bluuebunny/crossref_metadata_2025 huggingface dataset:
QS4: In Vivo Quantitative Analysis of Subcutaneous Membranous Layers -Superficial And Deep Fascia- In Eleven Regions of the Human Body
Authors: Hammoudeh Diya’ , Dohi Teruyuki , Cho Hoyu , Ogawa Rei
Published: July 2021

Purpose: Surgical Site Infections (SSIs) and Hypertrophic scars (HSs) are the most common complications of wound healing. Most SSIs are superficial infections involving the skin and subcutaneous tissue (SQ) only. Abnormal scaring is driven by ongoing dermal inflammation in high skin tension areas (e.g. anterior and posterior chest). For prevention, proper suturing techniques are required, in particular for subcutaneous adipose tissue, to reduce high skin stretching tension and prevent ischemia. While adipose lobules cannot be sutured, superficial fascia (SF) -the membranous structure of adipose stroma- must be sutured. However, the exact anatomy and characteristics such as number and thickness of SF throughout the body regions are still lacking. This is the first study to present a detailed quantitative analysis of SF anatomy. We believe such details will help in optimization of subcutaneous sutures.

Methods: Superficial and deep fascia (DF) were analyzed using ultrasound imaging in predefined 73-point locations, distributed among eleven body regions of ten healthy male volunteers; Anterior chest: 9 points, abdomen: 10, posterior chest: 9, lumbar region: 6, gluteus: 2, arm: 8, elbow: 3, forearm: 8, thigh: 9, knee: 3 and leg: 6. Using ImageJ software, thickness of SF and DF layers, dermis and SQ were measured along SF percentage. Three random measurements were taken for each variable then averaged and used this average for statistical analysis. In addition, number of SF layers was counted, total thickness of SF was calculated by summing the average thickness of all SF layers and total membranous layers thickness by summing total SF and DF thicknesses.

Results: Overall, 730 means were analyzed with multilevel mixed linear model for all variables except average layer thickness of SF which had 1635 means; since each point had one or more layers of SF. DF and dermis were significantly thickest in posterior chest region which had the highest layer thickness of SF measuring 0.64 ± 0.01 mm. Anterior chest and gluteus had the highest content of SF due to having the highest layers number (3.67 ± 0.08, 3.45 ± 0.143), yet significantly thickest gluteus SQ and lowest SF percentage. SF changed inconsistently within subcutaneous adipose tissue; SF, DF and dermis jointly handles stretching tension, therefore, to understand the effect of environment, analysis of the variable’s interaction was performed and showed significant accelerated increase in the thickness of SF and dermis in anterior and posterior chest as compared to lower tension regions (all p<0.001).

Conclusion: Our results showed that dermis and subcutaneous membranous layers tend to be thick in the high-tension areas such as the upper trunk. It was suggested that SSIs and HSs could be prevented by realizing the tension applied on the operated area; finding then suturing the membranous layers during the operation.
QS8: Enrichment of Nanofiber Hydrogel Composite with Fractionated Fat Promotes Pro-regenerative Macrophage Polarization and Angiogenesis for Soft Tissue Engineering
Authors: Henn Dominic , Fischer Katharina S. , Chen Kellen , Greco Autumn H. , Martin Russell A. , Sivaraj Dharshan , Trotsyuk Artem A. , Mao Hai-Quan , Reddy Sashank K. , Kneser Ulrich , Gurtner Geoffrey C. , Schmidt Volker J. , Sacks Justin M.
Published: July 2021

Purpose: Fractionated fat (FF) has been shown to promote dermal regeneration; however, the use of fat grafting for reconstruction of soft tissue defects is limited due to volume loss over time. We have developed a novel approach for engineering of vascularized soft tissue using an injectable nanofiber hydrogel (NHC) enriched with FF.

Methods: FF was generated by emulsification of groin fat pads from rats and mixed in a 3:1 ratio with NHC (NHC-FF). NHC-FF or NHC alone were placed into isolation chambers together with arteriovenous (AV) loops, which were subcutaneously implanted into the groin of rats (n=8 per group). After 21 days, animals were euthanized, systemically perfused with ink, and tissue was explanted for histological analysis. Immunofluorescent staining (IF) and confocal laser scanning microscopy were used to quantify CD34+ progenitor cells and macrophage subpopulations.

Results: NHC-FF tissue maintained its shape without shrinking and showed a significantly stronger functional neovascularization compared to NHC alone at 21 days after implantation (mean vessel count: 833.5 ± 206.1 vs. 296.5 ± 114.1, p = 0.04). Tissue remodeling and cellular infiltration were greater in NHC-FF (mean cell count: 49,707 ± 18,491 vs. 9,263 ± 3,790, p = 0.005) with a significantly higher amount of progenitor cells and regenerative CD163+ macrophages compared to NHC alone.

Conclusion: FF-enriched NHC transforms into highly vascularized soft tissue over 21 days without signs of shrinking and promotes macrophage polarization toward regenerative phenotypes. Enrichment of injectable NHC with FF represents a promising approach for durable reconstruction of soft tissue defects.
QS4: Fat Grafting for the Dysesthetic Digit: A Discussion of Technique And Pilot Data
Authors: Loder Shawn J. , Kim Justine S. , Moroni Elizabeth A. , Peter Rubin J. , Spiess Alexander M.
Published: July 2021

Purpose: Digital amputation represents a common injury requiring acute hand surgery intervention. These injuries are often complicated by pain, hypersensitivity, dysesthesia, cold intolerance, and contour deficits/pulp atrophy. Many secondary procedures exist to address these concerns; however, they are often limited by undesirable donor site morbidity and/or complex rehabilitation. There is currently no single gold standard for treatment of the dysesthetic digit. Free adipose transfer via lipofilling offers to correct these defects by providing soft, healthy bulk to the amputated site with minimal comorbidity. Here we describe a protocol and preliminary data for providers considering adipose transfer to the dysesthetic digit.

