bluuebunny/crossref_metadata_2025 huggingface dataset:
Upper Lip Fat Grafting Using the Anatomical Subunit and Fat Compartment Principles Improves Lip Cant and Symmetry in Patients With Unilateral Upper Lip Asymmetries
Authors: Denadai Rafael , Buzzo Celso Luiz , Raposo-Amaral Cesar Augusto , Raposo-Amaral Cassio Eduardo
Published: November 2019

Background

Fat grafting is a widely adopted method for reconstructing upper lip asymmetries. However, most surgical techniques are difficult to reproduce, and none follow anatomical principles.

Objectives

The aim of this study was to assess the clinical outcomes of upper lip contour asymmetry and lip cant correction by anatomical upper lip fat grafting using the subunit and fat compartment principles.

Methods

A prospective analysis was conducted of 113 consecutive patients who underwent anatomical upper lip fat grafting using the subunit and fat compartment principles for the management of lip cant and/or upper lip contour (volumetric) asymmetry. Quantitative photogrammetric upper lip symmetry and lip cant measurements were blindly performed preoperatively and at 3 and 12 months postoperatively. A panel assessment (by 8 blinded external plastic surgeons and 8 laypersons) was obtained to grade the qualitative upper lip symmetry. Bivariate and multivariate analyses were performed to identify independent variables associated with the 12-month postoperative lip cant change.

Results

There was significant (all P < 0.05) postoperative quantitative and qualitative upper lip symmetry and lip cant enhancement (preoperative < postoperative) after a single upper lip fat grafting procedure, and the outcomes were maintained (all P > 0.05) from 3 to 12 months postoperatively. Parry-Romberg syndrome was negatively associated (P < 0.05) with the 12-month postoperative lip cant change.

Conclusions

Anatomical upper lip fat grafting, using the subunit and fat compartment principles, improves lip cant and symmetry in patients with unilateral upper lip asymmetries.
Comparative Study of 2 Different Innervation Techniques in Facial Reanimation
Authors: Kim Min Ji , Kim Hyung Bae , Jeong Woo Shik , Choi Jong Woo , Kim Young Kug , Oh Tae Suk
Published: November 2019

Recently, 1-stage double innervation with the masseter nerve and the cross-face nerve graft (CFNG) has gained popularity owing to its outcomes of powerful and synchronous muscle contraction. In this study, we compared CFNG- and double-innervated free gracilis muscle transfer (FGMT) for facial palsy reconstruction.

A total of 49 patients with facial palsy who underwent facial reanimation surgery from August 2013 to January 2017 were enrolled. The CFNG group (18 patients) underwent 2-stage CFNG innervation, whereas the double-innervated FGMT group (31 patients) underwent dual coaptation with end-to-end masseter nerve and end-to-side CFNG. The FACEgram software was used for evaluating smile excursion, symmetry index, spontaneous smile occurrence, Terzis' score including palsy pathogenesis, and clinical progress.

In the CFNG group, the smile excursion at rest increased (P = 0.000); however, there was increased smile excursion both at rest and during smiling in the double-innervated FMGT group (rest P = 0.002, smile P = 0.028). Improvement of the symmetry index was observed only in the FMGT group (rest P = 0.001, smile P = 0.000). There was no significant difference in Terzis' scores. The average time to the first visible muscle contracture was statistically significantly shorter in the double-innervated FGMT group (P = 0.035). With respect to spontaneous smile achievement, the double-innervated FGMT group (25.8%) showed a satisfactory outcome.

Cross-face nerve graft-innervated FGMT improved only smile excursion at rest, whereas double-innervated FGMT provided improvement in both the resting and smiling postures. Furthermore, the double-innervated FGMT group showed a higher symmetry index. However, the 2 operations did not show a significant difference in functional aspects.
Photogrammetric Outcomes of Primary Nasal Correction in Unilateral Cleft Lip Patients
Authors: Nunez-Villaveiran Teresa , Fahradyan Vahe , McNinch Neil L. , Valentine Ashley , Larson Heather , Murthy Ananth S.
Published: November 2019

Background

Concerns of nonlasting results and potential nasal growth damage precluded cleft nasal correction at the time of initial cleft lip repair. Our goal was to evaluate the outcome of primary cleft nasal correction in our patients with unilateral cleft lip.

Methods

A retrospective review of patients with complete and incomplete unilateral cleft lip who underwent primary cleft nasal correction from 2010 to 2017 by the same surgeon was performed. The cleft-to-noncleft nostril height, width, one-fourth medial part of nostril height, nasal sill height, and nostril area ratios, as well as inner nostril height-to-width ratios were determined from standard basilar view photographs taken in different time points (T1, <3 months; T2, 3–12 months; T3, 12–36 months; and T4, >36 months after surgery). A 5-point visual analog scale (1 = worst, 5 = best) was used to assess each patient's nose appearance.

Results

Seventy-two patients were identified (66.7% male, 51.3% with a complete cleft lip). Average visual analog scale scores T1–T4 were 3.88 ± 0.85, 3.72 ± 0.93, 3.54 ± 0.99, and 3.40 ± 0.71, respectively. Intraclass correlation ranged from 0.61 to 0.94. A significant decrease [mean difference (SD)] was found for cleft-to-noncleft nostril width ratio [0.15 (0.18)] from T1 to T2, and an increase for one-fourth medial height ratio [−0.09 (0.07)] and for inner nostril height-to-width ratio in the noncleft side [−0.23 (0.25)] from T1 to T3. Thirteen patients required secondary surgical revision.

