bluuebunny/crossref_metadata_2025 huggingface dataset:
External Validation of the “Quick” Pediatric Logistic Organ Dysfunction-2 Score Using a Large North American Cohort of Critically Ill Children With Suspected Infection
Authors: Görges Matthias , Peters Cheryl , Murthy Srinivas , Pi Shanshan , Kissoon Niranjan
Published: September 2018

Objectives:

A quick Pediatric Logistic Organ Dysfunction 2 score on day 1, consisting of tachycardia, hypotension, and altered mentation, was shown to predict mortality with an area under the receiver operating characteristic curve of 82% (95% CI, 76–87%) in children admitted to a PICU with suspected infection. We performed an external validation of the quick Pediatric Logistic Organ Dysfunction 2, including its performance in predicting mortality in specific age groups.

Design:

Analysis of retrospective data obtained from the Virtual Pediatric Systems PICU registry.

Setting:

Prospectively collected clinical records from 130 participating PICUs in North America.

Patients:

Children admitted between January 2009 and December 2014, with a diagnosis of infection at discharge, for whom all required data were available.

Interventions:

None.

Measurements and Main Results:

Systolic blood pressures, heart rates, and Glasgow Coma Scale scores were used to evaluate the quick Pediatric Logistic Organ Dysfunction 2 using area under the receiver operating characteristic curve analysis. Performance was compared with Pediatric Risk of Mortality 3 and Pediatric Index of Mortality 2 risk scores. Data from 42,196 children with complete data were analyzed, with median age 2.7 years (interquartile range, 0.7–8.8 yr; range 0–18 yr) and a 4.27% mortality rate. Mortality was 13.4% for quick Pediatric Logistic Organ Dysfunction 2 greater than or equal to 2 and 2.5% for quick Pediatric Logistic Organ Dysfunction 2 less than 2, representing a false-negative rate of 49.5%. Also 311 children (17%) who died had a quick Pediatric Logistic Organ Dysfunction 2 score of 0. The area under the receiver operating characteristic curve was 72.6% (95% CI, 71.4–73.8%) for quick Pediatric Logistic Organ Dysfunction 2, compared with 85.0% (95% CI, 84.0–86.0%) for Pediatric Risk of Mortality 3 and 81.5% (95% CI, 80.5–82.5%) for Pediatric Index of Mortality 2. Performance of quick Pediatric Logistic Organ Dysfunction 2 was worst in the greater than 12 years age group (area under the receiver operating characteristic curve, 67.8%; 95% CI, 65–70.5) and best in the less than 1 month age group (area under the receiver operating characteristic curve, 78.9%; 95% CI, 75.3–82.4).

Conclusions:

Quick Pediatric Logistic Organ Dysfunction 2 performed markedly worse in our cohort, compared with the original study, and the high rate of false negatives limits its clinical utility in our population. Further work is needed to develop a robust quick pediatric sepsis diagnostic tool for both research and clinical care.
Prevalence and Prognostic Value of Abnormal Liver Test Results in Critically Ill Children and the Impact of Delaying Parenteral Nutrition*
Authors: Jenniskens Marc , Güiza Fabian , Haghedooren Renata , Verbruggen Sascha , Joosten Koen , Langouche Lies , Van den Berghe Greet
Published: September 2018

Objectives:

In the Early versus Late Parenteral Nutrition in the Pediatric ICU randomized controlled trial, delaying parenteral nutrition to beyond day 7 (late parenteral nutrition) was clinically superior to supplemental parenteral nutrition initiated within 24 hours (early parenteral nutrition), but resulted in a higher rise in bilirubin. We aimed to document prevalence and prognostic value of abnormal liver tests in the PICU and the impact hereon of withholding early parenteral nutrition.

Design:

Preplanned secondary analysis of the Early versus Late Parenteral Nutrition in the Pediatric ICU randomized controlled trial. Total bilirubin, alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transpeptidase, alkaline phosphatase plasma concentrations were measured systematically in PICU. Liver test analyses were adjusted for baseline characteristics including severity of illness.

Setting:

Three PICUs in Belgium, the Netherlands, and Canada.

Patients:

As neonatal jaundice was considered a confounder, only the 1,231 of the 1,440 Early versus Late Parenteral Nutrition in the Pediatric ICU-patients 28 days to 17 years old were included.

Interventions:

Late parenteral nutrition as compared with early parenteral nutrition.

Measurements and Main Results:

During the first seven PICU days, the prevalence of cholestasis (> 2 mg/dL [34.2 μmol/L] bilirubin) ranged between 3.8% and 4.9% and of hypoxic hepatitis (≥ 20-fold upper limit of normality for alanine aminotransferase and aspartate aminotransferase) between 0.8% and 2.2%, both unaffected by the use of parenteral nutrition. Throughout the first week in PICU plasma bilirubin concentrations were higher in late parenteral nutrition patients (p < 0.05), but became comparable to early parenteral nutrition patients as soon as parenteral nutrition was started on day 8. Plasma concentrations of gamma-glutamyl transpeptidase, alkaline phosphatase, alanine aminotransferase, and aspartate aminotransferase were unaffected by parenteral nutrition. High day 1 plasma concentrations of gamma-glutamyl transpeptidase, alanine aminotransferase, and aspartate aminotransferase (p ≤ 0.01), but not alkaline phosphatase, were independent risk factors for PICU mortality. Day 1 plasma bilirubin concentrations displayed a U-shaped association with PICU mortality, with higher mortality associated with bilirubin less than 0.20 mg/dL and greater than 0.76 mg/dL (< 3.42 μmol/L and > 13 μmol/L) (p ≤ 0.01).

