bluuebunny/crossref_metadata_2025 huggingface dataset:
Children With Behçet Disease–associated Thrombosis: A Single-Center Experience
Authors: Guzelkucuk Zeliha , Gurlek Gokcebay Dilek , Arman Bilir Ozlem , Basaran Ozge , Celikel Acar Banu , Ozbek Namik Y. , Yarali Nese
Published: June 2020

Behçet disease (BD) is a systemic vasculitis that can be complicated with thrombosis, which is an important cause of mortality and morbidity. The course of BD is more severe, and the diagnosis is usually delayed. In children, thrombosis associated with BD is very rare. In this study, we aimed to evaluate the characteristics of children with BD complicated with thrombosis. Forty-six patients with BD who were followed-up at a pediatric rheumatology department between January 2012 and September 2019 were evaluated retrospectively. Thrombosis was detected in 10 patients (21.7%), and it was the first sign of BD in 7 patients. Four patients had cerebral sinus venous thrombosis, 4 patients had deep-vein thrombosis, 1 patient had renal vein thrombosis, 1 had pulmonary artery thrombosis, and 1 had intracardiac thrombosis. None of the patients had arterial thrombosis. All patients had received anticoagulant therapy with immunosuppressive treatment. Any complication due to anticoagulant therapy was not detected. One patient had recurrent thrombosis, and none of the patients died during follow-up. Vasculitic diseases such as BD may cause a predisposition to thrombosis, and thrombosis might be the first sign of BD. Therefore, in children presenting with unprovoked thrombosis, BD should also be investigated.
Outcomes and Disposition of Oncology Patients With Non-neutropenic Fever and Positive Blood Cultures
Authors: Sharma Aditya , Sitthi-Amorn Jitsuda , Gavigan Patrick , Wolf Joshua , Agulnik Asya , Brenner Alex , Li Ying , Johnson Liza-Marie
Published: June 2020

Children with cancer and non-neutropenic fever (NNF) episodes are often treated as outpatients if they appear well. However, a small subset have bloodstream infections (BSIs) and must return for further evaluation. These patients may be directly admitted to inpatient units, whereas others are first evaluated in outpatient settings before admission. The best practice for securing care for patients discovered to have outpatient bacteremia are unclear. To determine outcomes and compare time to antibiotics between the 2 disposition, we retrospectively reviewed all NNF initially treated as outpatients and later had positive blood cultures from 2012 to 2016. Of 845 NNF cases initially treated in outpatient settings, 48 episodes (n=43 patients) had BSIs. Of those, 77.1% (n=37) were re-evaluated as outpatients and admitted; 14.6% (n=7) were direct admissions. The median time to antibiotic did not significantly differ between outpatient re-evaluations (119 min) and direct admissions (191 min), P=0.11. One patient met sepsis criteria upon return and required intensive care unit admission for vasopressor support. No patient died within 1 week of the febrile episode. Most patients with NNF and BSIs initially discharged are stable upon return. Institutions should evaluate their patient flows to ensure that patients receive timely care.
Stories of Lymphoma Survivors in Early Aftercare
Authors: Friesen-Storms Jolanda H. H. M. , Bours Gerrie J. J. W. , Quadvlieg-Delnoy Danny J. L. , Moser Albine , Heijmans José M. J. , van der Weijden Trudy , Beurskens Anna J. H. M. , Jie Kon-Siong G.
Published: June 2020

Background

Survivors of lymphoma experience multiple challenges after treatment. However, a lack of knowledge of in-depth experiences of lymphoma survivors in early aftercare persists.

Objective

To gain an in-depth understanding of the experiences of lymphoma survivors in early aftercare who have received an aftercare consultation based on evidence-based guideline recommendations, with an advanced practice nurse.

Methods

This study used a narrative design. We recruited lymphoma survivors after a best-practice aftercare consultation with an advanced practice nurse. A total of 22 lymphoma survivors and 9 partners participated. Data were collected through narrative interviews and analyzed according to thematic narrative analysis.

Results

Six themes emerged: living and dealing with health consequences, coping with work and financial challenges, having a positive outlook and dealing with uncertainty, deriving strength from and experiencing tensions in relationships, getting through tough times in life, and receiving support from healthcare professionals.

Conclusions

The stories of lymphoma survivors in early aftercare revealed their experiences of how they coped with a range of challenges in their personal lives. Choosing an aftercare trajectory based on an aftercare consultation that encourages patients to think about their issues, goals, and possible aftercare options may be useful for their transition from treatment to survivorship.

Implications for practice

Survivors’ social support and self-management capabilities are important aspects to be addressed in cancer care. An aftercare consultation involving shared goal setting and care planning may help nurses provide personalized aftercare.
Aberrant Cytoplasmic Terminal Deoxynucleotidyl Transferase (TdT) Immunostaining on Previously Frozen, Formalin-fixed Paraffin-embedded Tissue: Cryotomy-induced Antigen Diffusion (CIAD)
Authors: Henwood Anthony F.
Published: June 2020

