bluuebunny/crossref_metadata_2025 huggingface dataset:
Economics of Lymphovenous Bypass
Authors: Head Linden K. , Momtazi Moein
Published: November 2019

Background:

The objective of this study was to compare the economic impact of complete decongestive therapy and lymphovenous bypass in the management of upper extremity lymphedema.

Methods:

Economics were modeled for a patient with breast cancer–related lymphedema undergoing three different clinical pathways: (1) complete decongestive therapy alone; (2) lymphovenous bypass no longer requiring ongoing complete decongestive therapy; or (3) lymphovenous bypass requiring ongoing complete decongestive therapy. Activity-based cost analysis identified costs incurred with complete decongestive therapy and lymphovenous bypass. Costs were retrieved from supplier price lists, physician fee schedules, lymphedema therapists, and literature reviews. The net present value of all costs incurred for each clinical pathway were calculated.

Results:

The estimated net present value of all costs for a patient with breast cancer–related lymphedema undergoing treatment were as follows: (1) complete decongestive therapy alone ($30,400); (2) lymphovenous bypass no longer requiring ongoing complete decongestive therapy ($15,000); or (3) lymphovenous bypass requiring ongoing complete decongestive therapy ($42,100). The expected net present value of all costs for lymphovenous bypass was $26,800, which was comparable to that of complete decongestive therapy alone. Sensitivity analysis demonstrated that the expected net present value of lymphovenous bypass was dependent on the patient’s life expectancy, number of bypass anastomoses, and likelihood of discontinuing complete decongestive therapy.

Conclusions:

Lymphedema has substantial ongoing costs irrespective of the treatment modality. The cost of lymphovenous bypass appears comparable to that of complete decongestive therapy alone—the surgical costs of lymphovenous bypass are offset by the savings from discontinued ongoing therapy. Despite its limitations as a theoretical economic model, this study provides insight into the potential economic impact of lymphovenous bypass.
Forehead Fat Grafting: Asian Facial Contouring and Augmentation
Authors: Li Xin , Kubiak Carrie A. , Yang Xiaoning , Kemp Stephen W. P. , Cederna Paul S. , Ma Jiguang
Published: November 2019

Background:

Aesthetic facial contouring procedures, particularly forehead augmentation, continue to increase in popularity in the Asian population. However, there are very few reports in the literature specifically examining the long-term outcomes of forehead fat grafting. In the present study, the authors aimed to objectively evaluate the efficacy of autologous forehead fat grafting through evaluation of facial proportions and patient-reported outcomes.

Methods:

Patients who underwent autologous fat grafting for forehead contouring procedures between July of 2011 and June of 2017 were recruited for participation in the study. Patient demographic and clinical variables were collected preoperatively and postoperatively. Facial proportion analysis was collected and compared from preoperative and postoperative photographs. Satisfaction with outcome was assessed by the patient, the surgeon, and a layperson postoperatively. A related-samples Wilcoxon signed rank test was used for statistical analysis.

Results:

Postoperative outcomes were evaluated in a total of 24 patients who underwent forehead autologous fat-grafting procedures. The average postoperative follow-up was 8.1 months. There were no intraoperative or postoperative complications. More than 50 percent of the postoperative results were evaluated as “satisfactory” by all three groups (i.e., patient, surgeon, and layperson) in terms of aesthetic contouring. Average forehead projection increased 0.24 U (ratio of horizontal distance from midforehead plane to cornea plane/cornea diameter) after one round of fat grafting (p = 0.01). Seven patients (29.2 percent) required more than a single round of fat grafting to achieve optimal results.

Conclusions:

Autologous fat grafting remains a viable option for forehead contouring and augmentation. The findings of this study demonstrate that the operation is effective and offers stable satisfactory results after long-term follow-up.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
The Facial Fat Compartments Revisited: Clinical Relevance to Subcutaneous Dissection and Facial Deflation in Face Lifting
Authors: Stuzin James M. , Rohrich Rod J. , Dayan Erez
Published: November 2019

The facial fat compartments were described over a decade ago, but their clinical relevance to both deflation and techniques in facial rejuvenation is underappreciated. Although much of the literature following their description has focused on further anatomical elucidation of compartment anatomy, clinical relevance has focused on volumetric compartment augmentation. From the authors’ perspective, understanding compartmentalization of facial fat provides an anatomical roadmap of the facial subcutaneous plane and a patient-specific guide for the degree of skin flap dissection in facial rejuvenation. The compartmentalization of facial fat also explains the regional development of cheek deflation in aging. An individualized treatment plan to restore facial shape can be achieved with deep compartment volume augmentation and repositioning of superficial facial fat using the superficial musculoaponeurotic system.
Imaging Features of Sclerosing Angiomatoid Nodular Transformation in Spleen
Authors: Ma Jianbing , Zhang Weiqiang , Wang Lizhang , Zhu Zefeng , Wang Jia , Zhang Jingfeng , Yang Xiaofeng
Published: November 2019

Purpose

The purpose of this study was to evaluate the features of sclerosing angiomatoid nodular transformation (SANT) in spleen on the imaging of computed tomography (CT) and magnetic resonance (MR).

