bluuebunny/crossref_metadata_2025 huggingface dataset:
Health Care Costs and Utilization of Dabigatran Compared With Warfarin for Secondary Stroke Prevention in Patients With Nonvalvular Atrial Fibrillation
Authors: Chi Nai-Fang , Wang Ye , Chien Li-Nien , Chien Shu-Chen , Ko Yu
Published: March 2018

Background:

It remains unclear whether the use of new oral anticoagulants, compared with warfarin, is economically beneficial in Asian countries.

Objective:

The objective of this study is to compare the health care costs and utilization between dabigatran and warfarin in a real-world nonvalvular atrial fibrillation (NVAF) population.

Research Design:

Data were obtained from the Taiwan National Health Insurance Database, and patients with an NVAF diagnosis between June 1, 2012, and May 31, 2014, were identified using the International Classification of Diseases, Ninth Revision code of 427.31. The patients in the dabigatran cohort were matched 1:2 to those in the warfarin cohort by sex, age, residential region, and a propensity score that incorporated a major bleeding history, CHADS2 score, and Charlson Comorbidity Index. The all-cause health care utilization and associated costs of the 2 treatment groups were compared at 3 and 12 months.

Results:

A total of 1149 patients taking dabigatran were identified and matched with 2298 warfarin users. During the 3-month observation period, the likelihood of having at least 1 hospitalization among dabigatran users was significantly lower than that of warfarin users (odds ratio=0.78; P=0.001). Patients in the dabigatran group incurred lower mean emergency department costs ($2383.1 vs. $3033.6), mean ischemic stroke–related hospitalization costs ($8869.5 vs. $13,990.5), and mean all-cause hospitalization costs ($32,402.2 vs. $50,669.9) at 3 months. However, both the mean and median outpatient costs of warfarin users were consistently lower than those of dabigatran users ($17,161.2 vs. $24,931.4 and $10,509.0 vs. $20,671.5, respectively). Similar trends were observed at 12 months, except that the 2 groups had comparable total health care costs.

Conclusions:

The use of dabigatran is associated with lower emergency department and all-cause hospitalization costs but greater outpatient costs in a real-world, NVAF patient population compared with warfarin.
Failure-to-Rescue After Acute Myocardial Infarction
Authors: Silber Jeffrey H. , Arriaga Alexander F. , Niknam Bijan A. , Hill Alexander S. , Ross Richard N. , Romano Patrick S.
Published: March 2018

Background:

Failure-to-rescue (FTR), originally developed to study quality of care in surgery, measures an institution’s ability to prevent death after a patient becomes complicated.

Objectives:

Develop an FTR metric modified to analyze acute myocardial infarction (AMI) outcomes.

Research Design:

Split-sample design: a random 20% of hospitals to develop FTR definitions, a second 20% to validate test characteristics, and an out-of-sample 60% to validate results.

Subjects:

Older Medicare beneficiaries admitted to short-term acute-care hospitals for AMI between 2009 and 2011.

Measures:

Thirty-day mortality and FTR rates, and in-hospital complication rates.

Results:

The 60% out-of-sample validation included 234,277 patients across 1142 hospitals that admitted at least 50 patients over 2.5 years. In total, 72.1% of patients were defined as Medically Complicated (complex on admission or subsequently developed a complication or died without a recorded complication) of whom 19.3% died. Spearman r between hospital risk-adjusted 30-day mortality and FTR was 0.89 (P<0.0001); Mortality versus Complication=−0.01 (P=0.6198); FTR versus Complication=−0.10 (P=0.0011). Major teaching hospitals displayed 19% lower odds of FTR versus non-teaching hospitals (odds ratio=0.81, P<0.0001), while hospitals as a group defined by teaching hospital status, comprehensive cardiac technology, and having good nursing mix and staffing, displayed a 33% lower odds of FTR (odds ratio=0.67, P<0.0001) versus hospitals without any of these characteristics.

Conclusions:

A modified FTR metric can be created that has many of the advantageous properties of surgical FTR and can aid in studying the quality of care of AMI admissions.
Validation of the Combined Comorbidity Index of Charlson and Elixhauser to Predict 30-Day Mortality Across ICD-9 and ICD-10
Authors: Simard Marc , Sirois Caroline , Candas Bernard
Published: March 2018

Objectives:

To validate and compare performance of an International Classification of Diseases, tenth revision (ICD-10) version of a combined comorbidity index merging conditions of Charlson and Elixhauser measures against individual measures in the prediction of 30-day mortality. To select a weight derivation method providing optimal performance across ICD-9 and ICD-10 coding systems.

Research Design:

Using 2 adult population-based cohorts of patients with hospital admissions in ICD-9 (2005, n=337,367) and ICD-10 (2011, n=348,820), we validated a combined comorbidity index by predicting 30-day mortality with logistic regression. To appreciate performance of the Combined index and both individual measures, factors impacting indices performance such as population characteristics and weight derivation methods were accounted for. We applied 3 scoring methods (Van Walraven, Schneeweiss, and Charlson) and determined which provides best predictive values.

Results:

Combined index [c-statistics: 0.853 (95% confidence interval: CI, 0.848–0.856)] performed better than original Charlson [0.841 (95% CI, 0.835–0.844)] or Elixhauser [0.841 (95% CI, 0.837–0.844)] measures on ICD-10 cohort. All weight derivation methods provided close high discrimination results for the Combined index (Van Walraven: 0.852, Schneeweiss: 0.851, Charlson: 0.849). Results were consistent across both coding systems.