Terminal deoxynucleotidyl transferase (TdT) has been localized in both the nuclear and cytoplasmic compartments of lymphoblastic lymphomas when such tumors have been frozen for cryotomy and subsequently, formalin fixed and processed to paraffin. This cryotomy-induced antigen diffusion (CIAD) occurs with several different sources of anti-TdT antisera and was not observed in nonlymphoblastic tumors. CIAD was also not observed with other nuclear antigens including BRG1, Pax5, Ki67, BCL6, INI-1, myogenin, MyoD1, and Phox2B. TdT CIAD seems to be specific for lymphoblastic lymphomas. CIAD is another preanalytical artifact that needs to be considered in immunohistochemistry.
Ki67 Immunohistochemistry Quantification in Breast Carcinoma: A Comparison of Visual Estimation, Counting, and ImmunoRatio
Authors: van den Berg Eunice J. , Duarte Raquel , Dickens Caroline , Joffe Maureen , Mohanlal Reena
Published: June 2020

Background:

Molecular analysis has shown that breast carcinomas can be classified into several intrinsic subtypes, with implications for management and prognosis. In the majority of pathology laboratories molecular analysis of each case is not possible and immunohistochemistry is used for subtyping. This includes analysis of hormone receptors as well as HER2-neu and Ki67. The methodology for the interpretation of the proliferation index using Ki67 remains an area of uncertainty. We investigated the degree of agreement between different methods of Ki67 interpretation.

Materials and Methods:

We analyzed 204 breast core biopsies diagnostic of breast carcinoma using visual estimation/eyeballing (EB), ImmunoRatio, and counting by 2 pathologists (CP1 and CP2). The correlation between the different methods and the interobserver agreement between the 2 pathologists was assessed. Specific analysis was also done with respect to classification of cases into low Ki67 groups (using Ki67 values<14% and <20%) since this is critical in classifying tumors into luminal A and luminal B subtypes.

Results:

Correlation between the different methods was best achieved comparing ImmunoRatio and CP1, and worst comparing CP1 and EB. Correlation was better when considering interobserver variability (CP1 vs. CP2). Comparing the number of cases classified as low Ki67 (<14% and <20%) the Cohen κ statistic varied from κ=0.267 to 0.814 with different methods. When limiting the analysis to cases with a Ki67 of 10% to 25% according to any method, there was greater disagreement.

Conclusions:

At the higher and lower Ki67 levels, the correlation between the methods of assessment was acceptable, however, at levels close to the cut-off values for lumial A versus luminal B, several patients would be differently classified by the different methods and therefore potentially receive suboptimal management.
Chromogranin A Expression in Rectal Neuroendocrine Tumors Is Associated With More Aggressive Clinical Behavior and a Poorer Prognosis
Authors: Kim Jisup , Kim Joo Young , Oh Eun Hye , Yoo Changhoon , Park In Ja , Yang Dong-Hoon , Ryoo Baek-Yeol , Ryu Jin-Sook , Hong Seung-Mo
Published: June 2020

Although rectal neuroendocrine tumors (NETs) with an L-cell phenotype and small size are generally less clinically serious, the new 2019 World Health Organization (WHO) classification system has categorized all of these lesions as malignant. Identifying biomarkers of rectal NETs is thus important for stratifying their clinical behavior. Chromogranin A protein expression was assessed in 538 endoscopically or surgically resected rectal NETs and compared with clinicopathologic factors to identify its clinical and prognostic significance. All of the rectal NETs analyzed (100%) were synaptophysin positive, but chromogranin A labeling was only detected in 111 cases (20.6%). Chromogranin A expression in the rectal NETs was more commonly associated with older age (50 y and older; P=0.013), male sex (P=0.002), radical resection (P=0.003), large tumor size (≥1 cm; P=0.038), muscularis propria invasion (P=0.002), lymphovascular (P=0.014) and perineural (P<0.001) invasion, an involved resection margin (P=0.028), and lymph node metastasis (P=0.003). Patients with chromogranin A expression had higher plasma chromogranin A levels (P=0.023) than those without chromogranin A expression during follow-up. The 10-year disease-free survival rate in rectal NET patients with chromogranin A expression (91.5%) was significantly shorter than the negative cases (99.7%) by both univariate (hazard ratio=14.438; 95% confidence interval: 2.911-71.598; P<0.001) and multivariate (hazard ratio=12.099; 95% confidence interval, 2.044-71.608; P=0.006) analyses. In summary, rectal NETs that are positive for chromogranin A are less common than those with synaptophysin expression and show more aggressive clinical behavior. Chromogranin A is therefore a prognostic indicator of higher recurrence risk in patients with endoscopically or surgically resected rectal NETs.
Efficiency in DIEP Flap Breast Reconstruction: The Real Benefit of Computed Tomographic Angiography Imaging
Authors: Haddock Nicholas T. , Dumestre Danielle O. , Teotia Sumeet S.
Published: June 2020

Background:

In deep inferior epigastric perforator (DIEP) flap breast reconstruction, many surgeons use preoperative imaging for perforator mapping as a method to plan the operation, reduce operative times, and potentially limit morbidity. This study compared operative times for specific portions of DIEP flap harvest with and without preoperative computed tomographic angiography imaging.

Methods:

Two patient groups undergoing DIEP flap breast reconstruction were studied prospectively. In the experimental group, the harvesting surgeon was blinded to the preoperative computed tomographic angiography scan; in the control group, the harvesting surgeon assessed the scan preoperatively. Times for initial perforator identification, perforator selection, flap harvest time, and total procedure times were compared. Perforator choice was evaluated. Correlation of perforator choice preoperatively and intraoperatively was also performed.

