bluuebunny/crossref_metadata_2025 huggingface dataset:
Performance of Pediatric Emergency Medicine Faculty After Point-of-Care Ultrasound Credentialing Implementation
Authors: Nti Benjamin K. , Kennedy Sarah , Sarmiento Elisa , Weinstein Elizabeth , Russell Frances
Published: February 2021

Objective

As point-of-care ultrasound (POCUS) continues to evolve, a national standardized curriculum for training and credentialing pediatric emergency medicine (PEM) physicians is still lacking. The goal of this study was to assess PEM faculty in performing and interpreting POCUS during implementation of a training curriculum.

Methods

Sixteen full-time PEM faculty with either limited or no prior POCUS experience were trained to perform 4 ultrasound studies. Twelve of the 16 completed the training with a goal of credentialing within 12 months of implementation. For each faculty, we assessed competency by comparing precurriculum and postcurriculum test assessments and by evaluating quality of POCUS acquisition and accuracy of interpretation. We also monitored the amount of continuing medical education (CME) hours completed to ensure a minimum didactic component.

Results

We found a significant improvement in POCUS competency comparing precurriculum to postcurriculum test assessments (55.4% vs 75.6%, P < 0.0002). One thousand two hundred seventy images were submitted over the course of the curriculum. Accuracy, sensitivity, and specificity were 98.23% (confidence interval [CI] = 97.18–98.97), 97.01% (CI = 92.53–99.81), and 98.43% (CI = 97.33–99.81), respectively. Faculty self-rating of image quality was significantly higher than expert reviewer rating of image quality (3.4 ± 0.86 vs 3.2 ± 0.56, P < 0.0001). We found no change in expert reviewer rating of image quality over time. Faculty completed a combined 232.5 CME hours (average, 17.4 ± 10.8), with the majority of hours coming from an institutional POCUS CME workshop.

Conclusions

These results show that a structured curriculum can improve PEM faculty POCUS competency.
Funding Public Health: Achievements and Challenges in Public Health Financing Since the Institute of Medicine's 2012 Report
Authors: Yeager Valerie A. , Balio Casey P. , McCullough J. Mac , Leider Jonathon P. , Orr Jason , Singh Simone R. , Bekemeier Betty , Resnick Beth
Published: February 2021

Objective:

The purpose of this study was to review changes in public health finance since the 2012 Institute of Medicine (IOM) report “For the Public's Health: Investing in a Healthier Future.”

Design:

Qualitative study involving key informant interviews.

Setting and Participants:

Purposive sample of US public health practitioners, leaders, and academics expected to be knowledgeable about the report recommendations, public health practice, and changes in public health finance since the report.

Main Outcome Measures:

Qualitative feedback about changes to public health finance since the report.

Results:

Thirty-two interviews were conducted between April and May 2019. The greatest momentum toward the report recommendations has occurred predominantly at the state and local levels, with recommendations requiring federal action making less progress. In addition, much of the progress identified is consensus building and preparation for change rather than clear changes. Overall, progress toward the recommendations has been slow.

Conclusions:

Many of the achievements reported by respondents were characterized as increased dialogue and individual state or local progress rather than widespread, identifiable policy or practice changes. Participants suggested that public health as a field needs to achieve further consensus and a uniform voice in order to advocate for changes at a federal level.

Implications for Policy and Practice:

Slow progress in achieving 2012 IOM Finance Report recommendations and lack of a cohesive voice pose threats to the public's health, as can be seen in the context of COVID-19 emergency response activities. The pandemic and the nation's inadequate response have highlighted deficiencies in our current system and emphasize the need for coordinated and sustained core public health infrastructure funding at the federal level.
Velocity of the Body Center of Mass During Walking on Split-Belt Treadmill
Authors: Tesio Luigi , Scarano Stefano , Cerina Valeria , Malloggi Chiara , Catino Luigi
Published: February 2021

Walking on split-belt treadmills (each belt rotating at a different velocity) has inspired a growing number of researchers to study gait adaptation and rehabilitation. An overlooked peculiarity of this artificial form of gait is that the mean velocity adopted by the participant, considered as a whole system represented by the body Center of Mass, can be different from the mean velocity of the two belts. Twelve healthy adults (21–34 yrs) were requested to walk for 15 mins on a treadmill with belts rotating at 0.4 and 1.2 m sec−1, respectively (mean = 0.8 m sec−1). Each belt was supported by four 3-dimensional force sensors. For each participant, six strides were analyzed during the 1st and the 15th minute of the trial. The mean Center of Mass velocity was computed as the sum of the velocities of each belt weighted by the percentage of time during which the resulting forces, underlying the accelerations of the Center of Mass, originated from each belt. Across early and late observations, the median Center of Mass velocities were 0.72 and 0.67 m sec−1, respectively (P < 0.05). Therefore, the real velocity of the Center of Mass and its time course should be individually assessed when studying walking on split-belt treadmills.
Lifetime Prevalence of Nonspecific Low Back Pain in Adolescents
Authors: Masiero Stefano , Sarto Fabio , Cattelan Manuela , Sarto Diego , Del Felice Alessandra , Agostini Francesco , Scanu Anna
Published: February 2021

Background

Many nonconclusive studies have been conducted on low back pain (LBP) in adolescents and associated factors.

Objective

The aim was to assess the lifetime prevalence and associated factors of LBP in adolescents.

