bluuebunny/crossref_metadata_2025 huggingface dataset:
Ex Vivo Model to Decipher the Impact of Extracorporeal Membrane Oxygenation on Beta-lactam Degradation Kinetics
Authors: Leven Cyril , Fillâtre Pierre , Petitcollin Antoine , Verdier Marie-Clémence , Laurent Jérôme , Nesseler Nicolas , Launey Yoann , Tattevin Pierre , Bellissant Eric , Flécher Erwan , Lemaitre Florian
Published: December 2016

Background:

As a consequence of drug sequestration, increase in volume of distribution, or alteration of elimination, extracorporeal membrane oxygenation (ECMO) might lead to inadequate plasma concentrations of vital drugs. The aim of this experimental study was to develop an ex vivo model to better characterize the impact of ECMO procedure on beta-lactam antibiotics pharmacokinetics.

Methods:

Plasma concentrations of cefotaxime, ceftazidime, cefepime, piperacillin, oxacillin, amoxicillin, and ceftriaxone were measured in an ex vivo ECMO circuit primed with whole human blood and compared with controls stored in glass tubes and polyvinyl chloride tubing. Serial blood samples were collected over 48 hours, and the concentrations of beta-lactam antibiotics were quantified using a validated high-performance liquid chromatography assay. The concentrations' decay rate over time was compared between the ECMO circuits and controls using nonlinear mixed-effect modeling.

Results:

Cefotaxime concentrations decreased markedly: 86% of the initial concentration remained after 4 hours and only 21% after 48 hours (P < 0.05 for the comparison in rate of decrease with both glass and polyvinyl chloride controls). There was no difference in the rate of decrease between ECMO circuit and controls for the other beta-lactam antibiotics. The average drug recoveries from the ECMO circuits at 48 hours were as follows: ceftazidime, 73%; cefepime, 67%; piperacillin, 71%; oxacillin, 46%; and amoxicillin, 72%. Concentrations of ceftriaxone remained stable throughout the 48-hour study both in ECMO circuits and in controls.

Conclusions:

Significant losses of cefotaxime were observed, whereas ceftazidime, cefepime, piperacillin, oxacillin, and amoxicillin decrease was moderate and similar to that of the control group, and ceftriaxone concentrations remained unchanged. These results are reassuring for the use of beta-lactam antibiotics in critically ill patients treated with ECMO.
SUBFOVEAL NODULE IN COATS' DISEASE
Authors: Daruich Alejandra L. , Moulin Alexandre P. , Tran Hoai V. , Matet Alexandre , Munier Francis L.
Published: December 2016

Purpose:

To determine the prevalence, clinical characteristics and nature of subfoveal nodules in Coats' disease and the associated impact on the long-term visual outcome.

Methods:

Consecutive cases of Coats' disease with foveal exudation were retrospectively reviewed. The presence of a subfoveal nodule or macular fibrosis was recorded. Clinical characteristics, retinal imaging, and outcome were analyzed by comparative analysis. The histopathological description of an enucleated eye with subfoveal nodule was performed.

Results:

Among 40 patients presenting unilateral Stage 2B or 3A1 Coats' disease, a subfoveal nodule was detected in 21 patients (52.5%). The median follow-up was 4.7 years. Nineteen patients (47.5%) did not present a subfoveal nodule. Three patients (15.8%) without subfoveal nodule and 21 patients (100%) with subfoveal nodule progressed to a macular fibrotic scar (P < 0.0001), and the mean time of macular fibrosis onset was 11.0 ± 2.6 months. Final visual acuity was significantly worse in patients who presented a subfoveal nodule at diagnosis (P = 0.01). Of 18 cases with subfoveal nodule who underwent fluorescein angiography, retinal–retinal anastomosis and neovascularization were detected in 13 (72.2%) and 2 eyes (11.1%), respectively. Histopathological analysis of a subfoveal nodule revealed an aggregate of proteinaceous material including fibrin, spindle cells, macrophages, and pigmented cells.

Conclusion:

The presence of a subfoveal nodule at presentation is a predictive factor for macular fibrosis development and worse visual outcome in patients with Coats' disease. These observations suggest an updated classification introducing two subcategories within Stage 2B: without subfoveal nodule (Stage 2B1) and with subfoveal nodule (Stage 2B2).
LONGITUDINAL MICROPERIMETRY EVALUATION AFTER INTRAVITREAL OCRIPLASMIN INJECTION FOR VITREOMACULAR TRACTION
Authors: Cacciamani Andrea , Gelso Aldo , Simonett Joseph M. , Ripandelli Guido , Pileri Marco , Stirpe Mario , Scarinci Fabio
Published: December 2016

Purpose:

To determine whether improvements in microperimetry testing are associated with anatomic resolution after ocriplasmin treatment in patients with symptomatic vitreomacular adhesion (VMA)/vitreomacular traction and relatively preserved baseline best-corrected visual acuity (BCVA).

Methods:

Patients with vitreomacular traction received a single 125-μg intravitreal ocriplasmin injection and were followed longitudinally for 6 months with optical coherence tomography, BCVA testing, and microperimetry. Visual function changes were compared between eyes with and without VMA resolution on optical coherence tomography.

