bluuebunny/crossref_metadata_2025 huggingface dataset:
SUB-TENON TRIAMCINOLONE ACETONIDE INJECTION IN A PREGNANT PATIENT WITH VOGT–KOYANAGI–HARADA DISEASE
Authors: Nakamura Tomoko , Keino Hiroshi , Okada Annabelle A.
Published: December 2016

Purpose:

To report a case of new-onset Vogt–Koyanagi–Harada disease treated with sub-Tenon injection of triamcinolone acetonide in a 16-week pregnant patient.

Methods:

Review of clinical records.

Results:

A 33-year-old woman in her 16th week of pregnancy presented with bilateral serous retinal detachments associated with anterior chamber inflammation. Enhanced depth imaging optical coherence topography showed marked choroidal thickening. Headache and tinnitus developed 3 days later. The patient was diagnosed with incomplete Vogt–Koyanagi–Harada disease and treated with bilateral sub-Tenon triamcinolone acetonide injections. Within 2 weeks, the serous retinal detachments completely resolved with decreased choroidal thickness in both eyes. No recurrence of inflammation or choroidal thickening was noted over a follow-up of 13 months. The patient delivered a healthy baby at 41 weeks of pregnancy.

Conclusion:

Sub-Tenon triamcinolone acetonide injection may be an effective and safe treatment in pregnant women with new-onset Vogt–Koyanagi–Harada disease.
Case Series Description and Genomic Characterization of Invasive Group A Streptococcal Infections in Pediatric Patients
Authors: Dien Bard Jennifer , Mongkolrattanothai Kanokporn , Kachroo Priyanka , Beres Stephen , Olsen Randall J.
Published: December 2016

We report an unusual cluster of invasive group A Streptococcus infections in 6 pediatric patients and demonstrate that the strains were derived from diverse genetic backgrounds, confirming the occurrence of a community cluster rather than a clonal outbreak. Whole genome sequencing provided a rapid and comprehensive view of group A Streptococcus genotypes and helped guide our institutional response and public health maneuvers.
Congenital Cytomegalovirus Infection and Permanent Hearing Loss in Rural North Indian Children
Authors: Dar Lalit , Namdeo Divya , Kumar Pankaj , Thakar Alok , Kant Shashi , Rai Sanjay , Singh Pawan K. , Kabra Madhulika , Fowler Karen B. , Boppana Suresh B.
Published: December 2016

Background:

Congenital cytomegalovirus infection (cCMV) is a leading nongenetic cause of permanent congenital or early-onset hearing loss (PCEHL). Although cCMV rates are high despite near-universal seroimmunity, the contribution of cCMV to PCEHL in the developing world is unclear.

Methods:

Neonates at a rural North Indian hospital were screened for cCMV by saliva polymerase chain reaction and hearing by distortion-product otoacoustic emission testing. Cytomegalovirus (CMV)-positive infants and those not passing newborn hearing screening (NHS) were evaluated by auditory brainstem response to confirm PCEHL. Infants with cCMV and those with PCEHL were tested for mutations within the GJB2 gene.

Results:

Of the 1720 infants screened, 40 (2.3%) did not pass NHS and 20 (1.2%) were CMV positive. Auditory brainstem evoked response testing confirmed unilateral or bilateral PCEHL in 11 (0.64%) children who either did not pass NHS or CMV positive. PCEHL was 20-fold higher in neonates with cCMV (2/20, 10%) than those without (9/1700, 0.5%; P < 0.01). None of 11 infants with PCEHL had connexin 26 mutations.

Conclusion:

PCEHL incidence is high in India, with cCMV contributing significantly despite near-universal seroimmunity. Our findings also demonstrate the feasibility and the utility of simultaneous newborn screening for both cCMV and hearing loss in a resource-limited setting.
Validating the Use of ICD-9 Code Mapping to Generate Injury Severity Scores
Authors: Fleischman Ross J. , Mann N. Clay , Dai Mengtao , Holmes James F. , Wang N. Ewen , Haukoos Jason , Hsia Renee Y. , Rea Thomas , Newgard Craig D.
Published: December 2016

The Injury Severity Score (ISS) is a measure of injury severity widely used for research and quality assurance in trauma. Calculation of ISS requires chart abstraction, so it is often unavailable for patients cared for in nontrauma centers. Whether ISS can be accurately calculated from International Classification of Diseases, Ninth Revision (ICD-9) codes remains unclear. Our objective was to compare ISS derived from ICD-9 codes with those coded by trauma registrars. This was a retrospective study of patients entered into 9 U.S. trauma registries from January 2006 through December 2008. Two computer programs, ICDPIC and ICDMAP, were used to derive ISS from the ICD-9 codes in the registries. We compared derived ISS with ISS hand-coded by trained coders. There were 24,804 cases with a mortality rate of 3.9%. The median ISS derived by both ICDPIC (ISS-ICDPIC) and ICDMAP (ISS-ICDMAP) was 8 (interquartile range [IQR] = 4–13). The median ISS in the registry (ISS-registry) was 9 (IQR = 4–14). The median difference between either of the derived scores and ISS-registry was zero. However, the mean ISS derived by ICD-9 code mapping was lower than the hand-coded ISS in the registries (1.7 lower for ICDPIC, 95% CI [1.7, 1.8], Bland–Altman limits of agreement = −10.5 to 13.9; 1.8 lower for ICDMAP, 95% CI [1.7, 1.9], limits of agreement = −9.6 to 13.3). ICD-9-derived ISS slightly underestimated ISS compared with hand-coded scores. The 2 methods showed moderate to substantial agreement. Although hand-coded scores should be used when possible, ICD-9-derived scores may be useful in quality assurance and research when hand-coded scores are unavailable.
Air Medical Administration of Tranexamic Acid
Authors: Cornelius Brian
Published: December 2016