Materials and Methods

A questionnaire was administered in high school students (14–19-yr-old participants) in Veneto region (Italy). The self-administered, structured questionnaire included anthropometric data; psychologic factors and lifestyle; presence, intensity, and family history of LBP; referral to professional health care for LBP; and a short version of the International Physical Activity Questionnaire.

Results

A total of 6281 adolescents were recruited; 5204 questionnaires were included in the final analysis. A total of 2549 (48.98%) students reported one or more LBP episodes and 723 (13.89%) reported nonspecific disabling lumbar pain (i.e., no underlying pathology); 1040 (41.11%) subjects with LBP consulted a healthcare professional. A significant association emerged for LBP with sex (female), positive family history, time spent sitting or using electronic devices, sleep deprivation (<5 hrs/night), and low level of physical activity.

Conclusion

In a large sample of adolescents, LBP lifetime prevalence is high and often associated with disabling pain and sedentary lifestyle, requiring professional care. These findings may support the development of prevention and treatment strategies of LBP in adolescents, reducing the risk of developing chronic pain.
Safety of Every-Other-Day Fasting in the Treatment of Spinal Cord Injury
Authors: Zheng Jinqi , Liu Jiancheng , Jiang Yue , Pang Rizhao , Yang Xiao , Liu Hao , Lin Ning , Li Yunming , Xiong Deqi , Chen Xueqin , Yuan Li , Liu Jie , Plunet Ward T. , Wang Wenchun , Zhang Anren
Published: February 2021

Every-other-day fasting is effective for a variety of major human diseases, but the safety of these interventions is uncertain for patients with spinal cord injury. A randomized controlled study was conducted to investigate the safety of every-other-day fasting in patients with spinal cord injury. Participants who met the diagnostic inclusion and exclusion criteria were randomly divided into the control and every-other-day fasting groups. In the every-other-day fasting group, fasting lasted from 09:00 p.m. on day 1 to 06:00 p.m. on the following day (day 2). Dinner on day 2 was restricted to approximately 30% of the average daily calorie intake. The changes in plasma glucose were recorded daily for 2 days and every other day from the third day after every-other-day fasting intervention. The changes in albumin, prealbumin, plasma potassium, serum sodium, blood calcium, body weight, and body mass index were monitored at the baseline and at the end of the every-other-day fasting intervention. The results showed that compared with the control group, the mean blood glucose levels were significantly decreased from the second week after every-other-day fasting intervention. The body weight of patients in the every-other-day fasting group was notably reduced compared with that at baseline, whereas in body mass index, no obvious differences were observed before and after treatment with every-other-day fasting. In general, every-other-day fasting could be considered as a safe approach for individuals with spinal cord injury.
Screening for Deep Vein Thrombosis in Persons With COVID-19 Upon Admission to an Inpatient Rehabilitation Hospital
Authors: Kirshblum Steven C. , DeLauter Gabrielle , Eren Fatma , Pomeranz Bruce , DeLuca Robert , Hammerman Samuel , Gans Bruce M.
Published: February 2021

Objective

The aim of the study was to determine the prevalence of deep venous thrombosis detected by duplex screening and risk factors associated with deep venous thrombosis in patients with COVID-19 upon admission to an inpatient rehabilitation hospital.

Design

This is a retrospective review.

Setting

The setting is three freestanding inpatient rehabilitation hospitals operating as one system.

Participants

The participants are consecutive patients with a diagnosis of COVID-19 admitted to an inpatient rehabilitation hospital without a diagnosis of deep venous thrombosis or screening duplex ultrasound prior to transfer.

Interventions

A duplex ultrasound of lower limbs was performed upon admission to inpatient rehabilitation hospital.

Outcome Measures

Primary outcome was the percentage of admission patients with a lower limb deep venous thrombosis. Secondary factors included potential risk factors for a positive screen for deep venous thrombosis.

Results

A lower limb deep venous thrombosis was diagnosed in 22% (25/113) of the patients tested, with eight patients (7.1%) having a proximal deep venous thrombosis. Risk factors for screening positive for a deep venous thrombosis included being male, younger, and having been on a ventilator during the acute illness.

Conclusions

The high rate of deep venous thrombosis observed in these patients suggests that the risk of venous thromboembolic disorders after severe COVID-19 illness is considerable and surveillance measures of such patients should be undertaken.
Extracorporeal Shockwave Therapy With a Modified Technique on Tendon and Ligament for Knee Osteoarthritis
Authors: Ho Kun-Dong , Yang Chia-Ling , Lo Huei-Yu , Yeh Huan-Jui
Published: February 2021

Background

There have been no definitive guidelines on the treatment method and specific points in the body.

Purpose

The aim of the study was to investigate the effects of extracorporeal shockwave therapy on treating the main tendons and ligaments of knee osteoarthritis.

Method

A total of 36 patients with knee osteoarthritis were enrolled in trial and organized into two groups: 3-wk extracorporeal shockwave therapy for the intervention group and 3-wk sham extracorporeal shockwave therapy for control group. Both groups received the same physical therapies: (1) transcutaneous electrical nerve stimulation, (2) magnetic field treatment, and (3) quadricep muscle strength training. Evaluation was performed before the start of treatment, at third week after the start of treatment, and 1 wk after the end of treatment. The study used randomized controlled trials (level of evidence, 1).

