bluuebunny/crossref_metadata_2025 huggingface dataset:
Increased PA2G4 Expression Is an Unfavorable Factor in Nasopharyngeal Carcinoma
Authors: Xu Yan , Cai Hongbing , Tu Wei , Ding Lingying , Luo Rongcheng
Published: February 2021

PA2G4 plays a dual role in tumors. However, the correlation of its expression with clinical feature and prognosis has never been reported in nasopharyngeal carcinoma (NPC). Using immunohistochemical staining, we examined PA2G4 protein level in clinicopathologically characterized 201 NPC cases (138 male and 63 female) with age ranging from 21 to 83 years and 45 nasopharyngeal (NP) tissues. Statistical methods were used to assess the difference in PA2G4 expression and its relationship with clinical parameters and prognosis in NPC. Immunohistochemical analysis showed that the protein expression of PA2G4 examined in NPC tissues was higher than that in the nasopharyngeal tissues (P=0.005). In addition, high levels of PA2G4 protein were positively correlated with tumor size (T classification) (P<0.001), the status of lymph node metastasis (N classification) (P<0.001), distant metastasis (P=0.029), and clinical stage (P<0.001) of NPC patients. Patients with higher PA2G4 expression had a significantly shorter overall survival time than did patients with low PA2G4 expression. Stratified analysis indicated that high expression of PA2G4 showed the inversed survival time in clinical stages III-IV, but not stages I-II. Finally, multivariate analysis suggested that the level of PA2G4 expression was an independent prognostic indicator (P<0.001) for the survival of patients with NPC. Elevated protein expression of PA2G4 was significantly shown, which plays an unfavorable outcome for NPC patient survival.
Clinicopathologic Features of Myelodysplastic Syndromes Involving Lymph Nodes
Authors: Fang Hong , Wang Sa A. , Xie Wei , Tang Zhenya , Hu Shimin , Krishnamurthy Savitri , Medeiros L. Jeffrey , Wang Wei
Published: February 2021

Lymph nodes (LNs) involved by a myelodysplastic syndrome (MDS) are rare and uncommonly biopsied. In this study, we report 6 MDS patients who underwent an LN biopsy that showed MDS, and we summarize the clinicopathologic features of this cohort. All patients presented with lymphadenopathy (generalized in 5), 5 patients had splenomegaly, and 3 patients had hepatomegaly. Histologically, the LN architecture was distorted without complete effacement. MDS cells, mostly of the myeloid lineage, produced interfollicular expansion. These myeloid cells exhibited a spectrum of maturation, and immature and atypical forms were common, including eosinophils. Scattered megakaryocytes and nucleated erythroid cells were often present. Concurrent bone marrow aspirate and biopsy specimens in these patients showed persistent/resistant MDS. Following the diagnosis of LN involvement, patients did not respond well to therapy and all died by the time of the last follow-up, with a median survival of 6.7 months (range, 4.5 to 21.6 mo). In summary, patients with MDS uncommonly develop clinically evident lymphadenopathy prompting biopsy as a result of infiltration by MDS. MDS in LNs can be subtle, showing incomplete and sometimes mild distortion of the architecture, and ancillary studies including immunohistochemical and flow cytometric immunophenotypic analysis are often needed to establish the diagnosis. These data also suggest that the emergence of lymphadenopathy attributable to MDS is associated with poor treatment response and prognosis in MDS patients and that aggressive therapy or alternative treatment regimens need to be explored in this context.
Diffuse Gliomas of the Brainstem and Cerebellum in Adults Show Molecular Heterogeneity
Authors: Eschbacher Kathryn L. , Ida Cristiane M. , Johnson Derek R. , Alvi Mohammed A. , Jenkins Sarah M. , Ruff Michael W. , Kerezoudis Panagiotis , Neth Bryan J. , Pasion Romela M. , Daniels David J. , Kizilbash Sani H. , Raghunathan Aditya
Published: February 2021

Posterior fossa (PF) diffuse gliomas in pediatric patients frequently harbor the H3 K27M mutation. Among adults, PF diffuse gliomas are rare, with limited data regarding molecular features and clinical outcomes. We identified 28 adult PF diffuse glioma patients (17 males; median: 50 y, range: 19 to 78 y), with surgery performed at our institution (13 brainstem; 15 cerebellum). Histologic subtypes included anaplastic astrocytoma (n=21), glioblastoma (n=6), and diffuse astrocytoma (n=1). Immunohistochemistry was performed for H3 K27M (n=26), IDH1-R132H (n=28), and ATRX (n=28). A 150-gene neuro-oncology-targeted next-generation sequencing panel was attempted in 24/28, with sufficient informative material in 15 (51.7%). Tumors comprised 4 distinct groups: driver mutations in H3F3A (brainstem=4; cerebellum=2), IDH1 (brainstem=4; cerebellum=4), TERT promotor mutation (brainstem=0; cerebellum=3), and none of these (n=5), with the latter harboring mutations of TP53, PDGFRA, ATRX, NF1, and RB1. All TERT promoter–mutant cases were IDH-wild-type and arose within the cerebellum. To date, 20 patients have died of disease, with a median survival of 16.3 months, 1-year survival of 67.5%. Median survival within the subgroups included: H3F3A=16.4 months, IDH mutant=113.4 months, and TERT promoter mutant=12.9 months. These findings suggest that PF diffuse gliomas affecting adults show molecular heterogeneity, which may be associated with patient outcomes and possible response to therapy, and supports the utility of molecular testing in these tumors.
NUT Is a Specific Immunohistochemical Marker for the Diagnosis of YAP1-NUTM1-rearranged Cutaneous Poroid Neoplasms
Authors: Macagno Nicolas , Kervarrec Thibault , Sohier Pierre , Poirot Brigitte , Haffner Aurélie , Carlotti Agnès , Balme Brigitte , Castillo Christine , Jullie Marie-Laure , Osio Amélie , Lehmann-Che Jacqueline , Frouin Eric , Battistella Maxime
Published: February 2021