Traumatic injury is a significant cause of morbidity and mortality in the United States. Massive hemorrhage is responsible for the vast majority of deaths. Evolution in trauma treatment has resulted in major improvements to emergency care. Tranexamic acid (TXA), an antifibrinolytic agent, is synthetically derived from amino acids. The CRASH-2 study demonstrated that the early administration of TXA results in significant decreases in morbidity and mortality. Experiences by coalition forces in Southwest Asia found a substantial increase in survival of trauma patients with early TXA administration. The PAMPer trial has demonstrated the success of taking plasma to the scene of the incident by helicopter; TXA offers additional benefits when transported by the same means. Air medical utilization of TXA can take battlefield trauma care to the scene of civilian traumatic injuries and save lives.
Establishing Standards for Trauma Nursing Education: The Central Ohio Trauma System's Approach
Authors: Haley Kathy , Martin Stacey , Kilgore Jane , Lang Carrie , Rozzell Monica , Coffey Carla , Eley Scott , Light Andrea , Hubartt Jeff , Kovach Sherri , Deppe Sharon
Published: December 2016

Trauma nursing requires mastering a highly specialized body of knowledge. Expert nursing care is expected to be offered throughout the hospital continuum, yet identifying the necessary broad-based objectives for nurses working within this continuum has often been difficult to define. Trauma nurse leaders and educators from 7 central and southeastern Ohio trauma centers and 1 regional trauma organization convened to establish an approach to standardizing trauma nursing education from a regional perspective. Forty-two trauma nursing educational objectives were identified. The Delphi method was used to narrow the list to 3 learning objectives to serve as the framework for a regional trauma nursing education guideline. Although numerous trauma nursing educational needs were identified across the continuum of care, a lack of clearly defined standards exists. Recognizing and understanding the educational preparation and defined standards required for nurses providing optimal trauma care are vital for a positive impact on patient outcomes. This regional trauma nursing education guideline is a novel model and can be used to assist trauma care leaders in standardizing trauma education within their hospital, region, or state. The use of this model may also lead to the identification of gaps within trauma educational systems.
Serving Others Through Mission Trips
Authors: Hassler Deborah A.
Published: December 2016

Nurses have the opportunity to share their knowledge and skills in a variety of settings. One of these is by going on mission trips. Cultural sensitivity, adequate preparation, and flexibility are crucial elements for a successful experience. The benefits far outweigh the initial hesitation that one may experience as he or she begins making his or her preparations. There is an opportunity to meet new people, learn about a culture that is not your own, explore new terrain, and share medical knowledge. Often these trips lead to future opportunities for service abroad and the development of lasting relationships.
Effect of Outflow Graft Size on Flow in the Aortic Arch and Cerebral Blood Flow in Continuous Flow Pumps: Possible Relevance to Strokes
Authors: Bhat Sindhoor , Mathew Jayakala , Balakrishnan Komrakshi R. , Krishna Kumar Ramarathnam
Published: December 2016

One of the most devastating complications of continuous flow left ventricular devices (CFLVADS) is stroke, with a higher incidence in HeartWare Ventricular Assist Device (HVAD) as compared with HEARTMATE II. The reason for the observed difference in stroke rates is unclear. Because outflow graft diameters are different, we hypothesized that this could contribute to the difference in stroke rates. A computational fluid–structure interaction model was created from the computed tomography (CT) scan of a patient. Pressures were used as the boundary condition and the flow through the cerebral vessels was derived as outputs. Flow into the innominate artery was very sensitive to the anastomosis angle for a 10 mm as compared with a 14 mm graft, with the net innominate flow severely compromised with a 10 mm graft at 45° angle. Aortic insufficiency seems to affect cerebral blood flow nonlinearly with an 80% decrease at certain angles of outflow graft anastomosis. Arterial return in to the arch through a narrow graft has important jet effects and results in significant flow perturbations in the aortic arch and cerebral vessels and stasis. A 10 mm graft is more sensitive to angle of insertion than a 14 mm graft. Under some conditions, serious hypoperfusion of the innominate artery is possible. Aortic incompetence results in significant decrease of cerebral blood flow. No stasis was found in the pulsatile flow compared with LVAD flow.
Use of the Body Composition Monitor for Fluid Status Measurements in Elderly Malnourished Subjects
Authors: Keane David F. , Bowra Kim , Kearney Kathryn , Lindley Elizabeth
Published: December 2016