Result

Eextracorporeal shockwave therapy group had significant improvement in WOMAC pain score, physical function, and total score (mean difference = −2.8, P < 0.001; −5.1, P = 0.02; −8.3, P = 0.004, respectively), Visual Analog Scale score (mean difference = −2.3, P < 0.001), and the distance of 6-min walk test (mean difference = 28.7, P = 0.01) in the 1 wk after the end of treatment. Statistical significance in WOMAC pain, physical function, and total scores (mean difference = −3.0, P = 0.001; −5.6, P = 0.02; −9.3, P = 0.004, respectively) and Visual Analog Scale score (mean difference = −1.2, P = 0.027) was observed between the extracorporeal shockwave therapy group and control group.

Conclusions

Extracorporeal shockwave therapy for the tendons and ligaments has clinical benefits for pain and physical function improvement in knee osteoarthritis. In addition, improvement in physical performance was observed in the short-term follow-up.
Sustained Improvement in the Performance of Rapid Sequence Intubation Five Years after a Quality Improvement Initiative
Authors: Kerrey Benjamin T. , Mittiga Matthew R. , Boyd Stephanie , Frey Mary , Geis Gary L. , Rinderknecht Andrea S. , Ahaus Karen , Varadarajan Kartik R. , Luria Joseph W. , Iyer Srikant B.
Published: February 2021

Introduction:

Many quality improvement interventions do not lead to sustained improvement, and the sustainability of healthcare interventions remains understudied. We conducted a time-series analysis to determine whether improvements in the safety of rapid sequence intubation (RSI) in our academic pediatric emergency department were sustained 5 years after a quality improvement initiative.

Methods:

There were 3 study periods: baseline (April 2009–March 2010), improvement (July 2012–December 2013), and operational (January 2014–December 2018). All patients undergoing RSI were eligible. We collected data using a structured video review. We compared key processes and outcomes with statistical process control charts.

Results:

We collected data for 615 of 643 (96%) patient encounters with RSI performed: 114 baseline (12 months), 105 improvement (18 months), and 396 operational (60 months). Key characteristics were similar, including patient age. Statistical process control charts indicated sustained improvement of all 6 key processes and the primary outcome measure (oxyhemoglobin desaturation) throughout the 5-year operational period.

Conclusions:

Improvements in RSI safety were sustained 5 years after a successful improvement initiative, with further improvement seen in several key processes. Further research is needed to elucidate the factors contributing to sustainability.
Evaluating the Impact of Immediate Lymphatic Reconstruction for the Surgical Prevention of Lymphedema
Authors: Johnson Anna Rose , Fleishman Aaron , Granoff Melisa D. , Shillue Kathy , Houlihan Mary Jane , Sharma Ranjna , Kansal Kari J. , Teller Paige , James Ted A. , Lee Bernard T. , Singhal Dhruv
Published: February 2021

Background:

Breast cancer–related lymphedema affects one in five patients. Its risk is increased by axillary lymph node dissection and regional lymph node radiotherapy. The purpose of this study was to evaluate the impact of immediate lymphatic reconstruction or the lymphatic microsurgical preventative healing approach on postoperative lymphedema incidence.

Methods:

The authors performed a retrospective review of all patients referred for immediate lymphatic reconstruction at the authors’ institution from September of 2016 through February of 2019. Patients with preoperative measurements and a minimum of 6 months’ follow-up data were identified. Medical records were reviewed for demographics, cancer treatment data, intraoperative management, and lymphedema incidence.

Results:

A total of 97 women with unilateral node-positive breast cancer underwent axillary nodal surgery and attempt at immediate lymphatic reconstruction over the study period. Thirty-two patients underwent successful immediate lymphatic reconstruction with a mean patient age of 54 years and body mass index of 28 ± 6 kg/m2. The median number of lymph nodes removed was 14 and the median follow-up time was 11.4 months (range, 6.2 to 26.9 months). Eighty-eight percent of patients underwent adjuvant radiotherapy of which 93 percent received regional lymph node radiotherapy. Mean L-Dex change was 2.9 units and mean change in volumetry by circumferential measurements and perometry was −1.7 percent and 1.3 percent, respectively. At the end of the study period, we found an overall 3.1 percent rate of lymphedema.

Conclusion:

Using multiple measurement modalities and strict follow-up guidelines, the authors’ findings support that immediate lymphatic reconstruction at the time of axillary surgery is a promising, safe approach for lymphedema prevention in a high-risk patient population.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Three-Dimensional Treatment Outcomes of a Virtual Helmet Design Protocol for Sagittal Strip Craniectomy
Authors: Ramamurthi Aishwarya , Hallac Rami R. , Chou Pang-Yun , Kenyon Laura , Derderian Christopher A.
Published: February 2021

Background:

The helmet worn after sagittal strip craniectomy must be customized to the surgical procedure and the patient’s anatomy to achieve optimal outcomes. This study compares three-dimensional head shape outcomes obtained from a novel virtual helmet design and from a traditional helmet design.

Methods:

Twenty-four patients underwent extended sagittal strip craniectomy performed by a single surgeon and helmet management performed by a single orthotist. Eleven patients constitute the traditional helmet group, with helmet design based on laser scans. Thirteen patients constitute the virtual helmet group, with helmet design based on an overlay of a three-dimensional volume rendering of a low-radiation protocol computed tomographic scan and three-dimensional photograph. Cephalic index and vertical height were recorded from three-dimensional photographs. Three-dimensional whole-head composite images were generated to compare global head shape outcomes to those of age-matched controls.