Conclusions:

Overt cholestasis and hypoxic hepatitis were rare and unrelated to the nutritional strategy. However, withholding parenteral nutrition up to 1 week in PICU increased plasma bilirubin. A mild elevation of bilirubin on the first PICU day was associated with lower risk of death and may reflect a stress response, rather than true cholestasis.
PICU Autopsies: Rates, Patient Characteristics, and the Role of the Medical Examiner*
Authors: Basu Sonali , Holubkov Richard , Dean J. Michael , Meert Kathleen L. , Berg Robert A. , Carcillo Joseph , Newth Christopher J. L. , Harrison Rick E. , Pollack Murray M.
Published: September 2018

Objectives:

Autopsy rates in North American Children’s hospitals have not been recently evaluated. Our objectives were 1) to determine the autopsy rates from patients cared for in PICUs during a portion of their hospital stay, 2) to identify patient characteristics associated with autopsies, and 3) to understand the relative role of medical examiner cases.

Design:

Secondary analysis of data prospectively collected from a sample of patients (n = 10,078) admitted to PICUs affiliated with the Collaborative Pediatric Critical Care Research Network between December 2011 and April 2013.

Setting:

Eight quaternary care PICUs.

Patients:

Patients in the primary study were less than 18 years old, admitted to a PICU and not moribund on PICU admission. Patients included in this analysis were those who died during their hospital stay.

Interventions:

None.

Measurements and Main Results:

Sociodemographic, clinical, hospital, and PICU data were compared between patients who had autopsies conducted and those who did not and between medical examiner and nonmedical examiner autopsies. Of 10,078 patients, 275 died of which 36% (n = 100) had an autopsy performed. Patients with cancer who died were less likely to receive autopsies (p = 0.005), whereas those who died after trauma or cardiac arrest had autopsies performed more often (p < 0.01). Autopsies were more common in patients with greater physiologic instability at admission (p < 0.001), and those who received more aggressive PICU care. Medical examiner cases comprised nearly half of all autopsies (n = 47; 47%) were conducted in patients presenting with greater physiologic instability (p < 0.001) and more commonly after catastrophic events such as cardiac arrest or trauma (p < 0.001).

Conclusions:

In this first multicenter analysis of autopsy rates in children, 36% of deaths had autopsies conducted, of which nearly half were conducted by the medical examiner. Deaths with autopsy are more likely to be previously healthy children that had catastrophic events prior to admission.
Analysis of Patient Characteristics and Risk Factors for Thrombosis After Surgery for Congenital Heart Disease
Authors: Murphy Lee D. , Benneyworth Brian D. , Moser Elizabeth A. S. , Hege Kerry M. , Valentine Kevin M. , Mastropietro Christopher W.
Published: September 2018

Objectives:

Thrombosis is a cause of morbidity in 4–15% of children who undergo pediatric cardiac surgery. Data on how to prevent this complication are sorely needed. We aimed to identify risk factors for thrombosis following pediatric cardiac surgery and determine if use of low molecular weight heparin prophylaxis is associated with a reduction in thrombosis risk.

Design:

Retrospective cohort study.

Setting:

Tertiary pediatric cardiovascular ICU.

Patients:

Patients who underwent cardiac surgery between June 2014 and December 2015.

Interventions:

None.

Measurements and Main Results:

Data from patients with venous or arterial thrombosis confirmed by radiologic studies were matched two-to-one to controls based on age, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery mortality category, and gender. Thrombosis was detected in 33 patients (6.2%): 25 patients (76%) had venous thromboses, five patients (15%) had arterial thromboses, and three patients (9%) had both. Median time to thrombosis detection was 13 days (25–75%; 7–31 d). On multivariate analysis, which included adjustment for postoperative disease severity, fresh frozen plasma exposure was independently associated with thrombosis (odds ratio, 3.7; 95% CI, 1.4–9.4). Twenty-eight patients (85%) had central venous catheter-related thromboses. Low molecular weight heparin prophylaxis use in this subset of patients was not statistically different from controls (50% vs 45%, respectively; p = 0.47). On multivariable analysis, fresh frozen plasma exposure was also independently associated with central venous catheter-related thrombosis (odds ratio, 3.6; 95% CI, 1.2–10.6).

Conclusions:

The occurrence of thrombosis after pediatric cardiac surgery at our institution was 6.2%, similar to what has been reported in other studies, despite frequent use of low molecular weight heparin. Further study is needed to determine the role of low molecular weight heparin for thromboprophylaxis and the relationship between fresh frozen plasma and thrombosis risk in children who undergo cardiac surgery.
Interhospital Transport of Pediatric Patients in Denmark
Authors: Brønnum Nystrup Kristin , Poorisrisak Porntiva , Breindahl Morten , Hallas Peter
Published: September 2018

Objectives

No national guidelines exist in Denmark regarding interhospital transport of critically ill children. The aim of this study was to disclose which physicians actually accompany critically ill children during interhospital transports nationwide and whether the physicians have adequate clinical skills to perform interhospital transfers.