Most hemodialysis (HD) patients are able to finish dialysis at or below the normally hydrated weight determined using the body composition monitor (BCM). However, a minority become symptomatic when they are still fluid overloaded based on BCM-measured overhydration (OH). Malnourished patients frequently fall into this group, suggesting that they may have OH that is inaccessible to ultrafiltration. To isolate any effect of malnutrition on BCM-measured OH from those relating to renal failure, OH measurements for 20 elderly subjects with normal renal function who were classified as malnourished were compared with an age-matched cohort with no known nutritional issues. Body composition monitor measurements were also made on five malnourished HD patients. Mean OH for malnourished subjects with normal renal function was not significantly different from an age-matched cohort without known nutritional deficiencies (1.3 and 1.1 L, respectively; p = 0.5). Post-dialysis OH for HD patients ranged from −0.1 to +4.5 L. A slightly elevated BCM-measured OH appears to be common in elderly subjects and may be explained by changes in the composition of adipose tissue. The effect of malnutrition could not be isolated from sarcopenia, but this study supports the need for caution when reducing target weight in vulnerable patients.
Investigation of Osteoinductive Effects of Different Compositions of Bioactive Glass Nanoparticles for Bone Tissue Engineering
Authors: Tavakolizadeh AmirHossein , Ahmadian Mehdi , Fathi Mohammad Hossein , Doostmohammadi Ali , Seyedjafari Ehsan , Ardeshirylajimi Abdolreza
Published: December 2016

Bioactive glasses (BG) is one of the well-known materials that used as dental and bone implants, for this reason it is always interesting for researchers has been to increase BG efficiency in the bone tissue engineering. The aim of this study was to evaluate the osteoinductivity of BG different composition nanoparticles with SiO2–CaO–P2O5. The 45S, 58S, and 63S compositions were prepared via the sol–gel technique. Characterization techniques such as x-ray diffraction, field emission scanning electron microscopy (FE-SEM), and laser Doppler electrophoresis (LDE) were used. The osteoinductive capacity of prepared nanoparticles was investigated using unrestricted somatic stem cells (USSC). The particle size of the samples with an amorphous structure mainly ranged less than 40 nm. The zeta potential was negative for all compositions in distilled water at pH 7.4. Bioactive glass nanoparticles were shown to support proliferation of USSC, as shown by microculture tetrazolium (MTT) assay. During osteogenic differentiation, significantly highest values of alkaline phosphatase (ALP) activity and biomineralization were observed on 45S BG. Subsequently, these markers were measured in higher amounts in USSC on 58S and 63S BG compared with tissue culture polystyrene. The nanometric particle size, osteoinductivity, and negative zeta potential make this material a possible candidate for bone tissue engineering applications.
Complementary Feeding
Authors: Fewtrell Mary , Bronsky Jiri , Campoy Cristina , Domellöf Magnus , Embleton Nicholas , Fidler Mis Nataša , Hojsak Iva , Hulst Jessie M. , Indrio Flavia , Lapillonne Alexandre , Molgaard Christian
Published: December 2016

This position paper considers different aspects of complementary feeding (CF), focussing on healthy term infants in Europe. After reviewing current knowledge and practices, we have formulated these recommendations: Timing: Exclusive or full breast‐feeding should be promoted for at least 4 months (17 weeks, beginning of the 5th month of life) and exclusive or predominant breast‐feeding for approximately 6 months (26 weeks, beginning of the 7th month) is a desirable goal. Complementary foods (solids and liquids other than breast milk or infant formula) should not be introduced before 4 months but should not be delayed beyond 6 months. Content: Infants should be offered foods with a variety of flavours and textures including bitter tasting green vegetables. Continued breast‐feeding is recommended alongside CF. Whole cows’ milk should not be used as the main drink before 12 months of age. Allergenic foods may be introduced when CF is commenced any time after 4 months. Infants at high risk of peanut allergy (those with severe eczema, egg allergy, or both) should have peanut introduced between 4 and 11 months, following evaluation by an appropriately trained specialist. Gluten may be introduced between 4 and 12 months, but consumption of large quantities should be avoided during the first weeks after gluten introduction and later during infancy. All infants should receive iron‐rich CF including meat products and/or iron‐fortified foods. No sugar or salt should be added to CF and fruit juices or sugar‐sweetened beverages should be avoided. Vegan diets should only be used under appropriate medical or dietetic supervision and parents should understand the serious consequences of failing to follow advice regarding supplementation of the diet. Method: Parents should be encouraged to respond to their infant's hunger and satiety queues and to avoid feeding to comfort or as a reward.
Substance P in Flush Tears and Schirmer Strips of Healthy Participants
Authors: Markoulli Maria , Gokhale Moneisha , You Jingjing
Published: December 2016

Purpose

To determine the repeatability of the flush tear collection technique and the Schirmer strip for Substance P tear analysis.

Methods

The tears of 10 healthy non–contact-lens wearers were collected via Schirmer strip and microcapillary following instillation of either 20 μL (F-20) or 60 μL (F-60) of saline. Each technique was conducted on two occasions and in a randomized order. Total protein content (TPC) and Substance P concentrations were determined. The overall protein separation profile of each type of tears was examined using one-dimensional gel electrophoresis (1DGE).

Results

Collection rates were significantly faster for the F-60 compared to F-20 (17.3 ± 6.9 μL/min and 11.9 ± 5.3 μL/min, respectively, P < .001), with an average Schirmer strip length of 1.5 ± 2.1 mm/min. The coefficient of repeatability between days and eyes was greatest for the Schirmer strip, with eyes and days being significantly different (P = .03 and P = .03, respectively) for Schirmer strip Substance P. TPC was 3.8 ± 2.6 mg/mL, 3.3 ± 1.8 mg/mL, and 3.6 ± 3.0 mg/mL for F-20, F-60, and Schirmer strip techniques, respectively, with no significant difference between techniques (P = .85). Substance P concentration was 13.1 ± 14.8 ng/mL, 9.1 ± 6.1 ng/mL, and 14.9 ± 10.6 ng/mL for F-20, F-60, and Schirmer strip tears, respectively, with no significant difference between techniques (P = .57). 1DGE profile showed similar electrophoresis patterns among F-20, F-60, and basal tears.