Results:

Eleven of 16 eyes (68.8%) achieved VMA resolution after treatment. Mean baseline BCVA was relatively good (79 ± 3 Early Treatment Diabetic Retinopathy Study letters; 20/52); no patients had a ≥2-line improvement in BCVA over the 6-month follow-up period. In the group with VMA resolution, mean retinal sensitivity significantly increased in the central 4° (15.2 ± 1.9 dB vs. 18.9 ± 0.7 dB, P < 0.001) when comparing baseline and final follow-up microperimetry testing. No change in mean retinal sensitivity was found in the group without VMA resolution.

Conclusion:

Microperimetry demonstrates a significant gain in retinal sensitivity, particularly in the central 4° area, in eyes with anatomic resolution after treatment of vitreomacular traction with intravitreal ocriplasmin injection, even when no significant gain in BCVA is seen.
FACTORS INFLUENCING VISUAL ACUITY IN PATIENTS RECEIVING ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR FOR MYOPIC CHOROIDAL NEOVASCULARIZATION
Authors: Iacono Pierluigi , Battaglia Parodi Maurizio , Selvi Federico , Parravano MARIA Cristina , Chiaravalloti Adele , Varano Monica , Bandello Francesco
Published: December 2016

Purpose:

To identify the prognostic variables relative to myopic choroidal neovascularization (CNV) treated with intravitreal ranibizumab/bevacizumab.

Methods:

Forty-eight patients with myopic CNV were enrolled in a prospective, interventional, non-randomized 12-month study. Intravitreal ranibizumab/bevacizumab was administered in a pro-re-nata regimen and re-treatment was performed in the presence of angiographic leakage, intraretinal/subretinal fluid on optical coherence tomography, new hemorrhages, five-letter decrease and increased metamorphosia. The primary outcome measures were the identification of the predictive value of symptom duration, patient's age, refractive error, best-corrected visual acuity (BCVA), central macular thickness (CMT), CNV area, CNV location, retinal hemorrhages, atrophy, lacquer cracks, and CNV-fundus autofluorescence pattern (hyper-fundus autofluorescence/patchy pattern). The secondary outcomes were patients requiring either one or two injections to achieve CNV stabilization.

Results:

The mean BCVA improved from 0.49 ± 0.30 (logarithm of minimal angle resolution, Snellen equivalent 20/63) to 0.39 ± 0.32 (20/49) at 1-year follow-up (P = 0.043). Univariate and multiple stepwise linear regression analysis identified baseline BCVA (P = 0.0003), symptom duration (P = 0.005), CMT (P = 0.02), and fundus autofluorescence pattern (P = 0.005) as the explanatory variables on the final BCVA and the change in the mean BCVA. Overall, patients with better baseline BCVA, early diagnosis, lower CMT, or disclosing a hyperfundus autofluorescence CNV pattern achieved better visual outcomes. Patients responding with just one to two intravitreal injections (45.8%) obtained better visual outcomes compared with patients receiving three or more injections, and this group consisted of younger patients with lesser CMT, smaller CNV area, and fewer baseline hemorrhages.

Conclusion:

Ranibizumab/bevacizumab therapy was effective in improving and maintaining visual acuity in myopic choroidal neovascularization. Early diagnosis, better baseline BCVA, and hyperfundus autofluorescence CNV pattern were strongly associated with better functional outcomes. Moreover, CNV distinguished by its small size and low CMT responded more favorably, achieving a better visual outcome.
Recurrent Lingual Abscess in a Child
Authors: Kuge Rie , Komori Koji , Miyama Sahoko
Published: December 2016

We report the case of a 14-month-old boy who developed a swelling of the tongue with fever, dyspnea during sleep and dysphagia. An anterior lingual abscess was identified by magnetic resonance imaging. He developed 4 recurrent lingual abscesses thereafter. Pediatricians should be aware of this problem because it can be a life-threatening condition.
Hepatitis B Surface Antigen Testing Among Pregnant Women, United States 2014
Authors: Kolasa Maureen S. , Tsai Yuping , Xu Jing , Fenlon Nancy , Schillie Sarah
Published: December 2016

Background:

Post-exposure prophylaxis administered to infants shortly after birth prevents approximately 90% of cases of perinatal hepatitis B virus (HBV) transmission. The Advisory Committee on Immunization Practices recommends that all pregnant women be tested for hepatitis B surface antigen (HBsAg) at an early prenatal visit during each pregnancy to detect active infection with HBV. This study sought to determine the proportion and characteristics of pregnant women tested\not tested according to Advisory Committee on Immunization Practices recommendations.

Methods:

We analyzed MarketScan databases to assess prenatal HBsAg testing among women with commercial and Medicaid health care coverage according to demographic and clinical characteristics. Pregnant women 15–44 years of age continuously enrolled in a health plan in the MarketScan database during 2013 and 2014 and with a live birth in 2014 were included.

Results:

Among commercially insured women, 239,955 (87.7%) received HBsAg testing and 59.6% were tested during their first trimester. Among Medicaid-enrolled women, 57,268 (83.6%) received HBsAg testing and 39.4% were tested during their first trimester. Among women with high risk pregnancies, HBsAg testing occurred in 87.3% of those with commercial insurance and 84.8% with Medicaid. Testing also varied by maternal age; among women with commercial insurance, testing was greatest among women 26–44 years of age, and among women with Medicaid, testing was greatest among younger women (15–25 years). Testing was lowest among women residing in the Northeast (commercial insurance only).