Conclusions:

The Combined index remains valid with both ICD-9 and ICD-10 coding systems and the 3 weight derivation methods evaluated provided consistent high performance across those coding systems.
Care Coordination and Multispecialty Teams in the Care of Colorectal Cancer Patients
Authors: Trogdon Justin G. , Chang Yunkyung , Shai Saray , Mucha Peter J. , Kuo Tzy-Mey , Meyer Anne M. , Stitzenberg Karyn B.
Published: March 2018

Objectives:

To estimate the association between provider and team experience and adherence to guidelines, survival, and utilization among colorectal cancer patients in North Carolina.

Subjects:

The analysis cohort included 7295 patients diagnosed with incident stage II/III colorectal cancer between 2004 and 2013 who received surgery.

Methods:

Primary outcomes included adherence to guidelines: consultation with a medical oncologist (stage III), receipt of adjuvant chemotherapy (stage III), and receipt of surveillance colonoscopy posttreatment. Secondary outcomes included 5-year overall survival, number of surveillance radiology studies, any unplanned hospitalization, and any emergency department visit. The primary predictors were measures of provider volume and patient sharing across surgeons and medical oncologists. Regression analyses adjusted for patient and provider characteristics.

Results:

Patients whose surgeons shared >40% of their colorectal cancer patients in the previous year with a medical oncologist were (1) more likely to have had a consultation with a medical oncologist [marginal effect (ME)=13.3 percentage points, P-value<0.001], (2) less likely to receive a surveillance colonoscopy within 12 months (ME=3.5 percentage points, P-value=0.049), and (3) received more radiology studies (ME=0.254 studies, P-value=0.029). Patients whose surgeon and medical oncologist shared >20% of their colorectal cancer patients with each other in the previous year had a higher likelihood of receiving adjuvant chemotherapy (ME=11.5 percentage points, P-value<0.001) and surveillance colonoscopy within 12 months (ME=6.7 percentage points, P-value=0.030) and within 18 months (ME=6.2 percentage points, P-value=0.054).

Conclusions:

Our study shows that team experience is associated with patients’ quality of care, survival, and utilization.
Successful Management of a Rare Cause of Hemolytic Uremic Syndrome With Eculizumab in a Child
Authors: Alparslan Caner , Yavaşcan Önder , Kasap Demir Belde , Atmiş Bahriye , Karabay Bayazit Aysun , Leblebisatan Göksel , Öncel Elif P. , Alaygut Demet , Mutlubaş Fatma , Aksu Nejat
Published: March 2018

Background:

Hemolytic uremic syndrome (HUS) is characterized by microangiopathic hemolytic anemia, acute renal failure, and thrombocytopenia. It very rarely coexists with acute lymphoblastic leukemia (ALL) emerging before, simultaneously, or after the diagnosis has been made, and management of the patient may be difficult.

Case:

We present the case of a 7-year-old boy who was diagnosed with HUS and initially managed by hemodialysis (HD). Thereafter, HUS progressed, and neurological findings developed. The patient was treated with eculizumab, agressive blood pressure control, and antiepileptic drugs. At the fifth month of follow-up, the patient was diagnosed with acute B-cell lymphoblastic leukemia with fever, bone pain, hepatosplenomegaly, and pancytopenia. After initiation of ALL treatment, he had no episodes of HUS, despite cessation of eculizumab.

Conclusion:

In conclusion, eculizumab may be a treatment of choice to prevent further systemic damage in recurrent HUS episodes of patients with borderline changes in the bone marrow until ALL is constantly diagnosed.
Sickle Cell Disease is Associated With Elevated Levels of Skin Advanced Glycation Endproducts
Authors: Kashyap Liladhar , Alsaheel Abdulhameed , Ranck Megan , Gardner Renee , Maynard John , Chalew Stuart A.
Published: March 2018

Sickle cell disease (SCD) is associated with increased oxidative stress which potentially enhances generation of advanced glycation endproducts (AGEs). We estimated skin accumulation of AGEs in SCD patients and assessed their relationship with hemolysis and nephropathy. Skin intrinsic fluorescence (SIF), an estimate of AGEs, was assessed in African American patients with and without SCD. After skin excitation with light at 375, 405, and 420 nm, raw autofluorescence was adjusted using specific intrinsic corrections. Group differences in SIF were evaluated by multiple variable regression using chronological age and sex as covariates. The relationship of SIF with reticulocyte count, serum lactate dehydrogenase, estimated glomerular filtration rate (GFR), plasma creatinine, bilirubin, and urine microalbumin was assessed. There were 48 SCD patients (29 male/19 female, age=13.4±3.6 y) and 51 controls (25 male/26 female, age=10.4±5.0 y). SIF375(1.0,0.0), SIF405(0.5,0.5), and SIF420(0.5,0.5) were significantly higher in SCD patients. There was no difference in SIF between SCD patients with and without microalbuminuria. SIF 420(0.5,0.5) was correlated with reticulocyte count (r=0.33; P=0.03). Skin AGEs as estimated by SIF were higher in children with SCD and weakly associated with 1 measure of hemolysis. Further study is needed to determine whether chronic increased deposition of AGEs is associated with development of complications of SCD.
Intraoperative Consultation and Macroscopic Handling
Authors: Verrill Clare , Perry-Keene Joanna , Srigley John R. , Zhou Ming , Humphrey Peter A. , Lopez-Beltran Antonio , Egevad Lars , Ulbright Thomas M. , Tickoo Satish K. , Epstein Jonathan I. , Compérat Eva , Berney Daniel M.
Published: March 2018

