bluuebunny/crossref_metadata_2025 huggingface dataset:
Qualitative Study to Understand Pediatric Hospitalists and Emergency Medicine Physicians’ Perspectives of Clinical Pathways
Authors: O’Hara Kimberly , Tanverdi Melisa , Reich Jennifer , Scudamore D. David , Tyler Amy , Bakel Leigh Anne
Published: March 2020

Introduction:

Healthcare costs are rising, and clinical pathways (CPW) are one means to promote high-value care by standardizing care and improving outcomes without compromising cost or quality. However, providers do not always follow CPW, and our understanding of their perceptions is limited. Our objective was to examine pediatric hospital medicine (PHM) and pediatric emergency medicine (PEM) physician perspectives of CPW.

Methods:

We conducted semistructured, in-depth, one-on-one qualitative interviews with PHM and PEM physicians between February 2017 and August 2017. Interviews were audio-recorded, professionally transcribed, and accuracy verified. Using an inductive analytic strategy, we systematically coded the data to identify themes.

Results:

We interviewed 15 PHM and 15 PEM physicians. These providers identified many benefits and limitations of CPW, which positively or negatively impact resource utilization, communication, education of personnel, patients, and families, as well as practice behaviors and attitudes. Perceived benefits included (1) reduction of unnecessary utilization, (2) standardization of care, (3) improved communication, (4) education of oneself and others, and (5) confidence and validation when actions align with CPW. Limitations of CPW were (1) resource utilization for revisions, updates, and dissemination; (2) “tunnel vision” and cognitive biases; (3) loss of autonomy; (4) prescriptive medicine; (5) information overload; (6) pressure to adhere; and (7) guilt if actions do not align with CPW.

Conclusions:

CPW are tools with advantages and disadvantages that are used and viewed differently by providers. Such insight into how physicians perceive CPW may help to optimize hospital improvement work and enhance high-value care.
Reduction of Central Line-associated Bloodstream Infection Through Focus on the Mesosystem: Standardization, Data, and Accountability
Authors: Mathew Roshni , Simms Alison , Wood Matthew , Taylor Kristine , Ferrari Sarah , Rhein Michelle , Margallo Dionne , Bain Lisa C. , Valencia Amy K. , Bargmann-Losche Jessey , Donnelly Lane F. , Lee Grace M.
Published: March 2020

Introduction:

Efforts to reduce central line-associated bloodstream infection (CLABSI) rates require strong microsystems for success. However, variation in practices across units leads to challenges in ensuring accountability. We redesigned the organization’s mesosystem to provide oversight and alignment of microsystem efforts and ensure accountability in the context of the macrosystem. We implemented an A3 framework to achieve reductions in CLABSI through adherence to known evidence-based bundles.

Methods:

We conducted this CLABSI reduction improvement initiative at a 395-bed freestanding, academic, university-affiliated children’s hospital. A mesosystem-focused A3 emphasized bundle adherence through 3 key drivers (1) practice standardization, (2) data transparency, and (3) accountability. We evaluated the impact of this intervention on CLABSI rates during the pre-intervention (01/15-09/17) and post-intervention (07/18–06/19) periods using a Poisson model controlling for baseline trends.

Results:

Our quarterly CLABSI rates during the pre-intervention period ranged from 1.0 to 2.3 CLABSIs per 1,000 central line-days. With the mesosystem in place, CLABSI rates ranged from 0.4 to 0.7 per 1,000 central line days during the post-intervention period. Adjusting for secular trends, we observed a statistically significant decrease in the post versus pre-intervention CLABSI rate of 71%.

Conclusion:

Our hospital-wide CLABSI rate declined for the first time in many years after the redesign of the mesosystem and a focus on practice standardization, data transparency, and accountability. Our approach highlights the importance of alignment across unit-level microsystems to ensure high-fidelity implementation of practice standards throughout the healthcare-delivery system.
Reliable approaches to extract high-integrity RNA from skin and other pertinent tissues used in pain research
Authors: LoCoco Peter M. , Boyd Jacob T. , Espitia Olaya Claudia M. , Furr Ashley R. , Garcia Dawn K. , Weldon Korri S. , Zou Yi , Locke Erin , Tobon Alejandro , Lai Zhao , Ruparel Shivani B. , Ruparel Nikita B. , Hargreaves Kenneth M.
Published: March 2020

Introduction:

Comprehensive mRNA sequencing is a powerful tool for conducting unbiased, quantitative differential gene expression analysis. However, the reliability of these data is contingent on the extraction of high-quality RNA from samples. Preserving RNA integrity during extraction can be problematic, especially in tissues such as skin with dense, connective matrices and elevated ribonuclease expression. This is a major barrier to understanding the influences of altered gene expression in many preclinical pain models and clinical pain disorders where skin is the site of tissue injury.

Objective:

This study developed and evaluated extraction protocols for skin and other tissues to maximize recovery of high-integrity RNA needed for quantitative mRNA sequencing.

Methods:

Rodent and human tissue samples underwent one of the several different protocols that combined either RNA-stabilizing solution or snap-freezing with bead milling or cryosectioning. Indices of RNA integrity and purity were assessed for all samples.