Conclusions:

Prenatal HBsAg testing identifies HBV-infected pregnant women so their infants can receive timely immunoprophylaxis. Efforts to optimize HBsAg testing among all pregnant women are needed to further prevent perinatal HBV transmission.
Financial, Resource Utilization and Mortality Impacts of Teaching Hospital Status on Pediatric Patients Admitted for Sepsis
Authors: Hsu Benson S. , Meyer Benjamin D. , Lakhani Saquib A.
Published: December 2016

Background:

With the changing healthcare landscape in the United States, teaching hospitals face increasing pressure to provide medical education as well as cost–effective care. Our study investigated the financial, resource utilization and mortality impact of teaching hospital status on pediatric patients admitted with sepsis.

Methods:

We conducted a retrospective, weighted statistical analysis of hospitalized children with the diagnosis of sepsis. The Agency for Healthcare Research and Quality 2009 Kids’ Inpatient Database provided the data for analysis. Diagnosis of sepsis and severity of illness levels were based on All Patient Refined Diagnosis-Related Groups of 720: Septicemia and Disseminated Infections. Teaching hospital status was based on presence of training programs. Statistical analysis was conducted using STATA 12.1 (Stata Corporation, College Station, TX).

Results:

Weighted analysis revealed 17,461 patients with sepsis—9982 in teaching and 7479 in nonteaching hospitals. When comparing all patients, length of stay (8.2 vs. 4.8, P < 0.001), number of procedures received (2.03 vs. 0.87, P < 0.001), mortality (4.7% vs. 1.6%, P < 0.001), costs per day ($2326 vs. $1736, P < 0.001) and total costs ($20,428 vs. $7960, P < 0.001) were higher in teaching hospitals. Even when stratified by severity classes, length of stay, number of procedures received and total costs were higher in teaching hospitals with no difference in mortality.

Conclusions:

Our study suggested that teaching hospitals provide pediatric inpatient care for sepsis at greater costs and resource utilization without a clear improvement in overall mortality rates in comparison with nonteaching hospitals.
Risk Factors Associated With Bordetella pertussis Among Infants ≤4 Months of Age in the Pre-Tdap Era
Authors: Curtis Christine Robinette , Baughman Andrew L. , DeBolt Chas , Goodykoontz Susan , Kenyon Cynthia , Watson Barbara , Cassiday Pamela K. , Miller Claudia , Pawloski Lucia C. , Tondella Maria-Lucia C. , Bisgard Kristine M.
Published: December 2016

Background:

In the United States, infants have the highest reported pertussis incidence and death rates. Improved understanding of infant risk factors is needed to optimize prevention strategies.

Methods

We prospectively enrolled infants ≤4 months of age with incident-confirmed pertussis from 4 sites during 2002–2005 (preceding pertussis antigen-containing vaccination recommendations for adolescents/adults); each case-patient was age and site matched with 2 control subjects. Caregivers completed structured interviews. Infants and their contacts ≥11 years of age were offered serologic testing for IgG; being seropositive was defined as ≥94 antipertussis toxin IgG enzyme-linked immunosorbent assay units per milliliter.

Results:

Enrolled subjects (115 case-patients; 230 control subjects) had 4396 contacts during incubation periods; 83 (72%) case-patients had ≥1 contact with prolonged (≥5 days) new cough in primary or secondary households. In multivariable analysis, the odds for pertussis were higher for infants with primary/secondary household contacts who had a prolonged new cough, compared with infants who did not. These contacts included mother [adjusted matched odds ratio (aMOR), 43.8; 95% confidence interval (CI), 6.45–298.0] and ≥1 nonmother contact (aMOR, 20.1; 95% CI, 6.48–62.7). Infants receiving breast milk with 0–1 formula feedings daily had decreased pertussis odds (aMOR, 0.27; 95% CI, 0.08–0.89), compared with those receiving more formula. Of 41 tested case-patients, 37 (90%) were seropositive.

Conclusions:

Pertussis in infants was associated with prolonged new cough (≥5 days) in infants’ household contacts. Findings suggest that breastfeeding protects against pertussis and warrants recommendation with pertussis prevention strategies, which currently include pertussis vaccination of pregnant mothers and infants’ close contacts.
Daily Electronic Health Record Reports Meet Meaningful Use Requirements, Improve Care Efficiency, and Provide a Layer of Safety for Trauma Patients
Authors: Stimson Christopher E. , Botruff Anita L.
Published: December 2016

The electronic health record (EHR) is frequently viewed as a government-mandated charting system. As simply a replacement for the paper record, however, it was also frequently found to be inconvenient and a distraction to patient care. Broader use of the technology inherent in the EHR in the form of daily reports focused on key information that allows trauma clinical teams to efficiently monitor important information such as specific laboratory results or medications that might be missed or overlooked. In addition, other clinical personnel can monitor and assist in the care of trauma patients from remote locations such as an administrative office. Implementation of EHR reports is feasible, can be easily adopted by the clinical team, and has the potential to promote quality, safety, and efficiency. In addition, this innovation satisfies many of the requirements for meaningful use.
Staged Suprapectoral Expander/Implant Reconstruction without Acellular Dermal Matrix following Nipple-Sparing Mastectomy
Authors: Salibian Arthur H. , Harness Jay K. , Mowlds Donald S.
Published: December 2016

Background:

Since the introduction of nipple-sparing mastectomy as an oncologically safe procedure for the treatment of breast cancer, reconstructive efforts for immediate staged expander/implant reconstruction have focused on submuscular implantation with or without acellular dermal matrix. Suprapectoral reconstruction without acellular dermal matrix has received little attention in the reconstructive literature of nipple-sparing mastectomy.