Methods

A questionnaire was sent to the youngest pediatrician on-call at every hospital in Denmark receiving pediatric emergencies except the tertiary Copenhagen University Hospital, Rigshospitalet.

Results

Seventeen pediatric departments were contacted (response rate, 100%). All departments indicated that they perform interhospital transport of pediatric patients. When presented with 5 cases, great heterogeneity in the choice of transport physician and accompanying staff was seen. With increasing severity, fewer pediatricians were willing to transport the children (24% vs 6%). Irrespective of the degree of severity, more transports were delegated to anesthesiologists than performed by pediatricians. Pediatricians who agreed to transport the infant and neonate had adequate competencies. In cases with older children, 0 to 75% of physicians who would do the transport had adequate clinical skills and experience in emergency pediatric respiratory and cardiovascular management. Training in interhospital transport was offered by 1 department; 6 departments (35%) had local guidelines describing the management of pediatric transports.

Conclusions

Great heterogeneity was found in the local transport strategies and practical skill sets of accompanying physicians. Overall, there is room for improvement in the management of interhospital transport of critically ill children in Denmark, perhaps by increasing the availability of specialized pediatric transport services for critically ill children nationwide.
Influenza A–Associated Epiglottitis and Compensatory Pursed Lip Breathing in an Infant
Authors: O'Bryant Shelease C. , Lewis Jonathan D. , Cruz Andrea T. , Mothner Brent A.
Published: September 2018

The last 3 decades have seen a shift in the epidemiology of epiglottitis. Epiglottitis was once most commonly associated withHaemophilus influenzaetype B. However, with the implementation of theH. influenzaetype B vaccine in 1985, the incidence has drastically declined. There are now new emerging pathogens—bacteria, viruses, and fungi—causing epiglottitis. Here, we report the first case of epiglottitis secondary to influenza A in a former full-term, vaccinated infant who presented with cough, fever, stridor, pursed lip breathing, and progressive respiratory distress and eventual respiratory failure. This case highlights the presentation and clinical course of epiglottitis and describes a rare clinical feature, pursed lip breathing, in an infant.
Parental Attitudes and Knowledge About Lumbar Puncture in Children
Authors: Acoglu Esma Altinel , Oguz Melahat Melek , Sari Eyup , Yucel Husniye , Akcaboy Meltem , Zorlu Pelin , Sahin Sanliay , Senel Saliha
Published: September 2018

Objectives

Lumbar puncture (LP) is fundamental for diagnosis and treatment; however, some parents do not provide consent for their children to undergo the procedure, which can make diagnosis and determination of the optimal treatment difficult. The present study aimed to describe the level of knowledge and attitudes toward LP of parents whose children were scheduled to undergo the procedure.

Methods

A prospective cross-sectional descriptive study of a convenience sample of parents of 84 children aged 2 months to 17 years scheduled for LP at a single academic children's hospital between 2015 and 2017. Parents were administered a written survey and interviewed by a physician other than the person who did the LP. Data on parental level of knowledge and attitudes regarding LP, in addition to reasons for refusal, were collected.

The parents of 84 patients scheduled for LP due to various indications were administered a face-to-face survey interview. The survey was used to collect parental demographic data, as well as opinions and knowledge about LP and postinterventional complications.

Results

The mean age of the 84 patients (57% male and 43% female) was 6.4 ± 5.17 years. Lumbar puncture was planned for the presumptive diagnosis of neurological disease in 45.25% of the patients, central nervous system infection in 45.25%, and acute encephalopathy in 9.5%. Among the parents, 65% (n = 55) had no knowledge or attitude about LP prior to the survey interview. The most common parental concern related to LP was paralysis (25%), followed by infertility (2%), mental retardation (1%), and disease progression (1%). Only 4.7% of the parents did not provide consent for their child to undergo LP.

Conclusions

We found that most parents had little knowledge about LP, and the most common parental concern was paralysis. Despite this, in our study, only 5% of parents did not consent to LP.
Pediatric Malpractice Claims in the Emergency Department and Urgent Care Settings From 2001 to 2015
Authors: Glerum Kimberly M. , Selbst Steven M. , Parikh P. Divya , Zonfrillo Mark R.
Published: September 2018

Objectives

This study aimed to provide an assessment of medical malpractice claims involving pediatric patients cared for in emergency department and urgent care settings.

Methods

We performed a retrospective review of all closed malpractice claims involving children (0–17 years old) originating from emergency department or urgent care centers from the Physician Insurers Association of America's Data Sharing Project database for a 15-year period (2001–2015). Reported data collected include medical specialty involved, medical diagnoses, chief medical factors, severity of resulting injury, claim disposition, average indemnity, and average defense costs.

