bluuebunny/crossref_metadata_2025 huggingface dataset:
Comparable efficacy of 100 mg aspirin twice daily and rivaroxaban for venous thromboembolism prophylaxis following primary total hip arthroplasty: a randomized controlled trial
Authors: Ren Yi , Cao Shi-Liang , Li Zeng , Luo Tim , Feng Bin , Weng Xi-Sheng
Published: January 2021

Background:

Aspirin has demonstrated safety and efficacy for venous thromboembolism (VTE) prophylaxis following total hip arthroplasty (THA); however, inconsistent dose regimens have been reported in the literature. This study aimed to evaluate and compare the safety and efficacy of 100 mg aspirin twice daily with rivaroxaban in VTE prophylaxis following THA.

Methods:

Patients undergoing elective unilateral primary THA between January 2019 and January 2020 were prospectively enrolled in the study and randomly allocated to receive 5 weeks of VTE prophylaxis with either oral enteric-coated aspirin (100 mg twice daily) or rivaroxaban (10 mg once daily). Medication safety and efficacy were comprehensively evaluated through symptomatic VTE incidence, deep vein thrombosis (DVT) on Doppler ultrasonography, total blood loss (TBL), laboratory bloodwork, Harris hip score (HHS), post-operative recovery, and the incidence of other complications.

Results:

We included 70 patients in this study; 34 and 36 were allocated to receive aspirin and rivaroxaban prophylaxis, respectively. No cases of symptomatic VTE occurred in this study. The DVT rate on Doppler ultrasonography in the aspirin group was not significantly different from that in the rivaroxaban group (8.8% vs. 8.3%, χ
2 = 0.01, P = 0.91), confirming the non-inferiority of aspirin for DVT prophylaxis (χ
2 = 2.29, P = 0.01). The calculated TBL in the aspirin group (944.9 mL [658.5–1137.8 mL]) was similar to that in the rivaroxaban group (978.3 mL [747.4–1740.6mL]) (χ
2 = 1.55, P = 0.12). However, there were no significant inter-group differences in HHS at post-operative day (POD) 30 (Aspirin: 81.0 [78.8–83.0], Rivaroxaban: 81.0 [79.3–83.0], χ
2 = 0.43, P = 0.67) and POD 90 (Aspirin: 90.0 [89.0–92.0], Rivaroxaban: 91.5 [88.3–92.8], χ
2 = 0.77, P = 0.44), the incidence of bleeding events (2.9% vs. 8.3%, χ
2 = 0.96, P = 0.33), or gastrointestinal complications (2.9% vs. 5.6%, χ
2 = 1.13, P = 0.29).

Conclusion:

In terms of safety and efficacy, the prophylactic use of 100 mg aspirin twice daily was not statistically different from that of rivaroxaban in preventing VTE and reducing the risk of blood loss following elective primary THA. This supports the use of aspirin chemoprophylaxis following THA as a less expensive and more widely available option for future THAs.

Trial Registration:

Chictr.org, ChiCTR18000202894; http://www.chictr.org.cn/showproj.aspx?proj=33284
Congenital Blindness and Autism Spectrum Disorder
Authors: Conrad Cassandra , Linnea Kate , Augustyn Marilyn
Published: January 2021

CASE:

Emily is a 10-year-old girl who is in fifth grade. She has known congenital blindness secondary to septo-optic dysplasia with bilateral optic nerve hypoplasia and precocious puberty. Emily was referred to a Developmental-Behavioral Pediatrics clinic for concerns of academic, social, and language challenges.

Emily was born at term gestation after an uncomplicated pregnancy. At 4 months of age, she underwent ophthalmologic evaluation because of nystagmus, reduced visual tracking and response to light, and increased startle response to touch. An magnetic resonance imaging of the brain and orbits demonstrated bilateral hypoplastic optic nerves and the absence of posterior pituitary. Subsequent endocrinological evaluation for pituitary function was reassuring. Emily's early developmental milestones were delayed across all domains. She participated in early intervention programming including speech/language, physical, and occupational therapy with interval improvement in skills. She also received supports for low vision. In the elementary school, she received supports and services for low vision in a general education classroom. It was observed that Emily had reduced interest in her peers, a strong preference for routine, and distinctive play interests. As elementary school progressed, Emily had increasing challenges with academic achievement, despite performing well on formal testing in second grade.

At a recent ophthalmology visit, Emily's best-corrected visual acuity was noted to be 20/800 in each eye.

Neuropsychological testing was completed with visual accommodation and administration of measures with minimal visual requirements. Cognitive testing revealed variable verbal intellect and language skills. Academic testing revealed strong reading abilities and a relative weakness in math. Adaptive measures were notable for reduced function and highlighted social vulnerabilities. Parent measures regarding mood and behavior were not concerning.