The International Society of Urological Pathology held a conference on issues in testicular and penile pathology in Boston in March 2015, which included a presentation by the testis macroscopic features working group. The presentation focused on current published guidance for macroscopic handling of testicular tumors and retroperitoneal lymph node dissections with a summary of results from an online survey of members preceding the conference. The survey results were used to initiate discussions, but decisions on practice were made by expert consensus rather than voting. The importance of comprehensive assessment at the time of gross dissection with confirmation of findings by microscopic assessment was underscored. For example, the anatomic landmarks denoting the distinction of hilar soft tissue invasion (pT2) from spermatic cord invasion (pT3 category) can only be determined by careful macroscopic assessment in many cases. Other recommendations were to routinely sample epididymis, rete testis, hilar soft tissue, and tunica vaginalis in order to confirm macroscopic invasion of these structures or if not macroscopically evident, to exclude subtle microscopic invasion. Tumors 2 cm or less in greatest dimension should be completely embedded. If the tumor is >2 cm in greatest dimension, 10 blocks or a minimum of 1 to 2 additional blocks per centimeter should be taken (whichever is greater).
Histologic and Outcome Study Supports Reclassifying Appendiceal Goblet Cell Carcinoids as Goblet Cell Adenocarcinomas, and Grading and Staging Similarly to Colonic Adenocarcinomas
Authors: Yozu Masato , Johncilla Melanie E. , Srivastava Amitabh , Ryan David P. , Cusack James C. , Doyle Leona , Setia Namrata , Yang Michelle , Lauwers Gregory Y. , Odze Robert D. , Misdraji Joseph
Published: March 2018

Goblet cell carcinoid tumors are amphicrine tumors whose biological behavior ranges from indolent to highly aggressive, depending on tumor grade. Current grading systems for these tumors are based on identifying an adenocarcinoma arising in the setting of a goblet cell carcinoid tumor, which distinguishes this tumor from other gastrointestinal tract adenocarcinomas. Because goblet cell tumors are predominantly tumors of mucin secreting cells, we propose that they be classified as goblet cell adenocarcinomas, and graded using a methodology that has parallels in colorectal adenocarcinoma grading. We graded a large series of goblet cell adenocarcinomas by assessing the proportion of the tumor that demonstrates tubular or clustered growth. Histologic grade correlated with overall survival independent of stage, with median overall survival of 204, 86, and 29 months for low-grade, intermediate-grade, and high-grade goblet cell adenocarcinomas, respectively. Tumor stage also correlated with overall survival. We also graded the tumors according to previously proposed grading systems, and found that these systems are valid, in that they segregate patients according to prognosis.
Role of Pediatric Physical Therapists in Promoting Sports Participation in Developmental Coordination Disorder
Authors: Adams Imke L. J. , Broekkamp Wenke , Wilson Peter H. , Imms Christine , Overvelde Anneloes , Steenbergen Bert
Published: March 2018

Purpose:

To explore the role of pediatric physical therapists (PPT) in promoting sports participation in children with developmental coordination disorder (DCD) and identify associated barriers and facilitators.

Methods:

Questionnaires were provided to 243 PPTs. Qualitative, semistructured, in-depth interviews were administered with the PPTs, children with DCD, and parents.

Results:

Approximately 67% of questionnaires were returned. Approximately 46% of PPTs were active in guiding children with DCD to sports clubs. This guidance was facilitated by knowledge of local sports, clubs that include children with DCD, and contact persons. Barriers to sports participation were the motor impairment or coincident disorder, insufficient participants to compose a team, and lack of guidance on how to include children with DCD.

Conclusions:

PPTs currently guide children with DCD to sports clubs, but this guidance may be improved by connecting them to special exercise programs and mainstream sports clubs and examining children's experiences during sports.
Use of a Midliner Positioning System for Prevention of Dolichocephaly in Preterm Infants
Authors: McCarty Dana B. , O'Donnell Shannon , Goldstein Ricki F. , Smith P. Brian , Fisher Kimberley , Malcolm William F.
Published: March 2018

Purpose:

The purpose of this study was to determine effectiveness of a midliner positioning system (MPS, Tortle Midliner) for preventing dolichocephaly.

Methods:

This was a nonrandomized, prospective study of 30 premature infants (study cohort, SC) using an MPS compared with a retrospective study cohort (RSC) of 65 infants who received standard of care intervention.

Results:

RSC baseline cranial index (CI) of 80% and final CI of 77% significantly decreased over an average 5.5 weeks (P < .0001). The SC baseline CI and the final CI were both 79% over an average 5.7 weeks, indicating no significant difference between CI measures (P = .6). Gestational age, birth weight, reflux, time on continuous positive airway pressure, and time in a supine position were not associated with dolichocephaly.