Results:

Extraction of high-integrity RNA is highly dependent on the methods used. Bead-milling skin collected in RNA-stabilizing solution resulted in extensive RNA degradation. Snap-freezing in liquid nitrogen was required for skin and highly preferable for other tissues. Skin also required cryosectioning to achieve effective penetration of RNA-stabilizing solution to preserve RNA integrity, whereas bead milling could be used instead with other tissues. Each method was reproducible across multiple experimenters. Electrophoretic anomalies that skewed RNA integrity value assignment required manual correction and often resulted in score reduction.

Conclusion:

To achieve the potential of quantitative differential gene expression analysis requires verification of tissue-dependent extraction methods that yield high-integrity RNA.
Prevalence of Peyronie and Ledderhose Diseases in a Series of 730 Patients with Dupuytren Disease
Authors: Mohede Daan C.J. , Riesmeijer Sophie A. , de Jong Igle Jan , Werker Paul M.N. , van Driel Mels F.
Published: March 2020

Background:

Dupuytren, Peyronie, and Ledderhose diseases are related fibroproliferative disorders characterized by abnormalities in the connective tissue of the palm of the hand, the tunica albuginea of the penis, and the sole of the foot, respectively. Concomitant prevalence rates of these diseases have only been described in a few small populations. This article aims to report on a large population and to raise awareness in surgeons treating Dupuytren disease for concurring related fibroproliferative disorders.

Methods:

Patients diagnosed as having Dupuytren disease were recruited from outpatient clinics in the northern part of the Netherlands from 2007 to 2016. Questionnaires concerning demographics, clinical characteristics, the coexistence of Ledderhose and/or Peyronie diseases, and other factors were filled in by the participants and by plastic surgeons.

Results:

For 730 men with Dupuytren disease, the surgeons’ reported prevalence rate of Peyronie disease was 7.8 percent and of Ledderhose disease was 16.1 percent. The participants themselves reported prevalence rates of 8.8 percent for Peyronie disease and of 22.0 percent for Ledderhose disease.

Conclusions:

In the Dupuytren patient cohort, the prevalence of Peyronie disease was lower than that described in the literature. The prevalence of Ledderhose disease corresponded with the rates from the literature. However, both were underreported by plastic surgeons, which calls for a rise in awareness, recognition, and referral to a urologist when the conditions are bothersome or symptomatic.
Factors Associated with Primary and Secondary Amputation following Limb-Threatening Upper Extremity Trauma
Authors: Nawijn Femke , Westenberg Ritsaart F. , Langhammer Chris G. , Chen Neal C. , Eberlin Kyle R.
Published: March 2020

Background:

The aim of this study was to assess the factors associated with primary and secondary amputation in patients with limb-threatening trauma to the upper extremity, describe the incidence of these injuries, and describe the procedures involved in the treatment of these difficult injuries.

Methods:

A retrospective study of 49 cases (in 47 patients) with acute limb-threatening trauma of the upper extremity proximal to the carpometacarpal joint level treated with either amputation or limb salvage was performed in two urban level I trauma centers between January of 2001 and January of 2018.

Results:

Bivariate analysis demonstrated that cases of primary amputation more frequently had a higher Injury Severity Score, higher Abbreviated Injury Scale score, more proximal fractures, more severe muscle injuries, and a larger number of major nerve injuries. Secondary amputation, compared with limb salvage, was more frequently performed in patients who were younger, in cases with a higher Injury Severity Score, where there was more proximal soft-tissue injury, in case of nonsharp mechanism of injury, and in cases that required local flap procedures for wound closure. The authors found a yearly incidence of 62 cases of acute limb-threatening upper extremity trauma per 100,000 trauma admissions.

Conclusions:

Multiple factors influence the surgical decision to perform primary amputation or to attempt a salvage procedure following limb-threatening upper extremity trauma. Knowing which patients will have the most favorable outcomes of a salvage procedure is important, because salvage procedures impose a greater burden on the health care system and the patient, even more so in the case of secondary amputation.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, III.
Long-Term Follow-Up on Bone Stability and Complication Rate after Monobloc Advancement in Syndromic Craniosynostosis
Authors: Raposo-Amaral Cassio Eduardo , Denadai Rafael , Zanco Guilherme Luis , Ghizoni Enrico , Raposo-Amaral Cesar Augusto
Published: March 2020

Background:

Monobloc advancement is a complex procedure used to treat patients with syndromic craniosynostosis. Studies directly addressing the long-term stability of monobloc advancement with distraction osteogenesis are underreported in the literature. The objectives of this study were to assess 5-year midface bone stability following monobloc advancement performed on patients with syndromic craniosynostosis, identify risk factors for relapse, and present strategies for prevention and management of complications.

Methods:

An observational retrospective study was performed on consecutive patients with Apert, Crouzon, or Pfeiffer syndrome (n = 23) who underwent monobloc advancement using distraction osteogenesis between 1994 and 2013. A total of 130 lateral cephalograms were used to assess both long-term stability after monobloc advancement with distraction osteogenesis and risk factors for relapse. All serious complications were identified and recorded. The analysis of variance test was used to assess horizontal relapse of the midface and mandibular plane.

Results:

Cephalometric analysis revealed long-term stability of frontofacial advancement using distraction osteogenesis, regardless of the presence of tested variables. Serious complications arising from monobloc advancement using distraction osteogenesis included cerebrospinal fluid leakage in six patients (26 percent), accompanying meningitis in two patients (8.7 percent), seizures in seven patients (30.4 percent), and impaired visual acuity in one eye of one patient (4.3 percent).

