bluuebunny/crossref_metadata_2025 huggingface dataset:
DETERMINANTS OF ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS AMONG PATIENTS ATTENDING TERTIARY CARE HOSPITALS IN ISLAMABAD
Authors: Noreen Nadia , Bashir Faiza , Safi Malik Mohammad , Khan Abdul Wali , Naveed Irum , Ahmad Waheed , Niazi Saeed Ullah Khan , Khan Naveed Ullah
Published: April 2021

Objective:

Hypertension is one of the non-communicable diseases which reduces life expectancy and decreases productive years, accounting for almost 9·4 million deaths annually and 7·0% of global DALYs. The economic burden associated with NCD deaths will rise from $152 million in the year 2010 to $296 million in 2025. Nonadherence to medications leads to poor health outcomes. The annual cost of nonadherence was estimated to be at 100 million US dollars in 2011 or 70% of healthcare expenditure on drugs worldwide. We conducted this study to have an insight into our patient's behavior towards their treatment regimes.

Design and method:

A hospital-based analytical cross-sectional study involving adult hypertensive patients attending the cardiology clinic of tertiary care hospital in Islamabad Capital Territory (ICT), conducted from July 2019 to October 2019. The data was collected using a semi-structured pretested questionnaire. Proportionate to target population sample was calculated and 418 subjects were enrolled through systematic random sampling technique. Data analysis was done as descriptive statistics Bivariate analysis was carried out and a p-value of less than 0.05 considered as significant. Logistic regression was done to identify independent predictors of adherence

Results:

The mean age of respondents was 54.4 years SD ± 10.61. Participants were predominately male (56.2%). 327 (72.7%) of the respondents had High Bp Grade I, uncontrolled blood pressure. 218 (48.44%) were not able to afford to buy monthly medication, Average monthly cost of the medication was 7.42 USD (1150 PKR) ± 1136 Pak Rupees, with 28.89% were not able to buy the medications on their own. Multivariate logistic regression analysis revealed non-affordability of treatment (OR 2.2 p-value 0.0002) and testing, uncontrolled hypertension (OR 3.1 p-value 0.0001), as statistically significant determinants for being nonadherent, whereas being educated (OR O.6 p-value 0.02))and adequate counseling by a health practitioner (OR 0.2 p-value 0.000) were protective factors.

Conclusions:

For improving adherence to antihypertensive therapy, we concluded the prevalent paradigm of healthcare is nonsupportive in terms of enhanced and non-affordable treatment regimes, long waiting hours, non-availability of universal health coverage. Further, education and better counseling had a positive impact on the patient's altered attitude towards medications.
MENOPAUSAL HORMONE THERAPY AND RISK OF INCIDENT HYPERTENSION: IMPACT OF THE ROUTE OF ESTROGEN ADMINISTRATION AND PROGESTOGENS IN THE E3N COHORT
Authors: Madika Anne-Laure , Macdonald Conor-James , Fournier Agnes , Mounier-Vehier Claire , Beraud Guillaume , Boutron-Ruault Marie-Christine
Published: April 2021

Objective:

Although menopausal hormone therapy (MHT) remains the most efficacious treatment for vasomotor symptoms of menopause, its effects on the development of arterial hypertension remain unclear. We sought to determine the effect of different formulations of MHT on incident hypertension among menopausal women in a large prospective cohort study.

Design and method:

We used data from the E3N cohort study, a French prospective population-based study initiated in 1990 of 98,995 women. Out of these, 49,905 menopausal women with complete information on the use of MHT, and without prevalent hypertension at inclusion were included. Hypertension cases were self-reported and validated using the national drug reimbursement database.

Results:

Among these women with a mean age was 54.2 ± 4.3 years, 10 173 cases of hypertension were identified in an average follow-up time of 10.6 years and 32 183 (64.5%) of the women reported ever using MHT. Compared with women who never used MHT, those who ever used it had an increased risk of incident hypertension (adjusted HR 1.07, 95% CI 1.02–1.12) after adjustment for body mass index and other potential confounders (Table 1). When formulation was taken into account, oral but not transdermal estrogen use was associated with an increased risk of hypertension (adjusted HR = 1.09; 95% CI: 1.04–1.14 and HR = 1.03; 95% CI: 0.99–1.07, respectively). Regarding the impact of concomitant progestogens, pregnane and norpregnane derivatives were significantly associated with hypertension risk (HR = 1.12; 95% CI: 1.06–1.19 and HR = 1.06; 95% CI: 1.01–1.13, respectively).

Conclusions:

Use of MHT was associated with an increased risk of incident hypertension, especially when using oral estrogen and pregnane and norpregnane derivative in case of combined treatment. Surveillance of blood pressure should be added to the medical surveillance of MHT users.
RENOVASCULAR HYPERTENSION-INDUCED CARDIAC CHANGES IN A RAT MODEL: FEASIBILITY OF CONVENTIONAL AND RECENT ECHOCARDIOGRAPHY
Authors: Ma Danfu , Mandour Ahmed S. , Hendawy Hanan , Yoshida Tomohiko , El-Husseiny Hussein M. , Ozai Yusuke , Takeuchi Aki , Takahashi Ken , Uemura Akiko , Tanaka Ryou
Published: April 2021

Objective:

Renovascular hypertension (RH) is a major cause of secondary hypertension, and hypertension eventually led to cardiac remodeling in patients. Hypertension leads to concentric left ventricle hypertrophy, while hypervolemia originated from renal failure leads to eccentric hypertrophy. Both mechanisms occur in RH which results in complex cardiac remodeling. Uraemic cardiomyopathy results from RH is characterized by diastolic dysfunction, but traditional echocardiography was limited in evaluating the diastolic function due to unknown hemodynamic and morphologic status. Recently, non-invasive intraventricular pressure gradient (IVPG), a preload-independent diastolic function parameter, was established and showed higher sensitivity to evaluate diastolic dysfunctions, particularly during cardiomyopathy. However, no previous studies highlighted the feasibility of the IVPG in the diagnosis of RH.