Conclusions:

The SC developed less cranial molding (ie, had greater CI), compared with the RSC. A larger randomized study is needed to recommend routine use of MPS for prevention and/or treatment of cranial molding in premature infants.
Effects of Postural Management on Hip Migration in Children With Cerebral Palsy: A Systematic Review
Authors: Gmelig Meyling Christiaan , Ketelaar Marjolijn , Kuijper Marie-Anne , Voorman Jeanine , Buizer Annemieke I.
Published: March 2018

Purpose:

To review the existing literature on the effects of postural management on hip migration in children with cerebral palsy.

Methods:

A systematic literature search was performed using 5 databases. Quality of articles was assessed and study designs were appraised according to the American Academy of Cerebral Palsy and Developmental Medicine Systematic Review Method.

Results:

Eight of 655 identified studies were included, reporting postural management in children with cerebral palsy. Seven of 8 studies reported positive effects on hip migration after postural management interventions. However, level of evidence and quality of the articles were low.

Conclusion:

The evidence for postural management to prevent or reduce hip migration in children with cerebral palsy is limited by the lack of high-quality studies. Strong recommendations for clinical practice are not possible. Future high-quality research is crucial to improve our understanding of the effects of postural management to prevent hip migration in children with cerebral palsy.
Descriptive Report of the Impact of Fatigue and Current Management Strategies in Cerebral Palsy
Authors: Brunton Laura K.
Published: March 2018

Purpose:

To describe the effect of fatigue and self-management practices for adolescents and young adults with cerebral palsy.

Methods:

A survey of 124 people with cerebral palsy with the Fatigue Impact and Severity Self-Assessment.

Results:

Participants in Gross Motor Function Classification System (GMFCS) level I experienced little effect of fatigue, with high proportions of this group disagreeing to statements about fatigue impacting their general activities, mobility, and social activities. Participants in GMFCS levels II to V reported effect of fatigue on activities. Differences between groups were evident in questions related to fatigue interference with length of time for physical activity and with motivations to participate in social activities. All other items related to management of fatigue were not significantly different between groups.

Conclusions:

Fatigue effect is greater for participants with more functional limitations. The lack of significant differences between groups, on the Management and Activity Modification subscale, indicates more research is needed regarding strategies for fatigue management.
Epidemiology of Cerebral Palsy in Northeastern Switzerland
Authors: Forni Ruben , Stojicevic Violeta , van Son Careen , Lava Sebastiano A. G. , Kuenzle Christoph , Beretta-Piccoli Matteo
Published: March 2018

Purpose:

Cerebral palsy (CP) is the most common motor disability of childhood. Less is known about its prevalence and associated factors in Switzerland, so we aimed to fill this knowledge gap in one Swiss canton, evaluating the feasibility to build up a CP registry.

Methods:

A retrospective review of medical records was undertaken. Children born during 1995 and 2009 in the canton of Saint Gallen diagnosed with CP were eligible for inclusion.

Results:

A total of 140 patients formed the study cohort. The prevalence of CP was 0.19%, with 85% of children affected by spastic CP.

Conclusions:

The results of the present study were comparable with data of the Surveillance of Cerebral Palsy in Europe network. Moreover, this pilot study demonstrated the feasibility and usefulness of creating a registry of children affected by CP.
Head Control Changes After Headpod Use in Children With Poor Head Control: A Feasibility Study
Authors: Brown Julie E. , Thompson Mary , Brizzolara Kelli
Published: March 2018

Purpose:

To determine the feasibility of Headpod use to improve head control in children with cerebral palsy classified as Gross Motor Function Classification System level V.

Methods:

Children (3-11 years) with poor head control were video recorded before and after 3 and 6 months of Headpod use. Head control without Headpod was measured by active time children could hold head upright and number of head bobs in 5 minutes.

Results:

Fourteen children enrolled with 43% attrition rate. While average active time increased, average head bobs decreased and there were significant improvements in active time, but not head bobs. Active times were higher at 6 months compared with 3 months and baseline. Surveyed parents reported that the changes were apparent, supporting the large quantitative treatment effect.

Conclusions:

Six months of Headpod use, 45 minutes per day, appears to be feasible, has a large effect on active head control, and merits a larger randomized controlled trial.
Functional Mobility Improved After Intensive Progressive Resistance Exercise in an Adolescent With Spina Bifida
Authors: Baym Carol L. , Hedgecock James B. , Rapport Mary Jane K.
Published: March 2018

Purpose:

To describe the use and effectiveness of a novel intensive progressive resistance exercise (PRE) approach to address the functional goals of a 14-year-old adolescent with a myelomeningocele.

Summary of Key Points:

The child had lower extremity weakness, knee and hip flexion contractures, impaired somatosensation, and cardiopulmonary deconditioning, affecting gait mechanics and functional ambulation. An 8-week intensive PRE-based intervention was designed to improve walking in the home by targeting both power-generating and stabilizing lower extremity musculature. Secondary intervention focused on cardiopulmonary endurance training.

Conclusions:

The child demonstrated improvements in gait speed, walking endurance, and functional lower extremity strength. Knee contracture was moderately responsive to sustained stretching and positioning.

What This Case Adds to Evidence-Based Practice:

This intensive PRE training approach had been effective for improving function among youth with cerebral palsy, and to our knowledge it had not yet been applied to youth with other neurological conditions.
Targeted Training in Managing Children With Poor Trunk Control: 4 Case Reports
Authors: Pin Tamis W. , Butler Penelope B. , Shum Sandra Lai-Fong
Published: March 2018

Purpose:

This study investigated whether targeted training was feasible with young children younger than 2 years with poor trunk control due to cerebral palsy or developmental delay without using specialized equipment and the overall change in trunk control and functional ability, with the addition of targeted training to standard care physical therapy.