Methods: We examined 113 patients who sustained digit amputations between 2010 and 2019. Patients sustained an average of 1.6+/-0.9 amputations per trauma. 13 patients were identified with chronic pain, dysethesia, cold intolerance, or hypersensitivity that persisted after therapy. Controlling for reversible nail bed pathology, 10 patients demonstrated primary chronic dysesthesia.

Results: 4 of 10 patients presenting for chronic amputation stump dysesthesia elected for fat grafting to the fingertip. All patients reported improved pain and reduced dysesthesia/hypersensitivity post-intervention. 3 patients required no further intervention after one round of grafting; 1 patient underwent repeat grafting. Of the non-grafted group, 66.7% (4/6) progressed to revision amputation. There were no operative revision amputations after grafting.

Conclusions: Fat grafting to the fingertip offers a simple, safe, and easily accessible technique to augment soft tissue bulk at the digital stump. Our preliminary data suggests that this may be an effective option to manage digital dysesthesia/hyperesthesia.
QS8: The Roles of the TrkA and p75NTR NGF Receptors in Corneal Wound Healing
Authors: Tajdaran Kiana , Feinberg Konstantin , Mirmoeini Seyed Kaveh , Zhang Jennifer , Gordon Tessa , Borschel Gregory
Published: July 2021

Purpose: The cornea is the window through which we see the world and is one of the most densely innervated structures in the body. Besides providing protective sensory input, corneal nerves have been postulated to stimulate limbal stem cells (LSCs), hence governing corneal epithelial maintenance and recovery. Loss of corneal innervation, through injury, diabetes, tumors, infections, and even improper contact lens use, leads to neurotrophic keratopathy (NK), a degenerative corneal disease that is characterized by corneal epithelial breakdown, scarring, and permanent vision loss1. The only non-invasive treatment option for NK is the human recombinant nerve growth factor (rhNGF), but the short half-life of exogenous neurotrophins-based therapies make this therapeutic approach less effective2. Development of the small molecule ligands for neurotrophins receptors that have better pharmacokinetics and plasma stability showed promising results in the treatment of several neurodegenerative conditions in the recent years3. In this study, we were prompted to investigate the molecular mechanism of NK and the role of NGF receptors, TrkA and p75NTR, in corneal healing. We hypothesized that TrkA inhibition would delay corneal wound healing and p75NTR inhibition accelerates corneal healing. This knowledge will lay the basis for a new non-invasive approach for NK.

Methods: For this experiment, we took advantage of commercially available Ntrk1 mutant mice, which allow for pharmacological inhibition of TrkA receptor with an inhibitor known as not mammalian kinase inhibitor (1-NM-PP1)4. Ntrk1 mice (n=20) were divided into three groups, which received saline injection as a control. In one experimental group animals were received TrkA inhibitor and the other group received both TrkA and p75 inhibitor for 5 days. On day six we removed the corneal epithelium with a 0.5 mm rotating brush. To measure epithelial healing, we performed digital imaging of fluorescein staining daily for four days after injury. We then harvested the corneas for immunofluorescent and biochemical analyses.

Results: Our results show a significant delay in corneal epithelial healing following TrkA inhibition and acceleration in corneal healing after p75NTR inhibition.

Conclusion: A selective TrkA agonist or p75NTR inhibitors could be a new therapeutic approach for NK.
3: The Prevalence of Normocephalic Sagittal Craniosynostosis in Young Children
Authors: McGrath Jennifer L. , Manrique Monica , Mantilla-Rivas Esperanza , Rana Md Sohel , Crowder Hannah , Ichiuji Brynne , Aivaz Marudeen , Oh Nathanael , Oh Albert K. , Rogers Gary F.
Published: July 2021

Purpose: Sagittal craniosynostosis (SC) is usually diagnosed during early childhood due to the presence of an abnormal head shape termed scaphocephaly. However, patients with radiographic evidence of a prematurely fused sagittal suture but normal head shape (normocephalic) have been reported. A recent study from our group found that 3.3% of normal children under 5 years of age have partially or completely fused sagittal sutures by computed tomography but no corresponding changes in cranial form. The purpose of this paper is to validate our preliminary study with a larger cohort of patients, and to analyze factors that may be associated with incidental finding of early suture fusion.

Methods: We reviewed computerized tomography (CT) scans of patients from 0 to 71 months of age who presented to the emergency department (ED) of our tertiary care institution between 2008 and 2020. Patients who were found to have syndromes related with craniosynostosis, phenotypes consistent with craniosynostosis, VP shunt placement, brain or cranial abnormalities, were excluded. A panel of two craniofacial surgeons reviewed the CT scans for presence of craniosynostosis (CS). Demographic information, gestational age, past medical and family history, medications, chief complaint and fusion type were recorded as covariates. Possible medical or demographic differences between patients with and without craniosynostosis were analyzed using unpaired t-test and Chi-square/Fisher’s exact test; Firth logistic regression was performed to determine the association between the independent covariates and the presence of CS in two sub-cohorts; patients ≤ 24 months of age and patients over 24 months of age.