Design and method:

Twelve rats were received subtotal nephrectomy in 1 week to produce progressive renal failure as the RH group. The other twelve rats were sham-operated as a control group. Conventional and color M-mode echocardiography was performed for isoflurane-anesthetized rats at 2nd, 4th, 6th, and 8th weeks post-operation. IVPG was evaluated based on the Euler equation.

Results:

Hypertension, polyuria and hypervolemia were observed in RH group from the 2nd, 4th, and 8th week, respectively. Marked left ventricle hypertrophy was evidenced at 6th (1.32 ± 0.28 vs 1.09 ± 0.09, p = 0.016) and 8th-week post-operation (1.34 ± 0.28 vs 1.16 ± 0.09, p = 0.014) that was more prominent in the posterior papillary muscle. Peak mitral E velocity in RH rats was higher than control at the 8th week (106.35 ± 16.04 vs 91.23 ± 10.82, p = 0.031). In contrast, tissue Doppler index, total IVPG, basal IVPG, and mid-to-apical IVPG showed no difference between groups throughout the experiment.

Conclusions:

Hypervolemia and RH lead to unclassified geometry in RH-associated cardiac remodeling. Blood pressure change precedes the change of preload during the development of RH cardiac remodeling.
CAN A SYNTHETIC PREDICTOR BASED ON CAROTID DISTENSION WAVE ACQUIRED WITH AN OPTICAL FIBER SENSOR IDENTIFY PAST CARDIOVASCULAR EVENTS?
Authors: Rebelo Pedro Damião dos Santos , Antunes Paulo Fernando da Costa , Pinto João de Lemos , André Paulo Sergio de Brito , Bastos Jose Adelino Mesquita , Leitao Catia Sofia Jorge
Published: April 2021

Objective:

Exploratory study of the potential use of carotid distension pulses collected with a plastic optical fiber sensor (POFpen), for the identification of past cardiovascular (CV) events. The POFpen device working principle is based on the application of an optical signal on a reflector placed in the skin above the carotid surface, whose distension movements modulate the reflected signal, which is collected by the same fiber.

Design and method:

Carotid distension data were collected from 73 patients, where 68 were considered for this study (cases with no missing data), with 61 hypertensives. Exclusion criteria: cardiac arrhythmia, premature ventricular beats, respiratory problems, severe mental problems. 10 patients had a previous CV event (cerebrovascular accident or myocardial infarction). The study was approved by the local ethics committee.

The temporal sequences from the POFpen were studied in its raw form. The exploratory analysis of the data sets considered transformations of a segment per raw file with a length of 23 s. We extract 5 features that translate abstract geometric properties per raw data segment, namely: fractal dimension of the signal (FD_x); fractal dimension of the difference in the difference between 3 consecutive points (FD_2); signal entropy (entropy_x); the maximum frequency values (index_max_FFT), determined by FFT (Fast Fourier Transform), per segment; interquartile range of the Wavelet s5 (IQR_WT_S5) transforms (using R DWT package, wavDWT with filter type “s8”). We create a logistic model to predict the existence of previous CV event and the performance of the model was evaluated by Receiver Operating Characteristics (ROC) curve. All the statistical work was made with R version 3.6.3.

Results:

The features used by model which predicts CV event, are presented on figure a). The model achieved excellent discrimination with an area under the curve (AUC) of 0.849 [0.743, 0.955], see figure b).

Conclusions:

The results of this preliminary study show the potential of to use the raw data from the carotid distension data acquired with an optical probe to identify past CV event. In order to validate this methodology a new set of new patients’ data should be used.
PREVALENCE OF BLOOD PRESSURE CONTROL AND ITS DETERMINANTS AMONG ADULTS WITH HYPERTENSION IN URBAN PUDUCHERRY DISTRICT, PUDUCHERRY, INDIA, 2020
Authors: Lakshmanasamy Ravivarman , Kaur Prabhdeep
Published: April 2021

Objective:

Hypertension exerts a substantial public health burden on cardiovascular health status and healthcare system of India. We did this study with the objective to find the prevalence, awareness, treatment, control rate of hypertension and the factors associated with the control for hypertension in the urban Puducherry district.

Design and method:

We did a cross sectional survey at the community level among adults aged 18 to 69 years in Urban Puducherry. Sample size was calculated using multi stage cluster sampling design. A total of 2700 individuals were to be surveyed, in twenty seven clusters. Data was collected using ODK based app. We used modified WHO STEPS questionnaire, collected anthropometric measurements and recorded blood pressure. We analyzed the proportion of all variables, using epi info software. The study was approved by the Institutional Ethics Committee.

Results:

A total of 2000 households were surveyed, of which 1755 (87.8%) agreed to participate in the study. We surveyed 1686 individuals of which 40.9 %were males. The mean age was 42(+13) years. Among them, 331 (19.6%) people had high blood pressure and 209 (63.1%) were already known hypertensives. Although 173 (52.3%) were on treatment, only 63 (19%) had their blood pressure under control. Among people with hypertension, nearly half were obese (BMI >27.50 kg/m2) and about 20% reported consumption of high salt foods. Nearly one third (36%) had diabetes mellitus. Majority (61%) utilized private clinics for hypertension treatment. Among public sector users, 71% reported medicines were always available in the facilities. Majority (80%) received medicines for one month. The odds of having comorbidities is 2.7 times more in people with blood pressure control than those without control.