Conclusion:

Frontofacial monobloc advancement with distraction osteogenesis provides long-term midface bone stability.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Practical Things You Should Know about Wound Healing and Vacuum-Assisted Closure Management
Authors: Singh Devinder , Chopra Karan , Sabino Jennifer , Brown Emile
Published: March 2020

Learning Objectives:

After reading this article, the participant should be able to: 1. Understand the basics of negative-pressure wound therapy and practical uses of various vacuum-assisted closure dressings. 2. Understand the mechanisms of action of negative-pressure therapies and other important adjuncts, such as perfusion imaging. 3. Discuss the evidence for hyperbaric oxygen therapy in wound care.

Wound healing requires creating an environment that supports the healing process while decreasing inflammation and infection. Negative-pressure wound therapy has changed the way physicians manage acute and chronic wounds for more than 20 years. It contracts wound edges, removes exudate, including inflammatory and infectious material, and promotes angiogenesis and granulation tissue formation. These effects have been consistently demonstrated in multiple animal and human randomized controlled trials. Recent innovations that include instillation therapy and closed incision have further increased our arsenal against difficult-to-treat wounds and incisions at high risk of complications. Instillation of topical wound solutions allows physicians to cleanse the wound without return to the operating room, resulting in fewer debridements, shorter hospital stays, and faster time to wound closure. Other concepts have yielded negative-pressure therapy on top of closed surgical incisions, which holds incision edges together, reduces edema, promotes angiogenesis, and creates a barrier to protect incisions during the critical healing period, thereby reducing surgical-site complications, especially infection. Other practical adjuncts to the modern-day treatment of acute and chronic wounds include indocyanine green angiography, which allows real-time assessment of perfusion, and hyperbaric oxygen treatment, which has been suggested to augment healing in acute, chronic, specifically diabetic foot ulcers and radiation-related wounds.
Oncoplastic Procedures in Preparation for Nipple-Sparing Mastectomy and Autologous Breast Reconstruction: Controlling the Breast Envelope
Authors: Momeni Arash , Kanchwala Suhail , Sbitany Hani
Published: March 2020

Background:

Nipple-sparing mastectomy has been associated with superior aesthetic outcomes and oncologic safety. However, traditional contraindications, such as breast ptosis/macromastia, have excluded a large number of patients. The purpose of this study was to determine whether a staged approach would expand the indications for nipple-areolar complex preservation and permit greater control over nipple-areolar complex position and skin envelope following autologous reconstruction.

Methods:

A retrospective analysis was conducted of female patients with a diagnosis of breast cancer or BRCA mutation with grade 2 or 3 ptosis and/or macromastia who underwent bilateral (oncoplastic) reduction/mastopexy (stage 1) followed by bilateral nipple-sparing mastectomy with immediate reconstruction with free abdominal flaps (stage 2). The authors were specifically interested in the incidence of mastectomy skin necrosis and nipple-areolar complex necrosis and malposition following stage 2.

Results:

Sixty-one patients with a mean age of 45.1 years (range, 28 to 62 years) and mean body mass index of 32.6 kg/m2 (range, 23.4 to 49.0 kg/m2) underwent reconstruction with 122 flaps. The mean interval between stage 1 and 2 was 16.9 weeks (range, 3 to 31 weeks). Clear margins were obtained in all cases of invasive cancer and in situ disease following stage 1. Complications following stage 2 included partial nipple-areolar complex necrosis (n = 5, 8.2 percent), complete nipple-areolar complex necrosis (n = 4, 6.6 percent), nipple-areolar complex malposition (n = 1, 1.6 percent), and mastectomy skin necrosis (n = 4, 6.6 percent). No flap loss was noted in this series.

Conclusion:

Patients with moderate to severe breast ptosis and/or macromastia who wish to undergo mastectomy with reconstruction can be offered nipple-sparing approaches safely if a staged algorithm is implemented.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Toward Development of the Delayed Tolerance Induction Protocol for Vascularized Composite Allografts in Nonhuman Primates
Authors: Lellouch Alexandre G. , Ng Zhi Yang , Rosales Ivy A. , Schol Ilse M. , Leonard David A. , Gama Amon-Ra , Colvin Robert B. , Lantieri Laurent A. , Randolph Mark A. , Cetrulo Curtis L.
Published: March 2020

Background:

Transplantation of vascularized composite allografts is limited mainly by the need for life-long immunosuppression. The consequent side effects and looming specter of chronic rejection portend eventual allograft loss. Development of tolerogenic protocols is thus of utmost importance to the field of vascularized composite allograft transplantation.

Methods:

With a modified delayed tolerance induction protocol, 10 cynomolgus macaques received hand (n = 2) or face vascularized composite allografts across both full and haploidentical major histocompatibility complex barriers before donor bone marrow transplantation at a later date. Protocol and for-cause allograft skin biopsies were performed for immunohistochemical analysis and analysis of donor-recipient leukocyte contribution; mixed chimerism in peripheral blood and in vitro immune responses were assessed serially.

Results:

Before bone marrow transplantation, maintenance immunosuppression for 4 months led to lethal complications, including posttransplant lymphoproliferative disorder (in two of four recipients), which necessitated early study termination. Shortening the maintenance period to 2 months was clinically relevant and allowed all subsequent subjects (n = 6) to complete the delayed tolerance induction protocol. Acute rejection developed within the first 2 to 4 weeks after transplantation, with corresponding near-complete turnover of allograft leukocytes from donor to recipient origin, but donor-specific antibodies remained negative. After bone marrow transplantation, mixed chimerism failed to develop, although carboxyfluorescein succinimidyl ester mixed lymphocyte reaction demonstrated generalized unresponsiveness. However, the accrual of subsequent rejection episodes eventually culminated in graft vasculopathy and irreversible allograft loss.