Materials and Methods

From July 2006 to April 2017, 12 patients with SANT confirmed by pathology were evaluated in a retrospective study. Eight patients were with CT imaging only, 2 patients were with MR imaging only, and 2 patients were with both CT and MR. Three professional senior radiologists analyzed the imaging features on CT and MR. The main characteristic analysis included size, margin, density, signal intensity, and enhancement pattern. The significant enhancement was defined as the degree of enhancement of lesion that is higher than the surrounding spleen parenchyma, and the mild enhancement was defined as the degree of enhancement of lesion that is lower than the surrounding spleen parenchyma.

Results

All the 12 patients (5 men, 7 women; mean age, 45.8 years; age range, 21–62 years) presented as single lesion without special clinical symptoms. The range of lesions on diameter was from 25 to 80 mm. On CT images, 9 (90%) of 10 presented as hypodense in comparison with the parenchyma of spleen, 1 (10%) of 10 presented as isodense, and calcification was observed in 4 (40%) of 10 cases. On MR images, 4 (100%) of 4 manifested heterogeneous hypointensity on in-phase sequence and 3 (75%) of 4 performed as isointensity on out-of-phase sequence of T1-weighted. On the sequences of T2-weighted and diffusion-weighted image, 4 (100%) of 4 showed hypointensity. On CT and MR enhancement images, the number of significant enhancement and mild enhancement was 2 and 10, respectively. Seven (58%) of 12 showed progressive enhancement with the pattern of “spoke-wheel.”

Conclusions

Imaging features on CT and MR have a high diagnostic value for SANT, especially when CT combined with MR examination.
Application of Monochromatic Imaging and Metal Artifact Reduction Software in Computed Tomography Angiography after Treatment of Cerebral Aneurysms
Authors: Zhang Xuan , Pan Ting , Lu Shan shan , Hong Xun ning
Published: November 2019

Purpose

This study aimed to evaluate the image quality and degree of metal artifact reduction using the new-generation gemstone spectral imaging (GSI) and metal artifact reduction software (MARs) and to demonstrate the optimal monochromatic energy level for dual-energy cerebral computed tomography angiography (CTA) in patients with intracranial aneurysm after endovascular treatment.

Material and Methods

A total of 20 patients with cerebral aneurysms treated with coils or clips underwent CTA using gemstone spectral computed tomography. Artifact index was calculated at each energy level with and without MARs. Signal-to-noise (SNR) and contrast-to-noise (CNR) ratios were calculated on all axial images with MARs; subjective evaluation was done by using a 4-point scale and a 3-point scale for assessing noise and vessel contrast, respectively, and compared between the monochromatic energy levels.

Results

The artifact index value of group GSI-MARs was significantly lower than that of group GSI at each monochromatic energy level (all, P < 0.01). Contrast-to-noise ratio and SNR of the parent arteries decreased as the energy increased from 40 to 140 keV in group GSI-MARs (all, P < 0.01). Signal-to-noise ratio and CNR between each 2 adjacent monochromatic energy level showed significant difference (all, P < 0.01). Subjective evaluation showed that a monochromatic energy level between 40 and 70 keV provided the optimal image quality.

Conclusion

Gemstone spectral imaging with MARs could reduce metal artifacts and improve the image quality of cerebral CTA after coil or clip treatment. The new generation of GSI could provide better CNR and SNR at lower energy level, and the best image quality was obtained at energy level 40 to 70 keV for GSI-MARs.
Medication-Related Osteonecrosis of the Jaw—Comparison of Bone Imaging Using Ultrashort Echo-Time Magnetic Resonance Imaging and Cone-Beam Computed Tomography
Authors: Huber Florian A. , Schumann Paul , von Spiczak Jochen , Wurnig Moritz C. , Klarhöfer Markus , Finkenstaedt Tim , Bedogni Alberto , Guggenberger Roman
Published: November 2019

Objective

The aim of this study was to compare bone imaging between ultrashort echo-time (UTE) magnetic resonance (MR) imaging and cone-beam computed tomography (CBCT) as the reference standard in patients with medication-related osteonecrosis of the jaw (MRONJ).

Materials and Methods

A 1-year retrospective, blinded, and randomized qualitative analysis of UTE MR images and CBCT from 19 patients with clinically diagnosed MRONJ was performed by 2 independent radiologists. Medication-related osteonecrosis of the jaw imaging hallmarks such as osteolysis, periosteal thickening, and medullary osteosclerosis were rated visually (0 and 1 to 3 for normal and mild to severe changes) for defined anatomic regions of the jaw. In addition, segmentation of these regions was performed on coregistered MR/CBCT images for the following quantitative comparison of signal intensity (SI) on MR and gray values (GVs) on CBCT images. Interreader/modality agreement (Cohen kappa), standard testing for significant differences of (non)parametric values, and Pearson correlation of signal intensity/GV were used for statistical analysis.

