bluuebunny/crossref_metadata_2025 huggingface dataset:
Agreement Between Clinical Examination and Magnetic Resonance Imaging in Acute Knee Trauma With Hemarthrosis
Authors: Brown Jamie Sutherland , Frobell Richard B. , Isacsson Anders , Englund Martin , Olsson Ola
Published: June 2021

Objective:

Hemarthrosis after knee trauma often indicates serious joint injury. Few studies have evaluated agreement between clinical examination and findings from magnetic resonance imaging (MRI). We aimed to describe the agreement between acute clinical examination and subacute MRI findings after acute knee trauma with hemarthrosis and the importance of the subspecialty of the examiner.

Design:

Longitudinal cohort study. Agreement with MRI findings was evaluated by logistic regression.

Setting:

Helsingborg hospital.

Patients:

Thousand one hundred forty-five consecutive patients with hemarthrosis after knee trauma.

Interventions:

Clinical examination and MRI.

Main outcome measures:

agreement between clinical examination and findings from MRI. We considered the radiologist's report as the gold standard.

Results:

Median time (25th, 75th percentile) from injury to clinical examination was 2 (1, 7) days, and from injury to imaging was 8 (5, 15) days. The overall sensitivity and specificity of clinical examination versus MRI for major ligament injury or lateral patella dislocation (LPD) were 70% [95% confidence interval 67-73) and 66% (61-72), respectively. Orthopedic subspecialist knee had the highest agreement with anterior cruciate ligament rupture (adjusted odds ratios were 1.7 (95% confidence interval 1.2-2.3), 1.9 (1.2-3.0) and 5.9 (3.7-9.5) for orthopedic trainees, orthopedic subspecialists other, and orthopedic subspecialist knee, respectively]. For other ligament injuries and LPD, we did not find statistically significant differences.

Conclusions:

Clinical diagnosis after acute knee injury is relatively unreliable versus MRI findings even when performed by orthopedic specialists. However, the agreement is improved when the examination is performed by an orthopedic knee subspecialist.
The effects of amiodarone on thyroid function in pediatric and adolescent patients
Authors: Barrett Brett , Bauer Andrew J.
Published: June 2021

Purpose of review

Amiodarone-induced thyroid dysfunction is well established. The present review discusses recent literature related to the effects of amiodarone on the thyroid gland and thyroid function in pediatrics.

Recent findings

Current guidelines in adults treated with amiodarone recommend baseline thyroid function testing followed by initiation of thyroid hormone monitoring after 3 months on therapy. Two retrospective studies to evaluate amiodarone-induced thyroid dysfunction in children and young adults reveal thyroid dysfunction as soon as 2 weeks after amiodarone initiation with a greater percentage of pediatric patients developing amiodarone-induced hypothyroidism rather than thyrotoxicosis. Although additional studies are needed to determine if AIH is associated with negative impact on growth and neurocognitive development, what is clear is that in both adults and pediatrics, there is low compliance with recommended side effect-monitoring guidelines.

Pediatric patients are at similarly high risk to develop amiodarone-induced thyroid dysfunction as are adults. It is hoped that through improved education of providers and patients further research into the incidence, the potential risks of amiodarone therapy and the potential benefits of thyroid hormone replacement therapy in patients with AIH will be investigated and reported.
Mucosal Invariant T cells are Diminished in Very Early-Onset Inflammatory Bowel Disease
Authors: Dou Ying , Maurer Kelly , Conrad Maire , Patel Trusha , Shraim Rawan , Sullivan Kathleen E. , Kelsen Judith
Published: June 2021

Objectives:

Very early-onset inflammatory bowel disease (VEO-IBD) arises in children less than 6 years old, a critical time for immunologic development and maturation of the intestinal microbiome. Non-conventional lymphocytes, defined here as mucosal-associated invariant T cells and innate lymphocytes, require microbial products for either development or expansion, aspects that could be altered in very early-onset inflammatory bowel disease. Our objective was to define conventional leukocyte and non-conventional lymphocyte populations in controls and patients using multiparameter flow cytometry to test the hypothesis that their frequencies would be altered in a chronic inflammatory state associated with significant dysbiosis.

Methods:

Multiparameter flow cytometry was used in a control cohort of 105 subjects to define age-effects, not previously comprehensively examined for these cell types in humans. Differences were defined between 263 unique age-matched patients with VEO-IBD and 105 controls using Student t-test. Subjects were divided into two age groups at the time of sampling to control for age-related changes in immune composition.

Results:

Intermediate monocytes were consistently decreased in patients with VEO-IBD compared to controls. Mucosal-associated invariant T cells were significantly lower in patients with long-standing disease. Levels were less than half of those seen in the age-matched control cohort. The innate lymphoid cells type 2 population was expanded in the youngest patients.

Conclusion:

Mucosal-associated invariant T cells are diminished years after presentation with inflammatory bowel disease. This durable effect of early life intestinal inflammation may have long-term consequences. Diminished mucosal-associated invariant T cells could impact host defense of intestinal infections.
Secondary Hepatic Injury in Pediatric Intensive Care: Risk Factors and Prognostic Impact
Authors: Direito Joana , Fernandes Carla , Branquinho Rita G. , Ramos Daniela F. , Dionísio Teresa , Oliveira Guiomar G. , Pinto Carla R.
Published: June 2021

Objectives:

The aim of this study was to assess the profile of secondary hepatic injury (SHI), to determine risk factors and to evaluate its impact on prognosis of pediatric intensive care patients.