Results: We identified 870 patients with a mean age of 30.1 months. 41 patients (4.71%) had fusion the sagittal suture (25 complete, 16 incomplete); all patients had a normal cranial index (width/length >0.7). The prevalence increased from 0-24 months, then was constant from 25-71 months. In the affected patients under two years of age, those with family history of neurodevelopmental disease had 49.32 (95% CI [4.28, 567.2]) times higher odds of developing CS. Sub-cohort encompassing patients above 24 months of age showed no variable as independent predictor for developing CS.

Conclusion: Normocephalic SC in young children is common. While the impact of this condition is unknown, the correlation with family history of neurodevelopmental disease is concerning.
5: Long-term Follow-up of Pre-operative Infant Event-related Potential in Children with Craniosynostosis
Authors: Junn Alexandra , Dinis Jacob , Reategui Alvaro , Yang Jenny , Persing John A. , Alperovich Michael
Published: July 2021

Purpose: Event-related potentials (ERPs) provide a real-time safe, noninvasive method to assess neural networks in infancy. Limited data exist, however, as to the predictive value of these results with eventual neurocognitive outcomes at school age. The purpose of this study was to investigate whether ERP recordings at infancy also translated into neurocognitive deficits at school age.

Methods: 16 infants who underwent evaluation of auditory processing in infancy were followed up for neurocognitive testing. ERPs were extracted from electroencephalographic data evoked in response to language stimuli, and were found to have a positive inflection peaking 150 to 300msec (P150) after presentation of the stimuli, followed by a negative wave 300 to 700msec (N450) after. The P150 and N450 components were examined over the right and left frontotemporal scalp areas. Patients underwent a battery of neurocognitive tests including assessments of IQ (Weschler Abbreviated Scale of Intelligence 2nd edition), academic achievement (Kaufman Test of Educational Achievement 3rd edition), and motor coordination (Beery-Buktenica Development Test of Visual-Motor Integration 6th edition). Absolute deviation of ERP results from age-matched controls were computed. Spearman’s correlations were used to assess the strength of correlation between neurocognitive scores and ERP values, as well as other sociodemographic variables.

Results: 11 patients with ERP in infancy were neurocognitively tested. Average time to follow-up neurocognitive testing was 10.1 ± 1.7 years. 7 (63.6%) were male, 9 (81.8%) were white. 7 (63.6%) underwent whole vault cranioplasty while 4 (36.4%) underwent endoscopic strip craniectomy. Mean age at surgery was 7.4±2.5 months. A greater absolute difference from age-matched controls in the left-sided P150 component was correlated with worse outcomes in the following domains: full-scale IQ (r=-0.709, p=0.015), performance IQ (r=-0.673, p=0.023) and fine motor skills (r=-0.654, p=0.029). While aberrancy in the P150 component was also correlated with math achievement (r=-0.065, p=0.028) and reading comprehension (r=-0.603, p=0.036), significant correlations were also found between math achievement and mother and father’s highest level of education, and between reading comprehension and mother’s highest level of education and household income. There was no correlation, however, between any demographic variables and full-scale IQ or performance IQ. Various socioeconomic factors were found to correlate with math and reading achievement, but not IQ or motor skills.

Conclusion: Brain activity measured at infancy has predictive value for eventual neurocognitive outcome, with greater deviation from normal being associated with greater IQ deficits. Early ERP assessment may help manage patient expectations about neurocognitive outcomes following intervention.
6: Prenatal Diagnostic of Pierre-Robin Sequence (PRS) Using Ultrasound
Authors: Islam Raeesa , Anstadt Erin , Bruce Madeleine , Pfaff Miles , Canavan Timothy , Goldstein Jesse
Published: July 2021

Purpose: Pierre-Robin Sequence (PRS) is characterized by micrognathia and glossoptosis and can result in upper airway obstruction. Prenatal diagnosis of PRS facilitates delivery team preparation for an airway emergency. Routine 20-week ultrasounds screen facial features and can characterize mandibular morphology and the maxillomandibular relationship. This study aimed to evaluate 20-week fetal ultrasounds to determine if specific facial measurements could predict PRS diagnosis and disease severity.

Methods: A retrospective case control study of 40 patients with PRS and 40 gender-matched controls (24 male, 16 female in each cohort) between January 2014 and May 2019 was performed. Respiratory and surgical interventions were recorded and scored for severity. Mid-sagittal profile images of the ultrasounds were reviewed and measured for 3 parameters to assess micrognathia: facial nasomental angle (FNMA), facial-maxillary angle (FMA), and alveolar overjet. FMA <66°and FNMA <136° signify micrognathia. A one-tailed t-test was calculated and the mean ± standard deviation was reported.

Results: Patients with PRS demonstrated significantly smaller FNMA compared to the control group (129.6 ± 9 vs.137.9 ± 2.8, respectively; p<.001). FMA was significantly smaller in the PRS group compared to the control group (64.1 ± 9.3 vs. 75.3 ± 6.5; p<.001). The PRS group also demonstrated significantly larger overjet compared to the control group (3.7 ± 1.3 vs. 2.3 ± 0.8, respectively, p<.001). In the PRS group, 53% had an abnormally acute FMA compared to 3% in the control group. For FNMA, 82% in the PRS group demonstrated micrognathia compared to 18% in the control group. In the PRS cases, 38% did not require external respiratory support (n=15), 43% needed supplemental oxygen by nasal cannula or CPAP (n=17), and 20% were intubated (n=8). As respiratory support needs increased, median FMA decreased and alveolar overjet increased. In the control group, 93% required no external respiratory support (n=37) and 7% needed supplemental oxygen by CPAP (n=3). In the PRS cases, 45% received mandibular distraction or tongue-lip adhesion (n=18), 15% underwent supraglottoplasty only (n=6), 8% required tracheostomy (n=3) and 32% did not require surgical intervention (n=13). Surgical patients tended to have smaller FNMAs and greater overjet compared to nonsurgical patients; median FNMA was 127° versus 132°, and median overjet was 2.8 versus 4.15 mm, respectively, however this was not significant. None of the control patients underwent surgical intervention.