Results

The anterior corpus of the mandible was most often affected by MRONJ (P < 0.001). Overall, interreader agreement of qualitative MRONJ hallmark scores was almost perfect (κ = 0.81) and without significant differences between modalities (κ = 0.81 vs 0.82, CBCT vs MR, respectively). Intermodality agreement for qualitative gradings was substantial for both readers (κ = 0.77 and 0.70). Signal intensity/GV in MRONJ-affected areas differed significantly from healthy bone (P < 0.001) as well as correlation significantly between modalities (r = −0.77; P < 0.001).

Conclusions

Qualitative assessment of MRONJ with radiation-free UTE MR imaging is comparable to reference standard CBCT. Quantitative measurements of both modalities significantly distinguish diseased from normal bone with strong correlations among the quantitative values in both modalities.
Head-to-Head Comparison of 18F-Prostate-Specific Membrane Antigen-1007 and 18F-Fluorocholine PET/CT in Biochemically Relapsed Prostate Cancer
Authors: Witkowska-Patena Ewa , Giżewska Agnieszka , Dziuk Mirosław , Miśko Jolanta , Budzyńska Anna , Walęcka-Mazur Agata
Published: November 2019

Purpose of the Report

The aim of the study was to prospectively compare performance of 18F-fluorocholine (FCH) and 18F-prostate-specific membrane antigen (PSMA)-1007 PET/CT in patients with biochemical relapse (BCR) of prostate cancer and low prostate-specific antigen levels.

Methods

We prospectively enrolled 40 BCR patients after radical treatment and prostate-specific antigen levels 2.0 ng/mL or less. 18F-FCH and 18F-PSMA-1007 PET/CT imaging was performed within a mean interval of 54 ± 21 days. Scans were done 87 ± 10 and 95 ± 12 minutes after injecting 248 ± 35 and 295 ± 14 MBq of 18F-FCH and 18F-PSMA-1007, respectively. Rates of negative, equivocal, and positive scan results were compared per patient. Per lesion, findings were grouped as equivocal or highly suggestive of malignancy and then compared for their number, localization (local relapse, lymph nodes, bones), and SUVmax values.

Results

Positive, equivocal, and negative results were reported in 60%, 27.5%, and 12.5% of 18F-PSMA-1007 and in 5%, 37.5%, and 57.5% of 18F-FCH scans, respectively. In 70% of scans, 18F-PSMA-1007 PET/CT upgraded 18F-FCH PET/CT results. 18F-PSMA-1007 scans also showed significantly more lesions (184 vs 63, P = 0.0006). Local relapse, lymph node, and bone lesions accounted, respectively, for 9%, 58%, and 33% of 18F-PSMA-1007 and 5%, 89%, and 6% 18F-FCH of PET/CT findings. Highly suspicious lesions accounted for 74% of 18F-PSMA-1007 and 11% of 18F-FCH PET/CT findings. In 18F-PSMA-1007 PET/CT SUVmax values of highly suggestive lesions were significantly higher than in equivocal lesions (median, 3.6 vs 2.5; P < 0.00001).

Conclusions

In early BCR patients 18F-PSMA-1007 showed a higher detection rate than 18F-FCH PET/CT. The former also showed more lesions in total, more highly suggestive lesions and less equivocal lesions.
Renal Pelvis Urothelial Carcinoma With Bowel Metastases
Authors: Khoo Alex Cheen Hoe , Tang Weng Heng
Published: November 2019

Urothelial carcinoma is the fourth most common genitourinary tumor with the majority of the tumor involving the urinary bladder. Only 5% involves the renal pelvis and ureter. Metastatic urothelial carcinoma of the renal pelvis frequently involves the lymph nodes, lung, liver, bone, and peritoneum. We share rare interesting 18F-FDG PET/CT images of a 60-year-old man with metastatic urothelial carcinoma of the renal pelvis to the bowel.
99mTc-Labeled Native RBC Scintigraphy in Distinguishing Polysplenia From Abdominal Masses in a Patient With Situs Inversus Totalis
Authors: Wang Peipei , Jing Hongli , Li Fang , Wang Zhenghua , Huo Li
Published: November 2019

A 39-year-old previously healthy woman presented possible hematuria. An ultrasound examination showed right adrenal mass and suggested pheochromocytoma. A 99mTc-HYNIC-TOC SPECT/CT was performed, which incidentally detected situs inversus totalis and suspicion of polysplenia without definite normal spleen in the right upper abdomen. In order to differentiate the polysplenia from other etiologies, a heat-damaged 99mTc RBC scintigraphy was performed. The images showed significant activity in the multiple soft tissue nodules in the posterior right abdomen, consistent with ectopic polysplenia.
Extracorporeal Free Flap Perfusion Using Extracorporeal Membrane Oxygenation Device
Authors: Ozturk Muhammed Besir , Aksan Tolga , Ozcelik Ismail Bulent , Ertekin Cengiz , Akcakoyunlu Bahadir , Ozkanli Sidika Seyma , Tezcan Mustafa
Published: November 2019

Extracorporeal perfusion of organs has a wide range of clinical applications like prolonged vital storage of organs, isolated applications of drugs, bridging time to transplant, and free composite tissue transfer without anastomosis, but there are a limited number of experimental models on this topic.