Methods:

Between 2005 and 2015, 155 patients (250 breasts) underwent nipple-sparing mastectomy with prepectoral staged expander/implant reconstruction using thick mastectomy skin flaps without acellular dermal matrix. Patients with different breast sizes, including those patients with very large breasts who required a primary mastopexy, were considered candidates for the suprapectoral reconstruction. Tumor-related data, comorbidities, and preoperative or postoperative radiation therapy were evaluated for correlation with the final outcome.

Results:

Patients were followed up for an average of 55.5 months (range, 138.1 to 23.6 months). The tumor recurrence rate was 2.6 percent. Adverse outcomes such as capsular contracture, implant dystopia, and rippling were studied. Aesthetic outcome, based on a three-point evaluation scale, showed 53.6 percent of patients as having a very good result, 31.6 percent showing a good result, 9 percent showing a fair result, and 5.8 percent showing a poor result.

Conclusions:

The suprapectoral two-stage expander/implant reconstruction without acellular dermal matrix in nipple-sparing mastectomy has certain advantages with respect to breast shape, less morbidity related to expansion, ease of reconstruction, and cost effectiveness. These advantages have to be weighed against those of subpectoral reconstruction with acellular dermal matrix to determine the method of choice.

CLINCAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Improving Results in Closed Nasal Reduction: A Protocol for Reducing Secondary Deformity
Authors: Farber Scott J. , Nguyen Dennis C. , Parikh Rajiv P. , Jang Judy L. , Woo Albert S.
Published: December 2016

Background:

Nasal fractures are the most common facial fracture. Improper reduction is a common occurrence, resulting in a residual deformity that requires secondary surgery. A treatment protocol for nasal fracture management is presented with the aim of reducing secondary deformities requiring corrective surgery.

Methods:

After institutional review board approval, a retrospective review of all closed nasal reductions performed by a single surgeon between 2006 and 2015 was conducted. Patient age, sex, presence of secondary deformity, and need for a correctional operation were recorded. Clinical records were analyzed for evidence of postoperative deformity and need for subsequent manipulation or surgery.

Results:

A total of 90 patients with nasal bone fractures who underwent closed nasal reduction were identified. The mean age of patients was 24.9 years. The male-to-female ratio was 2.2:1. Postoperative deformity was reported in 14 patients (15.6 percent). Four of the 90 patients (4.4 percent) were found to have avulsion of their upper lateral cartilage from the nasal bone. Nine of the 14 subjects (64.3 percent) presenting with secondary deformity were managed with external manipulation, avoiding a secondary operation. Five patients (5.5 percent) from the original cohort of 90 underwent revision surgery.

Conclusions:

By using the described protocol to treat nasal fractures, we have seen a low rate of postreduction deformity and a small percentage of need for secondary operation. The overall success rate of closed nasal reduction with postoperative manipulation (when necessary) was identified to be 94.5 percent. Using this protocol, surgeons may see a decrease in secondary deformities following closed nasal reduction procedures.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Evidence-Based Medicine: Face Lift
Authors: Derby Brian M. , Codner Mark A.
Published: December 2016

Learning Objectives:

After studying this article, the participants should be able to: 1. Describe pertinent surgical anatomy relevant to safe and effective face-lifting techniques. 2. Identify key aspects of facial aging. 3. Incorporate risk-reduction strategies during preoperative assessment. 4. Tailor their approach to face lifting based on patient anatomy. 5. Identify and treat complications after face-lift surgery. 6. Incorporate use of valid patient outcomes assessment tools in their practice to facilitate standardized outcomes reporting in the face-lift literature.

Treating the aged face requires an understanding of bone and soft-tissue anatomy, including the analogous lamellar layers of the face and neck, and the techniques designed to restore youthful skin tone and facial contours. Although volume restoration with fillers is effective for restoring youthful facial contours, the power of face lifting is unmatched in its ability to rejuvenate a sagging facial shape. Standard face-lifting techniques are described, along with the authors’ preferred approach, supplemented by video demonstration of the high–superficial musculoaponeurotic system technique. Complications, along with their prevention and treatment, are reviewed. Currently available comparative studies of face-lifting outcomes consider surgeon opinion and postoperative complications rates. A valid, standardized, patient-reported outcome tool, the FACE-Q, has been available since 2010, and should be a component of any comparative discussion of face-lifting techniques in the future.
Evidence-Based Medicine: Cleft Palate
Authors: Woo Albert S.
Published: December 2016

Learning Objectives:

After studying this article, the participant should be able to: 1. Describe the incidence of cleft palate and risk factors associated with development of an orofacial cleft. 2. Understand differences among several techniques to repair clefts of both the hard and soft palates. 3. Discuss risk factors for development of postoperative fistulas, velopharyngeal insufficiency, and facial growth problems. 4. Establish a treatment plan for individualized care of a cleft palate patient.