Conclusion

Based on photogrammetry, primary cleft nasal correction in our patients with unilateral cleft lip achieved acceptable and stable outcomes during early childhood.
Reconstruction of Intrapelvic Defects Using the Free Anterolateral Thigh Flap
Authors: Wong Alvin , Sbitany Hani
Published: November 2019

Background

Reconstruction of intrapelvic soft tissue defects traditionally relies on regional pedicled myocutaneous flaps. However, there remain situations in which local options are unavailable. We review our experience treating intrapelvic defects with the anterolateral thigh (ALT) microvascular free flap.

Methods

A retrospective, institutional review was conducted from 2014 to 2018 of patients undergoing microvascular ALT flap reconstruction of intrapelvic defects. Four patients were identified in this cohort out of 92 total pelvic reconstruction cases.

Results

All patients underwent abdominoperineal resection (APR) for rectal cancer treatment. In the two male patients, pelvic abscesses and bladder leak necessitated soft tissue reconstruction after radiation and APR. In both, regional tissue options were unavailable, and a buried ALT free flap was used for soft tissue reconstruction. Both female patients developed rectovaginal fistulas secondary to their tumor burden, necessitating posterior vaginal wall resections. Prior surgical scars and ostomies made abdominal wall tissue unavailable; thus, free ALTs were used to eliminate intrapelvic dead space and reconstruct the posterior vaginal wall. In all cases, recipient vessels were the deep inferior epigastric artery and vein. Flap survival was 100%.

Conclusions

Pelvic reconstruction has traditionally been addressed with local/regional pedicled flaps. In cases where these are unavailable, the free ALT flap is a versatile option when buried for intrapelvic reconstruction or posterior vaginal wall lining. We also propose updating Cordeiro et al.'s classic vaginal defect reconstruction algorithm to include the free ALT flap for type IB cases in which the rectus abdominis is unavailable.
Noncontrast Magnetic Resonance Lymphangiography in a Rare Case of Everolimus-Related Lymphedema
Authors: Cellina Michaela , Oliva Giancarlo , Soresina Massimo , Menozzi Andrea , Boccanera Dario , Gibelli Daniele
Published: November 2019

Everolimus is a mammalian target of rapamycin (mTOR) inhibitor, which is used in immunosuppressive treatment regimens in solid-organ transplant recipients. Although mTOR inhibitors are usually well tolerated, their adverse effects have been reported: sirolimus treatment in transplant patients has been rarely reported to be associated with lymphedema of the skin and subcutaneous tissues, whereas the use of everolimus seemed to be less burdened by this type of adverse effect. We report the case of a 58-year-old man with a history of end-stage renal disease of unknown etiology who had undergone right renal transplantation 11 years before. After the transplant, the patient soon developed bilateral progressive swelling involving feet and legs. The symptoms of the left limb improved markedly after discontinuing everolimus. This condition has been classified as everolimus-induced lymphedema. The patient was referred to our department for the execution of a noncontrast magnetic resonance lymphangiography, that is, a noninvasive magnetic resonance imaging technique that has recently proposed for the study of lymphedema. Noncontrast magnetic resonance lymphangiography showed asymmetry between the lower extremities with signs of advanced lymphedema located in the right lower limb and dilated peripheral lymphatic vessels.

Drug withdrawal is currently the only effective solution for treating this type of secondary lymphedema; however, with the prolonged use of the drug, lymphedema tends to persist even after mTOR inhibitor suspension, with only partial clinical improvement, as in this case.

This case report describes the imaging characteristics of such condition at noncontrast magnetic resonance lymphangiography and discusses the rare adverse effects of everolimus. Immediate suspension of the drug is the only effective strategy to avoid the persistence of this disorder.
Prepectoral Versus Subpectoral Direct to Implant Immediate Breast Reconstruction
Authors: Mirhaidari Shayda J. , Azouz Vitali , Wagner Douglas S.
Published: November 2019

Background

Implant-based reconstruction is currently the most common postmastectomy breast reconstruction modality with over 86,000 procedures performed in 2017. Although various methods for reconstruction techniques have been described, partial subpectoral implant placement with or without acellular dermal matrix coverage remains the most popular approach. Recently, prepectoral implant placement has gained increased recognition as a method that avoids some of the potential morbidities of submuscular implant placement. Currently, few studies have examined the outcomes of performing this approach. The purpose of this study was to evaluate and compare the outcomes of prepectoral and subpectoral direct to implant (DTI) immediate breast reconstruction.

Methods

Data from a prospective cohort of consecutive patients undergoing prepectoral DTI immediate breast reconstructions at our institution from February 2016 to November 2017 were collected. The incidence of complications such as mastectomy skin flap necrosis, seroma, hematoma, infection, implant loss, and unexpected reoperation were recorded and compared with a cohort of consecutive patients who underwent subpectoral DTI immediate breast reconstruction from May 2014 to July 2015.

Results

One hundred twelve prepectoral DTI immediate breast reconstructions were performed on 62 patients. Four breasts (4.4%) were diagnosed with infection. There were 8 breasts (7.1%) that suffered from mastectomy skin flap necrosis (5 partial thickness necrosis, 3 full thickness necrosis). There was 1 implant loss related to full thickness necrosis that required salvage with autologous tissue reconstruction. Prepectoral breast reconstruction had less esthetic revisions and comparable complications when compared with the historical subpectoral cohort.

Conclusions

When compared with the subpectoral DTI approach, prepectoral DTI breast reconstruction grants favorable complication rates and improved esthetic outcomes. Prepectoral DTI breast reconstruction is a safe modality that should be considered in any patient who is a candidate for immediate breast reconstruction.
Outcomes Following Breast Reconstruction in Patients With Prior Mantle Radiation for Treatment of Hodgkin's Lymphoma
Authors: Freniere Brian , Irwin Timothy , Guldbrandsen Gretchen , Lafleur Emily H. , Dominici Laura , Sturgeon Daniel , Chun Yoon S.
Published: November 2019

Purpose

External beam radiation in the mantle field has been a mainstay of therapy for Hodgkin's lymphoma for decades. The incidence of breast cancer in patients treated with mantle radiation is known to be elevated. Few studies have examined outcomes of breast reconstruction in this high-risk group. The current study presents the largest series of immediate breast reconstruction in this population and aims to evaluate reconstructive outcomes and examine differences between implant-based and autologous reconstructions.

