and bone marrow examinations were normal. Patient referred for whole-body 18F-FDG PET/CT to look for skeletal and bone marrow lesions. It revealed intensely metabolic left fourth rib lesion with periosteal reaction and no other lesion in the rest of the body.
18F-FDG PET/CT and Serial Chest CT Findings in a COVID-19 Patient With Dynamic Clinical Characteristics in Different Period
Authors: Liu Chunbao , Zhou Jun , Xia Liang , Cheng Xiaojie , Lu Diyu
Published: April 2020

Neurological symptoms and gastrointestinal symptoms were rare at onset in COVID-19. Here we report a 37-year-old man with vertigo, fever, and diarrhea symptoms as the first manifestation. 18F-FDG PET/CT spotted multiple ground glass opacity (GGO) lesions in the lungs, with increased tracer uptake in both lung GGOs and the whole colon. Serial CT examinations showed the emersion and dissipation of lung GGOs. We illustrate the symptoms initiation, the laboratory test results, the imaging examination, and the treatment strategy in the duration of COVID-19 with a timeline chart.
Outlook for Independent Plastic Surgery Training
Authors: Ovadia Steven A. , Thaller Seth R.
Published: April 2020

Introduction

Traditionally, plastic surgery training occurs through the independent model after completion of another surgical residency. Training is a minimum of 3 years in duration. Integrated training in contrast commences upon completion of medical school and is a minimum of 6 years. Independent programs have increasingly been converting positions to integrated positions. Our survey was designed to evaluate possible plans for further conversion of independent positions to integrated positions.

Methods

An electronic survey was prepared using the online survey platform Qualtrics. The survey questions were designed to solicit information regarding plans to convert independent positions to integrated positions. The survey was distributed by e-mail to program directors of the independent programs participating in the 2019 match. A reminder was sent 3.5 weeks after initial distribution, and results were collected for an additional 3 weeks.

Results

Sixteen program directors responded to our survey including 15 complete responses and 1 partial response representing a 40% response rate. Four respondents reported that they are considering decreasing their independent program by 1 position and converting the position to an integrated position. Three respondents reported that they are considering eliminating their independent program and converting to an integrated program. Each of these programs reported their independent program as having 1 position per year. With only a 40% response rate, 7 or more positions may be converted to integrated positions in the coming years.

Conclusions

Independent programs have been converting some or all positions to integrated positions. Although most plastic surgery positions were previously through the independent model, in 2019, 172 positions were offered through the integrated match compared with 63 for the independent match. Results of our study indicate that independent positions will continue to be converted to integrated positions for the next few years.
Management and outcomes of wartime cervical carotid artery injury
Authors: White Paul W. , Walker Patrick F. , Bozzay Joseph D. , Patel Jigarkumar A. , Rasmussen Todd E. , White Joseph M.
Published: April 2020

BACKGROUND

Cervical carotid artery injuries entail high morbidity and mortality and are technically challenging to repair. This retrospective study describes the management and outcomes of cervical carotid injuries sustained during the recent wars in Iraq and Afghanistan.

METHODS

The Department of Defense Trauma Registry was queried to identify US military personnel who sustained battle-related cervical carotid injury between January 2002 and December 2015. Retrospective chart reviews of the military Electronic Health Record were performed on patients identified. Demographics, injury characteristics, surgical management, and outcomes were reviewed. Statistical analysis was performed to identify associations between injury and management factors, as well as stroke and mortality.

RESULTS

In total, 67 patients (100% male; age, 25 ± 7 years) were identified with cervical carotid artery injuries. Fifty-six patients (84%) sustained a common carotid artery (CCA) or internal carotid artery (ICA) injury, and 11 patients (16%) had an isolated external carotid artery (ECA) injury. The anatomic distribution of injury was as follows: CCA, 26 (38.8%); ICA, 24 (35.8%); CCA and ICA 2 (3%); ICA and ECA 3 (4.5%); and CCA, ICA, and ECA 1 (1.5%). Of the 56 CCA or ICA injuries, 39 underwent vascular repair, 9 (16%) were managed with ligation, 1 was treated with a temporary vascular shunt but succumbed to injuries before vascular repair, and 7 (13%) were treated nonoperatively. Seven (23%) of 30 ICA injuries were ligated compared with 2 (7.7%) of 26 injuries isolated to the CCA (p = 0.02). Compared with repair, ligation of the CCA/ICA was associated with a higher rate of stroke (89% vs. 33%, p = 0.003) and increased mortality without statistical significance (22% vs. 10%, p = 0.3). Every patient who underwent ICA ligation had a stroke (7/7). There was no difference in Injury Severity Score between the ligation and repair groups (23.8 ± 10.6 vs. 24.7 ± 13.4, p = 0.9). At a mean follow-up of 34.5 months, 10 of 17 stroke survivors had permanent neurologic deficits.