This study aimed to develop and evaluate a human extracorporeal free flap perfusion model using an extracorporeal membrane oxygenation device. Five patients undergoing esthetic abdominoplasty participated in this study. Deep inferior epigastric artery perforator flaps were obtained abdominoplasty flaps, which are normally medical waste, used in this model. Deep inferior epigastric artery perforator flaps were extracorporeally perfused with a mean of 6 days. The biochemical and pathological evaluations of the perfusions were discussed in the article.
Evaluating Current Scar Assessment Methods
Authors: Lipman Kelsey , Wang Maxwell , Berthiaume Emily , Holloway Janell , Da Lio Andrew , Ting Kang , Soo Chia , Zheng Zhong
Published: November 2019

Current scar surveys have included many questions to evaluate the physical characteristics of scars, with some expanding to include physical implications and patient opinions. This review provides an analysis of frequently used scar assessment methods to date and highlights potential areas for improvement. We build the case that a new assessment tool is necessary, specifically one that centers on psychosocial consequences of scars that influence patient decision making for treatment, allowing physicians to individualize treatment conversations with patients. We postulate that survey techniques used in consumer product marketing, such as choice-based conjoint analysis, may be effective in determining the factors strongly influencing patient decision making and spending in scar treatment; therefore, more research in this area is warranted. By incorporating these psychosocial and economic considerations driving scar treatment decisions, future scar assessment tools may accomplish much more than characterizing/documenting the clinical aspects of scars. Rather, these patient-centered, holistic tools may be implemented by plastic surgeons and other clinicians specifically to provide patients with personalized treatment options that maximize long-term patient satisfaction.
Psychological Pathologies and Sexual Orientation in Transgender Women Undergoing Gender Confirming Treatment
Authors: Papadopulos Nikolaos A. , Lellé Jean-Daniel , Zavlin Dmitry , Herschbach Peter , Henrich Gerhard , Kovacs Laszlo , Ehrenberger Benjamin , Machens Hans-Guenther , Schaff Jürgen
Published: November 2019

Background

There are few studies evaluating depression, self-esteem, and mental health after gender confirming treatment of transgender women. Most of these studies include different surgical techniques and nonvalidated questionnaires. With our survey, we are aiming to assess psychopathologies and mental health as well as sexuality among a group of patients treated by the same surgeon performing our self-developed combined surgical technique. This vaginoplasty approach is characterized by constructing the vaginal cavity with parts of the penile and scrotal skin as well as the longitudinally incised urethra.

Materials and Methods

Forty-seven transgender women who underwent gender confirming treatment between 2007 and 2013 were included in a retrospective study. The assessment of our study group was performed by means of self-developed indication-specific questionnaires and 3 standardized questionnaires that can be compared with norm data.

Results

Preoperative psychotherapy was mostly considered as helpful by the patients, yet postoperatively, only a third of our study participants were still under therapeutic treatment. Furthermore, we could show a change in sexual preference toward a more bisexual orientation. Gender confirming treatment satisfied the expectations for most of the patients and, in their opinion, should have been performed earlier. Results of the standardized Patient Health Questionnaire 4, a short depression screening questionnaire, did not significantly differ from healthy norm data. The Freiburg Personality Inventory, Revised, revealed normal emotionality and sane self-assessment within our study group. High self-esteem and significantly higher scores than norm data were found for the Rosenberg Self-esteem Scale.

Conclusions

Gender confirming treatment with the combined technique is an important part of a multi-structured treatment of transgenders and does have effects on psychological well-being. It seems to decrease psychopathologies and implicates several ameliorations for transgender women. Findings need to be verified in prospective studies including preoperative evaluations.
Lateral Malleolar Defect Coverage Using Abductor Digiti Minimi Muscle Flap
Authors: Elfeki Bassem , Eun Seokchan
Published: November 2019

Introduction

The lateral malleolar region is a prominent anatomic structure vulnerable to repetitive trauma and ulcer formation. The abductor digiti minimi (ADM) muscle flap offers a promising treatment option for the reconstruction of small- to moderate-sized defects that have exposed bone, joint, or tendons in the lateral malleolar area.

Methods

Between 2013 and 2016, 8 patients with foot ulcers were reconstructed with ADM muscle flap. The muscle component of the flap obliterated the dead space and provided a vascularized muscle over the debrided ankle joint. When it is needed, the flap is covered with a small split-thickness skin graft.

Results

In all cases, complete healing was achieved. The muscle flap functioned well as a versatile and shock absorbent coverage without recurrence of the ulcer during a mean follow-up period of around 2 years.