Conclusions: Mandibular features on 20-week anatomy ultrasound can be measured to predict PRS prenatally and prepare for respiratory intervention at delivery to minimize hypoxia at birth. Alveolar overjet, previously not described in prenatal ultrasound literature but routinely assessed on neonatal clinical evaluation, is measurable and has utility in prenatal diagnosis, as do FMA and FNMA.
QS1: Nasopharyngeal Airway and Subcranial Space Analysis in Pfeiffer Syndrome
Authors: Lu Xiaona , Jorge Forte Antonio , Alperovich Michael , Tonello Cristiano , Alonso Nivaldo , Persing John A.
Published: July 2021

Background: Tracheotomy in infancy helps patients with Pfeiffer syndrome survive by preventing respiratory crisis, however, difficulty in decannulation consequently may be a challenge. This study attempts to investigate the regional abnormalities of the nasopharyngeal airway in Pfeiffer syndrome, to provide an anatomic basis for the upper airway surgical treatment and decannulation.

Method: Seventy-two preoperative CT scans (Pfeiffer syndrome, n=30; control, n=42) were included in this study. The airway volume, cross-sectional area, and cephalometrics, were measured using Materialise software.

Results: Patients with Pfeiffer syndrome developed a 50% (p<0.001) reduction of nasal airway volume, and a 44% (p=0.003) restriction in pharyngeal airway volume. The cross-sectional area of Pfeiffer patients at the choana, was only half that of normals’ (p<0.001). The posterior width of nasal airway in Pfeiffer syndrome was shortened by 13% (p=0.003), and the height was reduced by 21% (p<0.001). The cross-sectional areas at condylion and gonion levels, indicating the caliber of pharyngeal airway at entrance and midsection, were reduced by 67% (p<0.001) and 47% (p<0.001), respectively, when compared with normals.

Conclusion: Nasal airway volume in Pfeiffer syndrome is significantly restricted, in length, height and width, along with the choanal stenosis in all cases in this cohort. The reduced anteroposterior length of nasal airway contributes to the shortened maxilla, more than the anteroposterior position. The limited nasal pathway height and width results from the hypoplastic sphenoid. Mediolateral and anteroposterior restricted dimensions are evident across the entire course of pharyngeal airway. Therefore, mediolateral maxillary expansion likely benefits Pfeiffer syndrome patients, in addition to maxillomandibular advancement.
QS3: Influence Of Nonsyndromic Bicoronal Synostosis And Syndromic Influences On And Periorbital Malformation
Authors: Lu Xiaona , Jorge Forte Antonio , Alperovich Michael , Alonso Nivaldo , Persing John A.
Published: July 2021

Background Oculo-orbital disproportion in patients with craniosynostosis have similarities and dissimilarities between syndromic and nonsyndromic cases. We hypothesize these two conditions have specific individual influences as it relates to development of the orbital and periorbital skeletons.

Method A total of 133 preoperative CT scans (nonsyndromic bicoronal synostosis, n=38; Apert syndrome bicoronal synostosis subtype, n=33; Crouzon syndrome bicoronal synostosis subtype, n=10; controls, n=52) were included. Craniometric and volumetric analyses related to the orbit and periorbital anatomy were performed.

Results The orbital cavity volume is mildly restricted in nonsyndromic bicoronal synostosis (7%, p=0.147), but more so in Apert and Crouzon syndromes, 17% (p=0.002) and 21% (p=0.005), respectively. The sphenoid side angle in Apert syndrome is wider than when compared to Crouzon syndrome (p=0.043). The ethmoid side angle in Apert patients however is narrower (p=0.066) than that in Crouzon patients. Maxilla anteroposterior length is more restricted in Apert syndrome than Crouzon syndrome (21%, p=0.003) and nonsyndromic cases (26%, p<0.001). The posterior nasal spine position is retruded in Crouzon syndrome (39%, p<0.001), yet the anterior nasal spine position is similar in Apert and Crouzon syndromes.

Conclusion Orbit and periorbital malformation in syndromic craniosynostosis is likely the combined influence of syndromic influences and premature suture fusion. Apert syndrome expands the anteriorly contoured lateral orbital wall associated with bicoronal synostosis, while Crouzon syndrome has more infraorbital rim retrusion, resulting in more severe exorbitism. Apert syndrome develops maxillary hypoplasia, in addition to the maxillary retrusion, observed in Crouzon syndrome and nonsyndromic bicoronal synostosis patients.
1: MicroRNAs: Potential For Molecular Modulation Of Mechanically-induced Skin Growth During TE
Authors: Ledwon Joanna K. , Stoehr Jenna R. , Vaca Elbert E. , Gosain Arun K.
Published: July 2021

Purpose: Tissue expansion (TE) is commonly utilized to promote skin growth prior to reconstructing a defect or deformity. In spite of its ubiquitous use, the role of molecular modulators during TE, such as microRNAs (miRNAs), has not previously been studied. MiRNAs are small endogenous molecules that regulate many biological processes, including cell proliferation, differentiation, and inflammatory response. Here, we investigate genome-wide changes in miRNA expression in skin during TE.