Conclusions

The F-60 method allows faster collection than F-20, but the latter results in better repeatability than both the F-60 and Schirmer sampling techniques. All three techniques return the same concentrations of TPC and Substance P. This indicates that tear collection using the F-20 may be more appropriate when conducting comparative analysis, whereas the F-60 may be more appropriate when more volume is required.
Scotoma Visibility and Reading Rate with Bilateral Central Scotomas
Authors: Pratt Joshua D. , Stevenson Scott B. , Bedell Harold E.
Published: December 2016

Purpose

In this experiment, we tested whether perceptually delineating the scotoma location and border with a gaze contingent polygon overlay improves reading speed and reading eye movements in patients with bilateral central scotomas.

Methods

Eight patients with age-related macular degeneration and bilateral central scotomas read aloud MNRead style sentences with their preferred eye. Eye movement signals from an EyeLink II eyetracker were used to create a gaze contingent display in which a polygon overlay delineating the area of the patient’s scotoma was superimposed on the text during 18 of the 42 trials. Blocks of six trials with the superimposed polygon were alternated with blocks of six trials without the polygon. Reading speed and reading eye movements were assessed before and after the subjects practiced reading with the polygon overlay.

Results

All of the subjects but one showed an increase in reading speed. A paired-samples t-test for the group as a whole revealed a statistically significant increase in reading speed of 0.075 ± 0.060 (SD) log wpm after reading with the superimposed polygon. Individual subjects demonstrated significant changes in reading eye movements, with the greatest number of subjects demonstrating a shift in the average vertical fixation locus. Across subjects, there was no significant difference between the initial and final reading eye movements in terms of saccades per second, average fixation duration, average amplitude of saccades, or proportion of non-horizontal saccades.

Conclusions

The improvement in reading speed (0.075 log wpm or 19%) over the short experimental session for the majority of subjects indicates that making the scotoma location more visible is potentially beneficial for improving reading speed in patients with bilateral central scotomas. Additional research to examine the efficacy of more extended training with this paradigm is warranted.
Ultrasound-Guided Bilateral Thoracic Paravertebral Blocks as an Adjunct to General Anesthesia in Patients Undergoing Reduction Mammaplasty: A Historical Cohort Study
Authors: Salviz Emine A. , Sivrikoz Nukhet , Ozonur Anil , Orhan-Sungur Mukadder , Savran-Karadeniz Meltem , Altun Demet , Hocaoglu Emre , Celet-Ozden Burcu , Tugrul Kamil M.
Published: December 2016

Background:

This study investigates whether ultrasound-guided thoracic paravertebral blocks would improve postoperative analgesia in patients undergoing bilateral reduction mammaplasty.

Methods:

After obtaining ethics committee approval, data of 70 patients who underwent bilateral reduction mammaplasty were reviewed. Sixty-four patients’ data were evaluable; 30 were in the general anesthesia group and 34 were in the thoracic paravertebral block group. Data such as time to first pain, intraoperative fentanyl requirement, postoperative numeric rating scale scores, number of patients who required tramadol in the postoperative care unit, and rescue analgesic consumption through the first 2 postoperative days were analyzed.

Results:

Time to first pain was 311 minutes (range, 0 to 1605 minutes) and 20 minutes (range, 0 to 120 minutes) in the thoracic paravertebral block and general anesthesia groups, respectively (p < 0.001). Fentanyl requirement was 52.94 ± 11.94 µg and 115 ± 29.79 µg in the thoracic paravertebral block and general anesthesia groups, respectively (p < 0.001). Numeric rating scale scores were lower in the thoracic paravertebral block group through the first 2 postoperative hours (p < 0.001), and only two of 34 patients required tramadol in the postoperative care unit (p < 0.001). On postoperative day 1, both metamizole sodium (p < 0.001) and paracetamol (p = 0.018), and on day 2, only metamizole sodium (p < 0.001) consumption was lower in the thoracic paravertebral block group.

Conclusion:

Adding ultrasound-guided thoracic paravertebral blocks to general anesthesia postponed time to first pain and reduced analgesic consumption in patients undergoing bilateral reduction mammaplasty.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Evidence-Based Medicine: A Graded Approach to Lower Lid Blepharoplasty
Authors: Hashem Ahmed M. , Couto Rafael A. , Waltzman Joshua T. , Drake Richard L. , Zins James E.
Published: December 2016

Learning Objectives:

After studying this article, the participant should be able to: 1. Define the anatomy of the lower eyelid tarsoligamentous framework and the related periorbital retaining ligaments, and cite their surgical relevance. 2. Perform a systematic functional and aesthetic evaluation of the lower eyelid focusing on the lid-cheek junction, and clinical tests that predict the need for lateral canthal tightening. 3. Enumerate the different approaches to lower eyelid rejuvenation and discuss their merits/limitations. 4. Describe surgical strategies to blend the lid-cheek junction and tighten the lateral canthal retinaculum.