CONCLUSION

In modern combat, penetrating injuries involving the cervical carotid arteries are relatively infrequent. In this experience, isolated ICA injuries were three times more likely to be ligated than those involving the CCA. As a surgical maneuver, ICA ligation resulted in stroke in all cases.

LEVEL OF EVIDENCE

Retrospective cohort analysis, level III.
Competing Risk Analysis in Renal Allograft Survival: A New Perspective to an Old Problem
Authors: El Ters Mireille , Smith Byron H. , Cosio Fernando G. , Kremers Walter K.
Published: April 2020

Background.

Graft survival after kidney transplant (KTX) is often estimated by the Kaplan-Meier (KM) method censoring for competing endpoints, primarily death. This method overestimates the incidence of graft loss.

Methods.

In 3157 adult KTX recipients followed for a mean of 79.2 months, we compared kidney and patient survival probabilities by KM versus competing risk analysis (CRA). These methods are extended to comparing different regression methods.

Results.

Compared with CRA, the probabilities of death and graft loss (censored for the other outcome) were substantially higher by KM. These differences increased with increasing follow-up time. Importantly, differences in graft losses were magnified in subgroups with greater probabilities of death. Among recipients with diabetes, the probabilities of graft loss at 20 years were 57% by KM and 32% by CRA, while for non-diabetes mellitus corresponding values were 44% and 35%. Similar results are noted when comparing older versus younger recipients. Finally, we find that the Fine-Gray method assumptions are violated when using age and gender as covariates and that the alternative method of Aalen-Johansen may be more appropriate.

Conclusions.

CRA provides more accurate estimates of long-term graft survival and death, particularly in subgroups of recipients with higher rates of the competing event. Overestimation of risk by KM leads to both quantitative and qualitative misinterpretations of long-term KTX outcomes. When using regression analyses, care should be taken to check assumptions to guide the choice of appropriate method.
Alpha-synuclein Levels in the Differential Diagnosis of Lewy Bodies Dementia and Other Neurodegenerative Disorders
Authors: Mavroudis Ioannis , Petridis Foivos , Chatzikonstantinou Symela , Kazis Dimitrios
Published: April 2020

Subjectives:

Lewy body dementia (LBD) is the second most common type of neurodegenerative dementia after Alzheimer disease (AD). It is characterized by the accumulation of Lewy bodies and Lewy neurites which are composed of aggregated phosphorylated alpha-synuclein, which is a presynaptic neuronal protein genetically and neuropathologically linked to Parkinson disease and to LBD. Alpha-synuclein is thought to contribute to LBD pathogenesis and to linked to disruption of cellular homeostasis and neuronal death, through effects on various intracellular targets, including synaptic function.

Methods:

In the present study, we did a meta-analysis on the reliability of alpha-synuclein levels in the cerebrospinal fluid (CSF) for the discrimination between LBD and other neurodegenerative disorders including AD, Parkinson disease (PD) dementia, progressive supranuclear palsy (PSP), multiple system atrophy (MSA) and frontotemporal dementia (FTD).

Results:

CSF alpha-synuclein levels were significantly different in LBD compared with AD, but no statistical difference was found between LBD, and dementia in PD, MSA, PSP, and FTD.

Conclusion:

Alpha-synuclein levels in the CSF can be used for the discrimination between LBD and AD, but not LBD and other neurodegenerative disorders such as dementia in PD, MSA, FTD, and PSP.
Chronic Constipation in the Community
Authors: Werth Barry L. , Fisher Murray J. , Williams Kylie A. , Pont Lisa G.
Published: April 2020

PURPOSE:

The aim of this study was to determine the prevalence of chronic constipation and identify factors associated with chronic constipation in community-dwelling adults.

DESIGN:

Cross-sectional study.

METHODS:

The target population was community-dwelling Australian adults; 1978 participants completed an online questionnaire exploring symptoms, management, and factors potentially associated with constipation. Chronic constipation was identified using Rome III criteria. Multivariate logistic regression model was used to identify factors associated with chronic constipation.

RESULTS:

The prevalence of chronic constipation was 23.9%. Factors significantly associated with chronic constipation in the multivariate model were female gender (odds ratio [OR] = 1.42, 95% confidence interval [CI], 1.12-1.81), current employment (OR = 1.45, 95% CI, 1.11-1.88), regular smoking (OR = 1.60, 95% CI, 1.19-2.14), poor self-rated health (OR = 2.57, 95% CI, 1.28-5.19), thyroid disease (OR = 1.77, 95% CI, 1.21-2.79), depression (OR = 1.49, 95% CI, 1.08-2.06), hemorrhoids (OR = 2.98, 95% CI, 1.84-4.83), irritable bowel syndrome (OR = 2.45, 95% CI, 1.73-3.46), and use of anti-inflammatory/antirheumatic medications (OR = 2.06, 95% CI, 1.15-3.68). In contrast to these factors, use of medications acting on the renin-angiotensin system was associated with a reduced likelihood of chronic constipation (OR = 0.47, 95% CI, 0.24-0.91).