Methods: Changes in miRNA expression were evaluated in a porcine TE model. Full-thickness skin biopsies were collected after 1 hour, 24 hours, 3 days, and 7 days of expansion, as well as from unexpanded skin (control). RNA extracted from biopsies was analyzed with next-generation sequencing (NGS). Differential expression analysis was performed using R software with the Bioconductor-DESeq2 package. Results were corrected for multiple testing using the Benjamini-Hochberg method. A combination of adjusted p-value < 0.05 and | log2 (fold change) | > 1 were used as the threshold to determine the significance of differentially expressed (DE) miRNAs. Potential target genes for DE miRNAs were identified by in silico analysis using three data bases: miRDB, miRTarBase, and DIANA Tools with Tarbase. Functional enrichment analysis of target genes was performed using the g:GOSt functional profiling tool, and results were visualized using R and Cytoscape software.

Results: We identified 52 miRNAs that were differentially upregulated (n = 18) or downregulated (n = 34) during at least one of the tested timepoints during TE. At the four time points (1 hour, 24 hours, 3 days and 7 days), there were 15, 6, 22, and 20 DE miRNAs, respectively. Eight miRNAs (ssc-miR-193a-5p, ssc-miR-21, ssc-miR-9-1, ssc-miR-708-3p, ssc-miR-212, ssc-miR-196a, ssc-miR-15b, ssc-miR-184) were DE at more than one timepoint. The comparative analysis showed 9, 4, 16 and 15 unique miRNAs after 1 hour, 24, hours, 3 days and 7 days of TE, respectively. Gene Ontology and KEGG pathway analyses for predicted target genes demonstrated enrichment in cellular processes related to metabolism, transcription, translation, signal transduction, cell differentiation, migration, and angiogenesis.
QS3: The Ideal Match: Optimizing Partial Face Transplants In Terms Of Skin Tone Discrepancies
Authors: Yesantharao Pooja S. , Garcia Jordan , Cooney Carisa M. , Cooney Damon
Published: July 2021

Background: Partial face composite allotransplantation poses a unique aesthetic challenge. Namely, partial face transplants need to resemble the patient’s native skin. The degree of resemblance considered acceptable is a prominent variable and may depend on the gender and underlying skin tone of the recipient. The primary aim of this study was to investigate the degree of skin tone matching deemed aesthetically tolerable, recipient gender, and recipient skin tone. Two populations were queried: (1) the general public and (2) plastic surgeons. Few studies have investigated this topic from either of these standpoints. A secondary aim was to determine whether participant characteristics such as demographics, skin color, and history of having had facial surgery impacted their perceptions.

Methods: This was a cross-sectional investigation of perceptions on skin tone matching. Participants from the general public were recruited through Amazon Mechanical Turk and surgeons were recruited through the American Council of Academic Plastic Surgeons. Participants were queried for aesthetic preferences using frontal face photos from age-standardized models. Skin tones of transplanted segments were varied using the Munsell color scale via Adobe Photoshop (Adobe Inc., San Jose, CA).

Results: In total, 550 lay participants from Amazon Mechanical Turk and 21 plastic surgeons provided complete survey responses. On average, plastic surgeons tolerated a lesser degree of skin tone discordance than the lay public: 87% of lay participants and 33% of plastic surgeons believed a change of 4 hues was acceptable (p=0.02). Additionally, all survey respondents tolerated less of a degree of skin tone discrepancy on female faces when compared to male faces (mean difference tolerated: 2 hues for females, 4 hues for males). Participants tended to tolerate less skin tone discrepancy in subjects with similar skin tones as their own (mean difference tolerated: 2 hues for own versus 4 hues for different skin tones, p=0.04).

Conclusion: This study highlighted the intensely- subjective nature of aesthetic preferences surrounding skin tone matching on the face, which varied by demographics and between surgeons versus the lay public. Surgeons should ensure that they truly elicit their patients’ preferences, especially given that our results demonstrated a greater tolerance for discrepancies among the lay public compared to plastic surgeons. Procuring a graft for facial allotransplantation is challenging; understanding what level of skin tone discrepancy is tolerable to the recipient can help surgeons improve patient satisfaction and may also lessen time-to-transplant by enlarging the potential donor pool for this type of transplant.
QS7: Effect Of Static Cold Storage On Vascularized Composite Allografts
Authors: Goutard Marion , Lellouch Alexandre , Lupon Elise , Pendexter Casie , Randolph Mark A. , Lantieri Laurent , Cetrulo Curtis L. , Uygun Korkut
Published: July 2021

Purpose: The current gold standard in organ storage is static cold storage (SCS) at 4°C in a preservation solution (UW, HTK). While kidneys can be stored for 24 hours in SCS, Vascularized Composite Allografts (VCA) have been transplanted up to 12 hours in this condition. We aimed to determine the limits of VCA viability with SCS. We used a partial heterotopic hindlimb transplantation model on rodent to assess VCA survival at various durations of SCS.

Methods: Right partial hind limbs in Lewis rats were procured and a 24G Angiocath inserted in the femoral artery. Limbs were flushed with 2ml of heparin saline (100UI/ml) at room temperature and then 5ml of ice cold HTK solution. The limbs were then immersed in HTK in a sterile bag and stored at 4°C for a period of 12(group 1), 18(group 2), 24(group 3), 48 (group 4) or 0 hours (fresh controls Group 5), before microsurgical transfer to the opposite groin. Graft weight was assessed before and after cold storage. At post-operative day (POD) 21, VCAs were harvested for histological analysis.