Results:

There was no significant difference in mean cephalic index between the virtual helmet group (83.70 ± 2.33) and controls (83.53 ± 2.40). The differences in mean cephalic index between the traditional helmet group (81.07 ± 3.37) and controls and in mean vertical height were each significant (p < 0.05). Three-dimensional analysis demonstrated normal biparietal and vertical dimensions in the virtual helmet group compared to controls. The traditional helmet group exhibited narrower biparietal dimension and greater vertical dimension compared to controls.

Conclusions:

Traditional and virtual helmet protocols improved mean cephalic index, but the virtual helmet group yielded more consistent and greater change in cephalic index. The virtual helmet design protocol yielded three-dimensional outcomes similar to those of age-matched controls. Traditional helmet design yielded a narrower biparietal dimension and greater vertical dimension to the cranial vault compared to the virtual helmet group and controls.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Plastic Surgical Management of Hidradenitis Suppurativa
Authors: Taylor Erin M. , Hamaguchi Ryoko , Kramer Kimberly M. , Kimball Alexa B. , Orgill Dennis P.
Published: February 2021

Learning Objectives:

After studying this article, the participant should be able to: 1. Describe the pathogenesis of hidradenitis suppurativa. 2. Discuss perioperative multimodal therapy of hidradenitis suppurativa, including medical optimization. 3. Determine an appropriate surgical plan with excision and reconstruction based on hidradenitis suppurativa severity, size, and anatomical location.

Successful treatment of hidradenitis suppurativa requires a multidisciplinary team approach and multimodal therapy.
Soft-Tissue Sarcoma as a Potential Differential Diagnosis of an Exophytic Soft-Tissue Mass: A Case Report
Authors: Alonso-Carpio Miriam , Sánchez-García Alberto , Trapero Ana , Valls Alejandro Ruíz , Pardo Andrea Vicente
Published: February 2021

The detection of a soft-tissue mass requires a detailed and conscientious examination to make a definitive diagnosis and propose appropriate treatment strategies. Benign mesenchymal tumors occur more frequently than malignant tumors. However, because of their aggressive growth and poor prognosis, sarcomas must always be considered as a potential differential diagnosis. To make a formal diagnosis and plan appropriate surgical treatment, the surgeon should obtain cross-sectional imaging studies and biopsies.
The Readability of Outpatient Plastic Surgery Clinic Letters: Are We Adhering to Plain English Writing Standards?
Authors: Drury Damien J. , Kaur Anjana , Dobbs Tom , Whitaker Iain S.
Published: February 2021

The readability of letters sent to patients plays a pivotal role in facilitating joint decision making and positive health outcomes. Guidance suggests that all correspondence should be directed to patients. Covid-19 led to an increase in direct-to-patient communication. This study aims to determine the quantity and quality of plastic surgery clinic letters sent to patients before and during the Covid-19 pandemic. A total of 127 pre-Covid clinic letters from November to December 2019 and 103 peri-Covid clinic letters from April to May 2020 were identified and assessed for readability. Text was analyzed using a standardized set of commonly used readability formulae, including SMOG, Flesch Reading Ease, and the Coleman-Liao Index. A total of 100 pre-Covid and 58 peri-Covid letters were suitable for inclusion. Median results for formulae that output a U.S. grade score ranged between 9 and 12.9 for letters written prior to Covid-19 and 9 and 13.2 for those written during Covid-19. Eight percent of letters were sent to patients pre-Covid, increasing to 28% during the pandemic. Letters sent to patients had a median grade score of between 8 and 12 prior to Covid-19 and 8 and 10.6 during Covid-19. Letters sent to clinicians ranged between 9 and 13 and 9 and 13.3, respectively. Outpatient plastic surgery letters are written at a readability level too high to facilitate understanding among the general population. The increase in direct-to-patient contact during the Covid-19 outbreak has not led to a significant improvement in the readability of clinic letters. The authors suggest an increase in letter standardization and raising awareness of readability when writing clinic letters.
Alterations in the Kynurenine Pathway of Tryptophan Metabolism Are Associated With Depression in People Living With HIV
Authors: Drivsholm Ninna , Knudsen Andreas D. , Faurholt-Jepsen Maria , Midttun Øivind , Trøseid Marius , Kirkegaard-Klitbo Ditte M. , Ueland Per M. , Nielsen Susanne D. , Gelpi Marco
Published: February 2021

Background:

People living with HIV have increased risk of depression compared with uninfected controls. The determinants of this association are unclear. Alterations in kynurenine (Kyn) metabolism have been associated with depression in uninfected individuals, but whether they are involved in the development of depression in the context of HIV infection is unknown.

Methods:

A total of 909 people living with HIV were recruited from the Copenhagen Comorbidity in HIV infection study. Information regarding demographics and depression was obtained from questionnaires. HIV-related variables and use of antidepressant medication were collected from patient records. Logistic regression models before and after adjustment for confounders were used to test our hypotheses.