YAP1-NUTM1 fusion transcripts have been recently reported in poroma and porocarcinoma. NUTM1 translocation can be screened by nuclear protein in testis (NUT) immunohistochemistry in various malignancies, but its diagnostic performance has not been thoroughly validated on a large cohort of cutaneous epithelial neoplasms. We have evaluated NUT immunohistochemical expression in a large cohort encompassing 835 cases of various cutaneous epidermal or adnexal epithelial neoplasms. NUT expression was specific to eccrine poromas and porocarcinoma, with 32% of cases showing NUT expression. All other cutaneous tumors tested lacked NUT expression, including mimickers such as seborrheic keratosis, Bowen disease, basal cell carcinoma, squamous cell carcinoma, Merkel cell carcinoma, nodular hidradenoma, and all other adnexal tumors tested. Remarkably, NUT expression was more frequent in a distinct morphologic subgroup. Indeed, 93% of poroid hidradenoma (dermal/subcutaneous nodular poroma, 13/14) and 80% of poroid hidradenocarcinoma cases (malignant poroid hidradenoma, 4/5) showed NUT expression, in contrast to 17% and 11% of classic poroma (4/23) and porocarcinoma cases (4/35), respectively. RNA sequencing of 12 NUT-positive neoplasms further confirmed the presence of a YAP1-NUTM1 fusion transcript in all cases, and also an EMC7-NUTM1 gene fusion in a single case. In the setting of a cutaneous adnexal neoplasm, nuclear expression of NUT accurately and specifically diagnosed a specific subgroup of benign and malignant poroid tumors, all associated with a NUTM1 fusion, which frequently harbored a poroid hidradenoma morphology.
Putting Theory to Practice
Authors: Cramer Natan , Zuckerbraun Noel Spears , Puller Justin , Furtado Andre D. , Deb Arjamon , Dorfsman Michele L. , Siripong Nalyn , Christie Meghan , Tavarez Melissa M.
Published: February 2021

Objective

We built 2 versions of an asynchronous pediatric orthopedic educational intervention for emergency medicine residents and sought to compare the two. We hypothesized that the version incorporating more instructional scaffolding in the form of a cognitive aid (CA) would optimize germane cognitive load for our target novice learners and result in higher test scores.

Methods

Learners were block randomized to either a “CA” or “non-CA” arm, each containing a random set of 18 modules. The CA arm incorporated an orthopedic fracture classification chart embedded within the diagnostic questions to guide the learner in forming a diagnosis. The non-CA arm was designed with more active learning as the classification chart was provided only after each diagnostic answer submission. For both arms, the final 6 modules completed per learner were scored. Learners also completed a perceived cognitive load assessment tool measured on a 10-point Likert scale.

Results

Learners in the non-CA arm had a mean total score on the testing modules of 33% correct compared with a mean total score of 44% correct for learners in the CA arm (mean difference, 11; 95% confidence interval, 4%–19%, P = 0.005). There was a trend for the CA arm to have lower perceived overall cognitive load scores; however, this did not reach statistical significance.

Conclusions

Emergency medicine residents performed better after completing the CA version of our educational intervention. Applying cognitive load theory to an educational intervention may increase its success among target learners.
Variables Associated With Shunt Failure in Children With Cerebrospinal Fluid Diverting Shunts
Authors: Burns Beech Stephen , Tanski Mary , Heilman James , Lin Amber , Ma Oscar John , Baird Lissa
Published: February 2021

Pediatric patients with shunted hydrocephalus are frequently evaluated in the emergency department (ED) with concern for shunt failure. Because shunt failure is potentially life-threatening, accurate diagnosis is essential. However, neuroimaging imperfectly detects children in failure, with reported sensitivities of 53% to 92% for computed tomography and 51% to 59% for magnetic resonance imaging.

Objectives

We sought to identify clinical characteristics that would negatively predict shunt failure, thus potentially obviating the need for further diagnostic workup or extended periods of observation. We hypothesized that viral symptoms and a patient history of epilepsy or chronic headaches would be negative predictors of shunt failure.

Methods

Data were retrospectively collected for children 19 years or younger with a cerebrospinal fluid diverting shunt in their medical history or problem list who underwent neuroimaging during an ED visit from March 2008 to September 2016. Patients were defined as having shunt failure if they required surgical exploration for shunt revision within 7 days of the ED visit. Descriptive statistics were used for patient demographics, current symptoms, and historical features. We conducted a logistic regression analysis to determine which characteristics were associated with the odds of shunt failure and used binary recursive partitioning to determine if there were features or a combination of features that were able to accurately classify patients without shunt failure.