Results

A total of 728 closed claims in pediatric emergency care settings were reviewed. Money was paid to the claimant in 30% of cases (220/728), with a total of US $70.3 million (average $319,513) paid to patients or families during the 15-year period. The most common resulting medical conditions were cardiac or cardiorespiratory arrest, appendicitis, and disorder of male genital organs. Error in diagnosis was the most common chief medical factor (41%), whereas those that involved failure or delay in admission to the hospital, which was the eighth most common chief medical factor, resulted in the highest average indemnity. Of the 728 closed claims, 220 involved a patient death (30%), but claims involving major permanent injury more often resulted in a payment. Of the 57 cases that went to trial, verdicts favored the physician in 47 cases (82%).

Conclusions

Cardiac conditions, appendicitis, and disorder of the male genital organs are the most common medical conditions, and error in diagnosis is the most common chief medical factor in pediatric emergency care malpractice suits. It is important for providers practicing in these settings to be familiar with the common diagnoses and chief medical factors involved in these claims.
Dental Abscess in Pediatric Patients
Authors: Jenkins Glyndwr W. , Bresnen Darren , Jenkins Elizabeth , Mullen Niall
Published: September 2018

Objectives

Neglect is defined as the persistent failure to meet a child or young person's basic physical or psychological needs. Dental caries is explicitly mentioned in guidance on child maltreatment. We discuss the link between dental caries and child abuse in patients presenting to the emergency department.

Methods

A review of patient medical records was undertaken within the Paediatric Emergency Department at Sunderland Royal Hospital, with the aim to determine whether neglect was considered as a possible contributory factor when a child or young person presented at triage with an “oral cavity” problem.

Results

Of the applicable cases with inferences of possible safeguarding concerns, 13% had these concerns documented.

Conclusions

Child abuse recognition has become a prominent issue in recent years due to high profile cases. It is clear from this work, which resonates with the reported literature, that there is a lack of recognition of dental neglect being a possible indicator of more systemic abuse.

There is likely underreporting of these cases to the relevant authorities.
Utility of Chest Radiographs in Children Presenting to a Pediatric Emergency Department With Acute Asthma Exacerbation and Chest Pain
Authors: Majerus Chelsea R. , Tredway Trevor L. , Yun Nicole K. , Gerard James M.
Published: September 2018

Objectives

Previous studies have not evaluated the utility of obtaining chest radiographs (CXR) in patients with acute asthma exacerbation reporting chest pain. The aims of this study were to evaluate the symptom of chest pain as a predictor for clinicians obtaining a CXR in these patients and to evaluate chest pain as a predictor of a positive CXR finding.

Methods

This was a retrospective chart review of patients, ages 2 to 18 years, presenting for acute asthma exacerbation to the emergency department from August 1, 2014, to March 31, 2016. Data collected included demographics, clinical data, provider type, and CXR results. Chest radiographs were classified as positive if they showed evidence of pneumonia, pneumothorax, or pneumomediastinum. Multivariate logistic regression models were developed with dependent variables of “obtaining a CXR” and “a positive CXR finding.”

Results

Seven hundred ninety-three subjects were included in the study. Two hundred thirty-one (29.1%) reported chest pain. Chest radiographs were obtained in 184 patients (23.2%). Of those, 74 patients (40.2%) had chest pain and 21 (11.4%) had a positive CXR. Providers were more likely to obtain CXRs in patients who reported chest pain (odds ratio = 2.2 [95% confidence interval = 1.5–3.2]). Patients reporting chest pain were more likely to have a positive CXR although this difference was not statistically significant (odds ratio = 2.0 [95% confidence interval = 0.7–5.6]).

Conclusions

Providers are more likely to obtain CXRs in asthmatic patients complaining of chest pain; however, these CXRs infrequently yield positive findings. This further supports limiting the use of chest radiography in patients with acute asthma exacerbation.
Trends in Head Computed Tomography Utilization in Children Presenting to Emergency Departments After Traumatic Head Injury
Authors: Ukwuoma Onyinyechi I. , Allareddy Veerajalandhar , Allareddy Veerasathpurush , Rampa Sankeerth , Rose Jerri A. , Shein Steven L. , Rotta Alexandre T.
Published: September 2018

Objectives

Although closed head injuries occur commonly in children, most do not have a clinically important traumatic brain injury (ciTBI) and do not require neuroimaging. We sought to determine whether the utilization of computed tomography of the head (CT-H) in children presenting to an emergency department (ED) with a closed head injury changed after publication of validated clinical prediction rules to identify children at risk of ciTBI by the Pediatric Emergency Care Applied Research Network (PECARN).

Methods

We used the nationwide ED sample (2008–2013) to examine children visiting an ED after a mild closed head injury. Multiple patient and hospital characteristics were assessed.

Results

Of the 4,552,071 children presenting to an ED with a mild closed head injury, 1,181,659 (26.0%) underwent CT-H. Care was most commonly received at metropolitan teaching hospitals (43.5%) and varied markedly by geographic region. Overall, there were no significant changes in the nationwide rates of CT-H utilization in the period immediately after publication of the PECARN prediction rules. However, compared with metropolitan teaching hospitals, CT-H utilization increased significantly for patients treated at nonteaching hospitals and at nonmetropolitan hospitals.