Methods:

An exploratory observational and retrospective study was conducted in a Pediatric Intensive Care Unit. Two groups were defined: with SHI [alanine aminotransferase (ALT) ≥100 IU/L or gamma glutamyl transpeptidase (GGT)≥100 IU/L or direct bilirubin ≥30 μmol/L] and without. SHI was divided into 3 patterns: cytolysis, cholestasis, and mixed.

Results:

SHI occurred in 16.5%, cytolysis in 5%, cholestasis in 4%, and mixed pattern in 7%. Independent risk factors for SHI were: organ dysfunction score PELOD-2 in D1 in cytolysis (n = 28); total parenteral nutrition and Pediatric Index of Mortality 3 (PIM3) in cholestasis (n = 23); sepsis, oncologic comorbidities, PIM3, and respiratory dysfunction in mixed pattern (n = 37). The ALT was an independent risk factor and a good predictor of mortality (AUC = 0.865) with a cut-off of 137 IU/L.

Conclusions:

SHI was associated with worst prognostic. ALT may be useful for detecting patients at increased risk of death, probably being a surrogate marker of the illness severity, reflecting a secondary injury.
Factors and Growth Trends Associated With the Need for Gastrostomy Tube in Neonates With Congenital Diaphragmatic Hernia
Authors: Schwab Marisa E. , Burke Shannon , Klarich Mary Kate , Vu Lan T.
Published: June 2021

Objectives:

A third of infants with congenital diaphragmatic hernia (CDH) require a gastrostomy tube (GT) for nutritional support. We compared CDH infants who are GT-dependent to those able to meet their nutritional needs orally, to identify factors associated with requiring a GT and evaluate their long-term growth.

Methods:

Patients with CDH repaired at a single institution between 2012 and 2020 were included. Charts were retrospectively reviewed for demographic, surgical, and post-operative details. Mann-Whitney test and Fischer exact test were performed to compare GT-dependent neonates (n = 38, experimental) with orally fed neonates (n = 63, control). Significance was set at <0.05.

Results:

Thirty-eight percent received a GT (median 67 days, interquartile range [IQR] 50–88). GT-dependent neonates were significantly more likely to have a lower lung-to-head ratio (median 1.2, IQR 0.9–1.4, vs 1.6, IQR 1.3–2.0, IQR P < 0.0001), undergone patch or flap repair (79% vs 33%, P < 0.0001), and been hospitalized longer (median 47, IQR 24–75 vs 28 days, P < 0.0001). Fourteen of 38 had their GT removed (median 26 months, IQR 14–36). GT-dependent neonates initiated oral feeds (calculated as time since extubation) later (median 21, IQR 8–26, vs 8 days, IQR 4–13, P = 0.006). Height-for-age z scores remained stable after GT removal, while weight-for-age z scores dropped initially and began improving a year later.

Conclusions:

The need for a gastrostomy for nutritional support is associated with more severe CDH. Over a third of patients no longer needed a GT at a median of 26 months. Linear growth generally remains stable after removal. These results may help counsel parents regarding nutritional expectations.
Mixed Methods Study of Nurse Assessment of Patient Preferences for Engagement During Hospitalization
Authors: Jerofke-Owen Teresa A. , Zielinski Alexandria , Brown Roger L.
Published: June 2021

Background

Global healthcare initiatives emphasize the importance of engaging patients in their healthcare to improve patients’ experience and outcomes. Assessing patient preferences for engagement is critical, as there are many ways patients can engage in their care and preferences vary across individuals.

Objective

The primary purpose of this study was to evaluate the effect of implementation of the Patient Preferences for Engagement Tool 13-Item Short Form (PPET13) during hospitalization on patient and nurse experience of engagement. Readmissions and emergency department (ED) usage within 30 days postdischarge were also examined.

Methods

The mixed methods study was conducted within two medical units in the United States between December 2018 and May 2019. Preimplementation group patients completed a demographic survey and the Patient Experience of Engagement Survey (PEES) on discharge. Implementation group patients completed the PPET13 within 24 hours of admission with their nurse and the demographic survey and PEES on discharge. A focus group with nurses who implemented the PPET13 was conducted following the implementation period. Data analysis included confirmatory factor analysis, multiple and logistic regression, and qualitative content analysis.

Results

There was significant improvement in PEES scores during the implementation phase. The PEES score was a significant predictor of ED visits, but not 30-day readmissions. Nurses were not always certain how to best integrate patient preferences for engagement into their care delivery and suggested integrating the PPET13 into the electronic health record to assist with streamlining the assessment and communicating preferences across the care team.

Discussion

Assessing patients’ preferences for engagement using the PPET13 was associated with an improved experience of engagement, which was found to mediate the relationship between utilization of PPET13 and ED usage within 30 days postdischarge. Use of a patient engagement preference tool, such as the PPET13, can help inform the delivery of individualized engagement strategies to improve patient and family engagement and outcomes; however, nurses need formalized education on how to tailor their care to meet the individual engagement preferences of their patients.
Bacterial Vaginosis and Alcohol Consumption: A Cross-Sectional Retrospective Study in Baltimore, Maryland
Authors: Froehle Leah , Ghanem Khalil G. , Page Kathleen , Hutton Heidi E. , Chander Geetanjali , Hamill Matthew M. , Gilliams Elizabeth , Tuddenham Susan
Published: June 2021

Background

Bacterial vaginosis (BV) is the most cited cause of vaginal complaints among women of reproductive age. Its etiology and associated risk factors are not entirely understood. Here we examined the association between BV and at-risk alcohol consumption in women attending 2 sexually transmitted infection (STI) clinics in Baltimore, MD.