Conclusions:

We observed high prevalence of hypertension, treatment among half of the patients and only one fifth had blood pressure control. More than half of the population utilized private doctor's clinic for hypertension treatment. People without other comorbidities are found to have less blood pressure control. We recommend frequent community level screening for hypertension and focus on compliance among people without other comorbidities.
RETINAL VASODILATORY RESPONSES ARE INVERSELY ASSOCIATED WITH PLASMINOGEN ACTIVATOR INHIBITOR-1: THE AFRICAN-PREDICT STUDY
Authors: Jacobs Adriaan , Pieters Marlien , Smith Wayne , Schutte Aletta
Published: April 2021

Objective: Aims:

Plasminogen activator inhibitor-1 (PAI-1), traditionally associated with fibrinolysis, is increasingly implicated in impaired vascular function. However, studies on its association with microvascular function are limited to the cutaneous and coronary microvascular beds in older and diseased individuals. To better understand its potential involvement in the early stages of disease development, we investigated the associations of retinal vasodilatory responses to flicker light with PAI-1 activity (PAI-1act) in young and healthy individuals.

Methods:

We included healthy Black and White women and men (n = 518; aged 20–30 years), and measured plasma PAI-1act and retinal vasodilatory responses to flicker light provocation. We also collected demographic and lifestyle data, measured blood pressure, anthropometry, blood lipids, inflammatory and other biomarkers.

Results:

In multivariate regression analyses, maximal retinal venular dilation associated independently and inversely with PAI-1act (Adj. R2 = 0.11; ? = -0.15; p = 0.001) in the total group. In exploratory subgroup analyses, this association remained in White women (Adj. R2 = 0.07; ? = -0.23; p = 0.005), and was more robust with younger age and lower blood pressure and in non-smokers, but also with greater central adiposity, higher low-density lipoprotein cholesterol and inflammation (all p < 0.05).

Conclusions:

Our data suggest that in young individuals, PAI-1 may already be associated with subclinical microvascular dysfunction.
Factors Contributing to Lingering Pain after Surgery: The Role of Patient Expectations
Authors: Willingham Mark D. , Vila Molly R. , Ben Abdallah Arbi , Avidan Michael S. , Haroutounian Simon
Published: April 2021

Background

Pain that lingers beyond the early weeks after the acute postoperative period is an important risk factor for chronic postsurgical pain. This study examined the hypothesis that patients’ expectations about their postsurgical pain would be independently associated with lingering postsurgical pain.

Methods

The study included 3,628 patients who underwent diverse surgeries between February 2015 and October 2016 in a single U.S. tertiary hospital and participated in the Systematic Assessment and Targeted Improvement of Services Following Yearlong Surgical Outcomes Surveys (SATISFY-SOS) observational study. Preoperatively, patients were asked about their expectations about pain 1 month after surgery. Patients were considered to have lingering postsurgical pain if they endorsed having pain in the area related to their surgeries during a follow-up survey obtained 1 to 3 months postoperatively. The independent associations between preselected perioperative variables and lingering postsurgical pain were evaluated.

Results

Of the cohort, 36% (1,308 of 3,628) experienced lingering postsurgical pain. Overall, two thirds (2,414 of 3,628) expected their postsurgical pain to be absent or improved from baseline, and 73% of these had their positive expectations fulfilled. A total of 19% (686 of 3,628) expected new, unabated, or worsened pain, and only 39% (257 of 661) of these had their negative expectations fulfilled. Negative expectations were most common in patients with presurgical pain unrelated to the reason for surgery, undergoing surgeries not typically performed to help alleviate pain. Endorsing negative expectations was independently associated with lingering postsurgical pain (odds ratio, 1.56; 95% CI, 1.23 to 1.98; P < 0.001). Additional major factors associated with lingering postsurgical pain included recollection of severe acute postoperative pain (odds ratio, 3.13; 95% CI, 2.58 to 3.78; P < 0.001), undergoing a procedure typically performed to help alleviate pain (odds ratio, 2.18; 95% CI, 1.73 to 2.75; P < 0.001), and preoperative pain related to surgery (odds ratio, 1.91; 95% CI, 1.52 to 2.40; P < 0.001).

Conclusions

Lingering postsurgical pain is relatively common after diverse surgeries and is associated with both fixed surgical characteristics and potentially modifiable factors like pain expectations and severe acute postoperative pain.

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Availability of Inpatient Pediatric Surgery in the United States
Authors: McManus Michael L. , França Urbano L.
Published: April 2021

Background

In 2015, the American College of Surgeons began its Children’s Surgery Verification Quality Improvement Program, promulgating standards intended to promote regionalization and improve pediatric surgical care. It was hypothesized that pediatric surgical care was already highly regionalized and concentrated before implementation of the program. This study aimed to demonstrate this by describing the sites and volume of nonambulatory pediatric surgery.

Methods

A two-part, retrospective, cross-sectional analysis was performed. First, six all-encounter state inpatient data sets (Arkansas, Florida, Kentucky, Maryland, and New York from the Healthcare Cost and Utilization Project and Massachusetts from the Center for Health Information) were used to evaluate all procedures performed within specific hospitals in 2014. Next, a national sample data set (2016 Kids’ Inpatient Database) was used to determine the generalizability of the single state results. All acute care hospital admissions for patients less than 18 yr of age were included to describe the nature and location of all surgical procedures therein by patient age, surgical specialty, procedure type, and hospital service breadth.