Results:

The prevalence of depression was 11%. Among traditional risk factors, only being unmarried was associated with greater odds of depression. Higher levels of quinolinic-to-kynurenic acid ratio (P = 0.018) and higher concentrations of quinolinic acid (P = 0.048) were found in individuals with depression than in those without. After adjusting for confounders, high levels of quinolinic-to-kynurenic acid ratio and high concentrations of quinolinic acid remained associated with depression [adjusted odds ratio 1.61 (1.01; 2.59) and adjusted odds ratio 1.68 (1.02; 2.77), respectively].

Conclusions:

The results from this study suggest that alterations in the kynurenine pathway of tryptophan metabolism are associated with the presence of depression in the context of HIV infection.
Referral Linkage to Preexposure Prophylaxis Care and Persistence on Preexposure Prophylaxis in an Integrated Health Care System
Authors: Bruxvoort Katia J. , Schumacher Christina M. , Towner William , Jones Joyce , Contreras Richard , Ling Grant Deborah , Hechter Rulin C.
Published: February 2021

Background:

Successful linkage to preexposure prophylaxis (PrEP) and retention in care are important for HIV prevention. We examined gaps in PrEP care following referral and factors associated with PrEP linkage and persistence in an integrated health care system in the United States.

Methods:

We identified individuals referred for PrEP from 2014 to 2017 at the Kaiser Permanente Southern California using electronic health records and assessed linkage to care, PrEP prescription orders and fills, and PrEP persistence (medication possession ratio ≥80%) in the year after the first fill. We evaluated demographic and clinical factors potentially associated with PrEP linkage and persistence using a series of multivariable modified Poisson regression models.

Results:

Of 2995 referred individuals, 74.9% were linked to PrEP care. Nearly all those linked to care were prescribed PrEP and filled a prescription, but only 47.4% of those who filled a prescription were persistent on PrEP. Individuals aged <25 years (vs ≥25 years), female subjects (vs males), and individuals with high-deductible insurance (vs no high deductible) were less likely to be linked to care. Individuals aged <25 years and Hispanics (vs non-Hispanic whites) were less likely to be persistent. Those with alcohol use disorder were more likely to be linked to PrEP care but less likely to be persistent. New HIV diagnoses occurred in 38 individuals, and only 1 had PrEP in possession at diagnosis.

Conclusions:

We observed PrEP care gaps and disparities among individuals referred for PrEP. Patient-centered interventions are needed in primary care to address barriers to successful PrEP linkage and persistence.
Nebulized antibiotics for ventilator-associated pneumonia: methodological framework for future multicenter randomized controlled trials
Authors: Monsel Antoine , Torres Antoni , Zhu Yinggang , Pugin Jerome , Rello Jordi , Rouby Jean-Jacques
Published: February 2021

Purpose of review

Although experimental evidence supports the use of nebulized antibiotics in ventilator-associated pneumonia (VAP), two recent multicenter randomized controlled trials (RCTs) have failed to demonstrate any benefit in VAP caused by Gram-negative bacteria (GNB). This review examines the methodological requirements concerning future RCTs.

Recent findings

High doses of nebulized antibiotics are required to reach the infected lung parenchyma. Breath-synchronized nebulizers do not allow delivery of high doses. Mesh nebulizers perform better than jet nebulizers. Epithelial lining fluid concentrations do not reflect interstitial lung concentrations in patients receiving nebulized antibiotics. Specific ventilator settings for optimizing lung deposition require sedation to avoid patient's asynchrony with the ventilator.

Future RCTs should compare a 3–5 day nebulization of amikacin or colistimethate sodium (CMS) to a 7-day intravenous administration of a new cephalosporine/ß-lactamase inhibitor. Inclusion criteria should be a VAP or ventilator-associated tracheobronchitis caused by documented extensive-drug or pandrug resistant GNB. If the GNB remains susceptible to aminoglycosides, nebulized amikacin should be administered at a dose of 40 mg/kg/day. If resistant to aminoglycosides, nebulized CMS should be administered at a dose of 15 millions international units (IU)/day. In VAP caused by pandrug-resistant GNB, 15 millions IU/day nebulized CMS (substitution therapy) should be compared with a 9 millions IU/day intravenous CMS.
Systematic Suicide Audit: An Enhanced Method to Assess System Gaps and Mobilize Leaders for Prevention
Authors: Fortin Gabrielle , Ligier Fabienne , Van Haaster Ian , Doyon Claude , Daneau Diane , Lesage Alain
Published: February 2021

Background and Objectives:

In Quebec, Canada, several independent processes are in place to investigate cases of death by suicide. An enhanced multidisciplinary audit process was developed to analyze these cases more thoroughly, with the aim of generating recommendations for suicide prevention. A study was undertaken to evaluate the feasibility and implementability of this process.

Methods:

The life trajectories of 14 people who died by suicide in Montreal, Canada, in 2016 were reconstructed on the basis of information retrieved by interviewing bereaved relatives and examining coroner investigation files and other records. A multidisciplinary panel that included a representative of families bereaved by suicide then reviewed case summaries to determine unmet needs and service gaps at 3 levels: individual intervention, regional programs, and the provincial health and social services system.

Results:

The feasibility of the audit process was demonstrated in the context of a public health care system. Thirty-one distinct recommendations were made variably across 13 of the 14 cases reviewed, whereas none had originally been made by the coroner. The recommendations that recurred most often were (1) improve training for professionals and educate the general public regarding depression and substance-related disorders; (2) deploy mobile crisis intervention teams from emergency departments; and (3) provide access to a family physician to all, especially men.