Conclusions:

Despite the various advantages of the delayed tolerance induction protocol, it failed to reliably induce mixed chimerism and thus immunologic tolerance to vascularized composite allografts, given currently available immunosuppression treatment options. Ongoing work shows promise in overcoming these limitations.
Simultaneous Ventral Hernia Repair and Panniculectomy: A Systematic Review and Meta-Analysis of Outcomes
Authors: Sosin Michael , Termanini Kareem M. , Black Cara K. , Thanik Vishal , Saadeh Pierre B. , Levine Jamie P.
Published: March 2020

Background:

Simultaneous ventral hernia repair and panniculectomy (SVHRP) is a procedure that is more commonly being offered to patients with excess skin and subcutaneous tissue in need of a ventral hernia repair; however, there are concerns about surgical-site complications and uncertainty regarding the durability of repair. SVHRP outcomes vary within the literature. This study assessed the durability, complication profile, and safety of SVHRP through a large data-driven repository of SVHRP cases.

Methods:

The current SVHRP literature was queried using the MEDLINE, PubMed, and Cochrane databases. Predefined selection criteria resulted in 76 relevant titles yielding 16 articles for analysis. Meta-analysis was used to analyze primary outcomes, identified as surgical-site occurrence and hernia recurrence. Secondary outcomes included review of techniques used and systemic complications, which were analyzed with pooled weighted mean analysis from the collected data.

Results:

There were 917 patients who underwent an SVHRP (mean age, 52.2 ± 7.0 years; mean body mass index, 36.1 ± 5.8 kg/m2; mean pannus weight, 3.2 kg). The mean surgical-site occurrence rate was 27.9 percent (95 percent CI, 15.6 to 40.2 percent; I
2 = 70.9 percent) and the mean hernia recurrence rate was 4.9 percent (95 percent CI, 2.4 to 7.3 percent; I
2 = 70.1 percent). Mean follow-up was 17.8 ± 7.7 months. The most common complications were superficial surgical-site infection (15.8 percent) and seroma formation (11.2 percent). Systemic complications were less common (7.8 percent), with a thromboembolic event rate of 1.2 percent. The overall mortality rate was 0.4 percent.

Conclusions:

SVHRP is associated with a high rate of surgical-site occurrence, but surgical-site infection seems to be less prominent than previously anticipated. The low hernia recurrence rate and the safety of this procedure support its current implementation in abdominal wall reconstruction.
Cranial Fossa Volume and Morphology Development in Apert Syndrome
Authors: Lu Xiaona , Forte Antonio Jorge , Wilson Alexander , Steinbacher Derek M. , Alperovich Michael , Alonso Nivaldo , Persing John A.
Published: March 2020

Background:

Apert syndrome causes normal or enlarged intracranial volume overall as patients grow. This study aimed to trace the segmental anterior, middle, and posterior cranial fossae volume and structural morphology in these patients, to help discern a more focused and individualized surgical treatment plan for patients with Apert syndrome.

Methods:

This study included 82 preoperative computed tomographic scans (Apert, n = 32; control, n = 50) divided into five age-related subgroups. The scans were measured using image processing and three-dimensional modeling software.

Results:

The middle cranial fossa volume was increased and was the earliest change noted. It was increased by 45 percent (p = 0.023) compared with controls before 6 months of age and remained increased into adulthood (161 percent, p = 0.016), with gradually increasing severity. The anterior and posterior cranial fossae volumes also increased, by 35 percent (p = 0.032) and 39 percent (p = 0.007), respectively. Increased depth of cranial fossae contributed most to the increase in volumes of patients with Apert syndrome, with correlation coefficients of 0.799, 0.908, and 0.888 for anterior, middle, and posterior cranial fossa, respectively. The intracranial volume was increased 12 percent (p = 0.098) across the entire test age range (0 to 26 years old), but only had statistical significance during the age range of 6 to 18 years (22 percent, p = 0.001).

Conclusions:

Malformation of the middle cranial fossa is an early, perhaps the initial, pivotal cranial morphologic change in Apert syndrome. Increased cranial fossae depth is an inherent characteristic of the maldevelopment. Normalization of cranial volume and circumference overall may not achieve a normal skull structure, as it does not correct regional craniocerebral disproportion.
Lumbar Flap versus the Gold Standard: Comparison to the DIEP Flap
Authors: Opsomer Dries , Vyncke Tom , Depypere Bernard , Stillaert Filip , Blondeel Phillip , Van Landuyt Koenraad
Published: March 2020

Background:

The lumbar artery perforator flap is an excellent free flap for breast reconstruction whenever the deep inferior epigastric perforator (DIEP) flap is not an option. The main indication is a lack of abdominal bulk, often seen in young BRCA-positive women seeking prophylactic amputation and immediate reconstruction.

Methods:

Between October of 2010 and July of 2016, a total of 661 free flap breast reconstructions were performed. The authors retrospectively analyzed patient demographics, perioperative parameters, and secondary corrections.