Results

Within the six study states, there were 713 hospitals, of which 635 (89.1%) admitted patients less than 18 yr old, and 516 (72.4%) reported pediatric procedures. Among these, there were 9 specialty hospitals and 39 hospitals with services comparable to independent children’s hospitals. Of 153,587 procedures among 1,065,655 pediatric admissions, 127,869 (83.3%) took place within these 48 centers. This fraction decreased with age (89.9% of patients less than 2 yr old and 68.5% of 15- to 17-yr-olds), varied slightly by specialty, and was similar across states. Outside of specialized centers, teenagers accounted for 47.4% of all procedures. Within the national data sample, the concentration was similar: 8.7% (328 of 3,777) of all hospitals admitting children were responsible for 90.1% (793,905 of 881,049) of all procedures, with little regional variation.

Conclusions

Before the American College of Surgeons Children’s Surgery Verification Quality Improvement Program, the vast majority of pediatric nonambulatory surgeries were already confined to a small subset of high-capability and specialty centers.

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Beef Tongue Surgical Simulation Model for Posterior Vaginal Repair
Authors: Sappenfield Elisabeth C. , Tunitsky-Bitton Elena
Published: April 2021

BACKGROUND:

This surgical simulation model for vaginal posterior repair is designed to enhance vaginal surgical training.

METHODS:

A beef tongue simulation model was previously described and validated to practice the repair of obstetric laceration. The model was modified for surgical simulation of vaginal posterior repair. Chicken skin was used to simulate the anal canal. The model was secured in a PVC (polyvinyl chloride) pipe attached to a wooden base to simulate operating within the vaginal canal.

Experience:

Materials can be obtained from the local supermarket and hardware store. The total cost of the model is $35.47 for initial setup and $7.11 per use. Residents performing on the model felt it was realistic and useful for practicing the steps and skills for this procedure.

CONCLUSION:

The beef tongue simulation model of vaginal posterior repair is realistic, easy to construct, and affordable. It can be incorporated into a vaginal surgery curriculum to augment resident surgical education.
Hemolysis, Elevated Liver Enzymes, and Low Platelet Count Syndrome With Severe Thrombocytopenia and Severe ADAMTS13 Activity Deficiency
Authors: Wade A. Nicole , Panchmatia Rikesh , Calderon Pamela
Published: April 2021

BACKGROUND:

Differentiating preeclampsia with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome from thrombotic thrombocytopenic purpura (TTP) can present a diagnostic dilemma.

CASE:

We report the case of a 34-year-old woman, G1P0, with monochorionic diamniotic twins who presented with new-onset blurry vision, hypertension, and a platelet count of 4×109/L. After a multidisciplinary discussion, a diagnosis of atypical HELLP syndrome was made, despite overlapping features concerning for TTP. Her platelet count and ADAMTS13 activity testing showed appropriate recovery after delivery, without plasma exchange therapy, supporting the diagnosis of HELLP syndrome.

CONCLUSION:

Hemolysis, elevated liver enzymes, and low platelet count syndrome may present with severe thrombocytopenia and severe ADAMTS13 activity deficiency in ranges otherwise known to be more common with TTP.
Contraindications to Hormonal Contraception Among Postpartum Women in Texas
Authors: Coleman-Minahan Kate , Ela Elizabeth J. , White Kari , Grossman Daniel
Published: April 2021

OBJECTIVE:

To examine the prevalence of contraindications to hormonal contraception among postpartum women.

METHODS:

Low-income postpartum women who planned to delay childbearing for 2 years or longer after delivery were recruited for a prospective cohort study from eight Texas hospitals. Women self-reported health conditions that corresponded to category 3 and 4 contraindications to combined hormonal contraception and progestin-only methods, based on the Centers for Disease Control and Prevention’s 2016 Medical Eligibility Criteria for Contraceptive Use. We used mixed-effects Poisson regression models to assess characteristics associated with reporting any contraindication 6 months after delivery. We examined the proportion of women who used a contraindicated method.

RESULTS:

Of 1,452 women who completed the 6-month interview, 19.1% reported a category 3 or 4 contraindication to combined hormonal contraception (16.8% category 4) and 5.4% reported a contraindication to depot medroxyprogesterone acetate (0.1% category 4). Only 0.8% had any category 3 or 4 contraindication to progestin-only pills and 0.6% to the implant. Migraine with aura (12.4%) and hypertension (4.8%) were the most common contraindications. The prevalence of any contraindication was higher among women who were 30 years or older (prevalence ratio 1.45 95% CI 1.21–1.73), overweight (prevalence ratio 1.39, 95% CI 1.07–1.80), obese (prevalence ratio 1.55, 95% CI 1.16–2.07), and insured (prevalence ratio 1.34, 95% CI 1.04–1.74). Compared with U.S.-born Latina women, the prevalence of contraindications was higher among Black women (prevalence ratio 1.37, 95% CI 1.14–1.64) and lower among foreign-born Latina women (prevalence ratio 0.71, 95% CI 0.59–0.86). Among women with contraindications, 28 (10.3%) were using combined hormonal contraception; six (8%) were using a contraindicated progestin-only method.

CONCLUSION:

Nearly one in five participants had a category 3 or 4 contraindication to combined hormonal contraception. Patients at higher risk for adverse birth outcomes are more likely to have contraindications. Clinicians should counsel on contraception and contraindications prenatally to facilitate the most informed postpartum decision.
Habitus and Pelvic Floor Symptoms and Support 1 Year Postpartum
Authors: Nygaard Ingrid E. , Bardsley Tyler , Sheng Xiaoming , Murtaugh Maureen A. , Shaw Janet M.
Published: April 2021

OBJECTIVE:

To estimate the association between habitus measures and pelvic floor support and symptoms in primiparous women 1 year after term vaginal delivery.