Results

There were 606 visits by 277 patients during this interval, 34% of whom were experiencing shunt failure. Variables found to be significantly predictive of shunt failure were revision within the prior 6 months, vomiting, personality changes, family opinion of shunt failure, and cranial nerve palsies. Viral symptoms and a history of epilepsy or chronic headaches were not predictive of shunt failure. Binary recursive partitioning identified family opinion and personality changes as predictive of shunt failure, with a sensitivity of 72.2% (95% confidence interval, 65.5%–78.2%) and specificity of 46.6% (95% confidence interval, 41.7%–51.7%).

Conclusions

Although certain clinical and historical features have modest predictive value in children with shunted hydrocephalus, these factors are insufficiently sensitive to exclude shunt failure, arguing for liberal neuroimaging and extended observation.
Unique Pattern of Intrahepatic T-cell Clonality in Biliary Atresia Livers Versus Intestinal Controls: A Pilot Study
Authors: Ogholikhan Sina , Schwarz Kathleen B. , Anders Robert
Published: February 2021

Biliary atresia (BA) is a rare infantile cholangiopathy of unclear etiology proposed by some to be due to virus-induced autoreactive T-cell-mediated inflammation. The hallmark of T cell activity is clonal expansion of T lymphocytes expressing similar T-cell receptor (TCR) variable regions of the β-chain.

Objective:

To test our hypothesis that BA liver tissues would show clonal expansion of 1 or several TCRs.

Methods:

The complementarity-determining region 3 region of the β-chain of the TCR was characterized using next-generation sequencing of 7 BA liver samples (age 51 ± 14 days) and 9 intestinal control samples (age 38 ± 16 days). Following sequencing, clonality scores, various VDJ recombinations, total and productive templates, and complementarity-determining region 3 length were measured using the immunoSEQ Analyzer.

Results:

Next-generation sequencing revealed 1 common TCR rearrangement in 3 BA samples not found in controls. There was a highly diverse TCR population among BA liver and the control samples. The clonality scores ranged from 0.0004 to 0.0062 using a Shannon’s entropy score, with numbers close to 0 being highly diverse and numbers close to 1 being highly clonal. The most common TCR VDJ recombinations comprised 1.47–12.9% of the total population of TCR for the BA tissues and 1.05–10.3% for the control samples.

Conclusions:

Our results show a highly diverse TCR repertoire among all of our samples. However, predominant TCR clonality was not found in any sample. Further studies are required for any possible antigenic triggers responsible for the unique T-cell rearrangements observed in the BA samples.
Effects of Transcranial Direct Current Stimulation on Muscle Fatigue in Recreational Runners
Authors: Uehara Laura , Boari Coelho Daniel , Leal-Junior Ernesto Cesar Pinto , Vicente de Paiva Paulo Roberto , Batista Abrahão Fontes , Duarte Moreira Rafael Jardim , Faria Coura Maria Helena , Hideki Okano Alexandre , Ferrari Corrêa João Carlos , Corrêa Fernanda Ishida
Published: February 2021

Objectives

The aim of this study is to evaluate the effects of transcranial direct current stimulation (tDCS) on central and peripheral fatigue in recreational runners.

Design

This is a clinical randomized, sham-controlled, triple-blind, crossover study. Twenty adult runners will be randomized on the first day of the intervention to receive active or sham tDCS before fatigue protocol. After 1 wk, the participants will receive the opposite therapy to the one that they received on the first day. The tDCS, 2 mA, will be applied for 20 mins over the motor cortex. The fatigue protocol will be performed after tDCS, in which the participant should perform concentric knee flexion/extension contractions until reaching three contractions at only 50% of maximum voluntary contraction. Central fatigue will be evaluated with the motor evoked potential of the quadriceps muscle; peripheral fatigue with the peak torque (N.m) using an isokinetic dynamometer; the electrical activity of the quadriceps muscle using surface electromyography (Hz); blood lactate level (mmol/L); and the subjective perception of effort (Borg scale). All evaluations will be repeated before and after the interventions.

Conclusion

This study will evaluate the effect of tDCS on fatigue in runners, possibly determining an application protocol for this population.
The Flexor Pollicis Longus Reflex
Authors: Gladitz Luisa Marilena , Schöttker-Königer Thomas , Sturm Christian , Gutenbrunner Christoph , Ranker Alexander
Published: February 2021

Objective

The aim of this study was to investigate the interrater reliability and intrarater reliability of the flexor pollicis longus muscle stretch reflex (FPLR) and compare it with clinically established reflexes.

Design

A total of 71 healthy volunteers participated. The FPLR, biceps reflex, brachioradialis reflex, and patellar tendon reflex of each participant were tested bilaterally and rated by eight examiners (four experienced, four inexperienced). For intrarater reliability evaluation, five examiners rated the reflexes of four volunteers at four different points in time.

Results

Analysis of the interrater reliability with Gwet’s AC1 demonstrated almost perfect agreement for FPLR (Gwet’s AC1 = 0.90), biceps reflex (Gwet’s AC1 = 0.90), and patellar tendon reflex (Gwet’s AC1 = 0.95) when using binary data (reflex present vs. absent). Only fair agreement was found for the brachioradialis reflex (Gwet’s AC1 = 0.56). Experienced raters had a higher agreement than inexperienced raters did when rating the biceps reflex and the patellar tendon reflex. The intrarater reliability was almost perfect for the patellar tendon reflex (Gwet’s AC1 = 0.94), followed by the FPLR (Gwet’s AC1 = 0.83) with substantial agreement and the biceps reflex (Gwet’s AC1 = 0.57) with moderate agreement.