Results:

Seventy-six lumbar artery perforator flaps were retained and compared with a cohort of 560 DIEP flaps. The average body mass index for lumbar patients was 23.8 kg/m2, with a mean age at operation of 46.3 years. Average body mass index for DIEP patients was 25.2 kg/m2, with a mean age at operation of 48.8 years old. Lumbar artery perforator flap weight was 504 g (range, 77 to 1216 g) on average versus 530 g (range, 108 to 1968 g) for the DIEP flaps. The amount of corrective procedures performed was very similar in both cohorts: 13 percent of the lumbar artery perforator and 12 percent of the DIEP patients underwent no procedures, 62 percent in both groups underwent one procedure, and 25 percent versus 27 percent underwent two or more procedures. Lipofilling was performed in 48 percent of lumbar artery perforator flaps compared with 57 percent of the DIEP flaps (p = 0.14). Mean volume injected was 98.0 cc and 125.1 cc for lumbar artery perforator and DIEP flaps, respectively (p = 0.071).

Conclusions:

The lumbar flap is a good alternative whenever a DIEP flap is not possible. Bilateral autologous reconstruction is possible even in very thin patients, and secondary corrections are comparable to those for the DIEP.
Facial Gender Confirmation Surgery: A Protocol for Diagnosis, Surgical Planning, and Postoperative Management
Authors: Capitán Luis , Gutiérrez Santamaría Javier , Simon Daniel , Coon Devin , Bailón Carlos , Bellinga Raúl J. , Tenório Thiago , Capitán-Cañadas Fermín
Published: March 2020

During the past 10 years, academic publications that address facial feminization surgery have largely examined the technical aspects of the different surgical procedures involved and clinical evaluations of postoperative results. This Special Topic article focuses on aspects that are underdeveloped to date but useful with regard to taking the correct therapeutic approach to transgender patients who are candidates for facial gender confirmation surgery. The authors propose a protocolized sequence, from the clinical evaluation to the postoperative period, based on a sample size of more than 1300 trans feminine patients, offering facial gender confirmation surgery specialists standardized guidelines to handle their patients’ needs in a way that is both objective and reproducible.
Rhinoplasty Using Three-Dimensional Analysis and Simulation
Authors: Singh Anusha , Maniskas Seija A. , Bruckman Karl C. , Steinbacher Derek M.
Published: March 2020

Treatment of nasal deformity and obstruction requires analysis, planning, and precise execution of rhinoplasty techniques. When performed well, rhinoplasty is a powerful tool for achieving appealing nasal morphology and optimizing function. This article aims to highlight an open approach to septorhinoplasty using a number of techniques that are preferred by the senior author (D.M.S.) to successfully correct a congenital nasal deformity and deviated septum.
Photographic and Video Deepfakes Have Arrived: How Machine Learning May Influence Plastic Surgery
Authors: Crystal Dustin T. , Cuccolo Nicholas G. , Ibrahim Ahmed M. S. , Furnas Heather , Lin Samuel J.
Published: March 2020

Advances in computer science and photography not only are pervasive but are also quantifiably influencing the practice of medicine. Recent progress in both software and hardware technology has translated into the design of advanced artificial neural networks: computer frameworks that can be thought of as algorithms modeled on the human brain. In practice, these networks have computational functions, including the autonomous generation of novel images and videos, frequently referred to as “deepfakes.” The technological advances that have resulted in deepfakes are readily applicable to facets of plastic surgery, posing both benefits and harms to patients, providers, and future research. As a specialty, plastic surgery should recognize these concepts, appropriately discuss them, and take steps to prevent nefarious uses. The aim of this article is to highlight these emerging technologies and discuss their potential relevance to plastic surgery.
Development and Validation of the Data Instrument for Surgical Global Outreach
Authors: Nasser Jacob S. , Chung Kevin C.
Published: March 2020

Countless efforts have been made by global surgery outreach organizations to provide care to individuals in low- and middle-income countries; however, there is a paucity of data on these interventions. The authors created the Data Instrument for Surgical Global Outreach to collect basic program, cost, and clinical data on surgical outreach efforts using the literature and the experience of our team. The authors performed a two-round modified Delphi technique to build content validity on the instrument and establish consensus. Experts engaged in global health or global surgery as a health care provider, researcher, or policymaker participated in the validation. In addition, the authors calculated Cronbach’s alpha to determine the degree of agreement among experts. A total of 22 experts in global health participated in the validation of the data tool. Changes were made to reword, combine, remove, add, clarify, and simplify data points. There was a unanimous decision to accept the revised data collection instrument among the experts after the second Delphi round. Cronbach’s alpha was 0.86 for the first round and 0.95 for the second round, indicating a high degree of internal consistency. The global surgery outreach community must define a set of strategies to collect more robust data on surgical outreach efforts to low- and middle-income countries. Such data will permit policymakers to identify shortfalls in programs and researchers to pursue sustainable treatment modalities and processes of care. Quality collaboratives for surgical outreach organizations may serve as a tool to overcome variation, reduce cost, and improve the quality of care for patients.
A Simplified Approach to Nasal Tip Shaping: The Five-Suture Technique
Authors: Cochran C. Spencer , Afrooz Paul N.
Published: March 2020

Techniques for nasal tip shaping have evolved from destructive to nondestructive techniques. These techniques have proven to be effective, yet they are often applied incrementally and require repeated intraoperative evaluation and manipulation to assess their efficacy. We describe a simple, effective, and reliable five-suture technique to achieve consistent results in tip shaping based on previously described ideals for nasal tip aesthetics
Facial Aging: A 54-Year, Three-Dimensional Population Study
Authors: Lambros Val
Published: March 2020

Background:

There is no accurate visual representation of the aging process, one that visually shows how the shape of the face changes with age in a rigorous and three-dimensional way.