Conclusions

There was no overall reduction in CT-H utilization after publication of the 2009 PECARN prediction rules. However, patients treated at metropolitan teaching hospitals were significantly less likely to undergo CT-H after 2009, suggesting some penetration of the PECARN tool in that setting. Further research should study patterns of CT-H utilization in nonteaching hospitals and nonmetropolitan hospitals to assess challenges for adoption of validated pediatric ciTBI prediction rules.
Audit of Endometrial Cancer Pathology for a Regional Gynecological Oncology Multidisciplinary Meeting
Authors: Spoor Emma , Cross Paul
Published: September 2018

Endometrial cancer is a common disease, and in England all cancer cases are discussed at a central multidisciplinary meeting (MDT) with pathology review. We reviewed cases discussed/reviewed at a regional Gynecology MDT comparing (i) original referral histology with review histology and (ii) final review histology with the final hysterectomy histology. Cases identified as potentially eligible for the study (n=884) were found over a 4-yr period. This was reduced to 630 due to data and other issues for the primary biopsy review, and to 488 for both biopsy and hysterectomy sample. Cases were classed by agreement by grade/type and compared by clinical management (low grade vs. high grade). Of the original biopsies, central review agreed exactly with 67% and disagreed with 33%. A total of 11.6% of low-grade cancers were upgraded to high grade on review, and 6.1% of high-grade cancers were downgraded. For the biopsy/hysterectomy comparison, this was 72.5% agreement and 27.5% disagreement, with 3.5% upgraded to high from low grade, and 7.5% downgraded from high to low grade. The main areas of significant change was the identification of high-grade serous carcinoma from low-grade endometrial cancers, as well some other high grade types (clear cell and carcinosarcoma) and the confident diagnosis of cancer as opposed to an atypical hyperplasia. Central pathology review for MDT discussion does highlight significant areas of pathologic disagreement that would affect clinical management. The audit highlights that a significant disagreement rate in reporting such material between pathologists may be inescapable, but can be reduced by review.
YWHAE-NUTM2A/B Translocated High-grade Endometrial Stromal Sarcoma Commonly Expresses CD56 and CD99
Authors: McCluggage W. Glenn , Lee Cheng-Han
Published: September 2018

YWHAE-NUTM2A/B translocated high-grade endometrial stromal sarcoma is an uncommon and clinically aggressive uterine mesenchymal neoplasm which is sometimes associated with a low-grade fibromyxoid component. Although the diagnosis is confirmed using molecular techniques, it is possible to make the diagnosis based on the characteristic morphology and the immunophenotype; the latter typically includes diffuse positive staining of the high-grade component with cyclin D1 and CD117 and negative staining with CD10 and hormone receptors. Especially in a small biopsy specimen, in cases without a low-grade component or when presenting with extrauterine disease, the differential diagnosis may be wide and potentially include “small round cell tumors” such as a high-grade neuroendocrine carcinoma and a tumor in the Ewing family. In this study, we report consistent CD56 and CD99 immunoreactivity in YWHAE-NUTM2A/B translocated high-grade endometrial stromal sarcoma. We stained 20 of these neoplasms (10 molecularly confirmed and 10 where diagnosis was based on the morphology and immunophenotype) with CD56 and CD99; in one case, CD56 staining was not performed. Nineteen of 19 (100%) and 17 of 20 (85%) were positive with CD56 and CD99, respectively. Staining was usually diffuse with membranous and cytoplasmic immunoreactivity. Pathologists should be aware that YWHAE-NUTM2A/B translocated high-grade endometrial stromal sarcoma is commonly positive with CD56 and CD99; as well as potentially assisting in diagnosis, positivity with these markers may also result in consideration of other neoplasms in the differential diagnosis.
Priorities for Investing in Community Health Improvement: A Comparison of Decision Makers in Public Health, Nonprofit Hospitals, and Community Nonprofits
Authors: Rozier Michael D. , Singh Simone R. , Jacobson Peter D. , Prosser Lisa A.
Published: September 2018

Context:

As a result of additional requirements for tax exemption, many nonprofit hospitals have become more actively involved in community health improvement. There is an open question, however, as to how decision makers in hospitals decide which kind of improvement projects should receive priority and how hospital managers' priorities compare with those of decision makers in public health agencies and community-based nonprofits.

Objective:

To understand the priorities that guide decision makers in public health, nonprofit hospitals, and community nonprofits when allocating resources to community health projects.

Design:

We conducted an online survey with a discrete choice experiment, asking respondents to choose between different types of community health projects, which varied along several project characteristics. Respondents included managers of community health and community benefit at nonprofit hospitals (n = 225), managers at local public health departments (n = 200), and leaders of community nonprofits (n = 136). Respondents were located in 47 of 50 US states. A conditional logit model was used to estimate how various project characteristics led to greater or lesser support of a given health project. Open-ended questions aided in interpretation of results.

Results:

Respondents from all 3 groups showed strong agreement on community health priorities. Projects were more likely to be selected when they addressed a health issue identified on community health needs assessment, involved cross-sector collaboration, or were supported by evidence. Project characteristics that mattered less included the time needed to measure the project's impact and the project's target population.

Conclusion:

Elements often considered central to community health, such as long-term investment and prioritizing vulnerable populations, may not be considered by decision makers as important as other aspects of resource allocation. If we want greater priority for ideas such as health equity and social determinants of health, it will take a concerted effort from practitioners and policy makers to reshape expectations.
The Public Face of Rhinoplasty: Impact on Perceived Attractiveness and Personality
Authors: Lu Stephen M. , Hsu David T. , Perry Adam D. , Leipziger Lyle S. , Kasabian Armen K. , Bartlett Scott P. , Thorne Charles H. , Broer P. Niclas , Tanna Neil
Published: September 2018

Background:

The authors assess the impact of rhinoplasty on public perception of a patient’s appearance and personality.