Emily's speech was noted to have a very distinctive prosody with notable response latency. Echolalia and scripting were appreciated, and Emily often asked about names and used made-up words. When excited, Emily flapped her arms and hands, jumped up and down, or clapped her hands quickly. Socially, Emily was engaged and seemed eager to please. She was able to participate in back-and-forth conversation. Although she often responded to social bids, she frequently directed the conversation to her own areas of interest. Emily looked in the direction of the examiner when talking to the examiner and when the examiner spoke. Although a diagnosis of autism spectrum disorder is under consideration, what special considerations are necessary in the context of congenital blindness?
Insights into the Cross-world Independence Assumption of Causal Mediation Analysis
Authors: Andrews Ryan M. , Didelez Vanessa
Published: January 2021

Causal mediation analysis is a useful tool for epidemiologic research, but it has been criticized for relying on a “cross-world” independence assumption that counterfactual outcome and mediator values are independent even in causal worlds where the exposure assignments for the outcome and mediator differ. This assumption is empirically difficult to verify and problematic to justify based on background knowledge. In the present article, we aim to assist the applied researcher in understanding this assumption. Synthesizing what is known about the cross-world independence assumption, we discuss the relationship between assumptions for causal mediation analyses, causal models, and nonparametric identification of natural direct and indirect effects. In particular, we give a practical example of an applied setting where the cross-world independence assumption is violated even without any post-treatment confounding. Further, we review possible alternatives to the cross-world independence assumption, including the use of bounds that avoid the assumption altogether. Finally, we carry out a numeric study in which the cross-world independence assumption is violated to assess the ensuing bias in estimating natural direct and indirect effects. We conclude with recommendations for carrying out causal mediation analyses.
The Association Between Ambient PM2.5 Exposure and Anemia Outcomes Among Children Under Five Years of Age in India
Authors: Mehta Unnati , Dey Sagnik , Chowdhury Sourangsu , Ghosh Santu , Hart Jaime E , Kurpad Anura
Published: January 2021

Background:

Anemia is highly prevalent in India, especially in children. Exposure to ambient fine particulate matter (PM2.5) is a potential risk factor for anemia via. systemic inflammation. Using health data from the National Family and Health Survey 2015–2016, we examined the association between ambient PM2.5 exposure and anemia in children under five across India through district-level ecological and individual-level analyses.

Methods:

The ecological analysis assessed average hemoglobin levels and anemia prevalence (hemoglobin < 11 g/dL considered anemic) by district using multiple linear regression models. The individual-level analysis assessed average individual hemoglobin level and anemia status (yes/no) using generalized linear mixed models to account for clustering by district. Ambient PM2.5 exposure data were derived from the Multiangle Imaging SpectroRadiometer (MISR) level 2 aerosol optical depth (AOD) data and averaged from birth date to date of interview.

Results:

The district-level ecological analysis found that, for every 10 μg m–3 increase in ambient PM2.5 exposure, average anemia prevalence increased by 1.90% (95% CI = 1.43, 2.36) and average hemoglobin decreased by 0.07 g/dL (95% CI = 0.09, 0.05). At the individual level, for every 10 μg m–3 increase in ambient PM2.5 exposure, average hemoglobin decreased by 0.14 g/dL (95% CI = 0.12, 0.16). The odds ratio associated with a 10-μg m–3 increase in ambient PM2.5 exposure was 1.09 (95% CI = 1.06, 1.11). There was evidence of effect modification by wealth index, maternal anemia status, and child BMI.

Conclusion:

Our results suggest that ambient PM2.5 exposure could be linked to anemia in Indian children, although additional research on the underlying biologic mechanisms is needed. Future studies on this association should specifically consider interactions with dietary iron deficiency, maternal anemia status, and child BMI.

Keywords: Anemia; Children; Ambient PM2.5 exposure; India; Association
A Bipedicled Flap for Closure of the Anterolateral Thigh Flap Donor Site
Authors: Piper Merisa L. , Stranix John T. , Bast John H. , Kovach Stephen J.
Published: January 2021

Anterolateral thigh (ALT) free flaps have become reliable options for head-to-toe reconstruction. Although perforator anatomy is fairly predictable, in cases of eccentric perforator location, we proposed shifting the entire flap laterally and preserving a medial bipedicled flap between the original incision and the new medial flap margin. This facilitates primary donor site closure instead of harvesting a flap larger than anticipated. We conducted a retrospective chart review of ALT flaps performed between 2007 and 2019 and identified patients who underwent bipedicled closure of the donor site. Demographics, flap characteristics, and surgical technique were evaluated. Six patients had bipedicled donor site closure related to primary perforators located lateral to the original flap design. The mean defect size was 91 cm2, and bipedicled flap width ranged from 4 to 6 cm. All donor sites were closed primarily. Five of the donor thigh sites healed without complications, and 1 patient had superficial delayed healing of the medial bipedicled incision, which healed with local wound care. The ALT has become an invaluable flap in microsurgical reconstruction, yet it is not without limitations. Primary donor site closure is generally not feasible for larger flaps, thus necessitating skin grafting of the donor site and/or prolonged wound care. Our technique facilitates primary closure of the donor site in patients who otherwise would have required harvest of a larger than necessary flap based on eccentric perforator anatomy. The medial bipedicled flap is straightforward, reproducible, and allows for modifications of the original flap design to better fit the defect.
Enhancing Face Transplant Outcomes: Fundamental Principles of Facial Allograft Revision
Authors: Diep Gustave K. , Ramly Elie P. , Alfonso Allyson R. , Berman Zoe P. , Rodriguez Eduardo D.
Published: January 2021

Background:

Facial transplantation (FT) has become a feasible reconstructive solution for patients with devastating facial injuries. Secondary revisions to optimize functional and aesthetic outcomes are to be expected, yet the optimal timing and approach remain to be determined. The purpose of this study was to analyze all facial allograft revisions reported to date, including the senior author’s experience with 3 FTs.