Methods

This was a retrospective cross-sectional analysis using data from first clinic visits from 2011–2016. At-risk alcohol use was defined as heavy episodic (“binge”) drinking within the last 30 days or a self-report of having had vaginal or anal sex in the context of alcohol consumption. Pearson χ2 test and Student t test were used to assess baseline associations. Log binomial models were used to estimate prevalence ratios (PRs) before and after adjustments for potential confounding factors.

Results

Of the 10,991 women included in the analysis, 2173 (19.7%) met the clinical diagnostic criteria for BV. Having had vaginal or anal sex in the context of alcohol consumption was associated with an increased risk of BV (PR, 1.25; 95% confidence interval, 1.13–1.37), as was binge drinking (PR, 1.15; 95% confidence interval, 1.04–1.27) after adjustment for confounders.

Conclusions

In this population, at-risk alcohol consumption was associated with an increased risk of BV. The mechanisms remain uncertain. Future prospective studies are needed to verify and evaluate causality in these associations.
Hands-On Workshops Improve Emergency Department Physicians' Self-Reported Understanding of Pediatric Hand Injuries
Authors: Market Marisa , Zhu-Pawlowsky Julia , Bhatt Maala , Cheung Kevin
Published: June 2021

Objectives

The aims of this study were to assess emergency department (ED) physician perception of hand injuries and improve their understanding and confidence in treating these injuries.

Methods

Combined didactic and hands-on workshops for ED physicians were developed and run by a team of medical students, plastic surgeons, and ED physicians. The workshops consisted of a short review by a hand surgeon followed by hands-on sessions involving radiograph assessment, administration of local anesthetic, closed reduction, and splinting. Two sessions, 6 months apart, were provided. The workshops were evaluated using preworkshop and postworkshop questionnaires to assess the following domains: confidence and competence in treating hand injuries, knowledge of basic hand injury care, and feedback on the intervention itself.

Results

Fifty physicians participated in the workshops. After the workshops, physician recognition of hand fracture reduction as a critical skill increased. Self-efficacy ratings of fracture assessment, administration of local anesthetic, performing a reduction, and applying postreduction immobilization increased. Median scores on knowledge-testing questions also increased postintervention from 73.3% (95% confidence interval, 70.2–78.5) to 86.7% (95% confidence interval, 79.3–86.2) (P < 0.05). Finally, physicians reported that they found the intervention educational, useful, and important, and approximately 90% of participants indicated they intended to change their practice based on this intervention.

Conclusions

Knowledge sharing between specialists and generalists through combined didactic and hands-on workshops is an effective and well-received method of refining physician knowledge and increasing confidence in treating subspecialty-specific clinical presentations.
Point-of-Care Ultrasound to Evaluate the Acute Abdomen
Authors: Malik Rabia , Leviter Julie , Gross Isabel , Saluja Saurabh , Cowles Robert A. , Riera Antonio
Published: June 2021

We report the case of a 3-year-old boy who presented to the pediatric emergency department in undifferentiated shock with an acute abdomen. Point-of-care ultrasound revealed viscous perforation with a large amount of free fluid. Intraoperatively, a single magnet was discovered as the likely cause of bowel perforation and the resulting state of shock.
Pediatric Ocular Injury Due to Hand Sanitizer Exposure
Authors: Wasser Lauren M. , Koppel Jordanna H. , Zadok David , Berkowitz Liron , Abulafia Adi , Heiman Eyal , Aryan Ahmad , Roditi Eduardo , Weill Yishay
Published: June 2021

Objectives

The objective of this study was to describe the incidence and severity of ocular exposure to alcohol-based hand rub (ABHR) in children presenting to a tertiary medical center during the severe acute respiratory syndrome coronavirus 2 pandemic.

Methods

A retrospective single-center observational study conducted from February 21, 2020, to October 11, 2020. Subjects 10 years or younger who presented with ABHR-induced ocular injury were included. The same period from 2019 was studied and a comparison was performed between the 2 years. Outcome measures included the number of subjects with ocular injury due to ABHR, extent of ocular epithelial defects, length of hospitalization and time to resolution.

Results

A total of 9 patients presented to the Pediatric Emergency Department after sustaining ocular chemical injuries from ABHR during this period. Treatment included immediate irrigation followed by topical antibiotics, steroids, and lubrication. Six children were discharged and followed as outpatients with no reported adverse ocular sequelae. Three patients exhibited epithelial defects involving 85% to 100% of the cornea, 30% to 75% of the conjunctiva and required inpatient treatment ranging from 4 to 11 days. All patients experienced a complete resolution of the ocular epithelial defects after 12 to 19 days. No long-term irreversible damage was observed and visual acuity returned to normal in all patients.