Conclusion

The FPLR is a reliable diagnostic neuromuscular test and may therefore be useful in the clinical examination for C8/T1 nerve root lesions or pathologies of the interosseous anterior nerve.

To Claim CME Credits

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME

CME Objectives

Upon completion of this article, the reader should be able to: (1) Elicit the flexor pollicis longus muscle stretch reflex; (2) Discuss the disadvantage of kappa statistics in assessing the interrater reliability when the prevalence of the studied trait is very high or very low; and (3) Name the spinal nerves involved in the innervation of the flexor pollicis longus muscle.

Level

Advanced

Accreditation

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
BREAST-Q Outcomes before and after Bilateral Reduction Mammaplasty
Authors: Wampler Ariel T. , Powelson Ian A. , Homa Karen , Freed Gary L.
Published: February 2021

Background:

The BREAST-Q is the only questionnaire specific to bilateral breast reduction that was developed according to federal and international standards. Many payors mandate minimum resection weights for preapproval, despite lacking supportive evidence for this practice. This study aimed to assess changes in BREAST-Q scores after bilateral breast reduction, and determine whether compliance with Schnur requirements impacts improvement in patient-reported outcomes.

Methods:

Patients presenting for bilateral breast reduction from 2011 to 2017 were asked to complete the BREAST-Q preoperatively and postoperatively. Multivariate regression analysis was performed to isolate factors associated with favorable outcomes.

Results:

Complete data were available for 238 patients. Mean time to postoperative BREAST-Q was 213 days. Complications occurred in 31 patients (13.0 percent). Mean preoperative BREAST-Q scores were below normative values (p < 0.001), and mean postoperative scores were above normative values (p < 0.001 for Satisfaction with Breasts, Psychosocial Well-being, and Sexual Well-being; and p = 0.05 for Physical Well-being). Postoperative Physical Well-being scores were similar to normative values for resections less than Schnur (p = 0.32), but below norms for resections greater than Schnur (p < 0.0001). On multivariate regression (n = 230), complication and surgeon experience were the only independent predictors of lesser improvement on the Satisfaction with Breasts subscale.

Conclusions:

This study is the largest to include both preoperative and postoperative bilateral breast reduction BREAST-Q scores, and to compare multiple subscales to normative data. Scores overwhelmingly increased, regardless of age or Schnur compliance. Complications negatively impacted degree of BREAST-Q improvement. Interestingly, postoperative Physical Well-being was slightly higher in women with non–Schnur-compliant resections. Bilateral breast reduction substantially improves patient welfare, and our data question the validity of insurer-mandated minimum resections.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Lipofilling after Laser-Assisted Treatment for Facial Filler Complication: Volumetric and Regenerative Effect
Authors: De Santis Giorgio , Pinelli Massimo , Benanti Elisa , Baccarani Alessio , Starnoni Marta
Published: February 2021

Background:

Nonresorbable substances are still injected to enhance soft-tissue volumes and fill subcutaneous defects. The minimally invasive intralesional laser treatment can remove foreign substances and the inflammatory reaction, eventually leaving depression and scar tissue in the treated area. Fat grafting can restore volume loss and improve scar tissue.

Methods:

From March of 2010 to February of 2017, 33 patients were studied. All of them had suffered from inflammatory reactions to permanent facial fillers and had been treated with the 808-nm diode laser at the authors’ institution. The evacuation of material had left facial asymmetry and visible depression. To restore facial aesthetic units, fat grafting was performed. The minimum follow-up was 6 months.

Results:

Volume restoration was recognized (according to the Global Aesthetic Improvement Scale) as significantly improved in 22 patients, moderately improved in eight patients, and slightly improved in three patients. Improvement in atrophic and scarred tissues (with an apparent thickening of the skin or even elimination of scars) was also assessed with the following results: 25 patients were very much improved and eight were moderately improved.

Conclusions:

This is the first study on filler-induced complications of the face treated by intralesional laser treatment followed by lipofilling. A systematic approach to volume restoration is proposed to patients who had filler removal of the face. There was a high degree of patient satisfaction with this technique.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Time-Driven, Activity-Based Costing of Presurgical Infant Orthopedics: A Critical Component of Establishing Value of Latham Appliance and Nasoalveolar Molding
Authors: Ganske Ingrid M. , Sanchez Karl , Le Elliot , Langa Olivia C. , Sharif-Askary Banafsheh , Ross Elizabeth , Santiago Pedro , Meara John G. , Padwa Bonnie L. , Allori Alexander C.
Published: February 2021

Background:

Value-based health-care reform requires assessment of outcomes and costs of medical interventions. In cleft care, presurgical infant orthopedics is still being evaluated for clinical benefits and risks; however, the cost of these procedures has been largely ignored. This study uses robust accounting methods to quantify the cost of providing two types of presurgical infant orthopedics: Latham appliance treatment and nasoalveolar molding.

Methods:

This is a prospective study of patients with nonsyndromic cleft lip and/or palate who underwent treatment with presurgical infant orthopedics from 2017 to 2019 at two academic centers. Costs were measured using time-driven activity-based costing. Personnel costs, facility costs (operating room, clinic, and inpatient ward), and equipment costs were included. Travel expenses were incorporated as an estimate of direct costs borne by the family, but indirect costs (e.g., time off from work) were not considered.