Orofacial clefts are the most common congenital malformations of the head and neck region, and approximately three-quarters of these patients have some form of cleft palate deformity. Cleft palate repair is generally performed in children between 6 and 12 months of age. The goals of palate repair are to minimize the occurrence of fistulas, establish a normal velopharyngeal mechanism, and optimize facial growth. This Maintenance of Certification review discusses the incidence and epidemiology associated with cleft palate deformity and specifics associated with patient care, including analgesia, surgical repair techniques, and complications associated with repair of the cleft palate.
Evidence-Based Medicine: Autologous Breast Reconstruction
Authors: Macadam Sheina A. , Bovill Esta S. , Buchel Edward W. , Lennox Peter A.
Published: December 2016

Learning Objectives:

After studying this article, the participant should be able to: 1. Gain an understanding of the different methods of autologous reconstruction available. 2. Understand the timing of autologous breast reconstruction and the impact of adjuvant and neoadjuvant treatments. 3 Understand the factors necessary for a comprehensive patient assessment. 4. Gain knowledge of patient factors that will affect autologous reconstruction and potential contraindications. 5. Summarize the patient-reported and clinical outcomes of autologous breast reconstruction.

This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured to outline the care of the patient with the postmastectomy breast deformity.
Evidence-Based Medicine: Liposuction
Authors: Chia Christopher T. , Neinstein Ryan M. , Theodorou Spero J.
Published: December 2016

Learning Objectives:

After studying this article, the participant should be able to: 1. Review the appropriate indications and techniques for suction-assisted lipectomy body contouring surgery. 2. Accurately calculate the patient limits of lidocaine for safe dosing during the tumescent infiltration phase of liposuction. 3. Determine preoperatively possible “red flags” or symptoms and signs in the patient history and physical examination that may indicate a heightened risk profile for a liposuction procedure. 4. Provide an introduction to adjunctive techniques to liposuction such as energy-assisted liposuction and to determine whether or not the reader may decide to add them to his or her practice.

With increased focus on one’s aesthetic appearance, liposuction has become the most popular cosmetic procedure in the world since its introduction in the 1980s. As it has become more refined with experience, safety, patient selection, preoperative assessment, fluid management, proper technique, and overall care of the patient have been emphasized and improved. For the present article, a systematic review of the relevant literature regarding patient workup, tumescent fluid techniques, medication overview, and operative technique was conducted with a practical approach that the reader will possibly find clinically applicable. Recent trends regarding energy-assisted liposuction and body contouring local anesthesia use are addressed. Deep venous thromboembolism prophylaxis is mentioned, as are other common and less common possible complications. The article provides a literature-supported overview on liposuction techniques with an emphasis on preoperative assessment, medicines used, operative technique, and outcomes.
Evidence-Based Medicine: Management of Acute Lower Extremity Trauma
Authors: Lachica Roberto D.
Published: December 2016

Learning Objectives:

After studying this article, the participant should be able to: 1. Select and design flaps for the acutely injured lower limb based on wound location, size, and complexity. 2. Select and design tissue-specific flaps based on the functional demand of the zone of injury. 3. Understand the indications for using a flap with a skin component versus a muscle-only flap. 4. Understand the preoperative vascular assessment for lower extremity flap reconstruction. 5. Recognize and manage risk factors to decrease complications and improve flap survival.

The Maintenance of Certification series is designed to help the experienced surgeon structure the study of specific areas appropriate to his or her clinical practice. This article is designed to accompany practice-based evaluation of preoperative assessment, surgical treatment plan, and outcomes. In this format, he or she is invited to compare his or her methods with authoritative, information-based references. This information base is then used for self-assessment and benchmarking in Parts II and IV of the Maintenance of Certification process used by the American Board of Plastic Surgery. This article is not meant to be an exhaustive treatise on the subject, but rather designed to serve as a reference point for further in-depth study by review of the articles referenced. The goal of this article is to present evidence that may serve as practice-changing information. Furthermore, this article is designed with the recognition that participants may have different backgrounds, experience, expertise, and resources. The breadth of the topics discussed is designed to accommodate these differences.
Quality of Life after Face Transplantation: Outcomes, Assessment Tools, and Future Directions
Authors: Aycart Mario A. , Kiwanuka Harriet , Krezdorn Nicco , Alhefzi Muayyad , Bueno Ericka M. , Pomahac Bohdan , Oser Megan L.
Published: December 2016

Background:

Face transplantation has emerged as a clinical reality for the restoration of complex facial defects. Critical to the advancement of the burgeoning field of reconstructive transplantation is the quality of the methods used to measure and report the impact of face transplantation on quality of life.

Methods:

A systematic search using PubMed and EMBASE was conducted for all studies matching the a priori inclusion criteria from 2005 through 2015. Bibliographies of included studies were also reviewed. Two authors (M.A.A and H.K) independently performed screening of titles.

Results:

The authors identified 17 articles reporting on quality-of-life outcomes among 14 face transplant recipients. Combinations of objective and subjective measures were used to assess quality of life. Instruments used to assess quality of life after face transplantation included over 25 different instruments. Four centers, comprising eight patients, have reported using prospective, systematic data with validated instruments. Overall, there is reported improvement in quality of life after face transplantation. Heterogeneity and a paucity of data between articles preclude a quantitative analysis.

Conclusions:

Anecdotal and subjective reports of improvements in quality of life after face transplantation constitute the majority of reported outcomes in the English peer-reviewed literature. Improved efforts in methods and standardization of collection and reporting of quality-of-life data after face transplantation are needed to better appreciate the impact of face transplantation on quality of life and justify lifelong immunosuppression and its attendant risks and morbidity.
Neurectomy for the Treatment of Chronic Postoperative Pain after Surgery of the Trunk
Authors: Nagarkar Purushottam , Ramanadham Smita , Chamseddin Khalil , Chhabra Avneesh , Rozen Shai M.
Published: December 2016

Background:

Incidence of chronic postoperative neurogenic pain after open and laparoscopic trunk operations is reported between 1 and 20 percent, rendering a large population in the United States and worldwide. One possible treatment is selective surgical neurectomy.