Methods:

A literature review was performed, with 2 reviewers independently conducting title and abstract screening, followed by a full-text review. All articles mentioning FT revision surgeries were evaluated. The medical records of the senior author’s 3 FT recipients were additionally reviewed.

Results:

Initially, 721 articles were captured and 37 were included in the final analysis. Thirty-two FTs were reported to have involved posttransplant allograft revisions, with FT recipients undergoing a mean of 4.8 ± 4.6 revision procedures. The mean duration between FT and the first revision procedure was 149 ± 179 days. A wide spectrum of revisions was identified and categorized as involving the soft tissues, craniofacial skeleton, dentition, oronasal cavity, salivary glands, facial nerve, or ocular region. In the senior author’s experience, when indicated, posttransplant occlusal changes and integrity of the donor–recipient intraoral interface were successfully addressed with secondary procedures without allograft compromise or loss.

Conclusions:

The worldwide experience shows that secondary procedures are nearly ubiquitous after FT and can be safely performed at various timepoints. The authors thereby establish 5 distinct categories of facial allograft revisions and define 7 critical principles to optimize posttransplant procedures.
Cutaneous Cholangiocarcinoma: An Interesting Presentation
Authors: Greco Gregory , Jennings Paul , Coleman Alexis , Abbas Syed Hussain
Published: January 2021

This is a case of a 64-year-old white man with a history of CCA, originally diagnosed in May 2018 and returning in November 2019 with growing cutaneous nodules. These were removed for cosmetic and functional purposes. Pathologic findings of the lesions showed likely metastatic disease from his original CCA. This represents a relatively rare presentation of metastatic disease in the setting of CCA. In cases of CCA with metastatic spread, treatment is not curative and should be focused on measures to improve the patient’s quality of life. This includes acceptable cosmesis, as well as factors aiding in completing activities of daily living.
Nrf2-activating Therapy Accelerates Wound Healing in a Model of Cutaneous Chronic Venous Insufficiency
Authors: Kuhn Joseph , Sultan Darren L. , Waqas Bukhtawar , Ellison Trevor , Kwong Jennifer , Kim Camille , Hassan Absara , Rabbani Piul S. , Ceradini Daniel J.
Published: January 2021

Background

Chronic venous insufficiency (CVI) stems from venous hypertension, extravasation of blood, and iron-rich skin deposits. The latter is central to ulcer development through generating reactive oxygen species (ROS) that drive persistent local inflammation and the development of lipodermatosclerosis. The ability to study CVI cutaneous inflammation is fundamental to advancing therapies. To address this end, a novel protocol was adapted to investigate cutaneous wound healing in iron-induced inflammation.

Methods:

Mice were injected subcutaneously or intraperitoneally with iron-dextran, and excisional wounding was performed. Histologic and biomolecular analysis was performed.

Results:

Iron loading was associated with dense iron deposits similar to those in chronic venous stasis. Subcutaneous but not intraperitoneal loading resulted in dermal collagen expansion. Iron overload was associated with atypical antioxidant expression as compared to vehicle controls (p < 0.0001) as well as delayed wound healing by 3-4 days. A potent activator of Nuclear factor erythroid 2-related factor 2 (Nrf2), a major transcriptional regulator of redox status, was applied to establish therapeutic efficacy. Nrf2 activation in the wound resulted in significant reduction of closure times across all experimental arms. Antioxidant expression following topical treatment was significantly increased for intraperitoneally iron-loaded mice (p < 0.0001) but did not achieve significance for the subcutaneously-loaded animals.

Conclusions:

We have characterized a novel model of cutaneous iron-overload designed to advance our understanding of dysfunctional wound healing in CVI. Cutaneous changes of iron overload coincide with redox imbalance and delayed wound healing. By activating Nrf2, we demonstrate the regenerative potential of pro-antioxidant mediators in treating CVI related wound complications.
Traumatic Degloving Injury of Penile and Scrotal Skin: A Case Report
Authors: Alkahtani Dahna , Mortada Hatan , Rashidi Mohammed , Al Tamimi Abdulla
Published: January 2021

Penile and scrotal skin degloving is uncommon and is mainly caused by accidents with agricultural and industrial machines. Such injuries are called “power take-off injuries,” defined as injuries caused by power transmitted from one object to another. Penile injuries can be extremely disturbing to the physical and mental state of the patient, if not managed properly. We present the case of a 26-year-old man with traumatic degloving of penile and scrotal skin and exposed spongy body, cavernous bodies, and testicles caused by an accident on a farm tractor. The patient was presented to our emergency department 14 hours after his pants getting caught in the rotating driveshaft, which subsequently pulled him at the groin level, whereby the machine grasped the redundant skin of the penis and scrotum. The patient underwent single-stage surgical reconstruction using split-thickness skin graft 48 hours within initial presentation. Postoperative period was uneventful. He was discharged 6 days after operation. At the 8-week follow-up visit, he showed a satisfactory cosmetic outcome, well-healed scrotal and penile grafts, reestablished sexual function, and normal voiding.
Long-term Effect of Cranioplasty on Overlying Scalp Atrophy
Authors: Kwiecien Grzegorz J. , Sinclair Nicholas , Coombs Demetrius M. , Djohan Risal S. , Mihal David , Zins James E.
Published: January 2021

Background:

Scalp thinning over a cranioplasty can lead to complex wound problems, such as extrusion and infection. However, the details of this process remain unknown. The aim of this study was to describe long-term soft-tissue changes over various cranioplasty materials and to examine risk factors associated with accelerated scalp thinning.