Methods:

A survey was created using standardized before-and-after photographs of 10 Caucasian women who had undergone primary rhinoplasty. Photographs of two additional women who had not undergone facial surgery were randomly included as controls, for a total of 12 survey items. Preoperative and postoperative photographs were placed side by side. The survey was administered by means of crowd-sourcing. Respondents were asked to evaluate which photograph better represented 11 traits of appearance or personality, according to a seven-point Likert scale. A score of 1 meant the preoperative photograph was much better, 7 meant the postoperative photograph was much better, and 4 meant no difference. T tests and analyses of variance were used to evaluate rating changes for each trait and differences between demographic groups.

Results:

There were 264 responses received. Averaged scores across the 10 survey patients produced a value for each appearance or personality trait. In 10 of 11 categories (i.e., symmetry, youthfulness, facial harmony, likeability, trustworthiness, confidence, femininity, attractiveness, approachability, and intelligence), the postoperative photograph was significantly favorable compared with the preoperative photograph (p < 0.00001). The preoperative photograph was rated higher only in aggressiveness (p < 0.001). The same scores were calculated for the controls; no significant difference in any category was seen except confidence, where the right image was viewed as more confident (mean, 4.19; p < 0.005).

Conclusion:

Aesthetic rhinoplasty improves the public perception of a person’s appearance and personality in multiple aspects.
Current Approaches to Prepectoral Breast Reconstruction
Authors: Nahabedian Maurice Y.
Published: September 2018

Prepectoral prosthetic breast reconstruction has become an acceptable option for women following mastectomy. Benefits include no animation deformity, absence of pectoralis major muscle spasm, and less pain and discomfort. Important aspects of prepectoral reconstruction include working with breast surgeons that are adept at performing an optimal mastectomy. Tissue perfusion and reasonable thickness of the mastectomy are critical components of success. Tissue necrosis, infection, and delayed healing can lead to reconstructive failure. Given the risks and benefits of this procedure, questions regarding indications, patient selection, and specific details related to technique remain because there is no consensus. Whether it is safe to perform prepectoral reconstruction in obese or previously irradiated patients is controversial. The use of acellular dermal matrix is common but not universal. The amount of acellular dermal matrix used is variable, with success being demonstrated with the partial and total wrap techniques. Device selection can vary but is critical in the prepectoral setting. Postoperative care and the management of adverse events are important to understand and can impact surgical and aesthetic outcomes. This article provides current approaches, recommendations, and an algorithm for prepectoral breast reconstruction with an emphasis on patient selection, immediate versus delayed prepectoral reconstruction, specific technical details, and postoperative management.
Postoperative Ketorolac in Breast and Body Contouring Procedures: A Nationwide Claims Analysis
Authors: Kelley Brian P. , Chung Kevin C. , Chung Ting-Ting , Bennett Katelyn G. , Sacks Gina , Sears Erika D. , Waljee Jennifer F.
Published: September 2018

Background:

Nonsteroidal antiinflammatory drugs are useful alternatives to narcotics for analgesia. However, concerns remain regarding their safety. The authors evaluated ketorolac use and complications. We hypothesized that no association between ketorolac and morbidity exists in patients undergoing body contouring.

Methods:

Truven MarketScan claims database was analyzed for patients undergoing breast and body contouring surgery. Patients selected received ketorolac and were enrolled a minimum of 90 days. The authors performed a multivariable logistic regression to calculate risk of morbidity, adjusting for clinical and sociodemographic factors.

Results:

Among the 106,279 patients enrolled, 4924 (4.6 percent) received postoperative ketorolac. In multivariable regression analysis, ketorolac was not associated with hematoma (OR, 1.20; 95 percent CI, 0.99 to 1.46; p > 0.05). There was an increased rate of reoperation within 72 hours (OR, 1.22; 95 percent CI, 1.00 to 1.49; p < 0.05; number needed to harm, 262 patients). Ketorolac was associated with fewer readmissions (OR, 0.76; 95 percent CI, 0.62 to 0.93; p < 0.05; number needed to treat, 87 patients), with a reduction in the rate of pain as a readmission diagnosis (0.6 percent versus 4.3 percent; p = 0.021). Ketorolac was associated with seroma, but this association may not be causal (OR, 1.28; 95 percent CI, 1.05 to 1.57; p < 0.05; number needed to harm, 247 patients). Ketorolac provided an estimated savings of $157 per patient.

Conclusions:

The benefits of ketorolac likely outweigh the risks after surgery. Absolute differences in reoperation rates were low, and improved rates of hospital admission impact cost savings. The authors advocate postoperative ketorolac once the wound is hemostatic.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Unplanned Emergency Department Visits within 30 Days of Mastectomy and Breast Reconstruction
Authors: Nasser Jacob S. , Huetteman Helen E. , Chung Ting-Ting , Chung Kevin C.
Published: September 2018

Background:

Unplanned emergency department visits are often overlooked as an indicator of care quality. The authors’ objectives were to (1) determine the rate of 30-day emergency department visits following mastectomy with or without immediate reconstruction, (2) perform a risk analysis of potential factors associated with emergency department return, and (3) assess for potentially preventable visits with a focus on returns for pain.