Results:

Twenty-three patients were treated with Latham appliance treatment and 14 were treated with nasoalveolar molding. For Latham appliance treatment, average total cost was $7553 per patient ($1041 for personnel, $637 for equipment, $4871 for facility, and $1004 for travel over 6.5 visits). Unilateral and bilateral costs were $6891 and $8860, respectively. For nasoalveolar molding, average cost totaled $2541 ($364 for personnel, $151 for equipment, $300 for facility, and $1726 for travel over 13 visits); $2120 for unilateral and $3048 for bilateral treatment.

Conclusions:

The major difference in cost is attributable to operative placement of the Latham device. Travel cost for nasoalveolar molding is often higher because of frequent clinical encounters required. Future investigation should focus on whether outcomes achieved by presurgical infant orthopedics justify the $2100 to $8900 expenditure for these adjunctive procedures.
A Safer Way to Harvest a Superthin Perforator Flap
Authors: Innocenti Marco , Calabrese Sara , Tanini Sara , Malzone Gerardo , Innocenti Alessandro
Published: February 2021

The updated knowledge of perforasome anatomy and the evolution of microsurgical techniques have enabled surgeons to safely harvest a thin flap. Recently, the anterolateral thigh perforator flap, the current workhorse in soft-tissue reconstruction, has started to be designed and harvested on the superficial fascia, which divides the deep from the superficial fat. This allows elevation of a very thin flap tailored to the defect. Faithful to the ultrathin concept, in an attempt to make flap dissection simpler and safer, the authors describe a revisited harvesting technique of superthin anterolateral thigh perforator flap. This study presents the outlined technique performed in 16 patients with complex soft-tissue defects after trauma or tumor ablation. All of them underwent primary reconstruction using superthin anterolateral thigh perforator free flaps by superficial fascia elevation harvested according to the described surgical procedure. Complications and functional outcomes were assessed. The authors’ series of anterolateral thigh perforator superthin flaps demonstrated an overall 100 percent survival rate. Of 16 anterolateral thigh perforators, 12 (75 percent) had no complications and four (25 percent) had minor complications. No major complications such as total flap loss requiring additional salvage surgery were reported. In no case was secondary debulking performed. The superthin anterolateral thigh perforator flap harvested with the described approach was used successfully in microsurgical reconstruction, providing an excellent outer skin cover tailored to the defect. The dissection procedure was safe, quick, simple, and free of major complications. With minimal donor- and recipient-site morbidity, it provided great aesthetic results, avoiding secondary operations.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Are You Ready to Negotiate Your First Employment Contract? Experience of More Than 700 Plastic Surgeons
Authors: Hollier Larry H. , Davis Matthew J. , Abu-Ghname Amjed , Patel Nirav B. , Pacitti Steven , Reece Edward M.
Published: February 2021

Background:

Plastic surgeons have been shown to be unprepared to negotiate their first employment contracts. Previous survey studies have attempted to assess plastic surgeons’ first employment contracts to outline common pitfalls in contract negotiation. With this study, the authors aim to expand these previous studies and help plastic surgeons become prepared to negotiate their employment contracts.

Methods:

A seven-question, cross-sectional survey was sent to attending-level surgeon members of the California Society of Plastic Surgeons, the American Society of Plastic Surgeons, the Texas Society of Plastic Surgeons, and the American Cleft Palate-Craniofacial Association. Questions investigated plastic surgeons’ first contracts. Correlations were determined using a two-sample Wilcoxon rank sum test in an attempt to link these questions with overall satisfaction.

Results:

From the 3908 distributed surveys, 782 (20 percent) responses were collected, and 744 were included for analysis. The majority of respondents were found to join a group-centered, private practice following residency. Surprisingly, 69 percent of surgeons did not use attorney assistance when negotiating their contract. Although greater than 70 percent of respondents reported a salary of $200,000 or less, satisfaction with one’s contract was most strongly correlated with a salary of greater than $300,000 (p < 0.0001). However, only 12 percent of respondent surgeons were able to secure such a salary.

Conclusions:

This study examined the largest, most diverse plastic surgeon cohort to date regarding surgeons’ first employment contract. Although the authors’ findings indicate that certain factors should be prioritized when approaching a first employment contract, they ultimately recommend that all surgeons take into account their personal priorities and attempt to proactively define their terms of employment before signing a contract.
Optimizing Throughput in Clinical Practice: Lean Management and Efficient Care in Plastic and Reconstructive Surgery
Authors: Bekeny Jenna C. , Fan Kenneth L. , Malphrus Elizabeth , Klein Doron , Song David H.
Published: February 2021

Background:

As the cost of health care continues to rise, the role of medical providers has evolved to include the duties of an operations manager. Two theories of operations management can be readily applied to health care—lean management, the process of identifying and eliminating waste; and Little’s law, the idea that throughput is maximized by changing the capacity to host patients or the time they spend in the system. Equipped with theories of operations management, providers are better able to identify and address flow limitations in their own practices.

Methods:

Operations flow data were collected from three areas of care—clinic, surgical booking, and the operating room—for one provider. Variables of interest included visit or procedure characteristics and operations flow characteristics, such as different time points involved in the sector of care.