Methods:

A retrospective review of patients treated with isolated cranioplasty between 2003 and 2015 was conducted. To limit confounders, patients with additional scalp reconstruction or who had a radiologic follow-up for less than 1 year were excluded. Computed tomography or magnetic resonance imaging was used to measure scalp thickness in identical locations and on the mirror image side of the scalp at different time points.

Results:

One hundred one patients treated with autogenous bone (N = 38), polymethylmethacrylate (N = 33), and titanium mesh (N = 30) were identified. Mean skull defect size was 104.6 ± 43.8 cm2. Mean length of follow-up was 5.6 ± 2.6 years. Significant thinning of the scalp occurred over all materials (P < 0.05). This was most notable over the first 2 years after reconstruction. Risk factors included the use of titanium mesh (P < 0.05), use of radiation (P < 0.05), reconstruction in temporal location (P < 0.05), and use of a T-shaped or “question mark” incision (P < 0.05).

Conclusions:

Thinning of the native scalp occurred over both autogenous and alloplastic materials. This process was more severe and more progressive when titanium mesh was used. In our group of patients without preexisting soft-tissue problems, native scalp atrophy rarely led to implant exposure. Other risk factors for scalp atrophy included radiation, temporal location, and type of surgical exposure.
Use of the Autologous Membrane in Structured Rhinoplasty: An Alternative to Camouflaging and Filling
Authors: da S. Neto Manoel P. , de S. Almeida Élia C. , da C. C. Tiveron Luciana R. , da Cunha Marco T. R. , Medeiros Aluísio G. , Etchebehere Renata M.
Published: January 2021

Background:

Rhinoplasty is one of the most challenging procedures in plastic surgery because the surgical modifications should attend to patient expectations and to the need for functional correction allied to aesthetics. Composed of leukocytes and platelet-rich fibrin, an autologous membrane has great potential for tissue repair. The purpose of this study was to assess the use of this membrane (associated or not associated with diced cartilage) as an alternative to techniques such as the camouflage and filling; correction of irregularities of the dorsum, nose tip, soft triangle, and K zone; filling in of dead space; skin camouflage; and an improvement in the healing process in primary or secondary rhinoplasties.

Methods:

The membranes were obtained by centrifuging patients’ peripheral blood before the rhinoplasty. At the time of use, the membrane was removed from the tube, separated from the clot, and used in the camouflage and filling process in patients operated on due to various indications: 19 associated with diced cartilage, and 4 sole. The authors present the clinical and photographic impressions of the immediate and late postoperative period, as well as the patients’ opinions using a specific questionnaire.

Results:

No patient had immediate or late postoperative complications. The use of leukocyte- and platelet-rich fibrin (L-PRF) was sufficient to carry out the camouflage and filling in all patients, and the patient declared satisfaction.

Conclusions:

This membrane was shown to be an excellent surgical alternative to the camouflage and filling in rhinoplasty. In addition, it is rich in factors that can improve and accelerate regeneration of tissues.
ACTA2 Mutation: Microsurgeon Beware!
Authors: Punjabi Ayesha , Kurlander David E. , Wee Corinne , Long Tobias C. , Gillis Joshua A. , Khouri Joseph S.
Published: January 2021

Patients with the alpha actin 2 genetic mutation suffer early onset aneurismal and vascular-occlusive conditions due to dysfunctional smooth muscle contractility. Outcomes of free flap reconstruction in this patient population are unknown. Here we report the case of a 21-year-old woman with alpha actin 2 mutation who required decompressive hemicraniectomy following an acute stroke. The entire Cushing flap underwent necrosis, requiring debridement and exposing dura. This condition was treated with a free latissimus myocutaneous flap. The patient’s post-operative course was complicated by venous thrombosis, requiring intra-flap tPA and revision of the venous anastomosis with a saphenous vein graft. Ultimately the distal 75% of the flap was lost, leaving the dura exposed. The patient’s course was further complicated by multiple wound healing complications: large areas of necrosis of the latissimus and saphenous vein donor sites, the neck vessel recipient site, and the right hand after IV infiltration. She ultimately healed with a regenerative tissue matrix strategy. Reconstructive options with no or minimal donor site morbidity should be considered in patients with the alpha actin 2 mutation. We encourage further reporting of outcomes in these patients.
A 2-step Procedure for Entropion Treatment: Eyelid Splitting and Full-thickness Everting Sutures
Authors: Lee Seunghyun , Lew Helen
Published: January 2021

Background:

This study aimed to evaluate the clinical efficacy of the 2-step procedure used for treating entropion patients: (1) performing a grey line split incision and recessing the anterior lamella; (2) using full-thickness everting sutures of the eyelid to enhance the rotating effect.