METHODS:

In this cross-sectional study including women enrolled at seven academic and community sites, we assessed pelvic floor support, weight, height, waist circumference, and percent fat using air displacement plethysmography and participants completed questionnaires, all at one year postpartum. We tested the association of quintiles of habitus measure, including body mass index (BMI), waist circumference, percent body fat, and waist/height ratio, with the primary outcomes: anatomic support, dichotomized as maximal vaginal descent less than 0 cm (better support) compared with 0 cm or more (worse support) per the pelvic organ prolapse quantification examination and symptom burden (positive with bothersome symptoms in two or more of six symptom domains), and on five secondary outcomes. The sample size provides 90% power to detect odds ratios (ORs) of 1.78 or greater between women at mean compared with mean+1 SD of habitus measure.

RESULTS:

Of 592 participants, 55 (9.3%) demonstrated worse support and 321 (54.2%) symptom burden. In multivariable analyses, habitus measures were not significantly associated with anatomic support or, except for the highest waist/height ratio quintile, with symptom burden. Compared with women in the first quintile of each habitus measure, those in most higher quintiles demonstrated elevated odds of moderate to severe urinary incontinence (UI); increased odds for stress urinary incontinence (SUI) were mainly limited to the highest quintile. After adjusting for percent body fat, the increased odds for BMI on SUI (OR 2.47, 95% CI 1.43–4.28) were no longer significant (OR 1.38, 95% CI 0.54, 3.51).

CONCLUSION:

Habitus in primiparous patients at 1 year postpartum was not associated with anatomic support or symptom burden. Habitus was more associated with moderate to severe UI than mild UI. The association of higher BMI with SUI was attenuated by fitness, reflected by fat percentage.
Postoperative Lower Extremity Neuropathy With Boot Stirrups Compared With Candy Cane Stirrups
Authors: Whitis Avery M. , Chen Edison , Sekhon Morgan , Akella Sraavya , Bradley Catherine S. , Kowalski Joseph T.
Published: April 2021

OBJECTIVE:

To assess whether candy cane stirrup use is associated with an increased risk of lower extremity peripheral neuropathy compared with boot stirrups in women undergoing surgery requiring dorsal lithotomy positioning.

METHODS:

This retrospective cohort study (June 2008–August 2015) included patients who underwent gynecologic surgery for benign indication lasting 60 minutes or longer in the lithotomy position. Patients with preexisting neurologic disease were excluded. Stirrup type, demographics, medical history, surgical factors, and relevant outcomes were collected from the medical record. Postoperative neuropathy was identified in clinical diagnoses or in physician documentation through the 6-week postoperative visit. Patient characteristics and outcomes were compared using Student’s t test, χ2 test, or Fisher exact test. Logistic regression analysis was used to adjust for other clinical characteristics associated with the outcome at P≤.1.

RESULTS:

The study included 2,449 patients, 1,838 (75.1%) with boot and 611 (24.9%) with candy cane stirrups. Women positioned in boot stirrups were younger (mean age 45.6 years [SD 13.5] vs 55.9 [SD 15.7] years; P<.001), heavier (mean body mass index [BMI] 31.5 [SD 8.7] vs 29.6 [SD 7.0]; P<.001), more likely to smoke (n=396 [21.5%] vs n=105 [17.2%]; P=.021), and had longer surgical duration (mean 176.5 minutes [SD 90.0] vs 145.3 [SD 63.9] minutes; P<.001), respectively. Diabetes (8.3%) did not differ between the groups (P=.122. Neuropathy occurred less often in the boot cohort (n=29, 1.6%, 95% CI 1.1–2.3%) than in the candy cane cohort (n=21, 3.4%, 95% CI 2.1–5.2%) (P=.008). After adjusting for age, BMI, smoking, anesthesia type and surgical time, only candy cane stirrup type (adjusted odds ratio [aOR] 2.87, 95% CI 1.59–5.19) and surgical time (per hour) (aOR 1.40, 95% CI 1.20–1.63) were independently associated with postoperative neuropathy.

CONCLUSION:

Candy cane stirrups are associated with a significantly increased risk of lower extremity postoperative neuropathy compared with boot stirrups for women undergoing gynecologic surgery for benign indication.
Rethinking Bias to Achieve Maternal Health Equity
Authors: Green Tiffany L. , Zapata Jasmine Y. , Brown Heidi W. , Hagiwara Nao
Published: April 2021

In this article, we address the limitations of existing implicit bias interventions as a strategy for achieving maternal health equity. We then focus on how institutionally sanctioned racial stereotyping harms Black maternal health and marginalizes a key group in the fight for health equity—Black physicians. Finally, we provide strategies to address racial bias in perinatal health care and structural barriers impeding Black physicians' success.
Controversies in Hereditary Cancer Management
Authors: AlHilli Mariam M. , Pederson Holly J.
Published: April 2021