Results:

Clinic data were collected from 48 patients. Variables with a significant relationship to total clinic visit time included afternoon appointments (p = 0.0080) and visit type (p = 0.0114). Surgical booking data were collected for 127 patients. Shorter estimated procedure length (p = 0.0211) decreased time to surgery. Operating room data were collected for 65 cases. Variables with a significant relationship to total operating room time were patient age (p = 0.0325), Charlson Comorbidity Index (p = 0.0039), flap type (p = 0.0153), and number of flaps (p < 0.0001).

Conclusions:

This brief single-provider study provides examples of how to apply operations management theories to each point of care within one’s own practice. Although longitudinal data following patients through each point of care are the next step in operations flow analysis, this work lays the foundation for evaluation at each time point with the goal of developing practical strategies to improve throughput in one’s practice.
Factors Associated With Increased Complications in Patients With BRCA Gene Mutations Undergoing Reconstructive Breast Surgery
Authors: Vanaclocha Nieves , Ripoll Orts Francisco , Moreda Rubio Maria Luisa , Sánchez García Alberto
Published: February 2021

Reconstructive breast surgery after bilateral prophylactic mastectomy in patients who carry a mutation of the breast cancer (BRCA) gene has been increasing. Undergoing risk-reducing breast surgery can be of great benefit to young patients who have a high risk of developing breast cancer. There is little available evidence about the rate of complications in these patients and which factors are related to increased complications. The objective of this study was to identify predictors of complications in BRCA gene mutation carriers who underwent reconstructive breast surgery. A single-center, retrospective cohort study was conducted that included all patients with a mutation of the BRCA gene who underwent a breast reconstructive procedure, either immediate or delayed, between January 2013 and March 2019 and received a minimum of 6 monthsʼ follow-up. The results of our study showed that smoking is the most important modifiable risk factor associated with an increased complication rate for reconstructive breast surgery in patients with BRCA gene mutation. Smoking cessation will reduce the patient's risk for postoperative complications by 50%; therefore, it should be encouraged in all surgical patients and enforced in patients undergoing prophylactic procedures.
Working Out the Woes: An Analysis of the Impact of Exercise on Depression
Authors: Anderson Steven Tate , Dorris Maggie , Littles Matrice , Rodriguez Tanya , Spear Marcia
Published: February 2021

The purpose of this review is to examine existing research to determine whether exercise has a significant effect on improving emotional well-being and symptoms of depression. At any given time, it is estimated that greater than 15% of Americans are plagued by a depressive mood disorder (L. Andrew, 2014). Plastic surgical nurses will encounter individuals with symptoms of depression who seek elective plastic surgical and cosmetic procedures. With a broad spectrum of symptoms and presentations, both practitioners and those suffering may have difficulty identifying depression. Even after being identified, it can be quite challenging to effectively treat depressive mood disorders. The integration of exercise into the plan of care not only helps tackle one's mental health condition but also benefits any physical health concerns. The plastic surgical nurse can advocate for evidence-based practices and educate the plastic surgical patient on the benefits of physical exercise. Additional research is needed to determine the most effective amount and types of exercise to be used in clinical settings.
Agreement between self-reported and objective measures of sleep in people with HIV and lifestyle-similar HIV-negative individuals
Authors: De Francesco Davide , Sabin Caroline A. , Winston Alan , Mallon Patrick W.G. , Anderson Jane , Boffito Marta , Doyle Nicki D. , Haddow Lewis , Post Frank A. , Vera Jaime H. , Sachikonye Memory , Redline Susan , Kunisaki Ken M.
Published: February 2021

Objectives:

The aim of this study was to evaluate the agreement between self-reported sleep measures and insomnia with objectively measured sleep parameters in people with HIV (PWH) and HIV-negative individuals.

Design:

A cross-sectional analysis of PWH and lifestyle-similar HIV-negative individuals.

Methods:

Self-reported measures included time spent in bed, sleep onset latency and a validated insomnia questionnaire. Objective measures were assessed via 7-days/nights of actigraphy data to determine average and intra-individual variability of several sleep measures (including time spent in bed and onset latency). Spearman's correlation coefficient and Cohen's κ were used to assess the agreement between self-reported and actigraphy-assessed measures. Associations between insomnia and actigraphy-assessed sleep parameters were evaluated using partial least-square discriminant analysis (PLS-DA).

Results:

We found fair correlation between self-reported and actigraphy-assessed time spent in bed in 342 PWH (r
s = 0.46) and 119 HIV-negative individuals (r
s = 0.48). Among PWH, the correlation did not differ by age, education, depressive symptoms and self-reported insomnia (all P > 0.05), but was stronger in men (P = 0.05) and in those with a BMI of at least 25 kg/m2 (P < 0.001). Agreement between self-reported and actigraphy-assessed sleep onset latency was poor in both PWH (κ = 0.002, P = 0.49) and HIV-negative individuals (κ = 0.009, P = 0.65). According to PLS-DA, self-reported insomnia most strongly correlated with intra-individual variability of sleep duration, movement index and efficiency.