Summary of Key Points:

Four children younger than 24 months with motor disorders were recruited. No difficulty was identified in using targeted training with this group. Within 3 months of commencing intervention, the 4 children had increased trunk control and functional abilities including independent sitting and bilateral hand use in play.

Conclusions and Recommendations for Clinical Practice:

This form of targeted training was feasible for young children with motor disorders and augmented standard care therapy in enhancing both trunk control and motor skills. Targeted training should be further investigated as a potentially effective treatment.
Clubfoot Does Not Impair Gross Motor Development in 5-Year-Olds
Authors: Zapata Karina A. , Karol Lori A. , Jeans Kelly A. , Jo Chan-Hee
Published: March 2018

Purpose:

To evaluate the gross motor development of 5-year-olds using the Peabody Developmental Motor Scales, 2nd Edition (PDMS-2), test after initial nonoperative management of clubfoot as infants.

Methods:

The PDMS-2 Stationary, Locomotion, and Object Manipulation subtests were assessed on 128 children with idiopathic clubfeet at the age of 5 years. Children were categorized by their initial clubfoot severity as greater than 13, unilateral or bilateral involvement, and required surgery.

Results:

Children with treated clubfeet had average gross motor scores (99 Gross Motor Quotient) compared with age-matched normative scores. Children with more severe clubfeet required surgery significantly more than children with less severe scores (P < .01). Peabody scores were not significantly different according to initial clubfoot severity, unilateral versus bilateral involvement, and surgical versus nonsurgical outcomes.

Conclusions:

Clubfoot does not significantly impair gross motor development in 5-year-olds.
Our Journal Unites Us: Global Responsibilities and Possibilities for Pediatric Physical Therapy
Authors: Van Sant Ann F.
Published: March 2018

Purpose:

This article was designed to describe personal and social responsibilities for strengthening the science of pediatric physical therapy and effective international research collaboration and communication.

Key Points:

Common flaws in research design and analysis are reviewed with recommendations for developing research students' design and analytical skills. Our social responsibility to be informed by global knowledge is highlighted. Barriers to scientific collaboration and communication including international disparities in scientific development and language barriers are presented. Suggestions to reduce these barriers are outlined. The importance of free access to scientific literature in developing countries is reviewed.

Conclusion:

The journal should assume a leadership role in building a strong science of pediatric physical therapy through encouraging personal and social responsibility in research and serving as a model of international collaboration and communication.

Clinical Relevance:

Treatment for children with movement disorders will be improved by stronger science, international collaboration, and communication.
Targeted Muscle Reinnervation: Considerations for Future Implementation in Adolescents and Younger Children
Authors: Zuo Kevin J. , Willand Michael P. , Ho Emily S. , Ramdial Sandra , Borschel Gregory H.
Published: March 2018

Prosthetic options for patients with proximal upper limb absence are limited. Current above-elbow prostheses may restore basic motor functions for crucial activities, but they are cumbersome to operate, lack sensory feedback, and are often abandoned. Targeted muscle reinnervation is a novel surgical procedure that enhances the ability of patients with above-elbow amputations to intuitively control a myoelectric prosthesis. By transferring multiple severed peripheral nerves to a robust target muscle, targeted muscle reinnervation restores physiologic continuity and enables more intuitive prosthetic control. Although reports have been limited to adults, targeted muscle reinnervation has great potential for application in a pediatric population with congenital or acquired proximal upper limb absence. In this review, the authors describe the rehabilitative challenges of proximal upper limb amputees and outline the objectives, techniques, and outcomes of targeted muscle reinnervation. The authors then discuss important considerations for adapting targeted muscle reinnervation to pediatric patients, including cause of upper limb absence, central plasticity, timing of prosthesis fitting, role of the family, surgical feasibility, and bioethical aspects. The authors believe that carefully screened school-age children and adolescents with bilateral proximal upper limb absence, and select adolescents with unilateral proximal upper limb absence, should be seriously considered for targeted muscle reinnervation performed by an experienced surgical and rehabilitation team.
Genetics of Nonsyndromic Craniosynostosis
Authors: Timberlake Andrew T. , Persing John A.
Published: March 2018