Methods

A retrospective review of records from a 10-year period at 2 institutions was undertaken. Patients treated with mantle radiation for Hodgkin's lymphoma who subsequently underwent mastectomy with immediate reconstruction were identified. Patient demographics, clinical characteristics, and outcomes including complications and operative revisions were gathered. Univariate and multivariate analyses were conducted to assess differences between implant-based and autologous reconstructions.

Results

A total of 97 breast reconstructions were performed in 52 patients. Seventy-nine reconstructions were implant-based, and 18 were autologous. Patients with implant-based reconstructions were older than autologous reconstructions (47 ± 8.8 years vs 42 ± 6.5 years, P < 0.05). Both groups had long-term follow-up; however, the mean follow-up duration was shorter in the implant-based compared with the autologous group (5 years vs 8.3 years; P < 0.05). Otherwise, the groups were similar with respect to BMI, medical comorbidities, oncologic diagnosis, and therapy. The interval between mantle radiation and reconstruction was comparable for implant-based and autologous groups (23.4 ± 9 years vs 21.3 ± 6.1 years, P = 0.6). The overall complication rate of breast reconstruction was not statistically different between the implant-based and autologous groups (35% vs 16%, P = 0.16). Three implant-based reconstructions (3.7%) required explantation. There were no complete flap losses in the autologous group. An associated 6-fold higher rate of unplanned revisions was observed with the autologous reconstruction group compared with the implant-based reconstruction group (odds ratio, 6.09; 95% confidence interval, 1.14–32.48; P = 0.035).

Conclusions

In this study, long-term follow-up suggests immediate breast reconstruction in patients with prior mantle radiation can be achieved safely with an acceptable complication profile utilizing either implant-based or autologous techniques. Autologous breast reconstruction is linked with a higher rate of revisions compared with implant-based breast reconstruction in this study population.
Three-Dimensional Morphological Changes of the Upper Airway in Patients With Skeletal Class III Malocclusion After Orthognathic Surgery
Authors: He Lin , He Song , Wu Xi , Huang Yue
Published: November 2019

Objective:

To evaluate the morphological changes of the upper airway of patients with skeletal Class III malocclusion after undergoing bilateral mandibular ramus dislocated mandibular retrogression (SSRO) or SSRO combined with Le Fort I maxillary osteotomy and 3-dimensional imaging.

Methods:

All previous studies related to the upper airway in patients with skeletal class III malocclusion and orthognathic surgery were collected from the PubMed, EMB, Cochrane Library, Web of science, ClinicalKey, EBSCO, Weipu, Wanfang, China National Knowledge Infrastructure, and Chinese BioMedical Literature databases. The search date ends in August 2017. RevMan5.3 software was used to perform a meta-analysis related to upper airway morphology. Ten studies were included.

Results:

The meta-analysis showed that 6 months after SSRO, CV1, and CV2 did not change significantly (P >0.05), whereas CV3 and CV4 narrowed (P <0.05) and remained narrow after 1 year (P <0.05). (CV1,CV2,CV3,CV4: Plans parallel to the FH plane passing through the most anterior inferior point of the anterior arch of the atlas, the 2nd cervical vertebra, the 3rd cervical vertebra, the 4th cervical vertebra.) There was no significant change in nasopharyngeal volume or laryngeal pharyngeal volume (P >0.05), but oropharyngeal volume and total volume decreased (P ≤0.01). Six months after SSRO combined with Le Fort I maxillary osteotomy, the minimum cross-sectional area of the upper airway was smaller (P <0.05), there was no significant change in nasopharyngeal volume or oropharyngeal volume (P >0.05), and oropharynx volume and total volume decreased (P <0.05).

Conclusions:

Single and double jaw surgery has no significant effect on nasopharynx and oropharynx, but reduces laryngopharynx and total volume; however, whether this will result in postoperative obstructive sleep apnea-hypopnea syndrome or become ameliorated over time requires more in-depth study and a longer period of clinical observation.
G-CSF Inhibits Growths of Osteoblasts and Osteocytes by Upregulating Nitric Oxide Production in Neutrophils
Authors: Zhao Jian , Zhao Qiang , Ning Peng , Shang Kai , Liu Cong , Ni Mei , Li Chunpu , Zhang Kaigang , Gao Chunzheng
Published: November 2019

Objective:

Granulocyte colony-stimulating factor (G-CSF) is the critical regulator of the proliferation, differentiation, and survival of granulocytes. Recently, it has been shown that G-CSF can adversely affect bone health in both animal models and patients. Here, the authors aimed to investigate whether G-CSF could inhibit the growth of osteoblasts and osteocytes by regulating nitric oxide.

Methods:

The C57BL/6 mice were divided into the control group, G-CSF treatment group and recovery group (G-CSF+L-NAME). The morphology of femurs was assessed by histology and immunohistochemistry. The expression of apoptosis-related molecules in femurs was detected by immunohistochemistry and quantitative RT-PCR, respectively. To examine if neutrophil-secreted factors can induce apoptosis in osteoblasts, Gr1-positive (Gr1+) neutrophils from the bone marrow of wild-type mice were sorted and co-cultured with MC3T3 pre-osteoblasts for 2 days.