Results:

Times were recorded in 60 DIEP flaps (27 blinded and 33 unblinded). The nonblinded group was more efficient in all categories: time to first perforator identification (28.6 minutes versus 17.8 minutes; p < 0.0001), time to perforator decision-making (23.1 minutes versus 5.6 minutes; p < 0.0001), time to flap harvest (128 minutes versus 80 minutes; p < 0.0001), and total operative time (417 minutes versus 353 minutes; p < 0.001). Perforator location was not different between groups. Blinded intraoperative decisions correlated with preoperative imaging in 74 percent of flaps. More perforators were included in the blinded flaps compared to the nonblinded flaps (2.3 versus 1.4; p < 0.001).

Conclusions:

Use of preoperative computed tomographic angiography leads to decreased operative times, specifically with regard to perforator identification and perforator selection. Without preoperative computed tomographic angiography, surgeons included more perforators in the flaps.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, II.
Radiographic Comparison of Superior and Inferior Gluteal Vessels in Jackknife versus Prone Position: A Prospective, Self-Controlled Trial
Authors: Barnes Connor W. , Ford Jonathan M. , Harrington Michael A. , Kedar Rajendra P. , Tran Thanh Q. , Karlnoski Rachel A. , Decker Summer J. , Smith David J.
Published: June 2020

Mortality after gluteal augmentation with fat transfer techniques is extremely high. Placement of fat subcutaneously versus in the gluteal musculature, or both, is considerably debated. The purpose of this study was to radiographically show the anatomical difference in live subjects in different procedural positions: the flexed or “jackknife” versus prone position. A total of 10 women underwent computed tomographic scanning of the pelvis with venous phase run-off in both the jackknife and prone positions. A computed tomography–specialized radiologist then reviewed images and measured distances from the inferior and superior gluteal veins to the skin and muscle. Three-dimensional imaging and analysis were also performed. Measurements were significantly shorter with respect to distance from skin to muscle, skin to vessel, and vessel to muscle observed from inferior and superior gluteal veins in the jackknife versus the prone position. Three-dimensional modeling showed a significant reduction in the volume and inferior and superior gluteal vein diameters when in the jackknife position. When placed in the jackknife position for gluteal augmentation with fat transfer, extreme caution should be taken with the injecting cannula, as the underlying muscle is only 2 to 3 cm deep. Three-dimensional analysis showed narrowed and reduced volume of gluteal vasculature when in the jackknife position; this is a possible indication of torsion or stretch on the vessel around the pelvic rim that could cause vein avulsion injury from the pressurized fat within the piriform space.
Facial Asymmetry in Unilateral Condylar Hyperplasia: Comparing Treatment for Active versus Burnt-Out Disease
Authors: Maniskas Seija , Ly Catherine L. , Parsaei Yassmin , Bruckman Karl C. , Steinbacher Derek M.
Published: June 2020

Background:

Facial asymmetry caused by unilateral condylar hyperplasia requires treatment to address facial and occlusal imbalances. There is no definitive evidence to suggest that a single intervention strategy (during either active condylar overgrowth or the burnt-out phase) results in better/more symmetric correction. This study sought to quantify preoperative and postoperative facial asymmetry in unilateral condylar hyperplasia patients comparing treatment for active versus burnt-out disease.

Methods:

Preoperative and postoperative three-dimensional photographs were obtained. Images were compared to those of unaffected controls as a standard for normal facial symmetry. Facial asymmetry was assessed using root-mean-square deviation. Pairedttests were performed to compare the root-mean-square deviations of preoperative and postoperative images between the unilateral condylar hyperplasia groups and against controls.

Results:

Forty patients were included (11 active, nine burnt-out, and 20 controls) and 60 three-dimensional images were evaluated. Preoperatively, patients in the burnt-out group had worse asymmetry than those with active unilateral condylar hyperplasia (p= 0.011). Both groups demonstrated significantly improved symmetry postoperatively (active,p= 0.0069; burnt-out,p= 1.74E-4). However, burnt-out patients remained with some residual asymmetry (p= 4.75E-4), whereas their active counterparts showed no significant difference compared to unaffected controls (p= 0.089).

Conclusions:

Patients with end-stage unilateral condylar hyperplasia have more severe facial asymmetry that is more difficult to normalize compared to earlier intervention during active unilateral condylar hyperplasia. These findings suggest that, if possible, corrective intervention is preferable during active unilateral condylar hyperplasia.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, II.
Litigation in Hand Surgery: A 30-Year Review
Authors: Sasor Sarah E. , Chung Kevin C.
Published: June 2020

Background:

Although hand surgery is generally safe and effective, some patients experience complications or poor outcomes prompting them to seek compensation. This study reviews malpractice claims in hand surgery using a national data set to assess reasons for litigation and identify predictors of outcome.

Methods:

The Westlaw database was queried for cases related to hand surgery and medical malpractice between 1989 and 2018. Jury verdicts and settlements were reviewed for relevance, and variables including plaintiff and defendant demographics, diagnosis, alleged reason for malpractice, verdicts, and payouts were recorded.