Methods:

Using the Healthcare Cost and Utilization Project data, the authors identified adult women who underwent mastectomy with or without reconstruction. Multivariable logistic regression was performed to evaluate risk of unplanned emergency department visits. The authors identified and sorted diagnostic codes to investigate why patients were seeking emergency department care. In addition, the authors performed a subgroup analysis on patients returning with a pain-related diagnosis to evaluate risk.

Results:

Of 159,275 cases of mastectomy with or without immediate reconstruction, 4917 (3.1 percent) experienced an unplanned return to the emergency department within 30 days of operation. A substantial proportion of those who returned (23 percent) presented with a pain-related diagnosis. Only 0.9 percent of cases with a 30-day emergency department return were readmitted.

Conclusions:

Numerous patients return to the emergency department within 30 days of mastectomy with or without immediate reconstruction. There is a need for policy makers and physicians to implement strategies to reduce discretionary emergency department use, specifically among younger or publicly insured patients. Combining unplanned emergency department visits with readmission rates as a care quality indicator warrants consideration.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, III.
The Relationship between Bone Remodeling and the Clockwise Rotation of the Facial Skeleton: A Computed Tomographic Imaging–Based Evaluation
Authors: Cotofana Sebastian , Gotkin Robert H. , Morozov Sergey P. , Kim Stanislav Y. , Gombolevskiy Victor A. , Laipan Albina S. , Pyatnitskiy Ilya A. , Movsisyan Tigran V. , Frank Konstantin
Published: September 2018

Background:

Information on the onset and gender differences of midfacial skeletal changes, including the complete understanding of the theory behind the clockwise rotational theory, remains elusive.

Methods:

One hundred fifty-seven Caucasian individuals (10 men and 10 women aged 20 to 29 years, 30 to 39 years, 40 to 49 years, 50 to 59 years, 60 to 69 years, 70 to 79 years, and 80 to 89 years, and eight men and nine women aged 90 to 98 years) were investigated. Multiplanar computed tomographic scans with standardized angle and distance measurements in all three anatomical axes and in alignment to the sella-nasion (horizontal) line were conducted.

Results:

Both men and women displayed an increase in orbital floor angle (p < 0.001, maximum at 60 to 69 years), decrease in maxillary angle (p = 0.035, 40 to 49 years), increase in palate angle (p < 0.001, 50 to 59 years), increase in vomer angle (p = 0.022, 30 to 39 years), but a decrease in the pterygoid angle (p = 0.002, 80 to 89 years). Orbital width decreased (p < 0.001, 60 to 69 years), pyriform aperture width increased (p = 0.015, 60 to 69 years), and midfacial height decreased with aging (p < 0.001, 60 to 69 years).

Conclusions:

Age-related changes of the midfacial skeleton occurred independently of gender, but at various time points in different locations. The observed changes seem to be driven by a bone resorption center located in the posterior maxilla, rather than by a rotational movement of the facial skeleton.
Implant Testing and the “Strain Energy” Concept
Authors: Caplin David A.
Published: September 2018

Benchtop performance test methodologies differ between manufacturers as regulatory agencies often leave the interpretation of testing standards up to manufacturer discretion, resulting in an inability to directly compare implants across manufacturers. Furthermore, traditional benchtop test methodologies focus on mechanical performance standards to address objective endpoints such as shell strength. However, other more difficult to define clinical performance requirements such as softness and natural feel are often difficult to measure via these methods. This review aims to discuss the evolution of breast implant testing standards, discuss the discrepancies in benchtop characterizations of implants, and highlight one manufacturer’s novel approach to utilizing benchtop methodologies to quantify previously subjective endpoints such as firmness and natural feel and define their clinical relevance.
Reporting Time Horizons in Randomized Controlled Trials in Plastic Surgery: A Systematic Review
Authors: Mowakket Sadek , Karpinski Marta , Gallo Lucas , Gallo Matteo , Banfield Laura , Murphy Jessica , Waltho Daniel , Copeland Andrea , Moltaji Syena , Thoma Achilleas
Published: September 2018

Background:

Current guidelines for randomized controlled trial reporting do not require authors to justify their choice of time horizon. This is concerning, as the time horizon when an outcome is assessed has important implications for the interpretation of study results, and resources allocated to an investigation. Therefore, this study seeks to examine the standards of time horizon reporting in the plastic surgery literature.

Methods:

This is a systematic review of plastic surgery randomized controlled trials published within the past 4 years. The MEDLINE database was searched to yield relevant studies. All studies included were English language, prospective, nonpharmaceutical randomized controlled trials, comparing two plastic surgical interventions. Studies were classified into plastic surgery domains, and information regarding study population, time horizon reporting, and justification of chosen time horizon, was extracted.

Results:

The search retrieved 720 articles, of which 103 were eligible for inclusion. Time horizons were reported as either a standardized time point at which all patients were assessed, or a follow-up duration range, or were not reported at all. Although most studies (85.4 percent) reported a standardized time horizon, the majority (85.4 percent) failed to provide a valid justification to support their selection of time horizon.