Methods:

All patients who underwent neurectomy for chronic trunk or groin postoperative neurogenic pain were identified. Based on individual history and examination, patients underwent neurectomies of the ilioinguinal, iliohypogastric, genitofemoral, lateral-femoral cutaneous, or intercostal nerves. Recorded preoperative pain levels (Likert score ranging from 0 to 10) were compared to postoperative pain levels and quality-of-life indices were assessed.

Results:

Fifty-six patients (32 men and 24 women) were included. Mean age was 49 years. All patients underwent preoperative nerve blocks by either surgeon, radiologist, or referring physician, and had either complete or significant response defined as over 50 percent relief. Forty-five patients completed the survey. Median follow-up was 2.8 years (range, 1.0 to 5.7 years). Average pain level was 9.0 preoperatively and 3.5 postoperatively. Quality-of-life impairment improved from 8.3 preoperatively to 3.5 postoperatively. A subset of patients (n = 12) had minimal improvement, reporting a decrease in pain from 8.5 to 7.2 and quality-of-life improvement from 8.5 to 7.1.

Conclusions:

Complete avoidance of nerve injury during all trunk and groin operations is likely unattainable. When chronic postoperative neurogenic pain develops, neurectomy can be an effective means of treatment, significantly improving pain and quality of life in most patients. Better insight is necessary into a patient subset responding to nerve blocks yet experiencing minimal postoperative improvement.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Base Nasal Bone Resection versus Oblique Nasal Bone Resection: A Comparative Study of the Outcomes for the Deviated Nose
Authors: Ince Bilsev , Dadaci Mehmet
Published: December 2016

Background:

The aim of this study was to compare the techniques used for resection of the long side of the base and the top of the bone based on the patient’s perspective, surgeon’s approach, aesthetic results, complications, and need for secondary surgery in patients with asymmetric nasal bones. This study also aimed to determine the perspective of another plastic surgeon who did not perform rhinoplasty in comparison with the perspective of the primary plastic surgeon.

Methods:

One hundred sixty-six patients with nasal bone asymmetry between 2010 and 2015 were included in this study. Patients were divided into two groups: group 1, those treated with wedge resection of the bony nasal pyramid from the base of the nasal bone; and group 2, those treated with an oblique hump resection. Three different plastic surgeons and plastic surgery nurses who had no information regarding the randomization, patients, and primary plastic surgeon evaluated the surgical results.

Results:

The mean secondary surgery rate was significantly greater in group 2 than in group 1. The mean satisfaction ratio was significantly decreased with different plastic surgeons than with the primary plastic surgeon. Base nasal bone resection was more successful than oblique hump resection in patients with greater than or equal to 0.5-cm nasal bone asymmetry.

Conclusions:

Surgeons who did not perform the rhinoplasties can evaluate the results differently from the primary surgeon. Performing base bone resection may reduce the secondary surgery rate in patients with greater than or equal to 0.5-cm nasal bone asymmetry.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, II.
Correction of Sagittal Craniosynostosis Using Distraction Osteogenesis Based on Strategic Categorization
Authors: Lee Myung Chul , Shim Kyu Won , Yun In Sik , Park Eun Kyung , Kim Yong Oock
Published: December 2016

Background:

Distraction osteogenesis has been used to correct sagittal craniosynostosis in various ways. The purpose of this study was to introduce three distraction osteogenesis procedures by describing four objective measurements.

Methods:

Fifty-four patients with sagittal synostosis were recruited and assigned to one of three therapeutic groups: group 1, anteroposterior compression with bitemporal expansion (n = 35); group 2, bitemporal expansion (n = 9); and group 3, anteroposterior expansion with bitemporal expansion (n = 10). Distraction procedures were performed while maintaining dural attachment. Four indices—namely cranial index, head circumference, intracranial volume, and neurodevelopmental index (using the Bayley Scales of Infant Development II), were analyzed.

Results:

The preoperative cranial index of group 1 (68.51 ± 4.73) differed significantly from those of groups 2 (76.75 ± 2.4; p < 0.05) and 3 (86.8 ± 3.99; p < 0.05). Postoperative cranial index in all groups converged to the mesocephalic cranial index. Preoperative intracranial volume determinations were within the normal range for the majority of participants in groups 1 and 2; however, most fell below −1 SD in group 3 [n = 8 (80 percent)]. Postoperatively, 90 percent of group 3 participants had intracranial volume values within the normal range. The preoperative mental and psychomotor developmental indices of group 3 were significantly lower than those in the other two groups. The postoperative analysis showed significant improvement in these indices in groups 1 and 3 or when all patients were analyzed.

Conclusion:

Symmetric sagittal synostosis can be effectively treated with distraction osteogenesis reformation guided by strategic categorization.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Experimental Rat Skin Flap Model That Distinguishes between Venous Congestion and Arterial Ischemia: The Reverse U-Shaped Bipedicled Superficial Inferior Epigastric Artery and Venous System Flap
Authors: Matsumoto Noriko M. , Aoki Masayo , Nakao Junichi , Peng Wei-Xia , Takami Yoshihiro , Umezawa Hiroki , Akaishi Satoshi , Ohashi Ryuji , Naito Zenya , Ogawa Rei
Published: December 2016

Background:

The commonly used flap models have drawbacks that limit their usefulness. In the random skin flap model, flap necrosis is caused by both arterial and venous insufficiency. In the axial skin flap model, flap viability is easily affected by the pedicle blood flow and can result in complete necrosis. This study aimed to establish a new rat skin flap model that has a consistent flap survival rate and in which venous congestion and arterial ischemia can be readily distinguished macroscopically.