Results:

The number of osteoblasts and newly embedding osteocytes significantly decreased and markers related to osteoblasts and osteocytes were downregulated in the G-CSF treatment compared to the control group. Moreover, G-CSF treatment did not change proliferation markers but induced apoptosis in osteoblast-lineage cells. The combined treatment of mice with G-CSF and a nitric oxide inhibitor partially restored the number of osteoblasts and osteocyte parameters.

Conclusions:

The G-CSF can inhibit osteoblasts and osteocytes by upregulating nitric oxide.
Aesthetic Cranial Vault Expansion in a Child With Slit Ventricle Syndrome and Eumorphic Face
Authors: Canzi Gabriele , Auricchio Anna Maria , Iacopino Giorgia , Cenzato Marco , Talamonti Giuseppe
Published: November 2019

Ventricular shunting procedures represent the classical surgical treatment for hydrocephalus. Slit ventricle syndrome (SVS) with craniocerebral disproportion (CCD) and secondary craniosynostosis (SCS) is a well-known but uncommon complication following cerebrospinal fluid (CSF) shunting in children. Its general management includes shunt upgrade or revision, placement of anti-siphon devices, lumbo-peritoneal shunting, and endoscopic third ventriculostomy. Cranial expansion is generally considered a major procedure and is indicated when less invasive treatments fail. In these cases, SVS and associated SCS have been usually managed through anterior cranial vault expansion. This procedure aims to decrease the risk of further shunt revisions and to improve neurologic symptoms, but it takes the disadvantage of considerable iatrogenic alterations of the facial proportions. The authors report a case of a 6-year old boy with SVS and SCS, who maintained eumorphic face and was treated by an innovative post-coronal vault expansion ensuring a wide volume increase while avoiding any change of facial conformation.
Posterior Ischemic Optic Neuropathy Following Radiofrequency Thermocoagulation for the Treatment of Trigeminal Neuralgia
Authors: Cai Yi , Cai Xian-Liang
Published: November 2019

Radiofrequency thermocoagulation is one of the effective methods to treat trigeminal neuralgia. However, the complication of posterior ischemic optic neuropathy after treatment has not been reported, at present. In the present study, preoperative examination and intraoperative operation were successful, but visual acuity decreased after the operation. The cause was considered to be vasospasm induced by atherosclerosis, blood viscosity, and mental stress, which caused local ischemia, and subsequently, ischemic optic neuropathy.
The Impact of Complications and Pain on Patient Satisfaction
Authors: Berkowitz Rachel , Vu Joceline , Brummett Chad , Waljee Jennifer , Englesbe Michael , Howard Ryan
Published: November 2019

Objective:

To measure the association between patient-reported satisfaction and regret and clinical outcomes.

Summary of Background Data:

Patient-reported outcomes are becoming an increasingly important marker of the quality of patient care. It is unclear however, how well patient-reported outcomes adequately reflect care quality and clinical outcomes in surgical patients.

Methods:

Retrospective, population-based analysis of adults ages 18 and older undergoing surgery across 38 hospitals in Michigan between January 1, 2017 and May 31, 2018.

Results:

In this study, 9953 patients (mean age 56 years; 5634 women (57%)) underwent 1 of 16 procedures. 9550 (96%) patients experienced no complication, whereas 240 (2%) and 163 (2%) patients experienced Grade 1 and Grade 2–3 complications, respectively. Postoperative pain scores were: none (908 (9%) patients), mild (3863 (40%) patients), moderate (3893 (40%) patients), and severe (1075 (11%) patients). Overall, 7881 (79%) patients were highly satisfied and 8911 (91%) had absolutely no regret after surgery. Patients were less likely to be highly satisfied if they experienced a Grade 1 complication [odds ratio (OR) 0.50, 95% confidence interval (CI) 0.37–0.66], Grade 2–3 complication (OR 0.44, 95% CI 0.31–0.62), minimal pain (OR 0.80, 95% CI 0.64–0.99, moderate pain (OR 0.39, 95% CI 0.32–0.49), or severe pain (OR 0.23, 95% CI 0.18–0.29). Patients were less likely to have no regret if they experienced a Grade 1 complication (OR 0.48, 95% CI 0.33–0.70), Grade 2–3 complication (OR 0.39, 95% CI 0.25–0.60), moderate pain (OR 0.55, 95% CI 0.40–0.76), or severe pain (OR 0.22, 95% CI 0.16–0.31). The predicted probability of being highly satisfied was 79% for patients who had no complications and 88% for patients who had no pain.

Conclusions:

Patients who experienced postoperative complications and pain were less likely to be highly satisfied or have no regret. Notably, postoperative pain had a more significant effect on satisfaction and regret after surgery, suggesting focused postsurgical pain management is an opportunity to substantially improve patient experiences. More research and patient education are needed for managing expectations of postoperative pain, and use of adjuncts and regional anesthesia.
Successful Implementation of Unmanned Aircraft Use for Delivery of a Human Organ for Transplantation
Authors: Scalea Joseph R. , Pucciarella Tony , Talaie Tara , Restaino Stephen , Drachenberg Cinthia Beskow , Alexander Charlie , Qaoud Talal Al , Barth Rolf N. , Wereley Norman M. , Scassero Matthew
Published: November 2019

Objective:

To understand and overcome the challenges associated with moving life-urgent payloads using unmanned aircraft.

Background Data:

Organ transportation has not been substantially innovated in the last 60 years. Unmanned aircraft systems (UAS; ie, drones) have the potential to reduce system inefficiencies and improve access to transplantation. We sought to determine if UASs could successfully be integrated into the current system of organ delivery.

Methods:

A multi-disciplinary team was convened to design and build an unmanned aircraft to autonomously carry a human organ. A kidney transplant recipient was enrolled to receive a drone-shipped kidney.