Methods:

In total, 31 eyelids of 21 patients were reviewed (male–female ratio = 11:10), with each patient having either upper or lower, or both eyelid entropion due to various causes. All patients underwent the two-step procedure by eyelid splitting and full-thickness everting sutures at the Bundang Cha Hospital from August 2014 until July 2018.

Results:

The mean follow-up duration was 24.3 months (range, 14–107 months). The causes of entropion included involutional entropion (15 eyelids), congenital entropion (10 eyelids), and cicatrical entropion (6 eyelids). Surgery was re-performed on 16 eyelids due to recurrences from previous electrolysis or surgical correction of entropion such as capsulopalpebral fascia repair, full-thickness rotating suture, or folliculectomy. The two-step procedure was performed on all 31 eyelids, and 9 eyelids received additional excision of skin. After the 2-step procedure, patients showed improvement in symptoms, and all were satisfied with the contour of their eyelids. During the follow-up period, there were no recurrences or complications.

Conclusion:

A two-step procedure involving eyelid splitting and full-thickness everting sutures is an effective surgical method to treat entropion due to various causes, when compared with other conventional methods.
Free Silicone Injections to the Breast: Delayed Complications and Surgical Management of Sequelae
Authors: Bhardwaj Priya , Greenwalt Ian , Ko Kyungmin , Sher Sarah R. , Tsiapali Ekaterini
Published: January 2021

This case describes a healthy 37-year-old woman who presented with bilateral breast pain and nodules years after receiving free silicone injections to her breasts. Mammogram revealed extremely dense breasts with innumerable bilateral masses of various sizes. Ultrasound was non-diagnostic due to poor penetration and artifact from silicone. Histologic examination revealed vacuolated histiocytes and innumerable cystic spaces containing material consistent with silicone. Patient underwent bilateral nipple-sparing mastectomy with immediate reconstruction using tissue expanders. This case highlights the potential for serious complications developing years after free silicone injections as well as our team’s surgical management of these complications.
Complication Rate of Prepectoral Implant-based Breast Reconstruction Using Human Acellular Dermal Matrices
Authors: Mangialardi Maria Lucia , Salgarello Marzia , Cacciatore Pasquale , Baldelli Ilaria , Raposio Edoardo
Published: January 2021

Background:

Implant-based breast reconstruction (IBR) is currently the most frequently performed reconstructive technique post mastectomy. Even though submuscular IBR continues to be the most commonly used technique, mastectomy technique optimization, the possibility to check skin viability with indocyanine green angiography, the enhanced propensity of patients undergoing prophylactic mastectomies, and the introduction of acellular dermal matrices (ADMs) have paved the way to the rediscovery of the subcutaneous reconstruction technique. The aim of this article is to update the complication rate of immediate and delayed prepectoral IBR using human ADMs (hADMs).

Methods:

A literature search, using PubMed, Medline, Cochrane, and Google Scholar database according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, was conducted to evaluate complication rates of prepectoral implant–based reconstructions using hADMs. The following MeSH terms were used: “prepectoral breast reconstruction acellular dermal matrix,” “prepectoral breast reconstruction ADM,” “human ADM breast reconstruction,” and “human acellular dermal matrix breast reconstruction” (period: 2005–2020; the last search took place on April 2, 2020).

Results:

This meta-analysis includes 1425 patients (2270 breasts) who had undergone immediate or delayed prepectoral IBR using different types of hADMs. The overall complication rate amounted to 19%. The most frequent complication was represented by infection (7.9%), followed by seroma (4.8%), mastectomy flap necrosis (3.4%), and implant loss (2.8%).

Conclusions:

The overall complication rate was 19%. The most frequent complications were infection, seroma, and mastectomy flap necrosis, while capsular contracture was rare.
Dr. Ian Thomas Jackson (1934–2020): A “Messiah” of the Deformed
Authors: Agarwal Rajiv , Agarwal Devisha
Published: January 2021

Ian Thomas Jackson was born and bred in Scotland and eventually settled in the United States. He rose to dizzying heights in his career due to his role in shaping the specialty of craniofacial surgery, not only in the United States but in the rest of the world. Jackson was first missed in Scotland, which lost this talented surgeon to America very early in his career; now this is everyone's loss, as we will all miss him forever. He was a skilled surgeon, great friend, and wonderful human being who touched the lives of innumerable patients with difficult deformities around the world. He never let any constraints affect his philanthropy and ushered a boy in Peru who had been abandoned by his parents through 80 operations, with a later adoption into the Jackson family, which is remarkable and unmatched by anyone even today. Jackson left indelible marks on the history and development of plastic surgery around the world and especially India, where he was introduced by Prof. Ramesh Chandra of Lucknow. The trailblazing and successful craniofacial surgeries conducted by Dr. Jackson in North India in the 1980s eventually opened the doors to the intriguing world of craniofacial surgery for the Indian plastic surgeon diaspora. He is in true sense a “messiah” of the deformed.
Breast Reconstruction Practices and Barriers in West Africa: A Survey of Surgeons
Authors: Ranganathan Kavitha , Ogunleye Adeyemi A. , Aliu Oluseyi , Agbenorku Pius , Momoh Adeyiza O.
Published: January 2021

Background:

Access to breast reconstruction is limited in low-income countries. Identifying current barriers that plague both providers and patients can inform future interventions focused on improving access to care. The goal of this study was to delineate perceptions of breast reconstruction among providers in West Africa and define current barriers to care.