Personalized management of patients at risk ideally should involve a multidisciplinary team of not only genetic counselors and surgeons, but also women's health or menopause specialists, knowledgeable psychologists, and primary care providers or obstetrician–gynecologists aware of the risks and fears “previvors” (survivors of a predisposition to cancer who have not had the disease) face as well as the issues that are common postoperatively. Identification of patients at risk for hereditary cancer, understanding of current genetic testing modalities and potential results, knowledge about screening and prevention including timing of surveillance, preventive medication and risk-reducing surgeries, understanding limitations and comorbidities associated with these risk management strategies and long-term psychological support are all important in hereditary cancer management. We describe issues surrounding the identification of the high-risk patient, universal testing in breast and ovarian cancer, and testing in special populations. We describe a simplified approach to understanding and communicating genetic testing results and nuances of testing including direct-to-consumer testing. We highlight concerns surrounding breast cancer screening during pregnancy and lactation. A framework for practical management and counseling of women who opt for risk-reducing salpingo-oophorectomy or risk-reducing mastectomy or both is provided. We provide an in-depth discussion of questions that arise in relation to timing of surgery, fertility preservation, management of menopausal symptoms, and surgical technique. Alternative choices in women who choose to delay bilateral salpingo-oophorectomy are reviewed. Finally, the psychosocial effects of carrying a genetic mutation and the issues that women face when undergoing to risk-reducing surgery including adjustment, sexuality issues, and cosmesis are addressed.
REPEATABILITY OF MACULAR MICROVASCULATURE MEASUREMENTS USING OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY ACCORDING TO TEAR BREAKUP TIME IN DRY EYE DISEASE
Authors: Lee Woo Hyuk , Lim Hyung-Bin , Kim Jaeyoung , Ryu Cheon Kuk , Shin Yong-Il , Kim Jung-Yeul
Published: April 2021

Purpose:

It is hypothesized that an unstable tear film would affect the quality and repeatability of optical coherence tomography angiography (OCTA). Therefore, OCTA repeatability according to tear break-up time (TBUT) was compared.

Methods:

The 3 × 3 OCTA was performed twice and, the eyes were divided into 3 groups according to the TBUT (Group 1: TBUT ≤ 5 seconds, 43 eyes; Group 2: 5 seconds < TBUT ≤ 10 seconds, 35 eyes; Group 3: TBUT > 10 seconds, 34 eyes). The intraclass correlation coefficient, coefficient of variation, and test–retest SD were calculated and compared.

Results:

The signal strengths of OCTA were 9.1 ± 1.2, 9.5 ± 0.8, and 9.5 ± 0.8 in each group from Groups 1, 2, and 3, respectively, which showed significant difference (P = 0.049). The intraclass correlation coefficient of vessel density were 0.733, 0.840, and 0.974 in Groups 1 to 3, respectively, and the values increased in the order of Groups 1, 2, and 3. The coefficient of variation were 6.41 ± 6.09, 3.29 ± 2.22, and 1.30 ± 1.17, and the test–retest SD were 0.83 ± 0.70, 0.47 ± 0.31, and 0.19 ± 0.17 in Groups 1, 2, and 3, respectively. The coefficient of variation and test–retest SD values decreased in the order of Groups 1, 2, and 3, and showed a significant difference (all, P < 0.05).

Conclusion:

The repeatability of OCTA tended to decrease with a shorter TBUT. When the TBUT is <5 seconds, care must be taken to interpret the OCTA results correctly.
Can Video Assistance Improve the Quality of Pediatric Dispatcher-Assisted Cardiopulmonary Resuscitation?
Authors: Peters Michael , Stipulante Samuel , Cloes Véronique , Mulder André , Lebrun Frédéric , Donneau Anne-Françoise , Ghuysen Alexandre
Published: April 2021

Objectives

This study aimed to evaluate the impact of adding video conferencing to dispatcher-assisted telephone cardiopulmonary resuscitation (CPR) on pediatric bystander CPR quality.

Methods

We conducted a prospective, randomized manikin study among volunteers with no CPR training and among bachelor nurses. Volunteers randomly received either video or audio assistance in a 6-minute pediatric cardiac arrest scenario. The main outcome measures were the results of the Cardiff Test to assess compression and ventilation performance.

Results

Of 255 candidates assessed for eligibility, 120 subjects were randomly assigned to 1 of the 4 following groups: untrained telephone-guided (U-T; n = 30) or video-guided (U-V; n = 30) groups and trained telephone-guided (T-T; n = 30) or video-guided (T-V; n = 30) groups. Cardiac arrest was appropriately identified in 86.7% of the U-T group and in 100% in the other groups (P = 0.0061). Hand positioning was adequate in 76.7% of T-T, 80% of T-V, and 60% of U-V, as compared with 23.4% of the U-T group (P = 0.0001). Fewer volunteers managed to deliver 2 rescue breaths/cycle (P = 0.0001) in the U-T (16.7%) compared with the U-V (43.3%), the T-T (56.7%), and the T-V groups (60%).Subjects in the video groups had a lower fraction of minute to ventilate as compared with the telephone groups (P = 0.0005).

Conclusions

In dispatcher-instructed children CPR simulation, using video assistance improves cardiac arrest recognition and CPR quality with more appropriate chest compression technique and ventilation delivering. The long interruptions in chest compression combined with the mixed success rate to deliver proper ventilation raise question about ventilation quality and its effectiveness.
Perforator-Based Intercostal Artery Muscle Flap: A Novel Approach for the Treatment of Tracheoesophageal or Bronchoesophageal Fistulas
Authors: Bertheuil Nicolas , Duisit Jérôme , Isola Nicolas , Lengelé Benoit , Bergeat Damien , Meunier Bernard
Published: April 2021