Conclusions

The utilization of ABHR during the severe acute respiratory syndrome coronavirus 2 pandemic resulted in childhood ocular injury. Prompt treatment led to good visual outcomes. These products should be regarded as potentially toxic and stored out of the reach of young children.
Single Versus Double-Sided Hypotheses and Probabilities
Authors: Murata Michelle A. , Yamamoto Loren G.
Published: June 2021

Single-sided (1-tailed) and double-sided (2-tailed) probabilities are products of statistical tests that can be crucial to drawing accurate conclusions in scientific studies. In a review of articles published in issues of Pediatric Emergency Care from 2020, we identified 2 where single-sided versus double-sided probability issues potentially reversed a conclusion of study investigators. The purpose of this study is to describe single-sided versus double-sided probability issues found in Pediatric Emergency Care 2020 articles to increase awareness surrounding these issues.

Methods

This study involved a review of all articles from 2020 issues of the Pediatric Emergency Care journal, examining whether P values between and including the values 0.05 and 0.10, were characterized as not significant when, in fact, they resulted from a double-sided test and arguably should have been halved to yield significant single-sided probabilities less than or equal to 0.05.

Results

Two such studies were identified. In the first study, researchers concluded that their intervention resulted in “no statistically significant improvement,” citing a P value of 0.08, but if a single-sided P value was used, it would have been 0.04 and the authors would have instead concluded that their intervention resulted in significant improvement. In the second study, researchers measured resuscitation times in pediatric and adult manikin simulations. They concluded no difference, citing a P value of 0.088, but if a single-sided P value was used, it would have been 0.044, and the authors would have instead concluded that the resuscitation times took longer in the pediatric simulation.

Conclusions

These articles demonstrate how single-sided versus double-sided probability issues can cause researchers to draw inaccurate conclusions. As such, we would urge that this be more rigorously evaluated when the P values are between 0.05 and 0.10.
Distinct Basal Brain Functional Activity and Connectivity in the Emotional-Arousal Network and Thalamus in Patients With Functional Constipation Associated With Anxiety and/or Depressive Disorders
Authors: Li Guanya , Zhang Wenchao , Hu Yang , Wang Jia , Li Jingyuan , Jia Zhenzhen , Zhang Lei , Sun Lijuan , von Deneen Karen M. , Duan Shijun , Wang Huaning , Wu Kaichun , Fan Daiming , Cui Guangbin , Zhang Yi , Nie Yongzhan
Published: June 2021

Objective

Functional constipation (FC) is a common gastrointestinal disorder. Anxiety and/or depressive disorders are common in patients with FC (FCAD). Brain dysfunction may play a role in FC, but the contribution of comorbid anxiety and/or depression in patients with FC is poorly understood.

Methods

Sixty-five FC patients and 42 healthy controls (HCs) were recruited, and a hierarchical clustering algorithm was used to classify FC patients into FCAD and patients without anxiety/depressive status (FCNAD) based on neuropsychological assessment. Resting-state functional magnetic resonance imaging measures including fractional amplitude of low-frequency fluctuation (fALFF) and functional connectivity were used to investigate brain functional differences.

Results

Thirty-seven patients were classified as FCAD, and 28 patients were classified as FCNAD; as compared with HC, both groups showed decreased activity (fALFF) in the perigenual anterior cingulate cortex (pACC), dorsomedial prefrontal cortex (DMPFC), and precuneus; enhanced precentral gyrus–thalamus connectivity and attenuated precuneus-thalamus connectivity in FCAD/FCNAD highlighted the thalamus as a critical connectivity node in the brain network (p
FWE < .05). In comparison with FCNAD/HC, the FCAD group also had decreased fALFF in the orbitofrontal cortex (OFC) and thalamus, and increased OFC-hippocampus connectivity. In the FCNAD group, brain activities (pACC/DMPFC) and connection (precuneus-thalamus) had correlations only with symptoms; in the FCAD group, brain activities (OFC, pACC/DMPFC) and connectivities (OFC-hippocampus/precentral gyrus–thalamus) showed correlations with both constipation symptoms and anxiety/depressive status ratings. Mediation analysis indicated that the relationship between abdominal distension and OFC activity was completely mediated by anxiety in FCAD.

Conclusions

These findings provide evidence of differences in brain activity and functional connectivity between FCAD and FCNAD, potentially providing important clues for improving treatment strategies.
Mindfulness and More: Toward a Science of Human Flourishing
Authors: Davidson Richard J.
Published: June 2021

This commentary for this Special Issue on mindfulness highlights the progress and maturity of this growing field of scientific investigation and points the way toward important questions that require further study. Important methodological and implementation issues including the nature of proper comparison groups, the extension of mindfulness-based interventions to underserved populations, the assessment of baseline characteristics that predict beneficial outcomes, and how mindfulness might be combined with other health-promoting activities such as physical exercise are considered. New questions for future research were also showcased, including best practices for mobile interventions, the development and assessment of microinterventions, and the need for a more expansive framework to cultivate human flourishing. The learning of well-being is conceptualized as an urgent public health need that will require new approaches for global scaling.
What Is the Burden of Heterosexually Acquired HIV Due to HSV-2? Global and Regional Model-Based Estimates of the Proportion and Number of HIV Infections Attributable to HSV-2 Infection
Authors: Silhol Romain , Coupland Helen , Baggaley Rebecca F. , Miller Lori , Staadegaard Lisa , Gottlieb Sami L. , Stannah James , Turner Katherine M. E. , Vickerman Peter , Hayes Richard , Mayaud Philippe , Looker Katharine J. , Boily Marie-Claude
Published: June 2021

Background:

Biological and epidemiological evidence suggest that herpes simplex virus type 2 (HSV-2) elevates HIV acquisition and transmission risks. We improved previous estimates of the contribution of HSV-2 to HIV infections by using a dynamic transmission model.