Modern lower lid blepharoplasty requires a thorough understanding of periorbital anatomy, age-related changes of the lid-cheek junction, and the variables controlling lower lid tone and position. The surgical strategies are best used in a graded fashion. The patient with isolated lower lid bags may be treated by transconjunctival fat resection alone. Additional mild skin laxity can be improved with skin pinch or skin-only undermining. Skin resurfacing using chemical peeling or laser can further address fine lines. In these patients with an abnormality of the lid-cheek junction, release of the medial orbicularis oculi muscle and variable amounts of the orbicularis retaining ligament is essential. This is combined with orbital fat resection or repositioning through a transconjunctival or transcutaneous skin-muscle flap. The transcutaneous approach most often necessitates lateral canthal tightening to optimize lid margin control. Generally, the degree of laxity dictates whether a canthopexy or a canthoplasty is most appropriate. Lateral canthal procedures can be applied to patients displaying clinical signs predictive of lid malposition and to those presenting with varying degrees of established lid descent.
Evidence-Based Medicine: Evaluation and Treatment of Zygoma Fractures
Authors: Birgfeld Craig B. , Mundinger Gerhard S. , Gruss Joseph S.
Published: December 2016

Learning Objectives:

After studying this article, the participant should be able to: 1. Diagnose zygomaticomaxillary complex fractures from physical examination and radiographic findings. 2. Plan the necessary surgical approaches for operative treatment of zygomaticomaxillary complex fractures depending on severity. 3. Understand the three-dimensional anatomy of the orbit and zygomaticomaxillary complex and the importance of the zygomaticosphenoid suture along the lateral orbital sidewall. 4. Be aware of pitfalls and associated fractures that can complicate anatomical reduction of zygomaticomaxillary complex fractures.

Fractures of the zygoma are some of the most commonly treated facial fractures, yet reconstruction of the three-dimensional structure of the zygomaticomaxillary complex can be challenging, and malunions are common. This article presents an evidence-based, systemic approach to the assessment and treatment of zygoma fractures from the simple to the complex. Anatomy, approaches, techniques, and pitfalls are described in an effort to improve the treatment of these common facial fractures.
Evidence-Based Medicine: Reduction Mammaplasty
Authors: Greco Richard , Noone Barrett
Published: December 2016

Learning Objectives:

After reading this article, the participant should be able to: 1. Understand the multiple reduction mammaplasty techniques available for patients and describe the advantages and disadvantages associated with each. 2. Describe the indications for the treatment of macromastia in patients younger than 18 years. 3. Identify the preoperative indications for breast imaging before surgery. 4. Describe the benefits of breast infiltration with local anesthesia with epinephrine before surgery. 5. Understand the use of deep venous thrombosis prophylaxis in breast reduction surgery. 6. Describe when the use of drains is indicated after breast reduction surgery.

The goal of this Continuing Medical Education module is to summarize key evidence-based data available to plastic surgeons to improve their care of patients with breast hypertrophy. The authors’ goal is to present the current controversies regarding their treatment and provide a discussion of the various options in their care. The article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification Program of the American Board of Plastic Surgery.
Pregnancy and the Plastic Surgery Resident
Authors: Garza Rebecca M. , Weston Jane S. , Furnas Heather J.
Published: December 2016

Background:

Combining pregnancy with plastic surgery residency has historically been difficult. Two decades ago, 36 percent of plastic surgery program directors surveyed actively discouraged pregnancy among residents, and 33 percent of women plastic surgeons suffered from infertility.
1
Most alarmingly, 26 percent of plastic surgery trainees had had an elective abortion during residency. With increasing numbers of women training in plastic surgery, this historical lack of support for pregnancy deserves further attention.

Methods:

To explore the current accommodations made for the pregnant plastic surgery resident, an electronic survey was sent to 88 plastic surgery program directors in the United States.

Results:

Fifty-four responded, for a response rate of 61.36 percent. On average, a director trained a total of 7.91 women among 17.28 residents trained over 8.19 years. Of the women residents, 1.43 were pregnant during a director’s tenure, with 1.35 of those residents taking maternity leave. An average 1.75 male residents took paternity leave. Approximately one-third of programs had a formal maternity/paternity leave policy (36.54 percent) which, in most cases, was limited to defining allowed weeks of leave, time required to fulfill program requirements, and remuneration during leave.

Conclusions:

This survey of plastic surgery directors is a first step in defining the challenges training programs face in supporting the pregnant resident. Directors provided comments describing their challenges accommodating an absent resident in a small program and complying with the American Board of Plastic Surgery’s required weeks of training per year. A discussion of these challenges is followed by suggested solutions.
Free Functioning Gracilis Muscle Transfer for Elbow Flexion Reconstruction after Traumatic Adult Brachial Pan-Plexus Injury: Where Is the Optimal Distal Tendon Attachment for Elbow Flexion?
Authors: Maldonado Andrés A. , Romero-Brufau Santiago , Kircher, R.N. Michelle F. , Spinner Robert J. , Bishop Allen T. , Shin Alexander Y.
Published: December 2016

Background:

Reconstruction after pan-plexus root avulsions often includes gracilis free functioning muscle transfer. For elbow flexion reconstruction, the free functioning muscle transfer distal tendon is inserted into the biceps tendon or more distally (i.e., flexor digitorum profundus/flexor pollicis longus tendons) for combined elbow and finger flexion; the theoretical drawback of the latter approach is weaker elbow flexion. The authors compared elbow flexion strength with a biceps tendon versus a flexor digitorum profundus/flexor pollicis longus tendon attachment to determine which insertion point resulted in better elbow flexion.