CONCLUSIONS:

Chronic constipation is prevalent among community-dwelling adults. Various factors associated with chronic constipation have been identified, and knowledge of these factors may help health care professionals recognize individuals who are at high risk of chronic constipation.
Superspreaders help covid-19 elimination
Authors: Kault David
Published: April 2020

There seems to be widespread pessimism regarding the ability of a nation to eliminate covid. One factor in this pessimism seems to be concern that covid might always be able to re-emerge because of the ongoing presence of unrecognised asymptomatic cases. However, it is shown here that it should be possible to eliminate covid more easily than anticipated, for a reason that at first glance seems paradoxical - the presence of superspreaders. If superspreaders are responsible for most of the spread, then, with the average number of secondary cases fixed at say R0 = 2.5, we have to conclude that superspreaders are relatively rare. When towards the end of an elimination program, there are very few infected people, whether symptomatic or asymptomatic, that small number of people may well not include any superspreaders. As a result, chance effects may make extinction likely. Nevertheless it is clear an attempt at elimination will require a rather onerous “lockdown”. In this paper we use a branching processes model to look at the tradeoff between risk of disease re-emergence and the length of “lockdown” required after a program of elimination has dropped the number of symptomatic cases in a region to just one.
Estimated inequities in COVID-19 infection fatality rates by ethnicity for Aotearoa New Zealand
Authors: Steyn Nicholas , Binny Rachelle N. , Hannah Kate , Hendy Shaun C. , James Alex , Kukutai Tahu , Lustig Audrey , McLeod Melissa , Plank Michael J. , Ridings Kannan , Sporle Andrew
Published: April 2020

There is limited evidence as to how COVID-19 infection fatality rates (IFR) may vary by ethnicity. We combine demographic and health data for ethnic groupings in Aotearoa New Zealand with international data on IFR for different age groups to estimate inequities in IFR by ethnicity. We find that, if age is the dominant factor determining IFR, estimated IFR for Māori is around 50% higher than non-Māori. If underlying health conditions are more important than age per se, then estimated IFR for Māori is more than 2.5 times that of New Zealand European, and estimated IFR for Pasifika is almost double that of New Zealand European. IFRs for Māori and Pasifika are likely to be increased above these estimates by racism within the healthcare system and other inequities not reflected in official data. IFR does not account for differences among ethnicities in COVID-19 incidence, which could be higher in Māori and Pasifika as a result of crowded housing and higher inter- generational contact rates. These factors should be included in future disease incidence modelling. The communities at the highest risk will be those with elderly populations, and Māori and Pasifika communities, where the compounded effects of underlying health conditions, socioeconomic disadvantage, and structural racism result in imbricated risk of contracting COVID-19, becoming unwell, and death.
XGMix: Local-Ancestry Inference with Stacked XGBoost
Authors: Kumar Arvind , Montserrat Daniel Mas , Bustamante Carlos , Ioannidis Alexander
Published: April 2020

Abstract

Genomic medicine promises increased resolution for accurate diagnosis, for personalized treatment, and for identification of population-wide health burdens at rapidly decreasing cost (with a genotype now cheaper than an MRI and dropping). The benefits of this emerging form of affordable, data-driven medicine will accrue predominantly to those populations whose genetic associations have been mapped, so it is of increasing concern that over 80% of such genome-wide association studies (GWAS) have been conducted solely within individuals of European ancestry [1]. The severe under-representation of the majority of the world’s populations in genetic association studies stems in part from an addressable algorithmic weakness: lack of simple, accurate, and easily trained methods for identifying and annotating ancestry along the genome (local ancestry). Here we present such a method (XGMix) based on gradient boosted trees, which, while being accurate, is also simple to use, and fast to train, taking minutes on consumer-level laptops.
Statistical analysis of the impact of environmental temperature on the exponential growth rate of cases infected by COVID-19
Authors: Livadiotis G.
Published: April 2020

We perform a statistical analysis for understanding the effect of the environmental temperature on the exponential growth rate of the cases infected by COVID-19 for US and Italian regions. In particular, we analyze the datasets of regional infected cases, derive the growth rates for regions characterized by a readable exponential growth phase in their evolution spread curve and plot them against the environmental temperatures averaged within the same regions, derive the relationship between temperature and growth rate, and evaluate its statistical confidence. The results clearly support the first reported statistically significant relationship of negative correlation between the average environmental temperature and exponential growth rates of the infected cases. The critical temperature, which eliminates the exponential growth, and thus the COVID-19 spread in US regions, is estimated to be TC = 86.1 ± 4.3 F0.