Setting:

World Health Organization regions.

Methods:

We developed a mathematical model of HSV-2/HIV transmission among 15- to 49-year-old heterosexual, non–drug-injecting populations, calibrated using region-specific demographic and HSV-2/HIV epidemiological data. We derived global and regional estimates of the contribution of HSV-2 to HIV infection over 10 years [the transmission population-attributable fraction (tPAF)] under 3 additive scenarios, assuming: (1) HSV-2 increases only HIV acquisition risk (conservative); (2) HSV-2 also increases HIV transmission risk (liberal); and (3) HIV or antiretroviral therapy (ART) also modifies HSV-2 transmission risk, and HSV-2 decreases ART effect on HIV transmission risk (fully liberal).

Results:

Under the conservative scenario, the predicted tPAF was 37.3% (95% uncertainty interval: 33.4%–43.2%), and an estimated 5.6 (4.5–7.0) million incident heterosexual HIV infections were due to HSV-2 globally over 2009–2018. The contribution of HSV-2 to HIV infections was largest for the African region [tPAF = 42.6% (38.0%–51.2%)] and lowest for the European region [tPAF = 11.2% (7.9%–13.8%)]. The tPAF was higher among female sex workers, their clients, and older populations, reflecting their higher HSV-2 prevalence. The tPAF was approximately 50% and 1.3- to 2.4-fold higher for the liberal or fully liberal scenario than the conservative scenario across regions.

Conclusion:

HSV-2 may have contributed to at least 37% of incident HIV infections in the past decade worldwide, and even more in Africa, and may continue to do so despite increased ART access unless future improved HSV-2 control measures, such as vaccines, become available.
Multidrug-resistant, gram-negative infections in high-risk haematologic patients: an update on epidemiology, diagnosis and treatment
Authors: Garcia-Vidal Carolina , Stern Anat , Gudiol Carlota
Published: June 2021

Purpose of review

Multidrug-resistant Gram-negative bacilli (MDR-GNB) infections are a significant cause of morbidity and mortality in high-risk hematologic patients. Early diagnosis and management of antibiotic treatment in these patients is a challenge for physicians. This review focuses on the latest literature reports that concern the epidemiology, diagnosis and treatment of MDR-GNB infections in this population.

Recent findings

High-risk haematological patients have several risk factors that make them particularly susceptible to MDR-GNB infections. Few studies have examined the implementation of rapid diagnostic methods for multidrug resistance, and their impact on management in this population. Inappropriate empiric antibiotic treatment in these patients has been described frequently and is associated with poor outcomes.

Knowledge of the local epidemiology of MDR-GNB is a basic requirement to guide empiric antibiotic treatments in each centre. New diagnosic tests might help in faster identification of MDR-GNB infections. Appropriate empiric antibiotic treatment is crucial for improving patients’ prognosis. Important strategies to reduce inadequate antibiotic treatment include better risk stratification for MDR-GNB infection and the introduction of new, more broad-spectrum antibiotic therapies
Employment as a Plastic Surgeon
Authors: Davis Matthew J. , Luu Bryan C. , Cole Samuel H. , Abu-Ghname Amjed , Winocour Sebastian , Reece Edward M.
Published: June 2021

Intrinsic to the field of plastic surgery, constant changes in health care policy, consumer demands, and medical technology necessitate periodic evaluation of trends in employment over time. In this article, we review the existing literature to report the current state of plastic surgery employment in the United States with regards to compensation, practice patterns, subspecialty trends, contract negotiation, representation of women in the field of plastic surgery, burnout and job satisfaction, and retirement. Understanding how the plastic surgery job market is changing not only serves as a valuable tool for the individual plastic surgeon regarding the navigation of his or her own career but also offers insight into the future of the field as a whole.
Pediatric Trigger Digit Presenting in the Setting of Trauma
Authors: Tadisina Kashyap Komarraju , Francoisse Caitlin A. , Frojo Gianfranco , Gorski John , Plikaitis Christina Marie
Published: June 2021

Background

Pediatric trigger digit is a relatively rare condition with incompletely understood etiology. In our practice, we noted a series of children presenting with pediatric trigger digit after an associated local trauma to the hand, which has not been previously described. The aim of this study was to analyze the nature of presentation of trigger digits, the accuracy of initial diagnosis, and the impact on treatment strategies used.

Methods

An institutional review board–approved retrospective review of our institution's experience with pediatric trigger finger from 2001 to 2015 was performed.

Results

Twenty-two patients with 26 affected digits were identified. Eighty-eight percent of patients were diagnosed with trigger thumb, whereas 3 patients (12%) had small finger triggering. Thirteen patients (59%) presented as outpatients, whereas 9 (41%) presented through the emergency department. All patients presenting to the emergency department were in the setting of recent minor trauma. Of this subset of patients, 67% had an incorrect initial diagnosis, leading to an average delay in treatment of 60 days. Ten patients (45% of total) were initially treated with immobilization versus surgical release of the A1 pulley. However, all but 2 of these patients required eventual A1 pulley release for persistent or recurrent triggering (88%).