Methods:

Rats underwent reverse U-shaped bipedicled superficial epigastric artery flap elevation. The right superficial epigastric vessels formed the pedicle. In the control rats (n = 3), the left superficial epigastric vessels were left intact. In the ischemia group (n = 10), the left superficial epigastric artery was ligated. In the congestion group (n = 10), the left superficial epigastric vein was ligated. The flap was returned to the original site and sutured. The surrounding neovascularization was blocked by polyurethane film. Flap survival rates were evaluated on postoperative day 3.

Results:

The flaps in the ischemia and congestion groups were noticeably pale and violet, respectively. Flap necrosis was noted in the contralateral distal zone only. It started on postoperative day 2 in the ischemia and congestion groups. The mean flap survival rates of the control, ischemia, and congestion groups were 100 percent, 61.8 percent (range, 56.9 to 67.1 percent), and 42.3 percent (35.7 to 48.7 percent), respectively (all p < 0.001).

Conclusions:

The flap facilitated discrimination of the effects of ischemia and congestion. This new rat skin flap model is simple and easy to construct, and has a consistent flap survival rate.
Use of Poly-4-Hydroxybutyrate Mesh to Optimize Soft-Tissue Support in Mastopexy: A Single-Site Study
Authors: Adams William P. , Moses Arikha C.
Published: December 2016

Background:

The ptotic breast is surgically rejuvenated through a mastopexy procedure. Recurrent ptosis or other negative changes to the breast shape are not uncommon following mastopexy, as the tissue laxity and skin quality that contributed to ptosis are not surgically corrected. The purpose of this study was to assess the postsurgical changes in the breasts of patients who underwent a primary mastopexy procedure with soft-tissue reinforcement using a long-term poly-4-hydroxybutyrate resorbable scaffold (i.e., GalaFLEX).

Methods:

From July of 2012 to January of 2014, 11 consecutive patients underwent a central mound mastopexy with soft-tissue reinforcement in the lower pole using a poly-4-hydroxybutyrate resorbable scaffold. Patients returned for postoperative follow-up visits that included three-dimensional scans of their breasts at months 1, 3, 6, and 12.

Results:

There were no major complications in the study. Changes in the breast shape defined by distances between predefined landmarks between months 1 and 12 ranged from 1.5 to 9.6 percent. Some postoperative breast settlement occurred between months 1 and 3. The mean change in the nipple-to–inframammary fold distance from months 1 to 12 was 8 mm. Lower pole stretch was 5 percent.

Conclusions:

Initial findings suggest that central mound mastopexy with soft-tissue reinforcement in the lower pole performed on difficult larger breasts yields a relatively stable result for 1 year after surgery. There was no statistically significant change between months 3 and 12 from the sternal notch to lowest point on the breast as determined by established three-dimensional imaging techniques.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Evaluation and Implementation of a High-Fidelity Cleft Palate Simulator
Authors: Podolsky Dale J. , Fisher David M. , Wong Karen W. , Looi Thomas , Drake James M. , Forrest Christopher R.
Published: December 2016

Background:

Cleft palate repair is a challenging procedure to learn because of the delicate tissue handling required and the small confines of the infant oral cavity. As a result, cleft palate simulators have previously been described to augment cleft palate repair training. Although valuable, they lack the fidelity for this complex procedure.

Methods:

A high-fidelity cleft palate simulator was evaluated by staff and fellows in pediatric plastic surgery who provided feedback on its realism, anatomical accuracy, and effectiveness as a training tool. The simulator was implemented within a training workshop following a didactic session on cleft palate repair and anatomy. A test was administered to each participant before and immediately after the workshop to assess knowledge transfer. Perceived confidence of performing a repair following the workshop was also assessed, as was the workshop’s effectiveness.

Results:

Overall, participants agreed that the simulator is anatomically accurate and realistic and strongly agreed that the simulator is a valuable training tool. The average test score increased from 25 percent before the workshop to 77.27 percent after the workshop. Overall, participants of the workshop felt more confident performing a repair and strongly agreed that the workshop was valuable and effective.

Conclusions:

A high-fidelity cleft palate simulator has been evaluated as realistic, anatomically accurate, and valuable as a training tool. The simulator was successfully integrated into a training workshop, which resulted in significant knowledge increase on anatomy and the procedure and perceived confidence and comfort in performing a cleft palate repair.
Assessment of Biopsychosocial Complexity and Health Care Needs: Measurement Properties of the INTERMED Self-Assessment Version
Authors: van Reedt Dortland Arianne K.B. , Peters Lilian L. , Boenink Annette D. , Smit Jan H. , Slaets Joris P.J. , Hoogendoorn Adriaan W. , Joos Andreas , Latour Corine H.M. , Stiefel Friedrich , Burrus Cyrille , Guitteny-Collas Marie , Ferrari Silvia
Published: December 2016

Objective

The INTERMED Self-Assessment questionnaire (IMSA) was developed as an alternative to the observer-rated INTERMED (IM) to assess biopsychosocial complexity and health care needs. We studied feasibility, reliability, and validity of the IMSA within a large and heterogeneous international sample of adult hospital inpatients and outpatients as well as its predictive value for health care use (HCU) and quality of life (QoL).