Methods:

Thirty-nine patients underwent free functioning muscle transfer with either a biceps tendon or a distal attachment. Groups were compared on postoperative elbow flexion strength, preoperative and postoperative Disabilities of the Arm, Shoulder, and Hand questionnaire scores, range of motion, and other surgical and demographic characteristics. A biomechanical analysis simulating different tendon attachments determined which reconstruction resulted in optimal elbow flexion mechanics.

Results:

Distal tendon attachment was associated with M3 or M4 elbow flexion and greater range of motion compared with the biceps tendon attachment (p < 0.05). There were no statistically significant improvements in Disabilities of the Arm, Shoulder, and Hand questionnaire scores. Biomechanical analysis demonstrated that all distal tendon attachments studied generated a 15 to 30 percent greater torque compared with the biceps tendon attachment; this was true for attachments either at the flexor digitorum profundus/flexor pollicis longus tendon, or directly at the radius at 10 cm or 15 cm from the elbow axis of rotation.

Conclusions:

The flexor digitorum profundus/flexor pollicis longus tendon attachment of the gracilis free functioning muscle transfer distal tendon was superior in achieving elbow flexion strength. Patients with only elbow flexion reconstruction may also benefit from a flexor digitorum profundus/flexor pollicis longus tendon attachment or from a more distal attachment to the radius.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Gastrostomy Placement Rates in Infants with Pierre Robin Sequence: A Comparison of Tongue-Lip Adhesion and Mandibular Distraction Osteogenesis
Authors: Susarla Srinivas M. , Mundinger Gerhard S. , Chang Christopher C. , Swanson Edward W. , Lough Denver , Rottgers S. Alex , Redett Richard J. , Kumar Anand R.
Published: December 2016

Background:

This study was conducted to compare the gastrostomy rates in infants with Pierre Robin sequence treated with tongue-lip adhesion or mandibular distraction osteogenesis.

Methods:

This was a retrospective study of symptomatic plastic and reconstructive surgery patients treated over an 8-year period. The primary predictor variable was surgical intervention (tongue-lip adhesion or distraction osteogenesis). Secondary predictor variables were categorized as demographic and clinical factors. The primary outcome was the need for gastrostomy tube placement. Secondary outcomes were complication rates, costs, and length of stay.

Results:

Thirty-one tongue-lip adhesion and 30 distraction osteogenesis patients were included in the study. The groups were statistically comparable with regard to demographic and clinical factors (p > 0.18). Gastrostomy rates were higher in patients who underwent tongue-lip adhesion (48 percent) versus those who underwent distraction osteogenesis (16.7 percent; p = 0.008). In an adjusted model, subjects undergoing tongue-lip adhesion were more likely to require gastrostomy tube for nutritional support (OR, 6.5; 95 percent CI, 1.7 to 25.2; p = 0.007). There were two major complications in the tongue-lip adhesion group and none in the distraction osteogenesis group. There were three minor complications in the tongue-lip adhesion group and five in the distraction osteogenesis group. Total operating room costs were higher for distraction osteogenesis (p = 0.05), and total hospital costs and length of stay were higher for tongue-lip adhesion (p < 0.05).

Conclusions:

Among infants with symptomatic Pierre Robin sequence, treatment by distraction osteogenesis is associated with a lower risk for gastrostomy placement for nutritional support. Hospital costs are higher for tongue-lip adhesion.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Very Low Prevalence of Intracranial Hypertension in Trigonocephaly
Authors: Cornelissen Martijn J. , Loudon Sjoukje E. , van Doorn Frida E. C. , Muller Rogier P. M. , van Veelen Marie-Lise C. , Mathijssen Irene M. J.
Published: December 2016

Background:

Trigonocephaly is caused by metopic suture synostosis. It is treated by fronto-orbital remodeling, not only to correct the deformity but also to prevent intracranial hypertension, the reported prevalence in trigonocephaly of which ranges from 0 to 33 percent. To support treatment analysis and the design of a treatment protocol for intracranial hypertension in these patients, the authors wished to more accurately quantify the prevalence of preoperative and postoperative intracranial hypertension in a large patient cohort.

Methods:

The authors included all trigonocephaly patients born between 2001 and 2013 who had all been operated on at a single center. During follow-up, the presence of intracranial hypertension was evaluated by funduscopy, and occipitofrontal head circumference was measured. The occipitofrontal head circumference curve was analyzed and its relation to intracranial hypertension assessed.

Results:

In total, 262 patients with trigonocephaly were included. Before surgery, 1.9 percent of them had intracranial hypertension; after surgery, 1.5 percent did (mean age at last follow-up, 4.9 years). Sixteen of 176 patients (9 percent) had occipitofrontal head circumference curve stagnation, which was significantly related to intracranial hypertension (p = 0.001, Fisher’s exact test).