Results:

Four hundred thirty relevant claims were identified. Distal radius fractures (21 percent), carpal tunnel syndrome (14 percent), and tendon lacerations (6 percent) were the most common diagnoses. Alleged reasons for malpractice included failure to diagnose/treat (34 percent), surgical negligence (29 percent), and improper procedure/treatment (19 percent). Thirty-six cases (8 percent) resolved in settlement for a mean payout of $551,957. A plaintiff verdict was reached in 98 cases (25 percent of trials), with a mean payout of $832,258. The remaining 296 cases (75 percent of trials) resulted in defendant verdicts (no payout). Plaintiff age, plaintiff sex, defendant sex, and defendant degree had no impact on trial outcome. Cases involving surgeons without subspecialty certification in hand surgery were significantly more likely to result in plaintiff verdicts (27 percent versus 7 percent with hand subspecialization; p = 0.003).

Conclusions:

This study reviews malpractice claims in hand surgery over the past 30 years. Providing timely diagnoses, managing expectations, and reducing procedural error may decrease the risk of litigation.
Free Lateral Forearm Flap in Head and Neck Reconstruction: An Attractive Alternative to the Radial Forearm Flap
Authors: Shuck John , Chang Edward I. , Mericli Alexander F. , Gross Neil D. , Hanasono Matthew M. , Garvey Patrick B. , Yu Peirong , Largo Rene D.
Published: June 2020

The lateral forearm flap—a thin, fasciocutaneous flap harvested over the lateral epicondyle based on the terminal anterior branch of the posterior radial collateral artery—is an attractive alternative to the radial forearm flap. The authors hypothesized that it is safe and effective for head and neck reconstruction. They conducted a retrospective review of all lateral forearm flap reconstructions performed between 2016 and 2018. Patient demographics, defect characteristics, adjuvant therapies, and postoperative complications were recorded. Swallowing and diet were assessed in patients undergoing intraoral reconstruction. The Disabilities of the Arm, Shoulder and Hand questionnaire was completed prospectively preoperatively and postoperatively. Flap and pedicle dimensions were recorded. Twenty-five lateral forearm flap reconstructions were performed; 23 were for intraoral defects. There were no partial or complete flap losses, one venous thrombosis, and one hematoma requiring reoperation. Preoperative and postoperative Disabilities of the Arm, Shoulder and Hand questionnaire scores were equivalent (p = 0.78). In the intraoral cohort, 22 patients (96 percent) resumed an oral diet following reconstruction. The average pedicle length was 11.8 cm (range, 9 to 16 cm); skin paddle length and width were 6.6 cm (range, 4 to 12 cm) and 4.7 cm (range, 4 to 12 cm), respectively; arterial diameter was 1.5 mm (range, 1.4 to 2.5 mm); and venous diameter was 2.8 mm (range, 2.4 to 3.6 mm). All donor sites were closed primarily; one superficial dehiscence was reported. In summary, the authors found that the free lateral forearm flap provided an excellent alternative to the radial forearm flap in head and neck reconstruction. It is a thin, pliable fasciocutaneous flap with excellent pedicle length, and the donor site can be closed primarily with minimal morbidity.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Supercharge End-to-Side Anterior Interosseous–to–Ulnar Motor Nerve Transfer Restores Intrinsic Function in Cubital Tunnel Syndrome
Authors: Dengler Jana , Dolen Utku , Patterson Jennifer M. M. , Davidge Kristen M. , Kahn Lorna C. , Yee Andrew , Mackinnon Susan E.
Published: June 2020

Background:

The supercharge end-to-side anterior interosseous nerve–to–ulnar motor nerve transfer offers a viable option to enhance recovery of intrinsic function following ulnar nerve injury. However, in the setting of chronic ulnar nerve compression where the timing of onset of axonal loss is unclear, there is a deficit in the literature on outcomes after supercharge end-to-side anterior interosseous nerve–to–ulnar motor nerve transfer.

Methods:

A retrospective study of patients who underwent supercharge end-to-side anterior interosseous nerve–to–ulnar motor nerve transfer for severe cubital tunnel syndrome over a 5-year period was performed. The primary outcomes were improvement in first dorsal interosseous Medical Research Council grade at final follow-up and time to reinnervation. Change in key pinch strength; grip strength; and Disabilities of the Arm, Shoulder and Hand questionnaire scores were also evaluated using paired t tests and Wilcoxon signed rank tests.

Results:

Forty-two patients with severe cubital tunnel syndrome were included in this study. Other than age, there were no significant clinical or diagnostic variables that were predictive of failure. There was no threshold of compound muscle action potential amplitude below which supercharge end-to-side anterior interosseous nerve–to–ulnar motor nerve transfer was unsuccessful.

Conclusions:

This study provides the first cohort of outcomes following supercharge end-to-side anterior interosseous nerve–to–ulnar motor nerve transfer in chronic ulnar compression neuropathy alone and underscores the importance of appropriate patient selection. Prospective cohort studies and randomized controlled trials with standardized outcome measures are required.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
The Central Mound Pedicle: A Safe and Effective Technique for Reduction Mammaplasty
Authors: DeLong Michael R. , Chang Irene , Farajzadeh Matt , Nahabet Edward H. , Roostaeian Jason , Festekjian Jaco , Rough James , Da Lio Andrew L.
Published: June 2020

Background:

The central mound technique offers a relatively less common approach for breast reduction. This study evaluated the expected safety and efficacy outcomes using this technique in a large patient series.