Occurring once in every 2000 live births, craniosynostosis is one of the most frequent congenital anomalies encountered by the craniofacial surgeon. Syndromic craniosynostoses account for approximately 15 percent of cases and demonstrate Mendelian patterns of inheritance with well-established genetic causes; however, nonsyndromic craniosynostoses, which account for approximately 85 percent of cases, are genetically heterogeneous and largely unexplored. Nonsyndromic craniosynostosis is sporadic in more than 95 percent of affected families; thus, surgeons have suggested for decades that nonsyndromic craniosynostosis is likely a fluke occurrence. Contrary to this, recent studies have established that genetics underlie a substantial fraction of nonsyndromic craniosynostosis risk. Given the predominantly sporadic occurrence of disease, parents are often bewildered by the primary occurrence of nonsyndromic craniosynostosis or even recurrence in their own families and request genetic testing. Existing genetic testing panels are useful when the phenotype strongly resembles a known syndrome, wherein the risk of disease recurrence can be accurately predicted for future offspring of the parents and the future offspring of the affected child. The diagnostic utility of existing panels for nonsyndromic craniosynostosis, however, is extremely low, and these tests are quite costly. Recent genetic studies have identified several novel genes and pathways that cause nonsyndromic craniosynostosis, providing genetic evidence linking the causes of syndromic and nonsyndromic craniosynostoses, and allowing for genotype-based prediction of risk of recurrence in some nonsyndromic families. Based on analysis of exome sequence data from 384 families, the authors provide recommendations for a new genetic testing protocol for children with nonsyndromic craniosynostosis, which include testing nonsyndromic cases of sagittal, metopic, and coronal craniosynostosis.
Long-Term Outcomes of Smile Reconstruction in Möbius Syndrome
Authors: Domantovsky Irina , Copeland Jocelyne , Clancy Rachel M. , Zuker Ronald M. , Borschel Gregory H.
Published: March 2018

Background:

Gracilis muscle transplant is the standard of care for smile reconstruction in children with Möbius syndrome. The authors describe the long-term clinical efficacy, durability, and psychosocial impact of this approach at a mean follow-up of 20 years.

Methods:

Patients with Möbius syndrome who underwent gracilis muscle transfer between 1985 and 2005 were included in the study. The authors assessed midfacial movements using photographs and Scaled Measurement of Improvement in Lip Excursion measure, administered the patient-reported Facial Clinimetric Evaluation Scale, and used semistructured interviews.

Results:

The mean age at surgery was 13.2 ±10.6 years and the mean follow-up was 20.4 ± 4.4 years postoperatively. Twenty-two gracilis muscle transplants were performed, all innervated by the motor nerve to the masseter. Photographic analysis using Scaled Measurement of Improvement in Lip Excursion software demonstrated that movement of the muscle was unchanged 20 years after surgery. Smile symmetry was stable long term. The overall mean Facial Clinimetric Evaluation score of the cohort was 62.3 ± 12.0. Facial comfort (86.4 ± 21.2) and social function (69.9 ± 18.5) subdomains were the highest. Although the facial movement subdomain score was 35.6 ± 12.4, the score related to smiling alone was 84.1 ± 20.2, indicating satisfaction with the midfacial reconstruction. Interview responses indicated high satisfaction with surgery; fulfilled expectations of social acceptance; improved communication; enhanced self-confidence; and a sense of increased facial symmetry, spontaneity, and smile excursion.

Conclusion:

Segmental gracilis muscle transplantation provides long-lasting, durable improvements in objective and patient-reported measures of facial function.
Using Black Bone Magnetic Resonance Imaging in Craniofacial Virtual Surgical Planning: A Comparative Cadaver Study
Authors: Suchyta Marissa A. , Gibreel Waleed , Hunt Christopher H. , Gorny Krzysztof R. , Bernstein Matthew A. , Mardini Samir
Published: March 2018

Background:

The use of magnetic resonance imaging (MRI) for virtual surgical planning has not yet been described. In the United States, over 600,000 computed tomographic (CT) scans are performed annually on children, who are at higher risk than adults of developing cancer caused by ionizing radiation. The aim of this study was to demonstrate whether three-dimensionally–printed craniofacial surgical guides created from “black bone” MRI are comparable in accuracy to those created from CT scans.

Methods:

A mock craniosynostosis surgery translocating four calvarial segments was virtually planned and performed in 10 cadavers. For five specimens, planning was performed and three-dimensionally–printed guides were created using black bone MRI scans. Five specimens underwent standard planning using CT scans. Reconstructed skulls underwent CT scans and three-dimensional reconstruction. Accuracy was compared to that of virtually planned surgeries.

Results:

The preoperative black bone MRI scan had an average deviation from the preoperative CT scan of 1.37 mm. There was no statistically significant difference in the fit accuracy of MRI versus CT–created guides. Average deviation of postoperative anatomy from preoperative plan was within 1.5 mm for guides created from either scanning modality, with no statistically significant difference in accuracy between the two methods. Planned versus postoperative skull volume was not statistically significantly different when MRI versus CT was used.

Conclusions:

This study demonstrates that virtual surgical planning and three-dimensional craniofacial surgical guide creation can be performed using black bone MRI with accuracy comparable to that of CT. This could dramatically reduce radiation exposure of craniofacial reconstruction patients.
Acellular Human Dermal Allograft as a Graft for Nasal Septal Perforation Reconstruction
Authors: Conrad Dustin J. , Zhang Han , Côté David W. J.
Published: March 2018

Background:

Nasal septal perforations pose a troubling source of morbidity for patients and a difficult problem for the otolaryngologist. Multiple surgical techniques have been tried, with inconsistent success. Prosthetic nasal buttons also have limitations, including patient intolerance and dissatisfaction. Acellular human dermal allograft (AlloDerm) has been described as an alternative material for septal perforation repair. The authors studied objective and subjective outcomes, including quantification of the patient’s symptoms in septal perforation repair with AlloDerm.

Methods:

The authors performed a prospective cohort study of 12 patients with 1- to 2-cm anterior septal perforations who were recruited from a tertiary care practice. Patients with admitted smoking or cocaine use in the previous 3 months or vascular or granulomatous diseases were excluded. Subjective scores on the Sino-nasal Outcome Test-22, along with objective nasal endoscopy and acoustic rhinometry measures, were collected at baseline and 2, 4, and 12 weeks postoperatively. Patients were followed for reperforation 9 to 20 months postoperatively. Data were normalized to baseline values and analyzed using analysis of variance and Bonferroni correction.