Postoperative tracheoesophageal or bronchoesophageal fistulas represent a major surgical challenge. The authors report the description of an original perforator-based intercostal artery muscle flap, aiming to cover all types of intrathoracic fistulas, from any location, in difficult cases such as postoperative fistulas after esophagectomy in an irradiated field. Between June of 2016 and January of 2019, eight male patients were treated with a perforator-based intercostal artery muscle flap. All had previous surgery for esophageal cancer and developed a tracheoesophageal or bronchoesophageal fistula during the perioperative course. The mean patient age was 55.9 ± 8.8 years. All patients received neoadjuvant chemotherapy and seven received neoadjuvant radiation therapy. A perforator-based intercostal artery muscle flap, with a mean skin paddle size of 9.86 × 5 cm, was harvested. The median operative time was 426.50 minutes. The tracheoesophageal or bronchoesophageal fistula was successfully and definitively occluded in three patients; two patients experienced recurrence; and one patient underwent re operation. At 1 year, five patients were alive (62.5 percent), and among them, three (37.5 percent) were free from any intrathoracic complications. Three patients died, because of massive digestive bleeding, mesenteric ischemia, and multiorgan failure, respectively. The perforator-based intercostal artery muscle flap, like the Taylor flap in abdominoperineal reconstruction, could become a workhorse flap for all intrathoracic reconstructions, as it can always be harvested, even if a previous thoracotomy has ruined most of the options. This surgical technique, easily feasible, reliable, and reproducible, became our first option for all postoperative tracheoesophageal or bronchoesophageal fistula patients during the postoperative course following esophagectomy.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Cone-Beam Computed Tomography: A User-Friendly, Practical Roadmap to the Planning and Execution of Every Rhinoplasty—A 5-Year Review
Authors: Robotti Enrico , Daniel Rollin K. , Leone Francesco
Published: April 2021

Background:

Cone-beam computed tomography has recently rapidly developed worldwide as a versatile and convenient alternative to traditional computed tomography for imaging of the maxillofacial region. However, most surgeons performing rhinoplasty are surprisingly unfamiliar with it, in both the plastic surgery and ear, nose, and throat communities.

Methods:

The broad clinical experience of a single center over the past 5 years is reviewed. The many applications of cone-beam computed tomography to primary and secondary rhinoplasty are analyzed regarding septum, turbinates, nasal bones, skin thickness, and other issues. The importance of a paradigm shift from a two-dimensional to a three-dimensional approach in image reconstruction is demonstrated, together with the value of surface contour enhancement.

Results:

Cone-beam computed tomography has a multitude of practical applications highly relevant to rhinoplasty. The surface image will strengthen aesthetic analysis, and the detailed preview of bony and functional anatomy will facilitate surgical planning. Cone-beam computed tomography serves as a roadmap to plan and execute rhinoplasties more predictably and efficiently. The availability of spatial views and accurate detail, together with the possibility of easy, accurate measuring, offers a plenitude of potential applications.

Conclusions:

Cone-beam computed tomography is a user-friendly, quick technique with abundant advantages in planning any rhinoplasty. It causes the patient no inconvenience and has very few, if any, drawbacks, with these being limited to radiation exposure and limited cost.
Antiretroviral hair levels, self-reported adherence, and virologic failure in second-line regimen patients in resource-limited settings
Authors: Apornpong Tanakorn , Grinsztejn Beatriz , Hughes Michael , Ritz Justin , Kerr Stephen J. , Fletcher Courtney V. , Ruxrungtham Kiat , Godfrey Catherine , Gross Robert , Hogg Evelyn , Wallis Carole L. , Badal-Faesen Sharlaa , Hosseinipour Mina C. , Mngqbisa Rosie , Santos Breno R. , Shah Sarita , Hovind Laura J. , Mawlana Sajeeda , Van Schalkwyk Marije , Chotirosniramit Nuntisa , Kanyama Cecilia , Kumarasamy Nagalingeswaran , Salata Robert , Collier Ann C. , Gandhi Monica
Published: April 2021

Objective:

To evaluate associations between hair antiretroviral hair concentrations as an objective, cumulative adherence metric, with self-reported adherence and virologic outcomes.

Design:

Analysis of cohort A of the ACTG-A5288 study. These patients in resource-limited settings were failing second-line protease inhibitor-based antiretroviral therapy (ART) but were susceptible to at least one nucleoside reverse transcriptase inhibitor (NRTI) and their protease inhibitor, and continued taking their protease inhibitor-based regimen.

Methods:

Antiretroviral hair concentrations in participants taking two NRTIs with boosted atazanavir (n = 69) or lopinavir (n = 112) were analyzed at weeks 12, 24, 36 and 48 using liquid-chromatography--tandem-mass-spectrometry assays. Participants’ self-reported percentage of doses taken in the previous month; virologic failure was confirmed HIV-1 RNA at least 1000 copies/ml at week 24 or 48.

Results:

From 181 participants with hair samples (61% women, median age: 39 years; CD4+ cell count: 167 cells/μl; HIV-1 RNA: 18 648 copies/ml), 91 (50%) experienced virologic failure at either visit. At 24 weeks, median hair concentrations were 2.95 [interquartile range (IQR) 0.49–4.60] ng/mg for atazanavir, 2.64 (IQR 0.73--7.16) for lopinavir, and 0.44 (IQR 0.11--0.76) for ritonavir. Plasma HIV-1 RNA demonstrated inverse correlations with hair levels (r
s −0.46 to −0.74) at weeks 24 and 48. Weaker associations were seen with self-reported adherence (r
s −0.03 to −0.24). Decreasing hair concentrations were significantly associated with virologic failure, the hazard ratio (95% CI) for ATV, LPV, and RTV were 0.69 (0.56-0.86), 0.77 (0.68–0.87), and 0.12 (0.06–0.27), respectively.