Methods:

Surveys were administered to surgeons attending the annual meeting of the West African College of Surgeons in 2018. Surgeons were surveyed regarding their practices and perceptions of breast reconstruction. Information on barriers to breast reconstruction focused on patient- and surgeon-related factors was also obtained. A univariate analysis was performed to assess association of demographic and practice information with perceptions of reconstruction barriers.

Results:

Thirty-eight surgeons completed the questionnaires; 10 of the respondents were plastic surgeons (27%). The survey response rate was 40%. Factors that a majority of surgeons believed to limit access to reconstruction included limited experience (72.9%), resources (76.3%), and a lack of referrals for reconstruction (75%). In total, 76.5% of surgeons had performed <10 breast reconstruction cases in the past year. Two patient factors highlighted by most surgeons (>80%) were a lack of knowledge and concerns about cost.

Conclusions:

Perspectives from surgeons in the West African College of Surgeons suggest that barriers in access, patient awareness, surgeon technical expertise, and cost limit the delivery of breast reconstructive services to women in the region. Implementation of interventions focused on these specific metrics may serve as valuable first steps in the movement to increase access to breast reconstruction.
Successful Intralesional Laser Therapy for Sclerotherapy-resistant Huge Venous Malformation
Authors: Wada Yoshitaka , Miyazaki Hidetaka , Kusuhara Hirohisa , Uemura Kazuhisa , Asamura Shinichi
Published: January 2021

Venous malformations (VMs) are compressible, blue-purple tumors that are present at birth, and are treated with either surgery or sclerotherapy, or a combination of both. Patients often experience recurrent hemorrhage, swelling, pain, or difficulty in daily life. Treatment of massive VMs can, therefore, be challenging. We applied intralesional laser photocoagulation (ILP) to a 19-year-old female patient with a huge VM who had shown resistance to sclerotherapy. It spanned from the dorsal area to the lateral chest. ILP is delivered directly into thick, deep lesions through a bare fiber delivery system. The effect on deep components is optimized without directly contacting the cutaneous or mucosal surfaces to minimize epithelial damage. We applied ILP to the lesion at 30 W in continuous mode (10 seconds) under ultrasound monitoring using an Nd:YAG laser of 1064-nm wavelength. In total, there have been 4 sessions of the same treatment; the lesion was treated with a combined 120 kJ of energy. Satisfactory regression of the huge VM was achieved by this ILP treatment. No significant complications (major bleeding, severe pain, post-perforation skin ulcer, and scar contraction) occurred during the treatment. ILP has been indicated for only sclerotherapy-resistant cases until now, but we suggest that it is a potentially safe and minimally-invasive resolution of VM without scarring or loss of normal shape, sensory feel, or function. ILP appears to be a safe and minimally-invasive resolution of VM. We propose that this technique could become a first-choice treatment modality for VM.
Hand Surgery Transfers to Level 1 Center: Variables Affecting Transfer Method and Diagnostic Accuracy
Authors: Putnam Jill , Pedreira Rachel , Fox Paige
Published: January 2021

Background:

We hypothesize that some costly patient transfers to a level 1 trauma center for hand specialist management may be unnecessary. This analysis evaluates transfer cost effectiveness and whether time of consult, transfer distance, diagnosis at time of transfer, and provider level influence diagnostic accuracy and transport method.

Methods:

Two hundred and sixty-five patients transferred to a suburban level 1 trauma center for hand surgeon evaluation between 2014 and 2019 were evaluated for patient and injury characteristics, time of consult, transfer distance, provider level, transport method, treatment cost, and diagnostic accuracy.

Results:

The average patient age was 36.2 years, and 80.3% were men. 21% of transfers had inaccurate pre-transfer diagnoses, and certain pre-transfer diagnoses correlated with an increased likelihood of inaccuracy, including flexor tenosynovitis and vascular injury. Patients with a language barrier had a greater likelihood of being transferred with an inaccurate diagnosis (P < 0.05). Compared with ground transport, air ambulance was associated with a higher cost of treatment ($225,679 versus $133,887, P < 0.00001). Of all transfers, 14 (5%) were discharged from the emergency department (ED) without a procedure, 9 (3%) were admitted for observation, 73 (27%) had an ED procedure before discharge, and 166 (62%) received operative management.

Conclusions:

Over 30% of transfers to a level 1 trauma center likely could have been managed at the transferring facility at a decreased cost. Certain diagnoses are associated with increased risk for diagnostic error and unnecessarily urgent transport. Providers can use this information to consider transfer patterns and to educate transferring providers.
Beyond the Core Suture: A New Approach to Tendon Repair
Authors: Zeng Weifeng , Albano Nicholas J. , Sanchez Ruston J. , Mccabe Ronald , Vanderby Ray , Poore Samuel O. , Dingle Aaron M.
Published: January 2021

Background:

Despite significant improvements in zone II flexor tendon repair over the last 2 decades, function-limiting complications persist. This article describes 2 novel repair techniques utilizing flexor digitorum superficialis (FDS) autografts to buttress the flexor digitorum profundus (FDP) repair site without the use of core sutures. The hypothesis being that the reclaimed FDS tendon autograft will redistribute tensile forces away from the FDP repair site, increasing overall strength and resistance to gapping in Zone II flexor tendon injuries compared with the current clinical techniques.