Results:

Successful closure of the septal perforation was obtained in 10 of 12 patients and confirmed with rigid nasal endoscopy. Nasal symptom scores (Sino-nasal Outcome Test-22 ) were significantly reduced to 52.8 percent (95 percent CI, 35.1 to 70.5 percent; p < 0.01) of baseline symptoms at 4 weeks postoperatively. At 12 weeks postoperatively, symptoms were measured at 26.6 percent (95 percent CI, 10.9 to 42.1 percent; p < 0.01) of baseline symptoms. Acoustic rhinometry confirmed perforation closure, demonstrating a reduction in cross-sectional nasal area from baseline of 55.1 percent (95 percent CI, 37.7 to 66.8 percent; p < 0.01).

Conclusion:

This is the first study to use objective and subjective measurements to confirm success with acellular dermis allograft as an adjunct for septal perforation repair, demonstrating a statistically significant reduction in patient nasal symptoms following repair.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
New Developments Are Improving Flexor Tendon Repair
Authors: Tang Jin Bo
Published: March 2018

New developments in primary tendon repair in recent decades include stronger core tendon repair techniques, judicious and adequate venting of critical pulleys, followed by a combination of passive and active digital flexion and extension. During repair, core sutures over the tendon should have sufficient suture purchase (no shorter than 0.7 to 1 cm) in each tendon end and must be sufficiently tensioned to resist loosening and gap formation between tendon ends. Slight or even modest bulkiness in the tendon substance at the repair site is not harmful, although marked bulkiness should always be avoided. To expose the tendon ends and reduce restriction to tendon gliding, the longest annular pulley in the fingers (i.e., the A2 pulley) can be vented partially with an incision over its distal or proximal sheath no longer than 1.5 to 2 cm; the annular pulley over the middle phalanx (i.e., the A4 pulley) can be vented entirely. Surgeons have not observed adverse effects on hand function after judicious and limited venting. The digital extension-flexion test to check the quality of the repair during surgery has become increasingly routine. A wide-awake surgical setting allows patient to actively move the digits. After surgery, surgeons and therapists protect patients with a short splint and flexible wrist positioning, and are now moving toward out-of-splint freer early active motion. Improved outcomes have been reported over the past decade with minimal or no rupture during postoperative active motion, along with lower rates of tenolysis.
Assessing Technical Performance and Determining the Learning Curve in Cleft Palate Surgery Using a High-Fidelity Cleft Palate Simulator
Authors: Podolsky Dale J. , Fisher David M. , Wong Riff Karen W. , Szasz Peter , Looi Thomas , Drake James M. , Forrest Christopher R.
Published: March 2018

Background:

This study assessed technical performance in cleft palate repair using a newly developed assessment tool and high-fidelity cleft palate simulator through a longitudinal simulation training exercise.

Methods:

Three residents performed five and one resident performed nine consecutive endoscopically recorded cleft palate repairs using a cleft palate simulator. Two fellows in pediatric plastic surgery and two expert cleft surgeons also performed recorded simulated repairs. The Cleft Palate Objective Structured Assessment of Technical Skill (CLOSATS) and end-product scales were developed to assess performance. Two blinded cleft surgeons assessed the recordings and the final repairs using the CLOSATS, end-product scale, and a previously developed global rating scale.

Results:

The average procedure-specific (CLOSATS), global rating, and end-product scores increased logarithmically after each successive simulation session for the residents. Reliability of the CLOSATS (average item intraclass correlation coefficient (ICC), 0.85 ± 0.093) and global ratings (average item ICC, 0.91 ± 0.02) among the raters was high. Reliability of the end-product assessments was lower (average item ICC, 0.66 ± 0.15). Standard setting linear regression using an overall cutoff score of 7 of 10 corresponded to a pass score for the CLOSATS and the global score of 44 (maximum, 60) and 23 (maximum, 30), respectively. Using logarithmic best-fit curves, 6.3 simulation sessions are required to reach the minimum standard.

Conclusions:

A high-fidelity cleft palate simulator has been developed that improves technical performance in cleft palate repair. The simulator and technical assessment scores can be used to determine performance before operating on patients.
Hepatic Epithelioid Angiomyolipoma and 18F-FDG PET/CT
Authors: Zhang Yiqiu , Li Beilei , Hou Jun , Yu Haojun , Shi Hongcheng
Published: March 2018

Hepatic epithelioid angiomyolipoma (AML) is rare. Although generally epithelioid AML shows benign biological behavior, it can occasionally have malignant potential. In this study, we report a case of 2 hepatic epithelioid AMLs with different 18F-FDG uptake; one is intensely FDG avid, and the other is non–FDG avid.
68Ga–Prostate-Specific Membrane Antigen PET/CT in Triple-Negative Breast Cancer
Authors: Passah Averilicia , Arora Saurabh , Damle Nishikant Avinash , Tripathi Madhavi , Bal Chandrasekhar , Subudhi T. Kishan , Arora Geetanjali
Published: March 2018