Methods

A total of 850 participants aged 17 to 90 years from five countries completed the IMSA and were evaluated with the IM. The following measurement properties were determined: feasibility by percentages of missing values; reliability by Cronbach α; interrater agreement by intraclass correlation coefficients; convergent validity of IMSA scores with mental health (Short Form 36 emotional well-being subscale and Hospital Anxiety and Depression Scale), medical health (Cumulative Illness Rating Scale) and QoL (Euroqol-5D) by Spearman rank correlations; and predictive validity of IMSA scores with HCU and QoL by (generalized) linear mixed models.

Results

Feasibility, face validity, and reliability (Cronbach α = 0.80) were satisfactory. Intraclass correlation coefficient between IMSA and IM total scores was .78 (95% CI = .75–.81). Correlations of the IMSA with the Short Form 36, Hospital Anxiety and Depression Scale, Cumulative Illness Rating Scale, and Euroqol-5D (convergent validity) were −.65, .15, .28, and −.59, respectively. The IMSA significantly predicted QoL and also HCU (emergency department visits, hospitalization, outpatient visits, and diagnostic examinations) after 3- and 6-month follow-up. Results were comparable between hospital sites, inpatients and outpatients, as well as age groups.

Conclusions

The IMSA is a generic and time-efficient method to assess biopsychosocial complexity and to provide guidance for multidisciplinary care trajectories in adult patients, with good reliability and validity across different cultures.
CpG traffic lights are markers of regulatory regions in humans
Authors: Khamis Abdullah M. , Lioznova Anna V. , Artemov Artem V. , Ramensky Vasily , Bajic Vladimir B. , Medvedeva Yulia A.
Published: December 2016

DNA methylation is involved in regulation of gene expression. Although modern methods profile DNA methylation at single CpG sites, methylation levels are usually averaged over genomic regions in the downstream analyses. In this study we demonstrate that single CpG methylation can serve as a more accurate predictor of gene expression compared to average promoter / gene body methylation. CpG positions with significant correlation between methylation and expression of a gene nearby (named CpG traffic lights) are evolutionary conserved and enriched for exact TSS positions and active enhancers. Among all promoter types, CpG traffic lights are especially enriched in poised promoters. Genes that harbor CpG traffic lights are associated with development and signal transduction. Methylation levels of individual CpG traffic lights vary between cell types dramatically with the increased frequency of intermediate methylation levels, indicating cell population heterogeneity in CpG methylation levels. Being in line with the concept of the inherited stochastic epigenetic variation, methylation of such CpG positions might contribute to transcriptional regulation. Alternatively, one can hypothesize that traffic lights are markers of absent gene expression resulting from inactivation of their regulatory elements. The CpG traffic lights provide a promising insight into mechanisms of enhancer activity and gene regulation linking methylation of single CpG to expression.
Viral Quasispecies Reconstruction via Correlation Clustering
Authors: Barik Somsubhra , Das Shreepriya , Vikalo Haris
Published: December 2016

RNA viruses are characterized by high mutation rates that give rise to populations of closely related viral genomes, the so-called viral quasispecies. The underlying genetic heterogeneity occurring as a result of natural mutation-selection process enables the virus to adapt and proliferate in face of changing conditions over the course of an infection. Determining genetic diversity (i.e., inferring viral haplotypes and their proportions in the population) of an RNA virus is essential for the understanding of its origin and mutation patterns, and the development of effective drug treatments. In this paper we present QSdpR, a novel correlation clustering formulation of the quasispecies reconstruction problem which relies on semidefinite programming to accurately estimate the sub-species and their frequencies in a mixed population. Extensive comparisons with existing methods are presented on both synthetic and real data, demonstrating efficacy and superior performance of QSdpR.
Highly-efficient Cpf1-mediated gene targeting in mice following high concentration pronuclear injection
Authors: Watkins-Chow Dawn E. , Varshney Gaurav K. , Garrett Lisa J. , Chen Zelin , Jimenez Erin A. , Rivas Cecilia , Bishop Kevin S. , Sood Raman , Harper Ursula L. , Pavan William J. , Burgess Shawn M.
Published: December 2016

Cpf1 has emerged as an alternative to the Cas9 RNA-guided nuclease. Here we show that gene targeting rates in mice using Cpf1 can meet or even surpass Cas9 targeting rates (approaching 100% targeting) but require higher concentrations of mRNA and guide. We also demonstrate that co-injecting two guides with close targeting sites can result in synergistic genomic cutting, even if one of the guides has minimal cutting activity.
Protein splicing of a recombinase intein induced by ssDNA and DNA damage
Authors: Lennon Christopher W. , Stanger Matthew , Belfort Marlene
Published: December 2016

Inteins (or protein introns) autocatalytically excise themselves through protein splicing. We challenge the long-considered notion that inteins are merely molecular parasites and posit that some inteins evolved to regulate host protein function. Here we show substrate-induced and DNA damage-induced splicing, in which an archaeal recombinase RadA intein splices dramatically faster and more accurately when provided with ssDNA. This unprecedented example of intein splicing stimulation by the substrate of the invaded host protein provides compelling support in favor of inteins acting as pause buttons to arrest protein function until needed; then, an immediate activity switch is triggered, representing a new form of post-translational control.