Methods:

Two novel FDP repair methods utilizing portions of FDS have been described: (1) asymmetric repair (AR), and (2) circumferential repair. Ultimate tensile strength and cyclical testing were used to compare novel techniques to current clinical standard repairs: 2-strand (2-St), 4-strand (4-St), and 6-strand (6-St) methods. All repairs were performed in cadaveric sheep tendons (n = 10/group), by a single surgeon.

Results:

AR and circumferential repair techniques demonstrated comparable ultimate tensile strength to 6-St repairs, with all 3 of these techniques able to tolerate significantly stronger loads than the 2-St and 4-St repairs (P < 0.0001). Cyclical testing demonstrated that AR and circumferential repair were able to withstand a significantly higher total cumulative force (P < 0.001 and P = 0.0064, respectively) than the 6-St, while only AR tolerated a significantly greater force to 2-mm gap formation (P = 0.042) than the 6-St repair.

Conclusion:

Incorporating FDS as an autologous graft for FDP repair provides at least a comparable ultimate tensile strength and a significantly greater cumulative force to failure and 2-mm gap formation than a traditional 6-St repair.
Pediatric Mandible Reconstruction: Controversies and Considerations
Authors: Shahzad Farooq
Published: January 2021

Mandibular reconstruction in pediatric patients has some unique considerations. The method of reconstruction has to factor in the growth potential of the neo-mandible, the native mandible, and the donor site. The condyle is considered the main growth center of the mandible. Current literature indicates that fibula, iliac crest, and scapula osseous flaps do not have the ability to grow. Costochondral grafts exhibit growth because of the costal cartilage component, although the growth is unpredictable. Preservation of the mandibular periosteum can result in spontaneous bone regeneration. Fibula bone harvest in a child mandates close follow-up till skeletal maturity, to monitor for ankle instability and valgus deformity. Dental rehabilitation maintains occlusal relationships, which promotes normal maxillary development. Elective hardware removal should be considered to facilitate future dental implant placement and possible revision procedures. After completion of growth, if occlusion or symmetry is not satisfactory, secondary procedures can be performed, including distraction osteogenesis, orthognathic-type bone sliding operations, and segmental ostectomy.
Deep Layer Radiofrequency Thermo-coagulative Technology for Cervicofacial Contouring: Sonographic and Clinical Results
Authors: Cohen Sarit , Dominsky Omri , Artzi Ofir , Dayan Erez , Eckstein Joseph
Published: January 2021

Background:

Radiofrequency energy thermally induces collagen contraction and remodeling. The resultant dermal tightening is well established. However, facial aging encompasses also deeper layers of collagen-containing tissues. We present a deep layer radiofrequency-based thermo-coagulative technique for cervicofacial contouring and evaluate its efficacy.

Methods:

This prospective single center study was conducted from June 2017 to June 2018 and included 10 women. Echogenicity and thickness of layers 1–5 of the lower face, lateral neck, and submental regions were sonographically measured at baseline and at 6 weeks postoperatively. Echogenicity analysis was based on the number of high echogenic pixels counted and processed using Matlab-based image application (The Mathworks, Natick, Mass.). Clinical outcome at 12 months postoperatively was evaluated by 2 independent evaluators using a validated 5-point lower face improvement scale and the Merz jawline scale (0–4). Patient satisfaction and adverse effects were recorded.

Results:

Mean age was 60.2 years (range, 52–76). A statistically significant increase in echogenicity (P ≤ 0.02) and a decrease in thickness (P = 0.01) was noted. Echogenicity increased at 149%, 78%, and 60%, for the lateral neck, lower face, and submental region, respectively. The corresponding decrease in thickness per site was 16%, 6%, and 19%. The average physicians’ improvement in lower face contour was 3.8, and the Merz jawline scale was improved from 2.85 at baseline to 1.05 at 12 months postoperatively. Patient satisfaction was high. Side effects were minimal.

Conclusions:

Deep layer radiofrequency-based technology thermally induces profound soft tissue tightening and neocollagenesis. It is a safe and effective technique for cervicofacial contouring in selected patients.
Brachial Plexus Desmoid Tumor: Care for Functional Preservation
Authors: Liechty Andrew E. , Liu Yusha , Kao Dennis S.
Published: January 2021

Desmoid tumors are a rare, locally invasive, non-metastasizing tumor of mesenchymal origin. Most of such tumors occur sporadically, but some arise as part of germline adenomatous polyposis coli mutations. They tend to aggregate in the abdomen, thorax, extremities, and the head and neck region. They are challenging to treat, with a high rate of recurrence even if achieving negative margins. We present the case of an 18-year-old woman with a desmoid tumor involving her brachial plexus. A non-oncological resection was performed, with a focus on functional preservation. Residual disease is being treated with β-catenin inhibitor and monitored with serial MRI.
Resuming Elective Surgery during Covid-19: Can Inpatient Hospitals Collaborate with Ambulatory Surgery Centers?
Authors: Squitieri Lee , Ko Clifford Y. , Brook Robert H. , Chung Kevin C.
Published: January 2021

Background:

Little is known about the volume and scope of surgical procedures performed in ambulatory surgery centers (ASCs) and the resources that ASCs may provide to assist local health systems. The purpose of this study was to evaluate elective surgical procedures in the inpatient and outpatient ASC setting using currently available administrative claims data.