Conclusion:

We report poor-to-fair agreement between self-reported and actigraphy-assessed sleep measures in PWH. Insomnia symptoms correlated with regularity of sleep duration, quality and efficiency. These findings highlight the importance of both patient-reported and objective measures of daily sleep variation, for better understanding sleep disorders in PWH.
Pre-treatment integrase inhibitor resistance is uncommon in antiretroviral therapy-naive individuals with HIV-1 subtype A1 and D infections in Uganda
Authors: McCluskey Suzanne M. , Kamelian Kimia , Musinguzi Nicholas , Kigozi Simone , Boum Yap , Bwana Mwebesa B. , Muzoora Conrad , Brumme Zabrina L. , Carrington Mary , Carlson Jonathan , Foley Brian , Hunt Peter W. , Martin Jeffrey N. , Bangsberg David R. , Harrigan P. Richard , Siedner Mark J. , Haberer Jessica E. , Lee Guinevere Q.
Published: February 2021

Objective:

Dolutegravir (DTG) is now a preferred component of first-line antiretroviral therapy (ART). However, prevalence data on natural resistance to integrase inhibitors [integrase strand transfer inhibitors (INSTIs)] in circulating non-subtype B HIV-1 in sub-Saharan Africa is scarce. Our objective is to report prevalence of pre-treatment integrase polymorphisms associated with resistance to INSTIs in an ART-naive cohort with diverse HIV-1 subtypes.

Design:

We retrospectively examined HIV-1 integrase sequences from Uganda.

Methods:

Plasma samples were derived from the Uganda AIDS Rural Treatment Outcomes (UARTO) cohort, reflecting enrollment from 2002 to 2010, prior to initiation of ART. HIV-1 integrase was amplified using nested-PCR and Sanger-sequenced (HXB2 4230-5093). Stanford HIVdb v8.8 was used to infer clinically significant INSTI-associated mutations. Human leukocyte antigen (HLA) typing was performed for all study participants.

Results:

Plasma samples from 511 ART-naive individuals (subtype: 48% A1, 39% D) yielded HIV-1 integrase genotyping results. Six out of 511 participants (1.2%) had any major INSTI-associated mutations. Of these, two had E138T (subtype A1), three had E138E/K (subtype D), and one had T66T/I (subtype D). No participants had mutations traditionally associated with high levels of INSTI resistance. HLA genotypes A∗02:01/05/14, B∗44:15, and C∗04:07 predicted the presence of L74I, a mutation recently observed in association with long-acting INSTI cabotegravir virologic failure.

Conclusion:

We detected no HIV-1 polymorphisms associated with high levels of DTG resistance in Uganda in the pre-DTG era. Our results support widespread implementation of DTG but careful monitoring of patients on INSTI with virologic failure is warranted to determine if unique mutations predict failure for non-B subtypes of HIV-1.
Brief Report: Switching to DOR/3TC/TDF Maintains HIV-1 Virologic Suppression Through Week 144 in the DRIVE-SHIFT Trial
Authors: Kumar Princy , Johnson Margaret , Molina Jean-Michel , Rizzardini Giuliano , Cahn Pedro , Bickel Markus , Wan Hong , Xu Zhi Jin , Morais Cristiana , Sklar Peter , Greaves Wayne ,   for the DRIVE-SHIFT Study Group
Published: February 2021

Background:

In the primary analysis of the DRIVE-SHIFT trial, switching to doravirine/lamivudine/tenofovir disoproxil fumarate (DOR/3TC/TDF) maintained suppression of HIV-1 through week 48. Here, we present long-term efficacy and safety outcomes through week 144 of the DRIVE-SHIFT trial.

Methods:

This phase 3, randomized, open-label trial evaluated switching from a stable antiretroviral regimen to once-daily DOR/3TC/TDF in adults with HIV-1 suppressed for ≥6 months and no previous virologic failure. Participants switched at day 1 [immediate switch group (ISG); n = 447] or week 24 [delayed switch group (DSG); n = 209]. Nine ISG participants who completed week 48 but did not enter extension-1 were excluded from week 144 efficacy analyses.

Results:

At week 144, HIV-1 RNA <50 copies/mL was maintained in 80.1% of the ISG (351/438) and 83.7% of the DSG (175/209), while 2.7% (12/438) and 4.8% (10/209), respectively, had HIV-1 RNA ≥50 copies/mL (Food and Drug Administration Snapshot approach). Protocol-defined virologic failure after switch occurred in 2.1% of ISG (9/438) and 3.3% of DSG (7/209); no viral resistance to doravirine was detected in 4 participants with samples available. Reductions in fasting lipids were observed at 24 weeks after switch and maintained through week 144. The mean weight change from switch to week 144 was +1.4 kg for ISG and +1.2 kg for DSG. The most common adverse events were nasopharyngitis (16.2%), headache (12.3%), and diarrhea (9.1%). Overall, 4.1% discontinued because of adverse events, and no deaths occurred.

Conclusions:

These results confirm that switching to once-daily DOR/3TC/TDF is a generally well-tolerated option for maintaining viral suppression in adults considering a change in therapy.

Registration:

ClinicalTrials.gov NCT02397096.
HIV Testing by Public Health Centers and Municipalities and New HIV Cases During the COVID-19 Pandemic in Japan
Authors: Ejima Keisuke , Koizumi Yoshiki , Yamamoto Nao , Rosenberg Molly , Ludema Christina , Bento Ana I. , Yoneoka Daisuke , Ichikawa Seiichi , Mizushima Daisuke , Iwami Shingo
Published: February 2021

Background:

During the COVID-19 outbreak, facility capacity for HIV testing has been limited. Furthermore, people may have opted against HIV testing during this period to avoid COVID-19 exposure. We investigated the influence of the COVID-19 pandemic on HIV testing and the number of reported HIV cases in Japan.