Results: In all groups, there was no significant difference of weight gain in SCS groups after extended SCS times. In group 1 (n=4), 3 rats survived until POD21; clinical evolution showed a limited epidermolysis (<1/3 donor skin surface) in 2 grafts. In group 2 (n=4), 2 rats survived until POD21 without complication. In group 3 (n=6), 3 rats survived until POD21; 1 showed partial superficial necrosis on 50% of the donor skin surface that led to late wound healing. In group 4 (n=4), 3 rats survived; all but one showed extended superficial necrosis over more than 2/3 of the donor skin surface; findings at end of study revealed patent arterial supply but venous thrombosis in 2 rats, inflammatory tissues around the graft and necrotic muscles. There was no difference in the VCA survival rate between the groups 1, 2 and 3 compared to the control group 5. Group 4 demonstrated delayed graft failure.

Conclusion: SCS provides a safe and simple method of organ storage but is very time limited. Cooling an organ down to 4°C aims to reduce cell metabolism 10-fold but does not make it zero. Hence, VCA hypothermic storage is limited by the remaining metabolism of the skeletal muscle. In our study, rat VCA can be stored in SCS for 24hours without significantly impacting its survival rate but an increase in muscular atrophy and epidermal necrosis correlates with longer hypothermic storage durations. We hypothesize that rat tissues are particularly resistant to SCS thus we need to scale up to a large animal model to better understand ischemic injuries on human tissues.
QS7: Does Genital Self-image Correspond With Sexual Health Before And After Vaginoplasty
Authors: Isabella Kloer Carmen , Blasdel Gaines , Shakir Nabeel , Zhao Lee , Bluebond-Langner Rachel
Published: July 2021

Purpose: Improvements in mental health and quality of life are well documented for transgender patients following vaginoplasty. Patient-reported outcomes (PROs) regarding sexual health are lacking in this intervention, or have not been validated in transgender patients.

Methods: A community advisory board of transgender women informed an anonymous online survey utilizing PROs for those who were contemplative of (pre-) and post-vaginoplasty. They were recruited on online platforms not associated with an individual institution. Survey measures included the Female Genital Self-Image Scale (FGSIS) and Patient-Reported Outcomes Measurement Information System (PROMIS) sexual health measures. Welch approximation t-tests were performed for FGSIS and PROMIS questions using Bonferroni correction.

Results: 687 transgender patients pre-vaginoplasty (n = 522, 76%) and post-vaginoplasty (n = 165, 24%) responded. In PROMIS measures, the postoperative cohort reported higher ability to orgasm (p = 0.0003), satisfaction with sex life (p = 0.001), pleasure in sex life (p = 0.002), use of lubricant (p < 0.0001), and scar interfere with sexual satisfaction (p < 0.0001). FGSIS total score was higher among postoperative patients (27.8 ± 6.0) than preoperative patients (17.8 ± 5.3) (p < 0.0001). Using Spearman’s rho, no significant correlation between FGSIS total score and any PROMIS sub-sectional measures was observed for either cohort. 193 patients (133 preoperative, 60 postoperative) reported their responses about sex being influenced by the Covid-19 crisis.

Conclusion: Patients who are contemplating vaginoplasty have worse sexual health and genital self-image than those who have had vaginoplasty. FGSIS scores did not correlate with PROMIS sexual health measures when controlling for prior vaginoplasty, demonstrating that sexual health is multimodal for each individual patient.
Symptom experience during the late reproductive stage and the menopausal transition: observations from the Women Living Better survey
Authors: Coslov Nina , Richardson Marcie K. , Woods Nancy Fugate
Published: July 2021

Objective:

The aim of this study was to examine the occurrence of a variety of symptoms, their frequency, bother, burden, and interference in the lives of women in the late reproductive stage (LRS) and compare their experiences to that of women in the menopausal transition (MT) stage.

Methods:

Women ages 35 to 55 years responded to an 82-question online survey offered by Women Living Better. Participants reported current menstrual patterns, recent changes and symptom frequency, bother, and interference. Women's cycles were classified as LRS or MT using Stages of Reproductive Aging Workshop +10 criteria.

Results:

Of 2,406 respondents, 946 met criteria for LRS and 583 for MT. Participants included 30% from outside the United States, 31% from diverse racial/ethnic groups, and 18% reported having difficulty paying for basics. A similar proportion of women in the LRS and MT+ groups reported each of the symptoms: there was a less than 10% difference for 54 of the 61 symptoms. Of mean bother ratings for all symptoms, only hot flashes differed significantly between the LRS and MT groups. LRS women experienced similar levels of symptom-related interference with personal relationships and daily living to those in the MT stage but did not anticipate these symptoms occurring until they were 50 years old.

Conclusions:

Women in the LRS experience symptoms strikingly similar to those often associated with the MT. Women do not expect these changes until the age of 50 years or later and are surprised by such symptoms before cycle irregularity. Research about the epidemiology and management of LRS symptoms, anticipatory guidance for women, and education for clinicians who care for them warrant increased attention.
Comparative venous thromboembolic safety of oral and transdermal postmenopausal hormone therapies among women Veterans
Authors: Blondon Marc , Timmons Andrew K. , Baraff Aaron J. , Floyd James S. , Harrington Laura B. , Korpak Anna M. , Smith Nicholas L.
Published: July 2021

Objective:

Hormone therapy (HT) is used by menopausal women to treat vasomotor symptoms. Venous thromboembolism (VTE) is an important risk of HT use, and more knowledge on the comparative safety of different estrogenic compounds is useful for women who use HT for these symptoms. The objective was to compare the risk of VTE among users of oral conjugated equine estrogen (CEE), oral estradiol (E2), and transdermal E2, in a cohort of women veterans.