Methods:

We used the 2019 Medicare Point of Service (POS) file to evaluate the geographic distribution of Medicare-certified ASCs in the U.S. To evaluate the volume and scope of elective procedures in the inpatient and outpatient ASC setting, we used the 2016 Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) and the 2018 California HHS Open Data Portal ambulatory surgery database. HCUP software programs were used to clinically categorize procedures and determine Elixhauser comorbidity profiles for each patient.

Results:

Among the 8,540 Medicare certified ASCs in 2019, the majority are freestanding (99.5%) and privately owned (92.9%). In the inpatient setting, 13.3% of elective operating room procedures occur in patients without any Elixhauser comorbidities and require < 2 days of hospital stay. However, the types of elective procedures performed in the inpatient setting are different from the types of procedures routinely performed in ASCs.

Conclusions:

Current administrative data lack robust facility, provider, and procedure level information to inform surge capacity protocols for elective surgery. Plastic surgeons are uniquely positioned to work with other specialties and local health systems to guide future development of surge capacity protocols that maintain and improve patient care.
Monotherapy vs combination treatments of different complexity: a meta-analysis of blood pressure lowering randomized outcome trials
Authors: Thomopoulos Costas , Bazoukis George , Grassi Guido , Tsioufis Costas , Mancia Giuseppe
Published: January 2021

Background:

Use of drug combinations is recommended by hypertension guidelines for most patients because of the greater blood pressure (BP)-lowering effect compared with monotherapy. However, no evidence is available on outcome benefits of treatment strategies based on drug combinations vs. simpler treatment regimens, using data from randomized clinical trials (RCTs). We evaluated drug combination therapies of different complexity.

Methods:

Electronic databases were searched for BP-lowering RCTs that compared combination treatment or monotherapy vs. placebo, no-treatment or less-complex treatment. Combination treatment was considered as follows: background treatment continued during follow-up on top of the trial drug(s) of interest and drug(s) were added to the initial drug(s) of interest in the majority of the patients. Monotherapy was considered whenever pre-randomization treatment was withdrawn or absent and a single drug was administered at randomization. Complexity of treatment indicates the higher averaged number of daily medications used in the eligible RCTs.

Results:

We selected 93 trials (290 304 patients; follow-up, 3.9 years). The on-treatment mean number of drugs was 2.10 and 0.99 in the more and less actively treated patients, respectively. Compared with placebo, no-treatment or less-complex treatment, combination treatments of any complexity (mean number of drugs, 1.40 vs. 0.41, 2.32 vs. 0.48, 2.56 vs. 1.62 and 3.14 vs. 2.19) were associated with reduction of all or most fatal and nonfatal outcomes. There was also an increased rate of side effects leading to treatment discontinuation, although in absolute numbers the benefit usually prevailed.

Conclusion:

These data provide randomized-based trial evidence that antihypertensive combination treatment up to three or more drugs is protective. The net benefit, however, may be attenuated when side effects are considered.
Oropharyngeal Carriage of Kingella kingae and Transient Synovitis of the Hip in Young Children: A Case-control Study
Authors: Gravel Jocelyn , Manzano Sergio , Nault Marie-Lyne , Vallières Émilie , Rallu Fabien , Renaud Christian
Published: January 2021

Background:

Transient synovitis of the hip affects mostly preschool children, and its etiology is unknown. Kingella kingae has been identified recently as a common etiologic agent of osteoarticular infections (OAI) in young children and could potentially be associated to transient synovitis of the hip. The main objective of this study was to evaluate the association between transient synovitis of the hip and oropharyngeal carriage of K. kingae among preschool children.

Methods:

This was a prospective case-control study conducted at a tertiary care pediatric emergency department. Cases were children between 6 and 71 months of ages with a diagnosis of transient synovitis of the hip. For each transient synovitis case, an age-matched control was recruited among children presenting for a trauma. A second control group included children with any OAI. The independent variable was the presence of oropharyngeal K. kingae identified by a specific polymerase chain reaction assay. The primary analysis was the association between oropharyngeal K. kingae carriage and final diagnosis.

Results:

A total of 73 children were included in the study. Among them, 25 had a transient synovitis, 16 an OAI, and 22 controls. Baseline demographics were similar between the groups. There was no difference in oropharyngeal carriage of K. kingae for children with transient synovitis (5/25; 0.20) in comparison to controls (3/22; 0.14), while it was higher for children with OAI (10/16; 0.63).

Conclusions:

There is no association between oropharyngeal K. kingae and transient synovitis of the hip among preschool children.
Fibrosing Mediastinitis Associated With Tuberculosis in Children
Authors: Singhal Kamal K. , Mathew Joseph L. , Vaidya Pankaj C. , Sodhi Kushaljit S. , Bhatia Anmol , Singh Meenu
Published: January 2021

Two children developed fibrosing mediastinitis following past tuberculosis disease. Both were microbiologically negative for tuberculosis at presentation. One was treated with steroids and supportive therapy, but developed active tuberculosis with complications. He ultimately succumbed to healthcare-associated infection. The other recovered with steroids, administered along with antituberculosis treatment.