Methods:

We analyzed quarterly HIV/AIDS-related data from 2015 to the second quarter of 2020 using an anomaly detection approach. The data included the number of consultations, the number of HIV tests performed by public health centers or municipalities, and the number of newly reported HIV cases with and without an AIDS diagnosis. We further performed the same analysis for 2 subgroups: men who have sex with men (MSM) and non-Japanese persons.

Results:

The number of HIV tests (9,584 vs. 35,908 in the year-before period) and consultations (11,689 vs. 32,565) performed by public health centers significantly declined in the second quarter of 2020, whereas the proportion of new HIV cases with an AIDS diagnosis (36.2% vs. 26.4%) significantly increased after removing the trend and seasonality effects. HIV cases without an AIDS diagnosis decreased (166 vs. 217), but the reduction was not significant. We confirmed similar trends for the men who have sex with men and non-Japanese subgroups.

Conclusions:

During the COVID-19 pandemic, the current HIV testing system in Japan seems to have missed more cases of HIV before developing AIDS. Continuously monitoring the situation and securing sufficient test resources by use of self-testing is essential to understand the clear epidemiological picture of HIV incidence during the COVID-19 pandemic.
Genetic Associations with Weight Gain among South Africans who Initiated Dolutegravir-Containing and Tenofovir-Containing Regimens
Authors: Cindi Zinhle , Maartens Gary , Bradford Yuki , Venter Willem D.F. , Sokhela Simiso , Chandiwana Nomathemba C. , Haas David W. , Sinxadi Phumla
Published: February 2021

Background:

Excessive weight gain affects some HIV-positive individuals prescribed dolutegravir-containing regimens. Mechanisms underlying such weight gain are unknown.

Setting:

Data and DNA from antiretroviral therapy–naïve participants who were randomized to initiate dolutegravir with emtricitabine plus either tenofovir alafenamide (TAF) or tenofovir disoproxil fumarate (TDF) in the ADVANCE study (NCT03122262) were used to characterize associations between human genetic polymorphisms and magnitude of weight gain.

Methods:

Associations with percent weight gain from baseline to week 48 were assessed using multivariable linear regression models. Primary analyses a priori considered 59 polymorphisms and 10 genes of potential relevance to dolutegravir, TAF, or TDF pharmacokinetics. We also explored genome-wide associations.

Results:

Among the 314 (92%) of 340 dolutegravir recipients who were successfully genotyped, 160 (47%) and 154 (45%) were randomized to TAF/emtricitabine and TDF/emtricitabine, respectively. In target gene analyses, the lowestP-values for the dolutegravir and tenofovir groups wereABCG2rs4148149 (P= 7.0 × 10−4) andABCC10rs67861980 (P= 1.0 × 10−2), respectively, which were not significant after correction for multiple testing. In genome-wide analyses, the lowestP-values were rs7590091 inTMEM163(P= 3.7 × 10−8) for dolutegravir, rs17137701 inLOC105379130(P= 6.4 × 10−8) for TAF, and rs76771105 inLOC105371716(P= 9.7 × 10−8) for TDF.

Conclusions:

Among South African participants in a randomized clinical trial of dolutegravir plus either TAF/emtricitabine or TDF/emtricitabine, we identified several potential genetic associations with weight gain. OnlyTMEM163rs7590091 withstood correction for multiple testing. These associations warrant replication in other cohorts.
Interaction of Religion/Spirituality With Internalized HIV Stigma, Depression, Alcohol Use, and Sexual Risk Among Black Men Who Have Sex With Men: The 6 City HPTN 061 Study
Authors: Taggart Tamara , Mayer Kenneth H. , Vermund Sten H. , Huang Shu , Hayashi Kamden , Ransome Yusuf
Published: February 2021

Background:

Black men who have sex with men (BMSM) remain at highest risk for HIV in the United States. Internalized HIV stigma and depression contribute to substance use and condomless anal intercourse (CAI). Religion and spirituality (R/S) are associated with decreased HIV-related risk behaviors for some groups, but their impact among BMSM is uncertain. We investigated the main and moderating roles of R/S on pathways from internalized HIV stigma to CAI while under the influence of drugs.

Methods:

We used baseline data from 1511 BMSM from the HIV Prevention Trials Network (HPTN) 061 study to examine the associations between internalized HIV stigma, depressive symptoms, alcohol use, and CAI while under the influence of drugs, adjusting for covariates in generalized structural equation models. We then tested whether R/S moderated the association between (1) internalized HIV stigma and depressive symptoms, (2) depressive symptoms and alcohol use, and (3) alcohol use and CAI while under the influence of drugs.

Results:

Spiritual beliefs [F(1,2) = 9.99, P < 0.001], spiritual activities [F(1,2) = 9.99, P < 0.001], and religious attendance [F(1,2) = 9.99, P < 0.001] moderated the pathway between internalized HIV stigma and depressive symptoms. As internalized HIV stigma increased, those with lower spiritual activity scores experienced significantly higher increases in depressive symptoms compared with those with higher spiritual activity scores whose depressive symptom scores remained unchanged [stigma × spiritual activities B = −0.18 (SE = 0.07), P < 0.001].

Conclusions:

Religion and spirituality were protective against CAI among BMSM. Future intervention research should explore ways to incorporate religious and/or spiritual activities to reduce internalized HIV stigma as one way to reduce depressive symptoms among BMSM.