Conclusions

The cause of trigger digit in children remains incompletely understood and may be multifactorial. In this series, a traumatic component to presentation was found in a significant number of patients. This association with minor trauma may contribute to misdiagnosis and delay in definitive treatment. Although initial treatment with immobilization does not seem to impact surgical outcome, we found a high rate of failure with initial immobilization. Most patients required eventual surgical management, regardless of whether or not the initial presentation was associated with trauma. When performed, we found that A1 pulley release alone has safe, reliable results.
Autoimmune Disease and Breast Implants
Authors: Coriddi Michelle , Burke Elizabeth Anne , Myers Paige , Soudant Celine , McCarthy Colleen M.
Published: June 2021

Given that the use of breast implants for both cosmetic and reconstructive purposes is growing in the United States, an evaluation of factors that may affect the outcome of breast implant surgery is needed. A systematic review was conducted to evaluate the question: Does a personal or family history of autoimmune disease affect outcomes in breast implant surgery? The literature search yielded 2425 records, but after removal of duplicates, abstract screening, and full-text assessment, only 2 studies met the inclusion criteria for the final review. Both studies provided level III evidence and the average Methodological Index for Non-Randomized Studies score was 16.5 (range, 15–18 of 24), indicating a fair level of evidence overall. This systematic review found no evidence to support that a diagnosis of an autoimmune disease and/or a family history of autoimmune diseases will lead to poor surgical outcomes in breast implant surgery. Further study is warranted.
Patents for the Plastic Surgeon
Authors: Schultz Brent E. , Jalalabadi Faryan , Raghuram Anjali C. , Davis Matthew J. , Abu-Ghname Amjed , Winocour Sebastian , Khan Umraz , Vorstenbosch Joshua , Reece Edward M.
Published: June 2021

Although innovation and entrepreneurship are complementary in the process of creating new products, plastic surgeons are frequently discouraged by the challenges associated with the regulatory and administrative environments in patent filing. The following primer provides a step-by-step guide for understanding patents and outlines the steps and costs involved in patent filing. To improve opportunities for successful patent filing, we elaborate on some of the common pitfalls in the process, including the timing of public disclosure, conducting a private art search, selecting a patent attorney or agent, determining the level of inventor involvement, and navigating academic and employment contracts. The innovative drive in plastic surgery provides a strong impetus for strengthening knowledge about patents and patent filing in order to support efforts for providing high-value patient care.
Reasons for Long-term Opioid Prescriptions After Guideline-directed Opioid Prescribing and Excess Opioid Pill Disposal
Authors: Barth Richard J. , Porter Eleah D. , Kelly Julia L. , Bessen Sarah Y. , Molloy Lida B. , Phillips Joseph D. , Loehrer Andrew P. , Wilson Matthew Z. , Ivatury Srinivas J. , Billmeier Sarah E. , Seigne John D. , Wong Sandra L. , Wilkinson-Ryan Ivy
Published: June 2021

Objectives:

The aim of this study was to determine the frequency and reasons for long-term opioid prescriptions (rxs) after surgery in the setting of guideline-directed prescribing and a high rate of excess opioid disposal.

Background:

Although previous studies have demonstrated that 5% to 10% of opioid-naïve patients prescribed opioids after surgery will receive long-term (3–12 months after surgery) opioid rxs, little is known about the reasons why long-term opioids are prescribed.

Methods:

We studied 221 opioid-naïve surgical patients enrolled in a previously reported prospective clinical trial which used a patient-centric guideline for discharge opioid prescribing and achieved a high rate of excess opioid disposal. Patients were treated on a wide variety of services; 88% of individuals underwent cancer-related surgery. Long-term opioid rxs were identified using a Prescription Drug Monitoring Program search and reasons for rxs and opioid adverse events were ascertained by medical record review. We used a consensus definition for persistent opioid use: opioid rx 3 to 12 months after surgery and >60day supply.

Results:

15.3% (34/221) filled an opioid rx 3 to 12 months after surgery, with 5.4% and 12.2% filling an rx 3 to 6 and 6 to 12 months after surgery, respectively. The median opioid rx days supply per patient was 7, interquartile range 5 to 27, range 1 to 447 days. The reasons for long-term opioid rxs were: 51% new painful medical condition, 40% new surgery, 6% related to the index operation; only 1 patient on 1 occasion was given an opioid rx for a nonspecific reason. Five patients (2.3%) developed persistent opioid use, 2 due to pain from recurrent cancer, 2 for new medical conditions, and 1 for a chronic abscess.

Conclusions:

In a group of prospectively studied opioid-naïve surgical patients discharged with guideline-directed opioid rxs and who achieved high rates of excess opioid disposal, no patients became persistent opioid users solely as a result of the opioid rx given after their index surgery. Long-term opioid use did occur for other, well-defined, medical or surgical reasons.
A Randomized Trial of Robotic Mastectomy Versus Open Surgery in Women With Breast Cancer or BrCA Mutation
Authors: Toesca Antonio , Sangalli Claudia , Maisonneuve Patrick , Massari Giulia , Girardi Antonia , Baker Jennifer L. , Lissidini Germana , Invento Alessandra , Farante Gabriel , Corso Giovanni , Rietjens Mario , Peradze Nickolas , Gottardi Alessandra , Magnoni Francesca , Bottiglieri Luca , Lazzeroni Matteo , Montagna Emilia , Labo Piergiorgio , Orecchia Roberto , Galimberti Viviana , Intra Mattia , Sacchini Virgilio , Veronesi Paolo
Published: June 2021

Objective:

The aim of this study was to compare robotic mastectomy with open classical technique outcomes in breast cancer patients.