Conclusions:

Intracranial hypertension occurs only sporadically in patients with metopic suture synostosis. Occipitofrontal head circumference measurement should take a prominent place in the postoperative follow-up of metopic suture synostosis patients; stagnation of the occipitofrontal head circumference requires additional screening for intracranial hypertension.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Selective Nerve Root Transection in the Rat Produces Permanent, Partial Nerve Injury Models with Variable Levels of Functional Deficit
Authors: Poppler Louis H. , Schellhardt Lauren M. , Hunter Daniel A. , Yan Ying , Mackinnon Susan E. , Wood Matthew D. , Moore Amy M.
Published: December 2016

Background:

The goal of this study was to develop a partial, nonregenerative nerve injury model in a rat that results in permanently reduced motoneuron numbers and function. This model could serve as a platform for the study of therapeutics, such as a reverse end-to-side nerve transfer (i.e., supercharge). The authors hypothesized that transection of one or more of the L4 to L6 nerve roots supplying the sciatic nerve would cause a permanent reduction in muscle force.

Methods:

Rats were randomized into five groups that underwent variations of nerve root transections or sham injury. The L4 to L6 nerve roots were selectively transected and capped to prevent regeneration. Tibial and common peroneal nerves were harvested for quantitative histology and retrograde-labeled to assess the number of motoneurons projecting axons. Muscle force and relative muscle mass were assessed as metrics of postinjury motor function.

Results:

At 6 months, the number of motoneurons projecting axons and myelinated axon counts were reduced in both the tibial and common peroneal nerves after injury in all groups. Transecting both L4 and L5 or both L4 and L6 reduced motoneuron numbers sufficiently below sham numbers to reduce muscle force and mass in major muscles of the hindlimb innervated by both nerves. Transecting L4 reduced muscle force and mass in common peroneal–innervated muscles, whereas transecting L5 reduced muscle force and mass in tibial-innervated muscles. These findings were stable over time.

Conclusion:

Transection of nerve roots produces stable (time-independent) partial nerve injury models with a selective decrease in motor function.
Intranasal Pathology in the Migraine Surgery Population: Incidence, Patterns, and Predictors of Surgical Success
Authors: Lee Michelle , Erickson Cameron , Guyuron Bahman
Published: December 2016

Background:

The purpose of this study was to identify patterns of nasal pathology in patients with rhinogenic migraine headaches (site III).

Methods:

A retrospective review was performed on patients with rhinogenic migraine headaches. Demographics, pre– and post–migraine surgery symptoms, and pathology seen on preoperative computed tomographic scans were reviewed.

Results:

Twenty percent of 98 patients had preoperative sinus disease. The following abnormalities were seen on computed tomographic scan: septal deviation, 75 (77 percent); septal spur, 33 (34 percent); middle concha bullosa, 48 (49 percent); sinus pathology, 20 (20 percent); and intranasal contact points, 62 (62 percent). A higher incidence of clinical sinusitis (20 percent migraine versus 5 to 15 percent in the general population) was also seen. Septoplasty was performed in 89 percent of patients, and conservative turbinectomy was performed in 60 percent of patients. Patients who failed surgery (<50 percent reduction in migraine headache index) had a significantly higher incidence of contact points (80 percent versus 56 percent; p = 0.034) than successful migraine patients. The surgery success group also had a higher incidence of preoperative middle concha bullosa compared with the failure group (71 percent versus 48 percent; p = 0.035).

Conclusions:

This is the first cohort study to identify the incidence and pattern of nasal pathology in migraine III patients. It is likely that the failure to achieve more successful outcomes in this patient population was the consequence of conservative nasal management and residual contact points because of concern for the development of nasal dryness. More frequent middle turbinate surgery may result in better clinical outcomes in this group of patients.
Comparing Round and Anatomically Shaped Implants in Augmentation Mammaplasty: The Experts’ Ability to Differentiate the Type of Implant
Authors: Rubi Carlos G. , Lozano Jose Angel , Pérez-Espadero Alberto , Leache M. Elena
Published: December 2016

Background:

The purpose of this study was to determine whether the aesthetic results of subpectoral augmentation mammaplasty using anatomically shaped versus round prostheses are differentiable.

Methods:

Thirty observers (i.e., plastic surgeons and nurses) assessed preoperative and postoperative photographs (frontal and oblique views) of 30 patients who had undergone subpectoral augmentation mammaplasty with cohesive silicone gel implants, with an average implant volume of 295 cc (range, 220 to 340 cc). The observers classified each case as round or shaped on two different occasions with a 12-week time interval. A statistical concordance analysis was performed, calculating the overall concordance rate, the interobserver, the intraobserver, and the overall intraobserver kappa indexes, to evaluate the expert observers’ capacity to differentiate the implant type.

Results:

Among the total of 1800 observations (30 observers assessed 30 cases on two occasions), the overall concordance rate was 50.33 percent (95 percent CI, 47.99 to 52.67). The interobserver kappa value was 0.010 (95 percent CI, 0.0025 to 0.04). The overall intraobserver kappa value was 0.0602 (95 percent CI, 0.0025 to 0.123). The observers were unable to recognize the type of implant used, nor was interobserver concordance noted. An agreement was not reached before the different observers, nor was an intraobserver concordance seen between the first and second classifications of the same cases by each observer.