Methods:

A retrospective review of all patients undergoing central mound breast reduction at the authors’ institution between June of 1999 and November of 2018 was performed. Both bilateral macromastia and unilateral symmetrizing reduction patients were included but evaluated separately for some outcomes. Patient demographics and comorbidities, operative details, postoperative adverse events, and BREAST-Q scores were recorded. Associations between preoperative variables and outcomes were assessed with chi-square tests, Wilcoxon tests, and Kendall tau-b correlations.

Results:

A total of 325 patients were identified for inclusion (227 bilateral and 98 unilateral; 552 breasts). The average patient age was 46 years, and the average body mass index was 27.4 kg/m2. Among the bilateral macromastia patients, the average operative time was 3 hours 34 minutes, and average breast tissue removed was 533 g (right breast) and 560 g (left breast). Among all patients, average follow-up was 169 days. On a per-breast basis for all patients, the following complication rates were observed: seroma, 0.2 percent; hematoma, 1.1 percent; dehiscence, 2.9 percent; infection, 1.5 percent; hypertrophic scar, 4.6 percent; nipple necrosis, 0.4 percent; fat necrosis, 0.9 percent; and skin flap necrosis, 1.7 percent. Using the BREAST-Q Reduction/Mastopexy questions on a Likert scale ranging from 1 to 5, restricted to the bilateral macromastia patient population, all scores improved with statistical significance.

Conclusion:

The central mound pedicle is a safe and effective approach for reduction mammaplasty for both bilateral macromastia patients and unilateral symmetrizing operations.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Lipoabdominoplasty with Anatomical Definition
Authors: Saldanha Osvaldo , Ordenes Andrés I. , Goyeneche Carlos , Cánchica Andrés F. , Saldanha Filho Osvaldo , Bonetto Saldanha Cristianna , Menegazzo Marcos Ricardo , Gonzalez Cação Eugênio
Published: June 2020

Background:

In the past two decades, lipoabdominoplasty has increased in popularity worldwide, presenting low rates of complications and morbidity when the proper surgical steps are followed. The authors present an update of the lipoabdominoplasty technique with the addition of an abdominal definition and standardized steps for its safe execution, an initial personal experience with the procedure that improves the aesthetic results.

Methods:

Anatomical limits are described for preoperative markings for selective liposuction with abdominal definition. Specific areas of the abdomen are presented to differentiate the areas for an intense or moderate liposuction and the areas for superficial and deep liposuction for anatomical definition. The principles of traditional lipoabdominoplasty are also described and maintained. The initial experiences with 128 patients undergoing the technique are included.

Results:

One hundred twenty-eight patients were operated on by the senior author (O.S.) from 2016 to 2019 using the described technique. One patient presented with a seroma (0.8 percent), and two had a small skin epitheliolysis (1.5 percent). No other major complications were observed. It is the senior author’s opinion that the obtained aesthetic results from the lipoabdominoplasty with definition are superior to those of the traditional technique, as it enhances the natural contour of the abdomen.

Conclusions:

Lipoabdominoplasty with anatomical definition has improved the aesthetic results of traditional lipoabdominoplasty without compromising the safety of that technique. More natural results along the abdominal contour that avoid a completely flat abdomen have been observed by most patients. This approach is safe and reproducible, with low complication rates, and it effectively enhances body contour.
A Four-Step Technique for Creating Individual Double-Eyelid Crease Shapes: A Free-Style Design
Authors: Suo Linlang , Li Jiaqi , Fu Rao , Xie Yun , Huang Ru-Lin
Published: June 2020

Background:

Double-eyelid blepharoplasty is the most frequently performed aesthetic surgery in the Asian population. However, the epicanthal fold has been a conundrum limiting the outcomes of Asian blepharoplasty. Furthermore, with the blending of Western and Asian cultures, patients have individual standards of beauty for the upper eyelids. Here, we developed a four-step technique to form infold or outfold double-eyelid creases to satisfy individual patient requirements.

Methods:

The medical records of patients who simultaneously underwent double-eyelid blepharoplasty and epicanthoplasty using this four-step technique from January of 2017 to January of 2019 were reviewed. The results were grouped by preoperative patient requirements for eyelid crease shapes. The rate of meeting patient expectations in each group was evaluated by two independent observers. Preoperative and postoperative photographs were collected, complications were identified, and postoperative results were assessed.

Results:

In total, 285 consecutive patients were included in this study, with a mean follow-up period of 9 months. Of the 285 patients, 207 requested infold eyelid creases, and 190 (92 percent) procedures met patient expectations; and 78 patients requested outfold eyelid creases, and 69 (87 percent) procedures met patient expectations. A high rate of satisfaction with the final eyelid crease shape and resulting scarring was noted in both patient groups. The revision rate was 3 percent. No severe complications were observed.

Conclusion:

The four-step technique is a simple, flexible, and effective method for creating infold or outfold double-eyelid creases according to individual patient requirements and should be considered a routine method for patients who request double eyelids.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Personality Traits and Traumatic Outcome Symptoms in Registered Nurses in the Aftermath of a Patient Safety Incident
Authors: Stovall Mady C. , Firkins Jenny , Hansen Lissi , Dieckmann Nathan F. , van Ryn Michelle
Published: June 2020

Objectives

The purpose of this study was to investigate the relationship between personality traits (perfectionism and neuroticism) and the traumatic outcomes of reexperiencing, avoidance, and alcohol abuse severity of registered nurses (RNs) who have been involved with a patient safety incident (PSI). We hypothesized that higher scores for perfectionism and neuroticism would predict higher reexperiencing and avoidance symptoms in RNs in the aftermath of a PSI. Also, RNs with higher perfectionism and neuroticism sum scores would be more likely to abuse alcohol.