Results:

A uniquely designed organ drone was built. The aircraft was flown 44 times (total of 7.38 hours). Three experimental missions were then flown in Baltimore City over 2.8 miles. For mission #1, no payload was carried. In mission #2, a payload of ice, saline, and blood tubes (3.8 kg, 8.4 lbs) was flown. In mission #3, a human kidney for transplant (4.4 kg, 9.7 lbs) was successfully flown by a UAS. The organ was transplanted into a 44-year-old female with a history of hypertensive nephrosclerosis and anuria on dialysis for 8 years. Between postoperative days (POD) 1 and 4, urine increased from 1.0 L to 3.6 L. Creatinine decreased starting on POD 3, to an inpatient nadir of 6.9 mg/dL. The patient was discharged on POD 4.

Conclusions:

Here, we completed the first successful delivery of a human organ using unmanned aircraft. This study brought together multidisciplinary resources to develop, build, and test the first organ drone system, through which we performed the first transplant of a drone transported kidney. These innovations could inform not just transplantation, but other areas of medicine requiring life-saving payload delivery as well.
Timing of Preoperative Antibiotic Prophylaxis and Surgical Site Infection
Authors: de Jonge Stijn W. , Boldingh Quirine J. J. , Koch Anna H. , Daniels Lidewine , de Vries Eefje N. , Spijkerman Ingrid J. B. , Ankum Wim M. , Kerkhoffs Gino M. M. J. , Dijkgraaf Marcel G. , Hollmann Markus W. , Boermeester Marja A.
Published: November 2019

Objective:

To test the hypothesis that surgical site infection (SSI) risk differs, after administration of surgical antibiotic prophylaxis (SAP) within 60–30 or 30–0 minutes before incision.

Background:

The importance of appropriate timing of SAP before surgery has long been recognized. However, available evidence is contradictive on the best timing within a 60–0 minutes time interval before incision. Here, we aim to evaluate previous contradictions with a carefully designed observational cohort.

Methods:

An observational cohort study was conducted in a Dutch tertiary referral center. For 2 years, consecutive patients with SAP indication undergoing general, orthopedic, or gynecologic surgery were followed for the occurrence of superficial and deep SSI as defined by the Center of Disease Control and Prevention. The association between timing of SAP and SSI was assessed using multivariable logistic regression.

Results:

After 3001 surgical procedures, 161 SSIs were detected. In 87% of the procedures, SAP was administered within 60 minutes before incision. Only antibiotics with short infusion time were used. Multivariable logistic regression indicated there was no conclusive evidence of a difference in SSI risk after SAP administration 60–30 minutes or 30–0 minutes before incision [odds ratio: 0.82; 95% confidence interval (0.57–1.19)].

Conclusions:

For SAP with short infusion time no clear superior timing interval within the 60-minute interval before incision could be identified in this cohort. We were unable to reproduce differences in SSI risk found in earlier studies.
Survival After Robotic-assisted Prostatectomy for Localized Prostate Cancer
Authors: Wang Yuefeng , Gieschen Holger , Greenberger Mark , Yu Xinhua , Tian Gary , VanderWalde Noam , Stockstill Todd , Farmer Michael , Rinker Lillian , Izaguirre Enrique W. , Somer Bradley , Ballo Matthew T.
Published: November 2019

Backgrounds:

To determine the potential survival benefit associated with robotic-assisted laparoscopic prostatectomy (RALP) compared to open radical prostatectomy (ORP) for prostate cancer.

Summary of Background Data:

RALP has become the dominant surgical approach for localized disease in the absence of randomized clinical evidence and despite of the factor that RALP is more expensive than ORP.

Methods:

We performed a cohort study involving patients who underwent RALP and ORP for localized prostate cancer at the Commission on Cancer- accredited hospitals in the United States. Overall survival was analyzed using the Kaplan-Meier method, log-rank test, Cox proportional hazards models, and propensity score-matched analyses. An interrupted time-series analysis using the surveillance, epidemiology, and end results program database was also performed.

Results:

From 2010 to 2011, 37,645 patients received RALP and 12,655 patients received ORP. At a median follow-up of 60.7 months, RALP was associated with improved overall survival by both univariate [hazard ratio (HR), 0.69; P < 0.001] and multivariate analysis (HR, 0.76; P < 0.001) compared with ORP. Propensity score-matched analysis demonstrated improved 5-year all-cause mortality (3.9% vs 5.5%, HR, 0.73; P < 0.001) for RALP. The interrupted time-series analysis demonstrated the adoption of robotic surgery coincided with a systematic improvement in the 5-year cancer-specific survival rate of 0.17% (95% confidence interval, 0.06–0.25) per year after 2003 (P = 0.004 for change of trend), as compared to the time before adoption of RALP (1998–2003, annual percentage change, 0.01%; 95% confidence interval, –0.06 to 0.08). Sensitivity analysis suggested that the results from the interrupted time-series analysis were consistent with the improvement in the all-cause mortality demonstrated in the survival analysis (P = 0.87).

Conclusions:

In this epidemiologic analysis, RALP was associated with a small but statistically significant improvement in 5-year all-cause mortality compared to ORP for localized prostate cancer. This is the first time in the literature to report a survival benefit with RALP. Our findings have significant quality and cost implications, and provide assurance regarding a dominant adoption of more expensive technology in the absence of randomized controlled trials.
Genomewide Expression Profiling Identifies a Novel miRNA-based Signature for the Detection of Peritoneal Metastasis in Patients With Gastric Cancer
Authors: Shimura Tadanobu , Toden Shusuke , Kandimalla Raju , Toiyama Yuji , Okugawa Yoshinaga , Kanda Mitsuro , Baba Hideo , Kodera Yasuhiro , Kusunoki Masato , Goel Ajay
Published: November 2019

Objective:

This study aimed to conduct a genomewide transcriptomic profiling to develop a microRNA (miRNA)-based signature for the identification of peritoneal metastasis (PM) in patients with gastric cancer (GC).