Conclusions:

Clinical investigators failed to justify their choice of time horizon in the majority of published randomized controlled trials. To limit heterogeneity, time horizons for given interventions should be standardized to improve validity of outcome assessments, enable future pooling of results, and increase research efficiency.
The Fibula Osteoseptocutaneous Flap: Concise Review, Goal-Oriented Surgical Technique, and Tips and Tricks
Authors: AL Deek Nidal F. , Kao Huang-Kai , Wei Fu-Chan
Published: September 2018

The fibula osteoseptocutaneous flap is a workhorse flap for bone reconstruction. Mastery of the flap is essential for a rewarding reconstruction. However, there is no complete work on this versatile flap. The authors provide a concise review of the literature, address the myths and challenges associated with the flap, and describe their refined techniques for different reconstruction scenarios and possible anatomical variations.
Using Lean Six Sigma to Improve Delayed Intracranial Hemorrhage Screening in a Geriatric Trauma Population
Authors: Birmingham Lauren E. , Sedorovich Ashley , Mann Nolan , George Richard L.
Published: September 2018

Purpose:

Geriatric trauma patients taking preinjury anticoagulant or antiplatelet (ACAP) medications are at greater risk for delayed intracranial hemorrhage (DICH), a rare but potentially life-threatening condition. Routine repeat head computed tomography (RRHCT) scans can identify DICH. Our objective was to decrease the rate of missed RRHCT in a level 1 Midwest trauma center geriatric minor trauma population on preinjury ACAP medications.

Objective:

The objective of the quality improvement project was to identify the root cause of the missed RRHCTs and to implement a comprehensive solution to reduce rates of missed RRHCTs.

Methods:

Medical records from before and after the intervention were evaluated. Frequencies and percentages were calculated. In addition, χ2 and logistic regression were utilized. The Lean Six Sigma (LSS) DMAIC (Define, Measure, Analyze, Improve, and Control) process was used to drive process improvement.

Results:

At baseline, 15% (41 of 267) of RRHCTs were missed. After solution implementation, missed RRHCTs dropped to 4% (2 of 50). Of the 2 that were missed, zero were clinically inappropriate misses, making the postimplementation rate effectively 0%.

Conclusion:

The LSS DMAIC process helped health care professional to facilitate improved adherence to the department's practice guideline with respect to RRHCT. Adherence with this guideline can help providers identify patients with DICH, a potentially life-threatening condition.
The Relationships Between Use of Quality-of-Care Feedback Reports on Chronic Diseases and Medical Engagement in General Practice
Authors: Ahnfeldt-Mollerup Peder , Søndergaard Jens , Barwell Fred , Mazelan Patti M. , Spurgeon Peter , Kristensen Troels
Published: September 2018

Background:

There is a limited knowledge on how medical engagement influences quality of care provided in primary care. The extent of the use of feedback reports from a national quality-of-care database can be considered as a measure of process quality. This study explores relationships between the use of feedback reports and medical engagement among general practitioners, general practitioner demographics, clinic characteristics, and services.

Methods:

A cross-sectional combined questionnaire and register study in a sample of 352 single-handed general practitioners in 2013. Logistic regression analysis was used to explore associations between the use of feedback reports for diabetes and chronic obstructive pulmonary disease and medical engagement.

Results:

For both diabetes and chronic obstructive pulmonary disease, a higher degree of medical engagement was associated with an increased use of feedback reports. Furthermore, we identified positive associations between using feedback reports and general practitioner services (spirometry, influenza vaccinations, performing annual reviews for patients with chronic diseases) and a negative association between usage of quality-of-care feedback reports and the number of consultations per patient.

Conclusion:

Using feedback reports for chronic diseases in general practice was positively associated with medical engagement and also with the provision of services in general practice.
Improving Communication Between Nurses and Resident Physicians: A 3-Year Quality Improvement Project
Authors: Smith Heather , Greenberg Joshua , Yeh Shang-Yee , Williams Lara , Moloo Husein
Published: September 2018

Breakdown in communication is a predictor of both nursing and surgical errors. In a 2013 survey at our institution, staff on the general surgery unit identified nurse-resident communication as the most important issue related to patient safety. The general surgery Comprehensive Unit-based Safety Program sought to improve nurse-resident communication through a 3-year quality improvement initiative. A multidisciplinary working group conducted a root-cause analysis and developed initiatives addressing priority issues in nurse-resident communication. Two main interventions were developed: structured face-to-face interaction at discharge rounds and notebooks to transfer nonurgent messages. Compliance was evaluated. The primary outcomes of percieved communication and collaboration were assessed using a validated survey distributed to residents and unit nurses before the intervention, 9 months after, and 2.5 years after the intervention. The interventions were associated with improvements in perceived communication and team function. Survey scores, on average, were significant higher at 9 months postintervention and remained significant compared with preintervention after 2.5 years (from 57% to 74%, P = .01, then 72%, P = .02, among residents; and from 63% to 80%, P = .01, then 77% among nurses). Our framework and initiatives addressing nurse-resident communication may be useful for other teams interested in addressing this critical patient safety issue.