Methods

A descriptive, correlational study design was used to characterize the relationships of personality traits and potential traumatic outcomes of RNs in the aftermath of a PSI. The Almost Perfect Scale—Revised, Neuroticism Scale, Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, and Alcohol Use Disorders Identification Test—Consumption measures were administered to RNs licensed in Oregon and New York.

Results

Perfectionist-discrepancy personality traits (P < 0.01) were the strongest predictors for reexperiencing symptoms and neuroticism (P < 0.05) was the strongest predictor for avoidance symptoms, when controlling for sociodemographics and experience. We found a negative linear relationship between perfectionism-order and alcohol abuse severity (β = −0.15, P < 0.01; confidence interval, −0.24 to 0.05).

Conclusions

This study demonstrated a statistically significant relationship between perfectionism-discrepancy and reexperiencing as well as between neuroticism and reexperiencing and avoidance, each explaining 4% of variance of their model. The results add to the nurse second victim literature by validating 2 posttraumatic stress disorder symptoms in RNs in the aftermath of a PSI. Registered nurses with perfectionism-order were less likely to abuse alcohol.
Single Versus Multiple Arterial Revascularization in Patients With Reduced Renal Function
Authors: Hayatsu Yukihiro , Ruel Marc , Bader Eddeen Anan , Sun Louise
Published: June 2020

Objective:

To compare the long-term outcomes of MAR versus SAR in patients with renal insufficiency.

Summary of Background Data:

Previous studies have been insufficiently powered to address whether MAR confers long-term benefit over SAR in patients with renal dysfunction who require CABG.

Methods:

We conducted retrospective cohort study in Ontario, Canada of patients who underwent isolated CABG (n = 23,406). The primary outcome was MACE, defined as the composite of stroke, myocardial infarction, and repeat revascularization. We compared patients by matching them on the propensity to have received SAR versus MAR, within groups with preoperative glomerular filtration rate (GFR) ≥60 mL/min/1.73 m2; GFR between 30 and 60; and GFR <30.

Results:

In patients with GFR ≥60, the use of MAR versus SAR was associated with a lower rate of MACE [hazard ratio (HR) 0.87 (0.80–0.94)], and a lower rate of long-term mortality [HR 0.87 (0.79–0.97)]. In those with GFR between 30 and 60, MAR was not associated with a difference in MACE [HR 1.04 (0.87–1.26)], and a lower rate of long-term mortality [HR 0.75 (0.65–0.87)] was observed. In those with GFR <30, MAR was not associated with a difference in outcomes.

Conclusions:

MAR versus SAR does not correlate with a difference in MACE amongst patients with GFR between 30 and 60 and better survival raises the possibility of indication bias. Furthermore, MAR did not confer a benefit in those with severely reduced renal function. These data suggest that the potential long-term benefits of using MAR in CABG patients with renal insufficiency may be offset by competing health risks.
Assessment of Technical Skills in Axillary Lymph Node Dissection
Authors: Muthuswamy Keerthini , Fisher Rebecca , Mavroveli Stella , Petrou Fotis , Khawar Sabrina , Amlani Ashik , Hanna George B. , Hadjiminas Dimitri J. , Thiruchelvam Paul T. R. , Leff Daniel R.
Published: June 2020

Objective:

A simulator to enable safe practice and assessment of ALND has been designed, and face, content and construct validity has been investigated.

Summary and Background Data:

The reduction in the number of ALNDs conducted has led to decreased resident exposure and confidence.

Methods:

A cross-sectional multicenter observational study was carried out between July 2017 and August 2018. Following model development, 30 surgeons of varying experience (n = “experts," n = 11 “senior residents," and n = 10 “junior residents”) were asked to perform a simulated ALND. Face and content validity questionnaires were administered immediately after ALND. All ALND procedures were retrospectively assessed by 2 attending breast surgeons, blinded to operator identity, using a video-based assessment tool, and an end product assessment tool.

Results:

Statistically significant differences between groups were observed across all operative subphases on the axillary clearance assessment tool (P < 0.001). Significant differences between groups were observed for overall procedure quality (P < 0.05) and total number of lymph nodes harvested (P < 0.001). However, operator grade could not be distinguished across other end product variables such as axillary vein damage (P = 0.864) and long thoracic nerve injury (P = 0.094). Overall, participants indicated that the simulator has good anatomical (median score >7) and procedural realism (median score >7).

Conclusions:

Video-based analysis demonstrates construct validity for ALND assessment. Given reduced ALND exposure, this simulation is a useful adjunct for both technical skills training and formative Deanery or Faculty administered assessments.
Comparing Clinician Consensus Recommendations to Patient-reported Opioid Use Across Multiple Hospital Systems
Authors: Robinson Kortney A. , Thiels Cornelius A. , Stokes Sean , Duncan Sarah , Feranil Mario , Fleishman Aaron , Cook Charles H. , Nathanson Larry A. , Huang Lyen C. , Habermann Elizabeth B. , Brat Gabriel A.
Published: June 2020

Objective: :

We compare consensus recommendations for 5 surgical procedures to prospectively collected patient consumption data. To address local variation, we combined data from multiple hospitals across the country.