Summary Background Data:

Even though PM in patients with GC has long been recognized to associate with poor prognosis, currently there is lack of availability of molecular biomarkers for its robust diagnosis.

Methods:

We performed a systematic biomarker discovery by analyzing miRNA expression profiles in primary tumors from GC patients with and without PM, and subsequently validated the expression of candidate miRNA biomarkers in 3 independent clinical cohorts of 354 patients with advanced GC.

Results:

Five miRNAs (miR-30a-5p, -134-5p, -337-3p, -659-3p, and -3917) were identified during the initial discovery phase; three of which (miR-30a-5p, -659-3p, and -3917) were significantly overexpressed in the primary tumors from PM-positive patients in the testing cohort (P = 0.002, 0.04, and 0.007, respectively), and distinguished patients with versus without peritoneal metastasis with the value of area under the curve (AUC) of 0.82. Furthermore, high expression of these miRNAs also associated with poor prognosis (hazard ratio = 2.18, P = 0.04). The efficacy of the combination miRNA signature was subsequently validated in an independent validation cohort (AUC = 0.74). Finally, our miRNA signature when combined together with the macroscopic Borrmann's type score offered a much superior diagnostic in all 3 cohorts (AUC = 0.87, 0.76, and 0.79, respectively).

Conclusions:

We have established an miRNA-based signature that have a potential to identify peritoneal metastasis in GC patients.
Long-Term Outcomes of Robotic-Assisted Laparoscopic Sacrocolpopexy Using Lightweight Y-Mesh
Authors: Culligan Patrick J. , Lewis Christa , Priestley Jennifer , Mushonga Nyarai
Published: November 2019

Objective

The objective of this study was to describe anatomic and symptomatic outcomes at 5 years or longer after robotic-assisted laparoscopic sacrocolpopexy using very lightweight polypropylene Y-mesh.

Methods

A prospective analysis of consecutive patients who underwent surgery at a single center between 2007 and 2011 was performed. Patients consented to objective and subjective assessment at 5 years or longer postoperatively. Surgical success was defined as meeting all of the following: (1) no retreatment for pelvic organ prolapse (POP) since surgery, (2) no prolapse beyond the introitus, (3) no apical descent below −5, and (4) no prolapse symptoms reported. Secondary outcome measures included Sandvik Incontinence Severity Index, the PFDI-20, the PFIQ-7, the PISQ-12, and the SSQ-8), rates of dyspareunia, mesh complications, and subjects’ need for any surgical or nonsurgical prolapse treatment since their index surgery.

Results

Eighty percent of the potential study group (253/316) presented for examination and subjective assessment at 5 years or longer after their index surgeries.

The surgical success rate was 226 (89.3%) of 253 with no apical failures. Only 4.4% (11/253) of the group met both objective and subjective failure criteria. Sixteen patients were classified as surgical failure owing to subjective criteria alone despite having no significant objective prolapse on examination. Ten patients (4%) elected to undergo subsequent POP repair. These operations consisted of 5 native tissue anterior repairs and 5 native tissue posterior repairs. In addition, 1 patient elected to use a pessary for recurrent anterior POP. The remaining 16 patients who experienced surgical failure elected no further prolapse treatment.

Conclusions

Robotic-assisted laparoscopic sacrocolpopexy using very lightweight mesh provided excellent long-term results with no mesh-related complications.
Desmopressin is a transfusion sparing option to reverse platelet dysfunction in patients with severe traumatic brain injury
Authors: Furay Elisa J. , Daley Mitch J. , Satarasinghe Praveen , Lara Sabino , Aydelotte Jayson D. , Teixeira Pedro G. , Coopwood Thomas B. , Ali Sadia , Brown Carlos V.R.
Published: November 2019

BACKGROUND

Platelet dysfunction (PD) is an independent predictor of mortality in patients with severe traumatic brain injury (sTBI). Platelet transfusions (PLTs) have been shown to be an effective treatment strategy to reverse platelet inhibition. Their use is contingent on availability and may be associated with increased cost and transfusion-related complications, making desmopressin (DDAVP) attractive. We hypothesized that DDAVP would correct PD similarly to PLTs in patients with sTBI.

METHODS

This retrospective study evaluated all blunt trauma patients admitted to an urban, level 1 trauma center from July 2015 to October 2016 with sTBI (defined as head abbreviated injury scale [AIS] ≥3) and PD (defined as adenosine diphosphate [ADP] inhibition ≥60% on thromboelastography) and subsequently received treatment. Per our institutional practice, patients with sTBI and PD are transfused one unit of apheresis platelets to reverse inhibition. During a platelet shortage, we interchanged DDAVP for the initial treatment. Patients were classified as receiving DDAVP or PLT based on the initial treatment.

RESULTS

A total of 57 patients were included (DDAVP, n = 23; PLT, n = 34). Patients who received DDAVP were more severely injured (injury severity score, 29 vs. 23; p = 0.045), but there was no difference in head AIS (4 vs. 4, p = 0.16). There was no difference between the two groups in admission platelet count (244 ± 68 × 103/μL vs. 265 ± 66 × 103/μL, p = 0.24) or other coagulation parameters such as prothrombin time, partial thromboplastin time, or international normalized ratio. Before treatment, both groups had similar ADP inhibition as measured by thromboelastography (ADP, 86% vs. 89%, p = 0.34). After treatment, both the DDAVP and PLT groups had similar correction of platelet ADP inhibition (p = 0.28).

CONCLUSION

In patients with severe traumatic brain injury and PD, DDAVP may be an alternative to PLTs to correct PD.