Methods:

This retrospective cohort study included all women veterans aged 40 to 89 years, using CEE or E2, without prior VTE, between 2003 and 2011. All incident VTE events were adjudicated. Time-to-event analyses using a time-varying HT exposure evaluated the relative VTE risk between estrogen subtypes, with adjustment for age, race, and body mass index, with stratification for prevalent versus incident use of HT.

Results:

Among 51,571 users of HT (74.5% CEE, 12.6% oral, and 12.9% transdermal E2 at cohort entry), with a mean age of 54.0 years, the incidence of VTE was 1.9/1,000 person-years. Compared with CEE use, in the multivariable regression model, there was no difference in the risk of incident VTE associated with oral E2 use (hazard ratio 0.96, 95% CI 0.64-1.46) or with transdermal E2 use (hazard ratio 0.95, 95% CI 0.60-1.49). Results were unchanged when restricting to incident users of HT.

Conclusions:

Among women veterans, the risk of VTE was similar in users of oral CEE, oral E2, and transdermal E2. These findings do not confirm the previously observed greater safety of transdermal and oral E2 over CEE.
Warm Weather and Surgical Site Infections: A Meta-analysis
Authors: Sahtoe Anouschka P.H. , Duraku Liron S. , van der Oest Mark J.W. , Hundepool Caroline A. , de Kraker Marjolein , Bode Lonneke G.M. , Zuidam J. Michiel
Published: July 2021

Background:

Seasonal variability, in terms of warm weather, has been demonstrated to be a significant risk factor for surgical site infections (SSIs). However, this remains an underexposed risk factor for SSIs, and many clinicians are not aware of this. Therefore, a systematic review and meta-analysis has been conducted to investigate and quantify this matter.

Methods:

Articles were searched in Embase, Medline Ovid, Web of Science, Cochrane Central, and Google Scholar, and data were extracted from relevant studies. Meta-analysis used random effects models to estimate and compare the pooled odds ratios (OR) and corresponding confidence intervals (CIs) of surgery performed during the warmest period of the year and the colder period of the year.

Results:

The systematic review included 20 studies (58,599,475 patients), of which 14 studies (58,441,420 patients) were included for meta-analysis. Various types of surgical procedures across different geographic regions were included. The warmest period of the year was associated with a statistically significant increase in the risk of SSIs (OR 1.39, 95%CI: [1.34–1.45], P < 0.0001). Selection of specific types of surgical procedures (eg, orthopedic or spinal surgery) significantly altered this increased risk.

Conclusions:

The current meta-analysis showed that warm weather seasons are associated with a statistically significant risk increasement of 39% in developing SSIs. This significant risk factor might aid clinicians in preoperative patient information, possible surgical planning adjustment for high risk patients, and potentially specific antibiotic treatments during the warmer weather seasons that could result in decrease of SSIs.
Clinical Presentations, Management and Outcomes of Rhino-Orbital-Cerebral Mucormycosis (ROCM) Following COVID-19: A Multi-Centric Study
Authors: Dave Tarjani Vivek , Gopinathan Nair Akshay , Hegde Raghuraj , Vithalani Nidhi , Desai Savari , Adulkar Namrata , Kamal Saurabh , Mittal Raman , Bradoo Renuka A.
Published: July 2021

Purpose:

To report clinical presentations and factors affecting outcomes in rhino-orbital-cerebral mucormycosis following COVID-19.

Methods:

Retrospective multi-centric interventional case series of 58 eyes with rhino-orbital-cerebral mucormycosis. Demography, clinical parameters and management outcomes were noted. Factors affecting outcome and mortality were analyzed. Outcome was defined as favorable when complete resolution or stabilization without further progression of the infection was noted at last visit.

Results:

Mean age was 55 ± 11 years (median 56). The mean HbA1c value was 10.44 ± 2.84 mg% (median 10.5). The duration between the diagnosis of COVID-19 and rhino-orbital-cerebral mucormycosis was 16 ± 21 days (median: 8 days). Thirty-six eyes (62%) had no vision at presentation. Imaging revealed paranasal sinus involvement (100%), orbital apex involvement (41%), cavernous sinus involvement (30%), and central nervous system (CNS) involvement (33%). All the patients were treated with systemic Liposomal amphotericin-B and sinus debridement. Twenty-two eyes (38%) underwent exenteration. One eye underwent transcutaneous retrobulbar amphotericin-B. The mean follow-up duration was 5.62 ± 0.78 months (median 6). Favorable outcome was seen in 35 (60%) cases. Presence of uncontrolled diabetes (p = 0.001), orbital apex involvement (p = 0.04), CNS involvement (p = 0.04), and history of steroid use (p < 0.0001) resulted in unfavorable outcome. CNS involvement was the only factor predicting mortality (p = 0.03). Mortality was seen in 20 (34%) patients.

Conclusion:

Over a third of patients with rhino-orbital-cerebral mucormycosis following COVID-19 have an unfavorable clinical outcome. Uncontrolled diabetes mellitus at presentation, involvement of the orbital apex, CNS, and the usage of steroids were associated with poorer outcomes. CNS involvement was a factor determining mortality.
Effects of Pemphigus Vulgaris Serum on the Expression of ATP2C1 and PKP3 in HaCaT Cells
Authors: Pan Qiao-Lin , Xie Zhi-Min , Dai Xiang-Nong , Zhang Yi , Shen Xu-Cheng , Li Qing-Qing , Ye Xing-Dong
Published: July 2021

Objective:

To investigate the effects of serum from patients with pemphigus vulgaris (PV) on the transcription and protein expression level of calcium-transporting ATPase type 2C member 1 (ATP2C1) and plakophilin 3 (PKP3) in HaCaT cells.