Conclusions

Coverage of a soft tissue defect at the lateral side of the ankle remains a challenge for surgeons because of the limited possibilities for local transposition. Free flaps have frequently been associated with postoperative complications and higher costs. Also, not all patients are suitable candidates for free tissue transfer because of existing comorbidities. Coverage with a split-thickness skin graft will not be possible for wounds with exposed bone or neurovascular structures or in wounds involving the weight bearing surface of the foot. Using ADM muscle offers no donor site morbidity, good soft tissue coverage, and an effective healing process. Also, no limb movement affection and normal daily life are acquired.
Atypical Mycobacterial Infections After Plastic Surgery Procedures Abroad
Authors: Leto Barone Angelo A. , Grzelak Michael J. , Frost Christopher , Ngaage Ledibabari M. , Ge Shealinna , Kolegraff Keli , Chopra Karan , Tornheim Jeffrey A. , Caffrey Julie , Lifchez Scott D. , Rasko Yvonne
Published: November 2019

Background

The recent rise in medical tourism, especially for cosmetic procedures, has been mirrored by an increase in the incidence of infections with Mycobacterium abscessus, which is an atypical mycobacterium that is ubiquitous in aquatic environments. M. abscessus soft tissue infections arise from the use of improperly sterilized water and surgical equipment during surgical procedures, and these infections have devastating consequences if not promptly treated. M. abscessus infections are notoriously difficult to diagnose and properly treat, and therefore, we illustrate a typical case presentation and provide a comprehensive diagnostic and treatment algorithm.

Methods

Of the patients who have presented to our hospital for treatment of cutaneous M. abscessus infections, a representative patient's story was included to illustrate the typical presentation and treatment timeline. The current literature on M. abscessus infections was reviewed, and this literature and the clinical experience of our plastic surgery and infectious disease teams were used in the creation of a diagnostic and treatment algorithm for M. abscessus infections.

Results

M. abscessus infections can have an incubation period of months, and the classic presenting signs include purulent drainage, violaceous nodules, and subcutaneous abscesses at the site of a recent surgery. A key finding is persistence of the infection despite debridement and empiric antibiotic treatment. Cultures grown on mycobacterial-specific growth media are considered the diagnostic criterion standard, but high clinical suspicion is enough to warrant the initiation of treatment. Treatment itself consists of surgical drainage and debridement in combination with multidrug antibiotic regimens that typically include amikacin, a macrolide, and a carbapenem or cephalosporin antibiotic, with the option for macrolide and fluoroquinolone maintenance therapy.

Conclusions

M. abscessus cutaneous infections present with unique history and physical examination findings and often require complex diagnostic workups and treatment plans. Increased provider awareness of the management and potential complications of M. abscessus is crucial to the improvement patient outcomes, as is a multidisciplinary approach that incorporates primary care providers, pathologists, plastic surgeons, and infectious disease specialists.
Suture Suspensionplasty Using Abductor Pollicis Longus and Flexor Carpi Radialis for Advanced Thumb Carpometacarpal Joint Arthritis
Authors: Lee Sang Ki , Ma Sang Beom , Choy Won Sik
Published: November 2019

Purpose

Current operative treatment for advanced thumb carpometacarpal (CMC) joint arthritis mainly constitutes complete trapeziectomy with or without additional stabilizing procedures. However, it is unclear whether the additional procedures influence overall clinical outcomes. Therefore, the purpose of this study was to evaluate the effectiveness of our posttrapeziectomy suture suspensionplasty technique, performed using the abductor pollicis longus and flexor carpi radialis tendons, in patients with advanced thumb CMC arthritis.

Materials and Methods

We evaluated 36 thumbs of 35 patients with advanced thumb CMC arthritis treated with combined operative excision of trapezium followed by a suture suspensionplasty using flexor carpi radialis and abductor pollicis longus tendons. We used a minimal volar approach to create a sling construct with a nonabsorbable suture material, which could support the thumb metacarpal base without pin fixation or tendon transfer. For radiographic evaluation, we used the ratio of the radial metacarpal subluxation to metacarpal articular width, estimated from the bilateral stress-view radiographic images of the thumb, and calculated the trapezial space ratio by dividing the trapezial space height by the proximal phalangeal length. The clinical outcomes were evaluated using the visual analog scale and disabilities of the arm, shoulder, and hand scores, along with evaluation of the improvement in both postoperative range of motion and strength recovery.

Results

The mean duration of follow-up was 26 months (range, 18–60 months). The average visual analog scale and disabilities of the arm, shoulder, and hand scores decreased from 5.9 to 0.4 and from 51.6 to 27.0, respectively. The range of motion during palmar abduction and opposition of the metacarpophalangeal joint improved with an increase in mean value from 49.1 degrees to 54.1 degrees, and from 7.8 to 9.3 Kapandji score, respectively. The grip and key pinch strengths showed no significant changes from mean preoperative values of 13.3 kg and 3.8 kg to 13.2 kg and 3.2 kg, respectively, as measured at the 18-month follow-up.