Conclusion:

Protease inhibitor hair concentrations showed stronger associations with subsequent virologic outcomes than self-reported adherence in this cohort. Hair adherence measures could identify individuals at risk of second-line treatment failure in need of interventions.
Hypophosphatemia in people with HIV: no benefit when switching from tenofovir disoproxil fumarate to tenfovir alafenamide
Authors: Sandmann Lisa , Stoll Matthias , Behrens Georg M.N.
Published: April 2021

Treatment with tenofovir disoproxil fumarate (TDF) has been associated with hypophosphatemia mainly because of injury of the renal proximal tubulus. Studies on the impact of tenfovir alafenamide (TAF) on phosphate homeostasis in people with HIV (PWH) are limited. Prompted by a patient with phosphate wasting under tenofovir but no other evidence for tubular dysfunction, a retrospective cohort analysis with 102 PWH revealed that hypophosphatemia remained largely unchanged after switching from TDF to TAF.
Neutralization sensitivity of genital tract HIV-1: shift in selective milieu shapes the population available to transmit
Authors: Kariuki Samuel Mundia , Selhorst Philippe , Abrahams Melissa-Rose , Rebe Kevin , Williamson Carolyn , Dorfman Jeffrey R.
Published: April 2021

Objective:

Previous studies indicate that transmitted/founder HIV-1 isolates are sensitive to neutralization by the transmitting donor's antibodies. This is true in at least a subset of sexual transmissions. We investigated whether this selection for neutralization-sensitive variants begins in the genital tract of the donor, prior to transmission.

Design:

Laboratory study.

Methods:

HIV-1 viruses from semen and blood of two male donors living with HIV-1 were tested for neutralization sensitivity to contemporaneous autologous antibodies.

Results:

In one donor, semen-derived clones (n = 10, geometric mean ID50 = 176) were 1.75-fold [95% confidence interval (CI) 1.11–2.76, P = 0.018] more sensitive than blood-derived clones (n = 12, geometric mean ID50 = 111) to the individual's own contemporaneous neutralizing antibodies. Enhanced overall neutralization sensitivity of the semen-derived clones could not explain the difference because these semen-derived isolates showed a trend of being less sensitive to neutralization by a pool of heterologous clade-matched sera. This relative sensitivity of semen-derived clones was not observed in a second donor who did not exhibit obvious independent HIV-1 replication in the genital tract. A Bayesian analysis suggested that the set of semen sequences that we analysed originated from a blood sequence.

Conclusion:

In some instances, selection for neutralization-sensitive variants during HIV-1 transmission begins in the genital tract of the donor and this may be driven by independent HIV-1 replication in this compartment. Thus, a shift in the selective milieu in the male genital tract allows outgrowth of neutralization-sensitive HIV-1 variants, shaping the population of isolates available for transmission to a new host.
Primary Cleft Rhinoplasty
Authors: Celie Karel-Bart , Wright Matthew A. , Ascherman Jeffrey A.
Published: April 2021

Background

Primary cleft rhinoplasty has become widely accepted owing to evidence of improved outcomes and need for fewer revisions. Several techniques have been described, but few surgeons have reported long-term outcomes of repairs performed via a single method. The present study examines long-term outcomes of a single surgeon's experience over 22 years using the same primary cleft rhinoplasty technique.

Methods

All consecutive cases of primary cleft rhinoplasty performed by the senior author at the time of unilateral cleft lip repair from 1996 to 2018 were selected for retrospective review. Patients older than 3 years or lacking documented follow-up were excluded. The primary outcome was the need for secondary rhinoplasty at age 15 years or later.

Results

Fifty-six patients met inclusion criteria. Median follow-up time was 7.52 years (interquartile range, 1.38–14.82). Twelve patients required minor long-term lip revision. No school-aged patients required additional correction of the nasal deformity before beginning school. Fifteen patients had follow-up beyond 14 years of age, 5 of whom had undergone definitive rhinoplasties as adolescents (8.9% of cohort; 33.3% of patients with follow-up beyond 14 years). Of the remaining 10 patients older than 14 years at last follow-up, none were seeking additional rhinoplasty.

Conclusions

This series represents one of the longest-running published experiences of primary cleft rhinoplasty. Using a technique that requires no nasal incisions, the senior author has had excellent long-term results, with no need for any elementary school age rhinoplasties and with the majority of patients with follow-up older than 14 years not requiring a rhinoplasty in adolescence.
Changes in Academic Plastic Surgery Programs During the COVID-19 Pandemic
Authors: Mehrzad Raman , Akiki Ronald , Liu Paul Y. , Schmidt Scott , Woo Albert S.
Published: April 2021

Background

The COVID-19 pandemic has presented unprecedented challenges for surgical teaching programs, as operating rooms closed and resources were redirected for patient care. As a result, both educational challenges and opportunities emerged. The objective of this study was to assess the changes used by plastic surgery programs as a result of the pandemic.

Methods

A 34-question American Council of Academic Plastic Surgeons-approved survey was distributed on April 29, 2020, to attendings in academic plastic surgery programs in the United States. Variables were controlled whenever multiple attending responses were submitted from the same program.

Results

A total of 113 attendings, including 30 (27.8%) program directors, responded to the survey. Most respondents were located in the northeast (41.4%). The average percentage of elective case volume was 23% of pre-COVID states. Those who reported a decrease in emergent surgical case volume (55.2%) estimated it to be at an average of 45% of the normal. Almost all the respondents (95.6%) agreed that they were working fewer hours than usual, and 40.9% of those reported a decrease of more than 20 hours per week of work. Most attendings (82.1%) also reported a decrease in their monthly salary. The percentage projected current salary compared with normal was 85%.

Conclusions

Our survey data suggest that academic plastic surgery programs have had impactful changes to their operative and educational schedules, teaching, revenue, and patient care. The data described in this study could be used as a baseline for future pandemics affecting plastic surgery programs to help strategize their operational and educational structures.