Methods:

The HaCaT cells were divided into four groups: PV sera group, anti-Dsg3 monoclonal antibody group (AK23, positive control group), normal healthy serum group, and blank cell group. The groups were treated with corresponding different conditions for 24 hours. Quantitative polymerase chain reaction and Western blot were used to detect mRNA and protein levels of ATP2C1 and PKP3.

Results:

Compared with the blank group, the mRNA level of the ATP2C1 and PKP3 genes in PV sera group was significantly increased by 384% and 404%, respectively (both P < 0.001). The treatment of PV sera and anti-Dsg3 antibody increased PKP3 protein expression (P = 0.03 and P = 0.004) but decreased protein expression of ATP2C1 in HaCaT cells (both P < 0.001).

Conclusions:

Our study indicates that serum from patients with PV promotes both ATP2C1 and PKP3 transcription in HaCaT cells, implying that the two genes may be involved in the pathological process of PV.
Effects of Living Alone and Sedentary Behavior on Quality of Life in Patients With Multimorbidities: A Secondary Analysis of Cross-Sectional Survey Data Obtained From the National Community Database
Authors: AHN Young Eun , KOH Chin Kang
Published: July 2021

Background

Having multimorbidities may increase health problems. Moreover, health-related quality of life correlates negatively with the number of chronic conditions a patient has. Living alone has been identified as a predictor of poorer quality of life, and a sedentary lifestyle is widely known to increase health problems and mortality.

Purpose

This study was designed to identify the effects of living alone and of sedentary behavior on health-related quality of life in patients with multimorbidities using nationally representative community data.

Methods

A secondary data analysis of the Korea National Health and Nutrition Examination Survey was conducted. In this study, 1,725 adult patients aged 19 years and above with two or more chronic diseases were selected for the analysis. Health-related quality of life was measured using the European Quality of Life-5 Dimensions. Multiple logistic regression was performed to identify the effects of living alone and of sedentary behavior on health-related quality of life. The statistical analyses took into account the components of the complex sampling design such as the strata, clusters, weights, and adjustment procedures, and missing data were treated in a valid manner.

Results

After adjusting for gender, age, employment status, and number of chronic diseases, it was found that the odds of having a high health-related quality of life were lower in single households than in multiperson households (odds ratio = 0.62, 95% confidence interval [0.46, 0.84]). In addition, after adjusting for gender, age, employment status, number of chronic diseases, and living arrangement, the odds of having a high health-related quality of life decreased as sedentary time increased (odds ratio = 0.93, 95% confidence interval [0.89, 0.96]).

Conclusions/Implications for Practice

To improve quality of life in patients with multimorbidities, nursing interventions that support patients who live alone and have complicated disease-related issues and that reduce sedentary behavior should be developed.
Making a Case for Multimodal IPE: Developing a Competency-Based Interprofessional Curriculum for Health Professions Learners at Rural Campuses
Authors: Woltenberg Leslie N. , Irving Shelley R. , Aulisio Madeline C. , Schuer Kevin M.
Published: July 2021

Purpose

The purpose of this 4-year study was to explore the efficacy of a multimodal interprofessional education (IPE) curriculum that was developed for learners at rural campuses.

Methods

Over the study period, participants included 113 learners and 7 faculty facilitators from 4 degree programs: Physician Assistant Studies, Social Work, Imaging Sciences, and Medicine. The study used a mixed-methods design, which included a combination of rating scale items (quantitative) and open response items (qualitative).

Results

The results demonstrated statistically significant gains in the development of interprofessional competencies and a medium-large effect size for practical significance. The overall program evaluation ratings demonstrated learner satisfaction at or above the midpoint (benchmark) for each of the 4 years evaluated. The faculty facilitation was also rated highly.

Conclusion

The results of this 4-year study indicate that the Rural IPE program curriculum effectively employed technology to meaningfully engage rural learners in the acquisition and application of interprofessional competencies.
Advance Directives for Adolescents and Young Adults Living With Neuromuscular Disease
Authors: Battista Vanessa , Baker Deborah J. , Trimarchi Tara , Sabri Bushra , Wright Rebecca , D'Aoust Rita F.
Published: July 2021

The use of advance directives is an important component in helping individuals living with chronic and/or life-threatening illnesses establish goals of care and make decisions regarding care at the end of life. Advance care planning may help achieve enhanced health outcomes, yet it is not routinely offered to adolescents/young adults living with neuromuscular disease. An integrative review of the literature was conducted to examine the evidence related to the use of advance directives with adolescents/young adults living with neuromuscular disease and to identify reasons why they are not being used and how this can be improved. Three-hundred-seven studies were retrieved from PubMed, CINAHL, and EMBASE. Five studies met the final inclusion search criteria and were included in the analysis. Four themes emerged from the literature: conversations about advance directives with adolescents/young adults with neuromuscular disease are not being conducted, only a small number of patients have documented advance directives, patients want to have conversations about goals of care and want to have them sooner, and there is a lack of evidence in this area. These findings may influence neuromuscular clinicians' practice surrounding the use of advance directives and increase their knowledge regarding the need for discussions regarding goals of care.