Conclusion:

Although the audit produced novel recommendations and is implementable, there was resistance from physicians and their hospital mortality review committee against this multidisciplinary audit involving families. These concerns could be alleviated by having the process endorsed by provincial authorities.
Fusion 68Ga-DOTANOC PET/MRI in Primary Juvenile Nasal Angiofibroma
Authors: Sakthivel Pirabu , Thakar Alok , Arunraj Sreedharan Thankarajan , Bhalla Ashu Seith , Prashanth Arun , Kumar Rakesh
Published: February 2021

Somatostatin cell surface receptors are expressed in many different benign and malignant tumors and are often exploited for imaging and therapy of neuroendocrine tumors. A 17-year-old adolescent boy with clinicoradiologically diagnosed JNA (juvenile nasopharyngeal angiofibroma) also underwent 68Ga-DOTANOC PET to explore somatostatin cell surface receptors’ expression and its theranostic potential. Fusion PET/MRI, a novel imaging technology, exactly depicted the anatomical extensions of the tumor with avid DOTANOC uptake. This software-based fusion technique is advantageous for easy early recurrence identification, better delineation from postoperative scar tissue, for planning the exact target volumes for stereotactic radiotherapy therapy of inoperable/residual/recurrent JNAs in the future.
Bone SPECT/CT in the Evaluation of Painful Total Ankle Replacement
Authors: Mertens Jeroen , Lootens Tom , Vercruysse Johan , Van Den Bossche Bieke , Berwouts Dieter , Lambert Bieke , Van den Wyngaert Tim
Published: February 2021

Purpose

Third-generation total ankle replacement (TAR) is an increasingly popular and effective treatment for end-stage osteoarthritis, yet identifying causes of failure remains challenging. We evaluated integrated bone SPECT/CT in recurrent pain after TAR by validating a standardized reporting scheme, identifying uptake patterns, and assessing diagnostic performance and impact on clinical management.

Patients and Methods

A total of 24 TARs in 16 patients with persistent or recurrent pain received integrated bone SPECT/CT using diagnostic CT settings. Images were retrospectively reviewed, and a novel localization scheme was validated by assessing interrater agreement. Distinct uptake patterns were identified, and diagnostic test characteristics were estimated. Reference standard consisted of clinical follow-up, laboratory findings, and subsequent procedures, including revision surgery.

Results

Standardized scoring of bone SPECT/CT uptake was highly reproducible (intraclass correlation coefficient, 0.79; 95% confidence interval [CI], 0.75–0.82). The final diagnoses were gutter impingement (n = 12), periprosthetic (stress) fracture (n = 5), loosening (n = 5), tarsal arthritis (n = 1), and erysipelas (n = 1). Overall, the diagnostic test characteristics of bone SPECT/CT were as follows: sensitivity of 100% (95% CI, 82%–100%), specificity of 80% (95% CI, 28%–99%), and accuracy of 96% (95% CI, 79%–100%). Gutter impingement, periprosthetic fracture, and loosening were correctly identified in all cases revealing distinct uptake patterns. Importantly, persistent diffuse uptake was frequently observed, warranting cautious interpretation. Bone SPECT/CT impacted clinical management in 86%, with symptomatic improvement in 83% of patients.

Conclusions

Integrated bone SPECT/CT of painful TARs may benefit from standardized localization to reveal distinct uptake patterns representing common complications after TAR. Initial results show highly promising diagnostic value with potentially important impact on clinical management.
The Association of Tumor Burden by 18F-FDG PET/CT and Survival in Vulvar Carcinoma
Authors: Mokoala Kgomotso M.G. , Lawal Ismaheel O. , Lengana Thabo , Popoola Gbenga O. , Boshomane Tebatso M.G. , Mokgoro Neo P. , Vorster Mariza , Sathekge Mike M.
Published: February 2021

Purpose

The aim of this study was to assess the impact of 18F-FDG PET/CT metabolic parameters obtained at initial staging of vulva carcinoma on survival in women with and without HIV infection.

Patients and Methods

18F-FDG PET/CT images of women with vulva cancer who are planned for definitive therapy were analyzed. SUVmax, SUVmean, MTV, and total lesion glycolysis (TLG) as well as whole-body MTV and whole-body TLG were computed.

Results

Twenty-five women were included with a mean age of 43.44 ± 10.32. The majority of the patients were HIV infected with a median CD4 count of 444.00 cells/mm3. The HIV-infected women are younger at diagnosis than their HIV-uninfected counterparts. All patients presented with inguinofemoral lymph node involvement, whereas half the patients had pelvic nodal metastasis. All the patients with distant visceral or skeletal metastasis were HIV infected. The lungs were the most common site of distant metastasis. When comparing the SUVmax, SUVmean, MTV, TLG, wbMTV, and wbTLG between HIV-infected and HIV-uninfected patients, we did not find statistical differences. Twelve patients (48%) were upstaged to metastatic disease. Seven patients had died at the time of analysis. The wbMTV and wbTLG were significantly higher in nonsurvivors than survivors.