Conclusions

Our suture suspensionplasty technique has several advantages including minimal invasive approach, short operative time, cost-effectiveness, and early mobilization. We suggest that it can be used as an effective, alternative stabilization method after a complete trapeziectomy.
Distally Based Sural Adipofascial Turnover Flap for Coverage of Complicated Wound in the Foot and Ankle Region
Authors: Li Bo , Chang Shi-Min , Du Shou-Chao , Zhuang Lei , Hu Sun-Jun
Published: November 2019

Backgrounds

Distally based perforator propeller flap from the lower leg region is a versatile local reconstructive technique for the foot and ankle defects. However, flap venous congestion remains a tough nut to crack. We hypothesize that raising an adipofascial flap with turnover mode of transposition can improve venous drainage and enhance flap safety.

Methods

Based on the 2 rows of septocutaneous perforators in the posterior distal third of the lower leg, distally based adipofascial flap was raised from medial sural region nourished by 1 perforator bundle from the posterior tibial artery or from the lateral sural region from the peroneal artery. The superficial dissection was performed in subdermal plane and deep in to the subfascial space. The flap was nourished by perforator-plus-adipofascial pedicle and turned over 180 degrees upside down to reach the distal wounds. One week later, a split-skin graft was used to cover the exposed fascial flap. Postoperatively, flap survival, complications, and patient functional recovery were evaluated.

Results

Distally based sural turnover adipofascial flaps were used in 12 cases with complicated wounds of the distal third lower leg, foot, and ankle region. All wounds were caused by trauma and experienced fracture implants fixation and 5 with osteomyelitis. The comorbidities include diabetes in 9 cases and smoking in 7. There were 8 medial ural flaps and 4 lateral sural flaps. The adipofiscial flaps measured from 6.0 cm × 5.0 cm to 17.0 cm × 6.0 cm (mean, 61.3 cm2). Postoperatively, all flaps survived uneventfully without any complication such as flap ischemia and/or necrosis. Two minor donor site complications were encountered, one was postoperative hematoma, and another was hyperproliferative scar. After a mean of 14.6 months of follow-up, the adipofascial flap plus skin graft showed a durable esthetic coverage, with normal shoe wearing and walking.

Conclusions

Distally based sural adipofascial turnover flap is a simple and reliable wound coverage technique. It avoids venous congestion as usually seen in distally based fasciocutaneous flaps.
Cosmetic Tourism in Northern Ireland
Authors: Martin Serena , Long Rebekah , Hill Christopher , Sinclair Stephen
Published: November 2019

Aim

Over the new year period, we recognized a high number of admissions with postoperative complications following cosmetic surgery abroad. We aimed to determine the driving forces behind this and financial impact on the National Health Service (NHS).

Methods

Cases of all patients attending the regional plastic surgery unit with complications following surgery abroad were reviewed. Patients completed a survey on the perioperative period abroad and driving forces. In addition, the costing department was contacted to determine the financial burden associated with cosmetic tourism.

Results

Six patients were admitted to the regional unit after independently organizing surgery abroad. Countries visited included Turkey, Belgium, Poland, Estonia, and India. Reasons included cost and access to procedures not recommended by UK surgeon. Type of surgery included breast (5), abdominoplasty (2), liposuction (2), and labiaplasty (1), and 50% had multiple procedures. Complications included necrotic wounds (33%), infected breast implant (33%), venous thromboembolism investigated (33%), and wound infection (17%). Overall, 67% required surgery on the NHS. The total cost was £23,976.82, with an average of £4000/patient (range, £1294–£6291).

Discussion/Conclusions

This surge in cosmetic complications occurred in the New Year period. Complications were seen after a wide range of surgical procedures. All patients required an inpatient stay, and two-thirds required surgery with a significant cost burden to the NHS. Patients are unaware of the risks involved, highlighted by the lack of preoperative counseling and follow-up. In addition, this series has highlighted the risks associated with traveling in the perioperative period, with 2 patients investigated for pulmonary embolus.
Nasolabial Changes Following Double Jaw Surgery
Authors: Allar Michelle L. , Movahed Reza , Wolford Larry M. , Oliver Donald R. , Harrison Steve D. , Thiesen Guilherme , Kim Ki Beom
Published: November 2019

Background:

This study aimed to analyze 3-dimensional nasolabial soft tissue changes following double jaw surgery with Le Fort I maxillary advancement and relate them to underlying surgical movements.

Methods:

Pre- and post-surgical cone-beam computed tomography images of 37 maxillomandibular surgery patients with ≥2 mm of advancement at A-point were analyzed. Lateral cephalograms were constructed to determine horizontal and vertical surgical movements and 3-dimensional facial images were created from the CBCTs to calculate linear and angular changes.