Summary Background Data:

As the use of robotic nipple sparing mastectomy continues to rise, improved understanding of the surgical, oncologic, and quality of life outcomes is imperative for appropriate patient selection as well as to better understand indications, limits, advantages, and dangers.

Methods:

In a phase III, open label, single-center, randomized controlled trial involving 80 women with breast cancer (69) or with BRCA mutation (11), we compared the outcome of robotic and open nipple sparing mastectomy. Primary outcomes were surgical complications and quality of life using specific validated questionnaires. Secondary objective included oncologic outcomes.

Results:

Robotic procedure was 1 hour and 18 minutes longer than open (P < 0.001). No differences in the number or type of complications (P = 0.11) were observed. Breast-Q scores in satisfaction with breasts, psychosocial, physical and sexual well-being were significantly higher after robotic mastectomy versus open procedure. Respect to baseline, physical and sexual well-being domains remained stable after robotic mastectomy, whereas they significantly decreased after open procedure (P < 0.02). The overall Body Image Scale questionnaire score was 20.7 ± 13.8 versus 9.9 ± 5.1 in the robotic versus open groups respectively, P < 0.0001. At median follow-up 28.6months (range 3.7–43.3), no local events were observed.

Conclusions:

Complications were similar among groups upholding the robotic technique to be safe. Quality of life was maintained after robotic mastectomy while significantly decrease after open surgery. Early follow-up confirm no premature local failure.

ClinicalTrials.gov NCT03440398
Disparities in Perioperative Use of Patient Engagement Technologies - Not All Use is Equal
Authors: Theiss Lauren M. , Wood Lauren , Shao Connie , Marques Isabel , Kim Dae Hyun , Hollis Robert , Gunnells Drew , Hardiman Karin , Cannon Jamie , Morris Melanie , Kennedy Gregory , Chu Daniel I.
Published: June 2021

Objective:

To determine the association of patient-level characteristics on the use of a patient engagement technology during the perioperative period.

Summary of Background Data:

As implementation of patient engagement technologies continues to grow, it remains unclear who uses, and not uses, these technologies. Existing literature suggests significant disparities in usage of other technologies by patient age, race, sex, and geographic location, however, have yet to characterize patient usage of patient engagement technologies.

Methods:

This is a retrospective cohort study of patients undergoing elective surgery by a colorectal surgeon between January 2018 and March 2020 who enrolled in a patient engagement technology at a single institution. Patients enrolled received educational content, healthcare reminders, patient reported outcome (PRO) surveys, and health checks preoperatively, in-hospital, and for 30-days postdischarge. The primary outcome was patient activation of the patient engagement technology. Secondary outcomes were completion of at least 1 PRO survey, 1 in-hospital health check, and 1 postdischarge health check.

Results:

Of 549 patients who enrolled in the patient engagement technology, 473 (86.2%) activated. On multivariable stepwise regression, female patients [odds ratio (OR) 2.4, confidence interval (CI) 1.4–4.0, P = 0.001] and privately insured patients (OR 2.0, CI 1.1–3.8, P = 0.03) were more likely to activate. Black patients were less likely to activate (OR 0.5, CI 0.3–0.9, P = 0.02). Once activated, privately insured patients were more likely to complete PRO surveys (OR 2.3, CI 1.2–4.3, P = 0.01), in-hospital health checks (OR 2.4, CI 1.4–4.1, P = 0.002), and postdischarge health checks (OR 1.9, CI 1.1 −3.3, P < 0.001) than uninsured patients. Black patients were less likely to complete PRO surveys (OR 0.4, CI 0.3-0.7, P = 0.001) and in-hospital health checks (OR 0.6, CI 0.4–0.9, P = 0.03) than White patients.

Conclusions:

Use of a patient engagement technology in the perioperative period differs significantly by sex, race/ethnicity, and insurance status. These technologies may not be used equally by all patients, which should be considered during implementation of interventions to improve surgical outcomes.
A Novel and Generic Workflow of Indocyanine Green Perfusion Assessment Integrating Standardization and Quantification Toward Clinical Implementation
Authors: Noltes Milou E. , Metman Madelon J. H. , Heeman Wido , Rotstein Lorne , van Ginhoven Tessa M. , Vriens Menno R. , Engelsman Anton F. , Boerma E. Christiaan , Brouwers Adrienne H. , van Dam Gooitzen M. , Pasternak Jesse D. , Kruijff Schelto
Published: June 2021

Objective:

This study aims to generate a reproducible and generalizable Workflow model of ICG-angiography integrating Standardization and Quantification (WISQ) that can be applied uniformly within the surgical innovation realm independent of the user.

Summary Background Data:

Tissue perfusion based on indocyanine green (ICG)-angiography is a rapidly growing application in surgical innovation. Interpretation of results has been subjective and error-prone due to the lack of a standardized and quantitative ICG-workflow and analytical methodology. There is a clinical need for a more generic, reproducible, and quantitative ICG perfusion model for objective assessment of tissue perfusion.