Method:

A total of 594 subjects were studied. Two hundred eighty three-dimensional images of male faces and 305 three-dimensional images of female faces were categorized into “young” and “old” groups by sex. The mean age of the younger men was 33.6, and the mean age of the older men was 70.3. The mean age of the younger women was 24, and the mean age of the older women was 74. Landmarks were placed on all images, and in the male groups the distances between these landmarks were analyzed with an independent t test to compare the differences between age groups. These measurements were then used to develop validated three-dimensional averaged models of the different groups. These averages were formed into comparative image transitions and studied.

Results:

The comparative image transitions of the average young and old faces in this series show accurate and registered age and shape changes. The faces of men and women age in almost identical ways. The images imply that the aging process is not solely along the surface planes of the face but at right angles to it, that is, many of the changes are in and out, not up and down. Males and females seem to age in quantitatively similar ways.

Conclusions:

These images are unique in the facial aging literature. The main points and conclusions of this article are derived from and only visible in the comparative image transitions included in this article as supplemental digital content. The reader is encouraged to study them because the side-by-side still images do not show the changes.
Standardized Surgical Primary Repair for Burst Abdomen Reduces the Risk of Fascial Redehiscence
Authors: Jensen Thomas K. , Gögenur Ismail , Tolstrup Mai-Britt
Published: March 2020

Objective:

To determine whether a standardized surgical primary repair for burst abdomen could lower the rate of fascial redehiscence.

Summary Background Data:

Burst abdomen after midline laparotomy is associated with increased morbidity and mortality. The surgical treatment is poorly investigated but known for a poor outcome with high rates of re-evisceration (redehiscence).

Methods:

This study was a single-center, interventional study comparing rates of fascial redehiscence after surgery for burst abdomen in a study cohort (July 2014–April 2019) to a historical cohort (January 2009–December 2013). A standardized surgical strategy was introduced for burst abdomen: The abdominal wall was closed using a slowly absorbable running suture in a mass closure technique with “large bites” of 3 cm in “small steps” of 5 mm, in an approximate wound–suture ratio of 1:10. Demographics, comorbidities, preceding type of surgery, and surgical technique were registered. The primary outcome was fascial redehiscence. The secondary outcome was 30- and 90-day mortality.

Results:

The study included 186 patients with burst abdomen (92 patients in the historical cohort vs 94 patients in the study cohort). No difference in sex, performance status, comorbidity, or body mass index was found. In 77% of the historical cohort and 80% of the study cohort, burst abdomen occurred after emergency laparotomy (P = 0.664). The rate of redehiscence was reduced from 13% (12/92 patients) in the historical cohort to 4% (4/94 patients) in the study cohort (P = 0.033). There was no difference in 30- or 90-day mortality.

Conclusion:

Standardized surgical primary repair for burst abdomen reduced the rate of fascial redehiscence.
A Call to Action: Black/African American Women Surgeon Scientists, Where are They?
Authors: Berry Cherisse , Khabele Dineo , Johnson-Mann Crystal , Henry-Tillman Ronda , Joseph Kathie-Ann , Turner Patricia , Pugh Carla , Fayanju Oluwadamilola M. , Backhus Leah , Sweeting Raeshell , Newman Erika A. , Oseni Tawakalitu , Hasson Rian M. , White Cassandra , Cobb Adrienne , Johnston Fabian M. , Stallion Anthony , Karpeh Martin , Nwariaku Fiemu , Rodriguez Luz Maria , Jordan Andrea Hayes
Published: March 2020

Objective:

To determine the representation of Black/AA women surgeons in academic medicine among U.S. medical school faculty and to assess the number of NIH grants awarded to Black/AA women surgeon-scientists over the past 2 decades.

Summary of Background Data:

Despite increasing ethnic/racial and sex diversity in U.S. medical schools and residencies, Black/AA women have historically been underrepresented in academic surgery.

Methods:

A retrospective review of the Association of American Medical Colleges 2017 Faculty Roster was performed and the number of grants awarded to surgeons from the NIH (1998–2017) was obtained. Data from the Association of American Medical Colleges included the total number of medical school surgery faculty, academic rank, tenure status, and department Chair roles. Descriptive statistics were performed.

Results:

Of the 15,671 U.S. medical school surgical faculty, 123 (0.79%) were Black/AA women surgeons with only 11 (0.54%) being tenured faculty. When stratified by academic rank, 15 (12%) Black/AA women surgeons were instructors, 73 (59%) were assistant professors, 19 (15%) were associate professors, and 10 (8%) were full professors of surgery. Of the 372 U.S. department Chairs of surgery, none were Black/AA women. Of the 9139 NIH grants awarded to academic surgeons from 1998 and 2017, 31 (0.34%) grants were awarded to fewer than 12 Black/AA women surgeons.

Conclusion:

A significant disparity in the number of Black/AA women in academic surgery exists with few attaining promotion to the rank of professor with tenure and none ascending to the role of department Chair of surgery. Identifying and removing structural barriers to promotion, NIH grant funding, and academic advancement of Black/AA women as leaders and surgeon-scientists is needed.
A Single Preoperative Dose of Tranexamic Acid Reduces Perioperative Blood Loss
Authors: Heyns Mieke , Knight Paige , Steve Anna K. , Yeung Justin K.
Published: March 2020

Objective:

To review the efficacy and safety of a single dose of intravenous tranexamic acid (TXA) given preoperatively.