Results:

Alar base width increased 1.9 mm, nasal tip protrusion decreased 0.74 mm, the upper lip flattened 7.71 degree and increased 0.9 mm in length, nasal tip was displaced 2.47 mm superiorly causing an increased concavity of 5.52 degree for the overall dorsal surface and 3.99 degree at the supratip break angle (SBA), nasal tip angle decreased 2.16 degree and nasolabial angle decreased 7.37 degree. Correlations were found between underlying surgical movements and nasal tip protrusion, SBA, nasolabial angle (NLA), and nasal tip elevation (NTE). Multiple linear regression equations were calculated to predict changes in SBA from horizontal change at A-point, NLA from horizontal change at B-point, and NTE from the change at A-point horizontally and U1-tip vertically.

Conclusion:

Double jaw surgery with maxillary advancement has significant effects on nasolabial anatomy.
Symptom and Quality of Life Improvements After Pelvic Floor Physical Therapy in a Clinical Population of Women With Pelvic Pain and Other Symptoms
Authors: Killinger Kim A. , Henrichsen Jacob L. , Han Esther , Dai Yi Ling , Nguyen Laura , Gilleran Jason , Odabachian Lisa , Boura Judith A. , Peters Kenneth M. , Sirls Larry T.
Published: November 2019

Objectives

This study aimed to evaluate changes in validated symptom scores at intake and discharge in women undergoing pelvic floor physical therapy (PFPT) for pain and other pelvic floor symptoms.

Methods

Consecutive women starting PFPT during 1 year were reviewed. History, demographics, and Pelvic Floor Distress Inventory Questionnaire – Short Form 20 (PFDI) total and domain scores (Pelvic Organ Prolapse Distress Inventory-6, Urogenital Distress Inventory-6, Colorectal-Anal Distress Inventory-8), Pelvic Floor Impact Questionnaire (PFIQ-7), and pain levels on a numeric rating scale (NRS) were collected at intake and discharge. Data were analyzed with descriptive statistics and sign tests.

Results

Of 474 women, mean age was 50.3 ± 16.7 years (range, 18–87 years) and the most common indication for PFPT was pelvic pain (208/474; 43.9%). In women with complete data, pretreatment to posttreatment median scores improved on the PFDI (77.3 vs 41.8; P < 0.0001), Urogenital Distress Inventory (37.5 vs 16.0; P < 0.0001), and PFIQ (58.0 vs 19.0; P < 0.0001), and the minimal clinically important difference was met for the PFDI, PFIQ, and Colorectal-Anal Distress Inventory. Women with primarily pelvic pain (n = 208) achieved significant improvements in PFDI, PFIQ, and NRS scores (P < 0.0001 for all) as well as the minimal clinically important difference for these measures. Pain patients with a history of pelvic surgery (n = 50) also had significant improvements in PFIQ and NRS but not PFDI scores.

Conclusions

Most women referred to PFPT demonstrated symptom improvements as measured by validated instruments.
Consequences of pre-injury utilization of direct oral anticoagulants in patients with traumatic brain injury: A systematic review and meta-analysis
Authors: Nederpelt Charlie J. , van der Aalst Stefano J.M. , Rosenthal Martin G. , Krijnen Pieta , Huisman Menno V. , Peul Wilco C. , Schipper Inger B.
Published: November 2019

BACKGROUND

The rapid adoption and widespread use of direct oral anticoagulants (DOACs) has outpaced research efforts to establish their effects in bleeding trauma patients. In patients with complicated traumatic brain injury (TBI) caused by intracranial hemorrhage, DOAC use may be associated with higher bleeding volume and potentially more disastrous sequelae than use of vitamin K antagonists (VKAs). In the current systematic review and meta-analysis we set out to evaluate the literature on the relationship between preinjury DOAC use and course of the intracranial hemorrhage. (ICH), its treatment and mortality rates in TBI patients, and to compare these outcomes to those of patients with preinjury VKA use.

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library were searched using a search strategy including three main terms: “traumatic brain injury,” “direct oral anticoagulants,” and “vitamin K antagonists.” There were 1,446 abstracts screened, and ultimately, six included articles. Random effects modeling meta-analysis was performed on in-hospital mortality, ICH progression and neurosurgical intervention rate.

RESULTS

All cohorts had similar baseline and emergency department parameters. Within individual studies surgery rate, reversal agents used, ICH progression and in-hospital mortality differed significantly between DOAC and VKA cohorts. Meta-analysis showed no significant difference in in-hospital mortality (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.23–4.06; I
2 = 76%; p = 0.97), neurosurgical interventions (OR, 0.48; 95% CI, 0.14–1.63; p = 0.24), or ICH progression rates (OR, 1.86; 95% CI, 0.32–10.66; p = 0.49) between patients that used preinjury DOACs versus patients that used VKAs.

CONCLUSION

Direct oral anticoagulant-using mild TBI patients do not appear to be at an increased risk of in-hospital mortality, nor of increased ICH progression or surgery rates, compared with those taking VKAs.