Summary of Background Data:

One approach to address the opioid epidemic has been to create prescribing consensus reports for common surgical procedures. However, it is unclear how these guidelines compare to patient-reported data from multiple hospital systems.

Methods:

Prospective observational studies of surgery patients were completed between 3/2017 and 12/2018. Data were collected utilizing post-discharge surveys and chart reviews from 5 hospitals (representing 3 hospital systems) in 5 states across the USA. Prescribing recommendations for 5 common surgical procedures identified in 2 recent consensus reports were compared to the prospectively collected aggregated data. Surgeries included: laparoscopic cholecystectomy, open inguinal hernia repair, laparoscopic inguinal hernia repair, partial mastectomy without sentinel lymph node biopsy, and partial mastectomy with sentinel lymph node biopsy.

Results:

Eight hundred forty-seven opioid-naïve patients who underwent 1 of the 5 studied procedures reported counts of unused opioid pills after discharge. Forty-one percent did not take any opioid medications, and across all surgeries, the median consumption was 3 5 mg oxycodone pills or less. Generally, consensus reports recommended opioid quantities that were greater than the 75th percentile of consumption, and for 2 procedures, recommendations exceeded the 90th percentile of consumption.

Conclusions:

Although consensus recommendations were an important first step to address opioid prescribing, our data suggests that following these recommendations would result in 47%–56% of pills prescribed remaining unused. Future multi-institutional efforts should be directed toward refining and personalizing prescribing recommendations.
Drain Placement After Uncomplicated Hepatic Resection Increases Severe Postoperative Complication Rate
Authors: Arita Junichi , Sakamaki Kentaro , Saiura Akio , Konishi Masaru , Sakamoto Yoshihiro , Hashimoto Masaji , Sano Tsuyoshi , Uesaka Katsuhiko , Kokudo Norihiro , Yamanaka Takeharu , Shimada Kazuaki
Published: June 2020

Objective:

To assess the clinical impact of a no-drain policy after hepatic resection.

Summary of Background Data:

Previous randomized controlled trials addressing no-drain policy after hepatic resection seem inconclusive because they did not adopt appropriate study design to validate its true clinical impact.

Methods:

This unblinded, randomized controlled trial was done at 7 Japanese institutions. Patients undergoing hepatic resection without biliary reconstruction were randomized to either D group or ND group. When the risk of postoperative bile leakage or hemorrhage were considered high, the patients were excluded during the operation. Primary endpoint was the postoperative complication of C-D grade 3 or higher within 90 postoperative days. A noninferiority of ND group to D group was assessed, and if it was confirmed, a superiority was assessed.

Results:

Between May 2015 and July 2017, a total of 400 patients were finally included in the per-protocol set analysis: 199 patients in D group and 201 patients in ND group. Intraoperatively, 37 patients were excluded from the final enrollment because of high risk of bile leakage or hemorrhage. Postoperative complication rate of C-D grade 3 or higher was 8.0% (16/199) in the D group and 2.5% (5/201) in the ND group. The risk difference was −5.5% (95% confidence interval: −9.9% to −1.2%) and fulfilled the prescribed noninferiority margin of 4%. No postoperative mortality was experienced in both groups. Bile leakage was diagnosed in 8.0% (16/199) of the D group and none in the ND group (P < 0.001). In none of the subgroups classified based on 8 potentially relevant factors, drain placement was favored in terms of C-D grade 3 or higher complication.

Conclusions:

Drains should not be placed after uncomplicated hepatic resections.
Fresh whole blood from walking blood banks for patients with traumatic hemorrhagic shock: A systematic review and meta-analysis
Authors: Naumann David N. , Boulton Adam J. , Sandhu Amrit , Campbell Kieran , Charlton William , Gurney Jennifer M. , Martin Matthew J. , Scorer Tom , Doughty Heidi
Published: June 2020

BACKGROUND

Whole blood is optimal for resuscitation of traumatic hemorrhage. Walking Blood Banks provide fresh whole blood (FWB) where conventional blood components or stored, tested whole blood are not readily available. There is an increasing interest in this as an emergency resilience measure for isolated communities and during crises including the coronavirus disease 2019 pandemic. We conducted a systematic review and meta-analysis of the available evidence to inform practice.

METHODS

Standard systematic review methodology was used to obtain studies that reported the delivery of FWB (PROSPERO registry CRD42019153849). Studies that only reported whole blood from conventional blood banking were excluded. For outcomes, odds ratios (ORs) and 95% confidence interval (CI) were calculated using random-effects modeling because of high risk of heterogeneity. Quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation system.

RESULTS

Twenty-seven studies published from 2006 to 2020 reported >10,000 U of FWB for >3,000 patients (precise values not available for all studies). Evidence for studies was “low” or “very low” except for one study, which was “moderate” in quality. Fresh whole blood patients were more severely injured than non-FWB patients. Overall, survival was equivalent between FWB and non-FWB groups for eight studies that compared these (OR, 1.00 [95% CI, 0.65–1.55];p= 0.61). However, the highest quality study (matched groups for physiological and injury characteristics) reported an adjusted OR of 0.27 (95% CI, 0.13–0.58) for mortality for the FWB group (p< 0.01).