Conclusions

18F-FDG PET/CT improves initial staging of squamous cell carcinoma among women with and without HIV infection. The whole-body tumor burden assessed by 18F-FDG PET metabolic metrics did not differ between HIV-infected and HIV-uninfected women. A higher whole-burden tumor burden is associated with a higher risk of mortality among women with vulva cancer.
An Intravenous 100-mL Lipid Emulsion Infusion Dramatically Improves Myocardial Glucose Metabolism Extinction in Cardiac FDG PET Clinical Practice
Authors: Dietz Matthieu , Paulmier Benoît , Berthier Frédéric , Civaia Filippo , Mocquot François , Serrano Benjamin , Nataf Valérie , Hugonnet Florent , Faraggi Marc
Published: February 2021

Purpose

Physiological myocardial accumulation of FDG impairs the diagnosis of inflammatory/infectious or tumoral myocardial detection by FDG PET/CT. We prospectively evaluated the addition, 3 hours before imaging, of an intravenous 100-mL lipid emulsion infusion (Intralipid) to a high-fat, low-carbohydrate diet (HFLCD) for at least 2 meals followed by a fast of at least 6 to 12 hours in patients referred for the diagnosis of myocardial inflammation, endocarditis, cardiac or paracardiac masses, intracardiac device, or prosthetic valve infections.

Methods

Data of 58 patients consecutively included (28 Intralipid patients, 30 controls with HFLCD alone) were compared. FDG uptake in normal myocardium was scored from 0 (complete myocardial suppression) to 3 (high diffuse uptake). Myocardial maximal, peak, and mean SUV and the rate of interpretable images according to the clinical indication were measured.

Results

Compared with controls, Intralipid infusion significantly improved the rate of score 0 (89% vs 63%, P = 0.021), of interpretable images according to the clinical indication (100% vs 72%, P = 0.0047) and decreased all myocardial SUV values (eg, SUVmax median, 1.9 [interquartile range, 1.7–2.5] vs 3.1 [interquartile range, 2.3–4.1]; P < 0.001).

Conclusions

A lipid emulsion infusion in addition to HFLCD better suppresses cardiac glucose metabolism than HFLCD alone.
A Case for the Use of the 5-Item Modified Frailty Index in Preoperative Risk Assessment for Tissue Expander Placement in Breast Reconstruction
Authors: Moss Whitney , Zhang Ruyan , Carter Gentry C. , Kwok Alvin C.
Published: February 2021

Background

Preoperative risk assessment is essential in determining which surgical candidates will have the most to gain from an operation. The 5-item modified frailty index (mFI-5) has been validated as an effective way to determine this risk. This study sought to evaluate the performance of the mFI-5 as a predictor of postoperative complications after tissue expander placement.

Methods

Patients who underwent placement of a tissue expander were identified using the 2012 to 2018 American College of Surgeons National Surgical Quality Improvement Project database. Univariate and multivariate regression analysis models were used to assess how mFI-5, the components of the mFI-5 (functional status, diabetes, chronic obstructive pulmonary disease, chronic heart failure, and hypertension), and other factors commonly used to risk stratify (age, body mass index [BMI], American Society of Anesthesiologists (ASA) classification, and history of smoking) were associated with complications.

Results

In 44,728 tissue expander placement cases, the overall complication rate was 10.5% (n = 4674). The mFI-5 score was significantly higher in the group that experienced complications (0.08 vs 0.06, P < 0.001). Compared with the mFI-5 individual components and other common variables used preoperatively to risk stratify patients, univariate analysis demonstrated that mFI-5 had the largest effect size (odds ratio [OR], 5.46; confidence interval [CI], 4.29–6.94; P < 0.001). After controlling for age, BMI, ASA classification, and history of smoking, the mFI-5 still remained the predictor of complications with the largest effect size (OR, 2.25; CI, 1.70–2.97; P < 0.001). In assessing specific complications, the mFI-5 is the independent predictor with the largest significant effect size for surgical dehiscence (OR, 12.76; CI, 5.58–28.18; P < 0.001), surgical site infection (OR, 6.68; CI, 4.53–9.78; P < 0.001), reoperation (OR, 5.23; CI, 3.90–6.99; P < 0.001), and readmission (OR, 4.59; CI, 3.25–6.45; P < 0.001) when compared with age, BMI, ASA class, and/or history of smoking alone.

Conclusions

The mFI-5 can be used as an effective preoperative predictor of postoperative complications in patients undergoing tissue expander placement. Not only does it have the largest effect size compared with other historical perioperative risk factors, it is more predictive than each of its individual components.
Measurement Method to Determine the Difference in Tear Trough and Palpebromalar Groove Distribution After Transconjunctival Fat Reposition
Authors: Ye Cui , Jiecong Wang , Xiaoling Feng
Published: February 2021

Purpose:

This study designed an efficient measurement method to evaluate the outcome of transconjunctival fat reposition in the tear trough and palpebromalar groove.

Methods and Techniques:

A total of 41 patients (82 eyes) who underwent transconjunctival fat reposition surgery between January 2016 and March 2019 were retrospectively analyzed. Preoperative and postoperative (at least six months) standardized digital images were taken from the patients. A satisfaction survey was conducted on all patients. Their images were analyzed by using the Adobe Photoshop CS5 software. Ratios of the tear trough and palpebromalar groove were calculated. These data were analyzed by SPSS 20.0.