LEVEL OF EVIDENCE

Therapeutic, level IV.
Ultrasonographic inferior vena cava diameter response to trauma resuscitation after 1 hour predicts 24-hour fluid requirement
Authors: Doucet Jay Joseph , Ferrada Paula , Murthi Sarah , Nirula Ram , Edwards Sara , Cantrell Emily , Han Jinfeng , Haase Daniel , Singleton Andrew , Birkas Yekaterina , Casola Giovanna , Coimbra Raul
Published: November 2019

BACKGROUND

Identification of occult hypovolemia in trauma patients is difficult. We hypothesized that in acute trauma patients, the response of ultrasound-measured minimum inferior vena cava diameter (IVCDMIN), IVC Collapsibility Index (IVCCI), minimum internal jugular diameter (IJVDMIN) or IJV Collapsibility Index (IJVCI) after up to 1 hour of fluid resuscitation would predict 24-hour resuscitation intravenous fluid requirements (24FR).

METHODS

An NTI-funded, American Association for the Surgery of Trauma Multi-Institutional Trials Committee prospective, cohort trial was conducted at four Level I Trauma Centers. Major trauma patients were screened for an IVCD of 12 mm or less or IVCCI of 50% or less on initial focused assessment sonographic evaluations for trauma. A second IVCD was obtained 40 minutes to 60 minutes later, after standard-of-care fluid resuscitation. Patients whose second measured IVCD was less than 10 mm were deemed nonrepleted (NONREPLETED), those 10 mm or greater were repleted (REPLETED). Prehospital and initial resuscitation fluids and 24FR were recorded. Demographics, Injury Severity Score, arterial blood gasses, length of stay, interventions, and complications were recorded. Means were compared by ANOVA and categorical variables were compared via χ2. Receiver operating characteristic curves analysis was used to compare the measures as 24FR predictors.

RESULTS

There were 4,798 patients screened, 196 were identified with admission IVCD of 12 mm or IVCCI of 50% or less, 144 were enrolled. There were 86 REPLETED and 58 NONREPLETED. Demographics, initial hemodynamics, or laboratory measures were not significantly different. NONREPLETED had smaller IVCD (6.0 ± 3.7 mm vs. 14.2 ± 4.3 mm,p< 0.001) and higher IVCCI (41.7% ± 30.0% vs. 13.2% ± 12.7%,p< 0.001) but no significant difference in IJVD or IJVCCI. REPLETED had greater 24FR than NONREPLETED (2503 ± 1751 mL vs. 1,243 ± 1,130 mL,p= 0.003). Receiver operating characteristic analysis indicates IVCDMINpredicted 24FR (area under the curve [AUC], 0.74; 95% confidence interval [CI], 0.64–0.84;p< 0.001) as did IVCCI (AUC, 0.75; 95% CI, 0.65–0.85;p< 0.001) but not IJVDMIN(AUC, 0.48; 95% CI, 0.24–0.60;p= 0.747) or IJVCI (AUC, 0.54; 95% CI, 0.42–0.67;p= 0.591).

CONCLUSION

Ultrasound assessed IVCDMINand IVCCI response initial resuscitation predicts 24-hour fluid resuscitation requirements.

LEVEL OF EVIDENCE

Diagnostic tests or criteria, level II.
Detecting direct oral anticoagulants in trauma patients using liquid chromatography–mass spectrometry: A novel approach to medication reconciliation
Authors: Jayaraman Sudha , DeAntonio Jonathan H. , Leichtle Stefan W. , Han Jinfeng , Liebrecht Loren , Contaifer Daniel , Young Caroline , Chou Christopher , Staschen Julia , Doan David , Kumar Naren Gajenthra , Wolfe Luke , Nguyen Tammy , Chenault Gregory , Anand Rahul J. , Bennett Jonathan D. , Ferrada Paula , Goldberg Stephanie , Procter Levi D. , Rodas Edgar B. , Rossi Alan P. , Whelan James F. , Feeser Ventaka Ramana , Vitto Michael J. , Broering Beth , Hobgood Sarah , Mangino Martin , Aboutanos Michel , Bachmann Lorin , Wijesinghe Dayanjan S.
Published: November 2019

BACKGROUND

Accurate medication reconciliation in trauma patients is essential but difficult. Currently, there is no established clinical method of detecting direct oral anticoagulants (DOACs) in trauma patients. We hypothesized that a liquid chromatography–mass spectrometry (LCMS)–based assay can be used to accurately detect DOACs in trauma patients upon hospital arrival.

METHODS

Plasma samples were collected from 356 patients who provided informed consent including 10 healthy controls, 19 known positive or negative controls, and 327 trauma patients older than 65 years who were evaluated at our large, urban level 1 trauma center. The assay methodology was developed in healthy and known controls to detect apixaban, rivaroxaban, and dabigatran using LCMS and then applied to 327 samples from trauma patients. Standard medication reconciliation processes in the electronic medical record documenting DOAC usage were compared with LCMS results to determine overall accuracy, sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of the assay.

RESULTS

Of 356 patients, 39 (10.96%) were on DOACs: 21 were on apixaban, 14 on rivaroxaban, and 4 on dabigatran. The overall accuracy of the assay for detecting any DOAC was 98.60%, with a sensitivity of 94.87% and specificity of 99.05% (PPV, 92.50%; NPV, 99.37%). The assay detected apixaban with a sensitivity of 90.48% and specificity of 99.10% (PPV, 86.36%; NPV 99.40%). There were three false-positive results and two false-negative LCMS results for apixaban. Dabigatran and rivaroxaban were detected with 100% sensitivity and specificity.

CONCLUSION

This LCMS-based assay was highly accurate in detecting DOACs in trauma patients. Further studies need to confirm the clinical efficacy of this LCMS assay and its value for medication reconciliation in trauma patients.