The prostate-specific membrane antigen (PSMA) is a transmembrane protein with elevated expression in prostate cancer cells. Breast cancer also shows PSMA expression. We present the case of a 30-year-old woman with triple-negative bilateral breast carcinoma who underwent bilateral mastectomy, chemotherapy, and radiotherapy. She developed a left chest wall and liver recurrence after primary therapy. Her recurrent disease was also triple-negative. In view of the known poor prognosis and very limited therapeutic options, we performed 68Ga-PSMA PET/CT scan to explore the possibility of PSMA-based therapy as a future option after exhausting standard-of-care treatments.
Unexpected Detection of Bone Metastases on Renal Dynamic Scintigraphy
Authors: Mi Yanxia , Huang Jianmin , Ren Yuan , Xie Peng
Published: March 2018

A 57-year-old man with renal mass underwent 99mTc–diethylenetriaminepentaacetic acid renal dynamic scintigraphy for evaluation of renal function. The blood flow phase images demonstrated a focus of abnormal increased tracer uptake in the region of the right lower quadrant. On the functional phase images, the activity became unimpressive gradually. This focus corresponded to an osteolytic lesion in the right ilium on the CT and MR images, which was a typical pattern of bone metastasis.
Defining and Predicting Early Recurrence in 957 Patients With Resected Pancreatic Ductal Adenocarcinoma
Authors: Groot Vincent P. , Gemenetzis Georgios , Blair Alex B. , Rivero-Soto Roberto J. , Yu Jun , Javed Ammar A. , Burkhart Richard A. , Rinkes Inne H. M. Borel , Molenaar I. Quintus , Cameron John L. , Weiss Matthew J. , Wolfgang Christopher L. , He Jin
Published: March 2018

Objectives:

To establish an evidence-based cut-off to differentiate between early and late recurrence and to compare clinicopathologic risk factors between the two groups.

Summary Background Data:

A clear definition of “early recurrence” after pancreatic ductal adenocarcinoma resection is currently lacking.

Methods:

Patients undergoing pancreatectomy for pancreatic ductal adenocarcinoma between 2000 and 2013 were included. Exclusion criteria were neoadjuvant therapy and incomplete follow-up. A minimum P-value approach was used to evaluate the optimal cut-off value of recurrence-free survival to divide the patients into early and late recurrence cohorts based on subsequent prognosis. Potential risk factors for early recurrence were assessed with logistic regression models.

Results:

Of 957 included patients, 204 (21.3%) were recurrence-free at last follow-up. The optimal length of recurrence-free survival to distinguish between early (n = 388, 51.5%) and late recurrence (n = 365, 48.5%) was 12 months (P < 0.001). Patients with early recurrence had 1-, and 2-year post-recurrence survival rates of 20 and 6% compared with 45 and 22% for the late recurrence group (both P < 0.001). Preoperative risk factors for early recurrence included a Charlson age-comorbidity index ≥4 (OR 1.65), tumor size > 3.0 cm on computed tomography (OR 1.53) and CA 19-9 > 210 U/mL (OR 2.30). Postoperative risk factors consisted of poor tumor differentiation grade (OR 1.66), microscopic lymphovascular invasion (OR 1.70), a lymph node ratio > 0.2 (OR 2.49), and CA 19-9 > 37 U/mL (OR 3.38). Adjuvant chemotherapy (OR 0.28) and chemoradiotherapy (OR 0.29) were associated with a reduced likelihood of early recurrence.

Conclusion:

A recurrence-free interval of 12 months is the optimal threshold for differentiating between early and late recurrence, based on subsequent prognosis.
Multisource Evaluation of Surgeon Behavior Is Associated With Malpractice Claims
Authors: Lagoo Janaka , Berry William R. , Miller Kate , Neal Brandon J. , Sato Luke , Lillemoe Keith D. , Doherty Gerard M. , Kasser James R. , Chaikof Elliot L. , Gawande Atul A. , Haynes Alex B.
Published: March 2018

Objective:

We merged direct, multisource, and systematic assessments of surgeon behavior with malpractice claims, to analyze the relationship between surgeon 360-degree reviews and malpractice history.

Background:

Previous work suggests that malpractice claims are associated with a poor physician-patient relationship, which is likely related to behaviors captured by 360-degree review. We hypothesize that 360-degree review results are associated with malpractice claims.

Methods:

Surgeons from 4 academic medical centers covered by a common malpractice carrier underwent 360-degree review in 2012 to 2013 (n = 385). Matched, de-identified reviews and malpractice claims data were available for 264 surgeons from 2000 to 2015. We analyzed 23 questions, highlighting positive and negative behaviors within the domains of education, excellence, humility, openness, respect, service, and teamwork. Regression analysis with robust standard error was used to assess the potential association between 360-degree review results and malpractice claims.

Results:

The range of claims among the 264 surgeons was 0 to 8, with 48.1% of surgeons having at least 1 claim. Multiple positive and negative behaviors were significantly associated with the risk of having malpractice claims (P < 0.05). Surgeons in the bottom decile for several items had an increased likelihood of having at least 1 claim.

Conclusion:

Surgeon behavior, as assessed by 360-degree review, is associated with malpractice claims. These findings highlight the importance of teamwork and communication in exposure to malpractice. Although the nature of malpractice claims is complex and multifactorial, the identification and modification of negative physician behaviors may mitigate malpractice risk and ultimately result in the improved quality of patient care.