Conclusion:

The results obtained from subpectoral augmentation mammaplasty using anatomically shaped and round prostheses with a volume of 340 cc or less are indistinguishable, not justifying the systematic use of anatomically shaped implants in this patient.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Microporous Polysaccharide Hemospheres Potentiate Ischemia-Induced Skin Flap Necrosis in a Murine Model
Authors: Offodile Anaeze C. , Chen Bin , Aherrera Andrew S. , Guo Lifei
Published: December 2016

Background:

Microporous polysaccharide hemospheres are an increasingly used adjunctive measure for obtaining operative field hemostasis. However, the impact of these agents on survival of vascularly challenged tissues is unknown. The aim of this study was to investigate the effect, if any, of microporous hemospheres on tissue survival in a murine model.

Methods:

Eighteen Sprague-Dawley rats underwent creation of two flanking dorsal, modified McFarlane-style flaps using a length-to-width ratio of 4:1. Microporous polysaccharide hemospheres were applied to the underside of only one flap in each animal. In a subset of five rats, tissue malondialdehyde activity was measured at 24 hours. The remaining 13 animals were killed after 7 days, and the area of flap necrosis was measured photographically. Histopathologic analysis was also performed on the margins of the necrotic area.

Results:

Size comparison showed a significantly larger area of necrosis in the microporous polysaccharide hemosphere–treated flaps relative to controls (1.69 ± 1.21 cm2 versus 0.28 ± 0.28 cm2; p = 0.00135). Higher malondialdehyde levels were also found in the microporous polysaccharide hemosphere–treated flaps at 24 hours (0.462 ± 0.098 versus 0.315 ± 0.065; p = 0.047). The areas of skin necrosis were noted to be partial thickness on histologic examination.

Conclusions:

Microporous polysaccharide hemospheres are associated with an increased incidence of distal tip necrosis in dorsal rat skin flaps. Despite their efficacy in surgical hemostasis, their use should be judicious, especially with marginally perfused tissues such as mastectomy skin flaps.
Important Developments in Burn Care
Authors: Zuo Kevin J. , Medina Abelardo , Tredget Edward E.
Published: December 2016

Learning Objectives:

After studying this article, the participant should be able to: 1. Explain the epidemiology of severe burn injury in the context of socioeconomic status, gender, age, and burn cause. 2. Describe challenges with burn depth evaluation and novel methods of adjunctive assessment. 3. Summarize the survival and functional outcomes of severe burn injury. 4. State strategies of fluid resuscitation, endpoints to guide fluid titration, and sequelae of overresuscitation. 5. Recognize preventative measures of sepsis. 6. Explain intraoperative strategies to improve patient outcomes, including hemostasis, restrictive transfusion, temperature regulation, skin substitutes, and Meek skin grafting. 7. Translate updates in the pathophysiology of hypertrophic scarring into novel methods of clinical management. 8. Discuss the potential role of free tissue transfer in primary and secondary burn reconstruction.

Management of burn-injured patients is a challenging and unique field for plastic surgeons. Significant advances over the past decade have occurred in resuscitation, burn wound management, sepsis, and reconstruction that have improved outcomes and quality of life after thermal injury. However, as patients with larger burns are resuscitated, an increased risk of nosocomial infections, sepsis, compartment syndromes, and venous thromboembolic phenomena have required adjustments in care to maintain quality of life after injury. This article outlines a number of recent developments in burn care that illustrate the evolution of the field to assist plastic surgeons involved in burn care.
Optimizing Outcomes in Pharyngoesophageal Reconstruction and Neck Resurfacing: 10-Year Experience of 294 Cases
Authors: Sharaf Basel , Xue Amy , Solari Mario G. , Boa Olivier , Liu Jun , Hanasono Matthew M. , Skoracki Roman , Yu Peirong , Selber Jesse C.
Published: December 2016

Background:

Pharyngoesophageal reconstruction is a complex endeavor that poses many challenges. This 10-year series examines factors impacting the need for neck skin resurfacing and evaluates the impact of reconstructive modalities on outcomes.

Methods:

A review identified 294 patients who underwent pharyngoesophageal reconstruction from 2002 to 2012. Patients were divided based on neck skin resurfacing requirements. Patients undergoing neck resurfacing were further subdivided into reconstructive technique, including a second skin paddle or muscle component from the same free flap pedicle, a local flap, or a second free flap. All groups were compared by comorbidities, complications, and functional outcomes.

Results:

Of 294 patients, 179 (60.9 percent) required neck skin resurfacing. In the resurfaced group, there were 90 circumferential defects (50.3 percent) and 89 partial defects (49.7 percent). In the resurfaced group, 110 (61.4 percent) underwent reconstruction with a second skin paddle from the same free flap pedicle, 21 (11.7 percent) underwent reconstruction with a muscle component from the same pedicle, and 25 (13.9 percent) received a pectoralis major flap. There were five external paddle flap losses in the resurfaced group (2.8 percent) and no internal flap losses. Overall complications were similar among groups. The resurfaced group had a lower pharyngocutaneous fistula rate (4.5 percent) compared with the primary closure group (11.3 percent) (p = 0.026). Prior neck surgery and radiation therapy were strong predictors of neck skin resurfacing (p < 0.001).

Conclusions:

Neck resurfacing is often required in salvage pharyngoesophageal reconstruction. Providing additional vascularized tissue over the neoconduit is predictive of lower pharyngocutaneous fistula rates. An algorithmic approach to neck resurfacing is presented.