LEVEL OF EVIDENCE

Diagnostic Test, level III.
Severity of hemorrhage and the survival benefit associated with plasma: Results from a randomized prehospital plasma trial
Authors: Anto Vincent P. , Guyette Frank X. , Brown Joshua , Daley Brian , Miller Richard , Harbrecht Brian , Claridge Jeffrey , Phelan Herb , Neal Matthew , Forsythe Raquel , Zuckerbraun Brian , Sperry Jason
Published: November 2019

BACKGROUND

Recent randomized clinical trial evidence demonstrated a survival benefit with the use of prehospital plasma in patients at risk of hemorrhagic shock. We sought to characterize the survival benefit associated with prehospital plasma relative to the blood transfusion volume over the initial 24 hours. We hypothesized that the beneficial effects of prehospital plasma would be most robust in those with higher severity of hemorrhage.

METHODS

We performed a prespecified secondary analysis using data derived from a prospective randomized prehospital plasma trial. Blood component transfusion volumes were recorded over the initial 24 hours. Massive transfusion (MT) was defined a priori as receiving ≥10 units of red cells in 24 hours. We characterized the 30-day survival benefit of prehospital plasma and the need for MT and overall 24-hour red cell transfusion volume utilizing Kaplan-Meier survival analysis and Cox proportional hazard regression.

RESULTS

There were 501 patients included in this analysis with 230 randomized to prehospital plasma with 104 patients requiring MT. Mortality in patients who received MT were higher compared with those that did not (MT vs. NO-MT, 42% vs. 26%, p = 0.001). Kaplan-Meier survival curves demonstrated early separation in the NO-MT subgroup (log rank p = 0.008) with no survival benefit found in the MT group (log rank p = 0.949). Cox regression analysis verified these findings. When 24-hour red cell transfusion was divided into quartiles, there was a significant independent association with 30-day survival in patients who received 4 to 7 units (hazard ratio, 0.33, 95% confidence interval, 0.14–0.80, p = 0.013).

CONCLUSION

The survival benefits of prehospital plasma was demonstrated only in patients with red cell requirements below the transfusion level of MT. Patients who received 4 to 7 units of red cells demonstrated the most robust independent survival benefit attributable to prehospital plasma transfusion. Prehospital plasma may be most beneficial in those patients with moderate transfusion requirements and mortality risk.

LEVEL OF EVIDENCE

Therapeutic, Level I.
Implementation of a Team-Focused High-Performance CPR (TF-HP-CPR) Protocol Within a Rural Area EMS System
Authors: McHone Adam J. , Edsall Jason , Gunn Jennie , Lineberry Everett
Published: November 2019

Team-focused, high-performance cardiopulmonary resuscitation (TF-HP-CPR) improves the return of spontaneous circulation (ROSC) among patients with out-of-hospital cardiac arrest (OHCA) events. In 2010, the American Heart Association began endorsing TF-HP-CPR (Meaney et al., 2013). A rural-area Virginia emergency medical services (EMS) system receives assistant medical oversight from an emergency nurse practitioner (ENP). The ENP is responsible for assisting the physician medical director in promoting continuous quality improvement (QI) within the EMS system. In January 2018, a QI project implemented a TF-HP-CPR protocol. The QI project encompassed the provision of education for EMS personnel about TF-HP-CPR with mock code evaluations. The protocol incorporated a newly designated blind insertion airway device and integrated the routine monitoring of end-tidal carbon dioxide (ETco
2) values. The QI project also introduced postresuscitation attempt report cards that were completed by the team leader at the conclusion of each CPR event. A random 16-week sample of patients with OHCA just before implementation of the QI project was analyzed and compared with patients who experienced an OHCA event within a 16-week period after implementation of the TF-HP-CPR protocol. The preimplementation group had 13 patients compared with 11 patients in the postimplementation group. The rate of ROSC in the preimplementation group was 38.46% compared with 54.55% in the postimplementation group. Although the rate of ROSC increased by 16.09%, the findings were not statistically significant (p = 0.6824) and were perceived to be likely due to the small sample sizes. The implementation of a TF-HP-CPR protocol improved the rate of ROSC among patients with OHCA; however, the findings were not statistically significant. A more extensive study is essential for further evaluation.
Skin and Soft Tissue Infections
Authors: Myers Charlene M. , Miller Jennifer J. , Davis Wesley D.
Published: November 2019

Necrotizing fasciitis is a rapidly progressing soft tissue infection associated with a high rate of mortality. Vibrio vulnificus, a gram-negative bacillus found in warm seawater, is a rare but serious cause of necrotizing fasciitis. Definitive treatment is often delayed because of the vague clinical manifestations associated with the early stages of the disease. Delays in diagnosis are directly associated with increased mortality. Because infection with V. vulnificus progresses more rapidly than other causes of necrotizing fasciitis, patients presenting with soft tissue symptoms and who have been in contact with raw seafood or seawater should be considered at high risk for V. vulnificus-associated necrotizing fasciitis. Health care providers in northern and inland areas must be aware of patients who have recently traveled to regions where V. vulnificus is more common, such as warm coastal regions. Early fasciotomy, debridement, and culture-directed antimicrobial therapy are essential to improve survival. The case presented in this report highlights the importance of early diagnosis of V. vulnificus-associated necrotizing fasciitis.
Nursemaid's Elbow Reduction
Authors: Johnson Melinda K.
Published: November 2019

Nursemaid's elbow, also known as radial head subluxation, is a common childhood orthopedic injury that can easily be diagnosed and reduced by the advanced practice nurse. It is most common in children 1–4 years of age and typically occurs as the result of a pulling mechanism on an outstretched arm. This leads to subluxation of the radial head at the annular ligament. The child subsequently refuses to use the affected arm, leading the caregiver to present for evaluation. This article explores epidemiology, pathophysiology, clinical presentation, reduction techniques, and parent education.