Results:

The overall satisfaction rate was 90.2%. With a partition in the infraorbital region, a line graph showed that the location of the tear trough and palpebromalar groove moved to the upper squares postoperatively. The number of patients whose end points of the tear trough and palpebromalar groove located outside the midline of the pupil decreased by 30.5%. When we processed all the parameters of the preoperative and postoperative groups by profile analysis, a significant difference in the tear trough and palpebromalar groove before and after surgery was observed (right: F = 79.844, P = 0.000 < 0.01; left: F = 161.799, P = 0.000 < 0.01).

Conclusions:

Digital image analysis is feasible and useful in investigating the improvement of the tear trough and palpebromalar groove. The tear trough and palpebromalar groove shifted up and became shortened, which provided a more reliable evidence for lower eyelid rejuvenation.
Craniofacial Fractures in Equine-Related Injuries: What Should a Maxillofacial Surgeon Expect?
Authors: Puolakkainen Tero , Marttila Emilia , Thorén Hanna , Snäll Johanna
Published: February 2021

Patients with equine-related injuries (ERI) have high rates of hospitalization and often require surgical treatment. This study aimed to clarify the injury profiles of patients sustaining ERI-related craniofacial fractures and their relationship with other severe head and neck injuries.

This retrospective study included all patients with craniofacial fractures admitted to a tertiary trauma center during 2013 to 2018. Out of 3256 patients, a total of 39 patients were included in the study (1.2%). Demographic and clinically relevant variables were reported and statistically evaluated.

Males represented only 7.7% of the study population. Isolated facial fractures were over-represented in this study population at 84.6% whereas only 7.7% of patients sustained isolated cranial fractures and 7.7% of patients sustained combined craniofacial fractures, respectively. Surgical intervention for craniofacial fractures was required in 48.7% of patients. In total, 17.9% of patients sustained severe head and neck injuries. Periods of unconsciousness and/or post-traumatic amnesia were seen in 41% of patients. Helmet use could only be confirmed in 17.9% of patients.

As trauma mechanisms behind ERI are often multifactorial and patients are at a high risk of sustaining associated injuries, attentive examination, and exclusion of serious life-threatening injuries through a multi-disciplinary approach is imperative for this specific patient population.
A Finite Element Analysis Model is Suitable for Biomechanical Analysis of Orbital Development
Authors: Song Dongyu , Zhang Jiwu , Yuan Bowei , Rong Qiguo , Li Dongmei
Published: February 2021

The authors investigated orbital bone development in congenital microphthalmia (CM) using a three-dimensional finite element analysis model, after the orbital dimension deficiency was improved with a self-inflating hydrogel expander implant.

Data of a 2-year-old male CM patient were examined. The orbital structure, eyeball, eye muscles, and self-inflating hydrogel expander were constructed according to computed tomography examination data. The effects of self-expanding spherical hydrogel at various locations in the muscle cone on orbital bone development were examined using 3-mL self-expanding expanders placed at shallow (model 1: 2 mm depth) and deep (model 2: 8 mm depth) muscle cone positions. This model simulated the hydrogel expansion process; the orbital bone biomechanics and radial displacement nephograms were obtained when the hydrogel volume increased 3, 5, 7, and 9 times and analyzed.

The orbital bone biomechanics were concentrated at the medial orbital wall center, gradually spreading to the whole orbital wall. Biomechanics and radial displacement of the inferior temporal and lateral distal orbital wall region were the most significant, and were more significant in model 1 than in model 2.

Finite element analysis is suitable for the biomechanical analysis of orbital development in CM. The shallow position inside CM patients’ muscle cone is the optimal site for hydrogel implantation.
Real Appearance of Dendritic Cell on Failed Implant Fixture
Authors: Nguyen Truc Thi Hoang , Eo Mi Young , Kim Soung Min
Published: February 2021

Dendritic cells (DCs) are considered a multifunctional cell population that links the innate and adaptive immune systems. Dendritic cells have a capacity for antigen capture and presentation to T cells, which initiates a cascade of inflammatory reactions. On contrary to its importance in immunology, DCs have not been known well in peri-implantitis.

A scanning electron microscopy coupled with energy-dispersive X-ray spectroscopy examination was used to examine a fixture that failed due to peri-implantitis, and a transmission electron microscopy was used to examine the peri-implant inflamed soft tissue. The presence of a DC was suggested in both scanning electron microscopy and transmission electron microscopy images. Titanium elements were also detected in the fixture-attached bone with energy-dispersive X-ray spectroscopy analysis. These findings suggested a link between Ti particles and DCs activation. The correlation between the presence of Ti particles and DCs will help to elucidate the detailed mechanism of peri-implantitis.
Neuroma of The Supraorbital Nerve Following Forehead Flap Reconstruction – Presentation and Surgical Management
Authors: Bhoopalam Myan , Manson Paul N. , Grant Michael , Reddy Sashank K.
Published: February 2021

Localized pain or headache from neuroma formation is a rare and challenging complication of forehead flap surgery. Here the authors present a patient who developed local pain and dysesthesia following iatrogenic injury to the left supraorbital nerve during forehead flap elevation. Following a diagnostic nerve block in clinic, surgical excision of the neuroma was performed through an upper blepharoplasty approach. The patient had immediate postoperative pain relief and remains pain free at fifteen-month follow-up. The authors describe etiology, workup, and surgical management of sensory nerve injury during forehead flap reconstruction.