Summary Background Data:

TXA is a synthetic antifibrinolytic that has been used in various surgical disciplines to reduce blood loss, blood transfusions, ecchymosis, and hematoma formation. However, there is no universal standard on the most effective dose and route of TXA administration, limiting its routine use in many centers. This study evaluates the current evidence for the efficacy and safety of a single preoperative dose of TXA on surgical blood loss in all surgical disciplines.

Methods:

With the guidance of a research librarian, in accordance with the Cochrane Handbook Medline, Cochrane Central and Embase were searched in November 2018. Search terms included “Tranexamic Acid” AND “Intravenous,” with studies limited to randomized controlled trails in adult humans. Two independent reviewers and an arbitrator assessed articles for inclusion. Criteria included a single preoperative bolus dose of intravenous TXA, surgical patients, and intraoperative blood loss measurement or perioperative blood loss up to 24 hours postsurgery. Quality assessment was done using the Cochrane Collaboration risk-of-bias tool by 2 reviewers. Statistical analysis was carried out using Cochrane Review Manager 5.3. The primary outcome was surgical blood loss. Secondary outcomes included venous thromboembolic complications, transfusion requirements, and dosing.

Results:

A total of 1906 articles were screened, 57 met inclusion criteria. The majority of included studies were orthopedic (27), followed by obstetric and gynecological (16), oral maxillofacial and otolaryngology (10), cardiac (3), and 1 plastic surgery study focusing on acute burn reconstruction. Across all surgical specialties (n = 5698), the perioperative estimated blood loss was lower in patients receiving TXA, with a standard mean difference of −153.33 mL (95% CI = −187.79 to −118.87). Overall, surgical patients with TXA had a 72% reduced odds of transfusion (odds ratio = 0.28 [95% CI = 0.22–0.36]). The most frequently used dose of TXA was 15 mg/kg. There was no difference in the incidence of venous thromboembolic events between TXA and control groups.

Conclusions:

While there is a growing body of evidence to support benefits of perioperative TXA use, this is the first meta-analysis to identify the efficacy and safety of a single preoperative dose of IV TXA. The potential implications for expanding the use of preoperative TXA for elective day surgery procedures is substantial. Preoperative intravenous TXA reduced perioperative blood loss and transfusion requirements in a variety of surgical disciplines without increasing the risk of thromboembolic events. Therefore, it should be considered for prophylactic use in surgery to reduce operative bleeding.
Mixed Reality and 3D Printed Models for Planning and Execution of Face Transplantation
Authors: Cho Ki-Hyun , Papay Francis A. , Yanof Jeff , West Karl , Bassiri Gharb Bahar , Rampazzo Antonio , Gastman Brian , Schwarz Graham S.
Published: March 2020

Objective:

The aim of this study was to evaluate a novel holographic craniofacial surgical planning application and its implementation throughout the planning and operative stages of facial transplantation by performing a critical analysis of comparative utility, cost, and limitations of MR and 3D printing.

Summary of Background Data:

Face transplantation is a highly complex form of craniofacial reconstruction requiring significant planning, knowledge of patient-specific spatial relationships, and time-sensitive decision making. Computer-aided 3D modeling has improved efficiency and outcomes of complex craniofacial reconstruction by enabling virtual surgical planning and 3D printed model generation. MR technology can enhance surgical planning, improve visualization, and allow manipulation of virtual craniofacial biomodels within the operative field.

Methods:

Accounting for the time-sensitive nature of face transplantation, a unique, highly coordinated workflow for image acquisition and processing was designed to facilitate rapid holographic rendering and 3D printing. During recent face transplantation, both holographic and 3D printed models were utilized, and the time and cost of fabrication were compared.

Results:

Holographic models required less time and cost for fabrication. They provided both comprehensive visualization of 3D spatial relationships and novel means to perform VSP and virtual face transplantation by interacting with and manipulating patient-specific, anatomic holograms.

Conclusion:

Time efficiency, low-cost biomodel production, provision of unlimited preoperative surgical rehearsal, and potential for intraoperative surgical guidance makes holographic VSP and MR highly promising technology for use in complex craniofacial surgery.
The Risk of Going Small
Authors: Wong Tiffany Cho-Lam , Fung James Y. Y. , Cui Tracy Y. S. , Sin S. L. , Ma K. W. , She Brian W. H. , Chan Albert C. Y. , Chok Kenneth S. H. , Dai Jeff W. C. , Cheung Tan-To , Lo Chung-Mau
Published: March 2020

Objective:

The aim of this study was to determine the outcomes of living donor liver transplantation (LDLT) according to various graft-to-recipient weight ratio (GRWR).

Background:

The standard GRWR in LDLT is >0.8%. Our center accepted predicted GRWR ≥0.6% in selected patients.

Methods:

Data from patients who underwent LDLT from 2001 to 2017 were included. Patients were stratified according to actual GRWR (Group 1:GRWR ≤0.6%; Group 2: 0.6%0.8%).

Results:

There were 545 LDLT (group 1 = 39; group 2 = 159; group 3 = 347) performed. Pretransplant predicted GRWR showed good correlation to actual GRWR (R
2 = 0.834) and these figures differed within a ± 10%margin (P = 0.034) using an equivalence test. There were more left lobe grafts in group 1 (33.3%) than group 2 (10.7%) and 3 (2.9%). Median donor age was <35 years and steatosis >10% was rare.