CONCLUSION

Thousands of units of FWB from Walking Blood Banks have been transfused in patients following life-threatening hemorrhage. Survival is equivalent for FWB resuscitation when compared with non-FWB, even when patients were more severely injured. Evidence is scarce and of relative low quality and may underestimate potential adverse events. Whereas Walking Blood Banks may be an attractive resilience measure, caution is still advised. Walking Blood Banks should be subject to prospective evaluation to optimize care and inform policy.

LEVEL OF EVIDENCE

Systematic/therapeutic, level 3.
Pain across traumatic injury groups: A National Institute on Disability, Independent Living, and Rehabilitation Research model systems study
Authors: Amtmann Dagmar , Bamer Alyssa M. , McMullen Kara , Gibran Nicole S. , Hoffman Jeanne M. , Bombardier Charles H. , Carrougher Gretchen J.
Published: June 2020

BACKGROUND

Pain is a common problem after traumatic injury. We describe pain intensity and interference at baseline and 1 year postinjury in burn, traumatic brain injury (TBI), and spinal cord injury (SCI) survivors and compare them with the general population (GP). We tested a custom Patient Reported Outcomes Measurement Information System (PROMIS) pain interference short form developed for use in trauma populations.

METHODS

We administered a pain intensity numerical rating scale and custom PROMIS pain interference short forms at baseline and/or 1 year postinjury from participants (≥18 years) at three Model System projects (burn, TBI, and SCI). Scores were compared across injury groups and pain intensity levels, and to the GP. Reliability and floor and ceiling effects of the custom PROMIS pain measures were calculated.

RESULTS

Participants (burn, 161; TBI, 232; SCI, 134) responded to the pain intensity and/or pain interference measures at baseline (n = 432), 1 year (n = 288), or both (n = 193). At baseline, pain interference and intensity were both significantly higher in all three groups than in the GP (all p < 0.01). At 1 year, average pain intensity in SCI and burn (p < 0.01) participants was higher than the GP, but only SCI participants reported higher pain interference (p < 0.01) than the GP. Half of all participants reported clinically significant pain interference (55 or higher) at baseline and one third at 1 year. Reliability of the custom pain interference measure was excellent (>0.9) between T-scores of 48 and 79.

CONCLUSION

The custom pain interference short forms functioned well and demonstrated the utility of the custom PROMIS pain interference short forms in traumatic injury. Results indicate that, for many people with burn, TBI and SCI, pain remains an ongoing concern long after the acute injury phase is over. This suggests a need to continue to assess pain months or years after injury to provide better pain management for those with traumatic injuries.

LEVEL OF EVIDENCE

Epidemiologic/Therapeutic study, level IV.
Dizziness and Vertigo: The Skillful Examination
Authors: Shemesh Ari A. , Gold Daniel R.
Published: June 2020

Background:

The visual, ocular motor and vestibular systems have intimate neural and close anatomical relationship that dictates their assessment in a patient with dizziness and vertigo.

Results:

Recognition of the pearls and pitfalls of a targeted clinical examination HINTS/HINTS “Plus” allows the clinician to probe at the bedside the most crucial hypothesis in a patient with acute isolated vestibular syndrome, “Is this a stroke?”

Conclusion:

By applying a methodical approach to examination of patients with dizziness and vertigo, localization of the offending lesion, management, and even elucidation of the underlying diagnosis is feasible.
Role of Ocular Ultrasonography to Distinguish Papilledema From Pseudopapilledema
Authors: Kohli Anita A. , Pistilli Maxwell , Alfaro Cesar , Ross Ahmara G. , Jivraj Imran , Bagchi Sheila , Chan Jessie , May Dionne , Liu Grant T. , Shindler Kenneth S. , Tamhankar Madhura A.
Published: June 2020

Background:

We prospectively evaluated the sensitivity and specificity of ocular ultrasonography (OUS) to distinguish papilledema from pseudopapilledema.

Methods:

Forty-nine study participants, with optic disc elevation, underwent neuro-ophthalmic evaluation, OUS, fundus photography, and optical coherence tomography (OCT) of the optic nerve head at the initial and follow-up visits (≤6 months apart). Participants were classified as having papilledema if there was a change in optic nerve appearance on fundus photographs, as determined by a masked observer, between initial and follow-up visits ≤6 months apart. OUS was considered positive when the optic nerve sheath width was >3.3 mm and the 30° test was positive. Ocular ultrasonographic findings were correlated in patients who had papilledema vs patients who had pseudopapilledema. In a subanalysis, OUS findings were also correlated with change in peripapillary retinal nerve fiber layer thickness on OCT of the optic nerve head between initial and follow-up visits.

Results:

OUS was 68% (17/25) sensitive for papilledema and 54% (13/24) specific for pseudopapilledema. When using OCT parameters to define papilledema, the sensitivity of OUS to diagnose papilledema decreased to 62%. Positive OUS correlated with elevated opening pressure on lumbar puncture and with signs of increased intracranial pressure on MRI.

Conclusion:

OUS alone was less sensitive in diagnosing papilledema than previously thought. Therefore, OUS may not be helpful in distinguishing between papilledema and pseudopapilledema.