Methods:

In this multicenter, proof-of-concept study, we present a generic and reproducible ICG-workflow integrating standardization and quantification for perfusion assessment. To evaluate our model's clinical feasibility and reproducibility, we assessed the viability of parathyroid glands after performing thyroidectomy. Biochemical hypoparathyroidism was used as the postoperative endpoint and its correlation with ICG quantification intraoperatively. Parathyroid gland is an ideal model as parathyroid function post-surgery is only affected by perfusion.

Results:

We show that visual subjective interpretation of ICG-angiography by experienced surgeons on parathyroid perfusion cannot reliably predict organ function impairment postoperatively, emphasizing the importance of an ICG quantification model. WISQ was able to standardize and quantify ICG-angiography and provided a robust and reproducible perfusion curve analysis. A low ingress slope of the perfusion curve combined with a compromised egress slope was indicative for parathyroid organ dysfunction in 100% of the cases.

Conclusion:

WISQ needs prospective validation in larger series and may eventually support clinical decision-making to predict and prevent postoperative organ function impairment in a large and varied surgical population.
Muscle deteriorations become prominent within 24 hours after admission in severely burned adults
Authors: Martini Wenjun Z. , Yu Yong-Ming , Chung Kevin K. , Dubick Michael A.
Published: June 2021

BACKGROUND

Severe burn injury results in profound catabolic deterioration. Although burn-related catabolism has been well stated, it is unclear when the catabolic response begins. This study characterized acute changes of muscle protein breakdown at the admission and the day after in severely burned adults.

METHODS

Twelve patients (43 ± 19 years old) with 40% ± 21% total body surface area burns were prospectively enrolled into an observational study approved by institutional review board. Urinary samples were collected on admission day and the day after (day 1). Patient demographic and clinical data of vital signs, blood gas and chemistry, and coagulation status were collected. Catabolic changes of muscle breakdown were quantified by urinary excretion of 3-methylhisitidine, determined by gas chromatography and mass spectrometry analysis.

RESULTS

Compared with admission day, burned patients had elevated mean ± SD arterial pressure (from 90 ± 5 mm Hg to 108 ± 7 mm Hg) and heart rate (from 102 ± 7 beats per minute to 119 ± 4 beats per minute both p < 0.05) after 24 hours. Their 24-hour urinary output was 1,586 ± 813 mL at admission day to 1,911 ± 1,048 mL on day 1. The 24-hour urea excretion was elevated from 172 ± 101 mg/kg per day at admission day to 302 ± 183 mg/kg per day on day 1 (both p < 0.05), with no change in creatinine excretion. Urinary 3-methylhisitidine excretion increased from 0.75 ± 0.74 mg/kg per day at admission to 1.14 ± 0.86 mg/kg per day on day 1 (p < 0.05). The estimated skeletal muscle protein breakdown was increased from 1.1 ± 1.0 g/kg per day at admission day to 1.6 ± 1.2 g/kg per day on day 1 (p < 0.05). There were no changes in prothrombin time, activated partial thromboplastin time, or platelets.

CONCLUSION

In severely burned patients, catabolic muscle protein breakdown is elevated within 24 hours after admission and before changes in coagulation. These findings suggest that early interventions may be needed to effectively attenuate the catabolic responses in burn patients.

LEVEL OF EVIDENCE

Prospective and observational study, level II.
Allele-specific epigenetic activity in prostate cancer and normal prostate tissue implicates prostate cancer risk mechanisms
Authors: Shetty Anamay , Seo Ji-Heui , Bell Connor A. , O’Connor Edward P. , Pomerantz Mark , Freedman Matthew L. , Gusev Alexander
Published: June 2021

Background

Genome-wide association studies of prostate cancer have identified >250 significant risk loci, but the causal variants and mechanisms for these loci remain largely unknown. Here, we sought to identify and characterize risk harboring regulatory elements by integrating epigenomes from primary prostate tumor and normal tissues of 27 patients across the H3K27ac, H3K4me3, and H3K4me2 histone marks and FOXA1 and HOXB13 transcription factors.

Results

We identified 7,371 peaks with significant allele-specificity (asQTL peaks). Showcasing their relevance to prostate cancer risk, H3K27ac T-asQTL peaks were the single annotation most enriched for prostate cancer GWAS heritability (40x), significantly higher than corresponding non-asQTL H3K27ac peaks (14x) or coding regions (14x). Surprisingly, fine-mapped GWAS risk variants were most significantly enriched for asQTL peaks observed in tumors, including asQTL peaks that were differentially imbalanced with respect to tumor-normal states. These data pinpointed putative causal regulatory elements at 20 GWAS loci, of which 11 were detected only in the tumor samples. More broadly, tumor-specific asQTLs were enriched for expression QTLs in benign tissues as well as accessible regions found in stem cells, supporting a hypothesis where some germline variants become reactivated during/after transformation and can be captured by epigenomic profiling of the tumor.

Conclusion

Our study demonstrates the power of allele-specificity in chromatin signals to uncover GWAS mechanisms, highlights the relevance of tumor-specific regulation in the context of cancer risk, and prioritizes multiple loci for experimental follow-up.