There was no difference in postoperative complication, vascular and biliary complication rate between groups. Over one-fifth (20.5%) of group 1 patients required portal flow modulation (PFM) and was higher than group 2 (3.1%) and group 3 (4%) (P = 0.001). Twenty-six patients developed small-for-size syndrome (SFSS): 5 of 39 (12.8%) in group 1 and 21 of 159 (13.2%) in group 2 and none in group 3 (P < 0.001). There were 2 hospital mortalities; otherwise, the remaining patients [24/26 (92.3%)] survive with a functional liver graft. The 5-year graft survival rates were 85.4% versus 87.8% versus 84.7% for group 1, 2, and 3, respectively (P = 0.718). GRWR did not predict worse survivals in multivariable analysis.

Conclusions:

Graft size in LDLT can be lowered to 0.6% after careful recipient selection, with low incidence of SFSS and excellent outcomes. Accurate graft weight prediction, donor-recipient matching, meticulous surgical techniques, appropriate use of PFM, and vigilant perioperative care is important to the success of such approach.
Heavyweight Mesh Is Superior to Lightweight Mesh in Laparo-endoscopic Inguinal Hernia Repair
Authors: Bakker Wouter J. , Aufenacker Theo J. , Boschman Julitta S. , Burgmans Josephina P. J.
Published: March 2020

Objective:

This meta-analysis and trial sequential analysis aims to provide an update on the available randomized controlled trials (RCTs) and recommendations on using lightweight mesh (LWM) or heavyweight mesh (HWM) in laparo-endoscopic inguinal hernia repair.

Background:

LWM might reduce chronic pain through improved mesh flexibility and less fibrosis formation. However, in laparo-endoscopic repair chronic pain is already rare and LWM raise concerns of higher recurrence rates.

Methods:

A literature search was conducted in May 2019 in MEDLINE, Embase, and the Cochrane library for RCTs that compared lightweight (≤50 g/m2) and heavyweight (>70 g/m2) mesh in patients undergoing laparo-endoscopic surgery for uncomplicated inguinal hernias. Outcomes were recurrences, chronic pain, and foreign-body sensation. The level of evidence was assessed using GRADE. Risk ratios (RR) and 95% confidence intervals (CI) were calculated by random effect meta-analyses. Trial-sequential-analyses were subsequently performed.

Results:

Twelve RCTs, encompassing 2909 patients (LWM 1490 vs HWM 1419), were included. The follow-up range was 3 to 60 months. Using LWM increased the recurrence risk (LWM 32/1571, HWM 13/1508; RR 2.21; CI 1.14–4.31), especially in nonfixated mesh direct repairs (LWM 13/180, HWM 1/171; RR 7.27; CI 1.33–39.73) and/or large hernia defects. No difference was determined regarding any pain (LWM 123/1362, HWM 127/1277; RR 0.79; CI 0.52–1.20), severe pain (LWM 3/1226, HWM 9/1079; RR 0.38; CI 0.11–1.35), and foreign-body sensation (LWM 100/1074, HWM 103/913; RR 0.94; CI 0.73–1.20).

Conclusion:

HWM should be used in laparo-endoscopic repairs of direct or large inguinal hernias to reduce recurrence rates. LWM provide no benefit in indirect hernias.
Simultaneous Versus Delayed Resection for Initially Resectable Synchronous Colorectal Cancer Liver Metastases
Authors: Boudjema Karim , Locher Clara , Sabbagh Charles , Ortega-Deballon Pablo , Heyd Bruno , Bachellier Philippe , Métairie Sylvie , Paye François , Bourlier Pascal , Adam René , Merdrignac Aude , Tual Christelle , Le Pabic Estelle , Sulpice Laurent , Meunier Bernard , Regimbeau Jean-Marc , Bellissant Eric
Published: March 2020

Objective:

To answer whether synchronous colorectal cancer liver metastases (SLM) should be resected simultaneously with primary cancer or should be delayed.

Summary Background Data:

Numerous studies have compared both strategies. All were retrospective and conclusions were contradictory.

Methods:

Adults with colorectal cancer and resectable SLM were randomly assigned to either simultaneous or delayed resection of the metastases. The primary outcome was the rate of major complications within 60 days following surgery. Secondary outcomes included overall and disease-free survival.

Results:

A total of 105 patients were recruited. Eighty-five patients (39 and 46 in the simultaneous- and delayed-resection groups, respectively) were analyzed. The percentage of major perioperative complications did not differ between groups (49% and 46% in the simultaneous- and delayed-resection groups, respectively, adjusted OR 0.84, 95% CI 0.35–2.01; P = 0.70, logistic regression). Complications rates were 28% and 13% (P = 0.08, χ2 test) at colorectal site and 15% and 17% (P = 0.80, χ2 test) at liver site, in simultaneous- and delayed-resection groups, respectively. In the delayed-resection group, 8 patients did not reach the liver resection stage, and this was due to disease progression in 6 cases. After 2 years, overall and disease-free survival tended to be improved in simultaneous as compared with delayed-resection groups (P = 0.05), a tendency which persisted for OS after a median follow-up of 47 months.

Conclusions:

Complication rates did not appear to differ when colorectal cancer and synchronous liver metastases are resected simultaneously. Delayed resection tended to impair overall survival.