LEVEL OF EVIDENCE

Systematic review, level III.
Rotational thromboelastometry predicts transfusion and disability in pediatric trauma
Authors: Cunningham Aaron J. , Condron Mary , Schreiber Martin A. , Azarow Kenneth , Hamilton Nicholas A. , Downie Katie , Long William B. , Maxwell Bryan G. , Jafri Mubeen A.
Published: November 2019

BACKGROUND

Trauma-induced coagulopathy seen on rotational thromboelastometry (ROTEM) is associated with poor outcomes in adults; however, this relationship is poorly understood in the pediatric population. We sought to define thresholds for product-specific transfusion and evaluate the prognostic efficacy of ROTEM in injured children.

METHODS

Demographics, ROTEM, and clinical outcomes from severely injured children (age, < 18 years) admitted to a Level I trauma center between 2014 and 2018 were retrospectively analyzed. Receiver operating characteristic curves were plotted and Youden indexes were calculated against the endpoint of packed red blood cell transfusion to identify thresholds for intervention. The ROTEM parameters were compared against the clinical outcomes of mortality or disability at discharge.

RESULTS

Ninety subjects were reviewed. Increased tissue factor-triggered extrinsic pathway (EXTEM) clotting time (CT) >84.5 sec (p = 0.049), decreased EXTEM amplitude at 10 minutes (A10) <43.5 mm (p = 0.025), and decreased EXTEM maximal clot firmness (MCF) <64.5 mm (p = 0.026) were associated with need for blood product transfusion. Additionally, EXTEM CT longer than 68.5 seconds was associated with mortality or disability at discharge.

CONCLUSION

Coagulation dysregulation on thromboelastometry is associated with disability and mortality in children. Based on our findings, we propose ROTEM thresholds: plasma transfusion for EXTEM CT longer than 84.5 seconds, fibrinogen replacement for EXTEM A10 less than 43.5 mm, and platelet transfusion for EXTEM MCF less than 64.5 mm.

LEVEL OF EVIDENCE

Prognostic, Level III; Therapeutic, Level IV.
Venous thromboembolism chemoprophylaxis regimens in trauma and surgery patients with obesity: A systematic review
Authors: Shaikh Saamia , Boneva Dessy , Hai Shaikh , McKenney Mark , Elkbuli Adel
Published: November 2019

BACKGROUND

Venous thromboembolism (VTE) continues to be a devastating source of morbidity and mortality in obese patients who suffer traumatic injuries or obese surgery patients. High incidence rates in VTE despite adherence to prevention protocols have stirred interest in new dosing regimens. The purpose of this study was to systematically review the literature and present the existing VTE chemoprophylaxis regimens for obese trauma and surgical patients in terms of efficacy and safety as measured by the incidence of VTE, anti-factor Xa levels, and the occurrence of bleeding events.

METHODS

An online search of seven literature databases including PubMed, Excerpta Medica Database, GoogleScholar, JAMA Network, CINAHL, Cochrane, and SAGE Journals was performed for original studies evaluating the safety and efficacy of VTE chemoprophylaxis dosing regimens according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. The risk of bias was assessed using the Cochrane Risk of Bias Tool and the quality of evidence was determined using the GRADE Working Group criteria.

RESULTS

Of the 5,083 citations identified, 45 studies with 27,717 patients met inclusion criteria. In this group, six studies evaluated weight-based dosing regimens, four used a weight-stratified or weight-tiered strategy, five used a body mass index–stratified approach, 29 assessed fixed-dose regimens, and two used continuous infusions. The majority of the studies evaluated anti-factor Xa levels as their primary outcome rather than reduction in VTE.

CONCLUSION

Weight-based and high fixed-dose chemoprophylaxis regimens achieved target anti-Xa concentrations more frequently than standard fixed-dose regimens but were not associated with a reduction in VTE. Additionally, high fixed-dose approaches are associated with increased bleeding complications. Further evaluation with large randomized trials is warranted in trauma and surgery patients with obesity.

LEVEL OF EVIDENCE

Systematic review, level III.
Encephalopathic Presentation of West Nile Virus Neuroinvasive Disease Confounded by Concomitant History of Acute Alcohol Withdrawal
Authors: Profita Alyssa , Haglund Kristin
Published: November 2019

West Nile neuroinvasive disease (WNND) is a rare and severe manifestation of West Nile virus (WNV) infection that occurs in less than 1% of infected persons. It should be considered in patients who present with fever, neurological symptoms, and a history of recent outdoor activity where mosquitoes were active. This article highlights a case of a 55-year-old man whose history and symptoms of WNND were confounded with an alternate diagnosis, acute alcohol withdrawal. An overview of WNV infections, and important historical clues and objective findings characteristic of neuroinvasive disease, is discussed to increase readers' knowledge of WNV and awareness of when to consider WNND in the diagnostic differential.
The Use of Ultrasonography in the Emergency Department to Screen Patients After Blunt and Penetrating Trauma: A Clinical Update for the Advanced Practice Provider
Authors: González Juan M. , Ortega Johis , Crenshaw Nichole , de Tantillo Lila
Published: November 2019

Use of bedside ultrasonography to identify life-threatening injuries for patients with blunt and penetrating trauma is the standard of care in the emergency department. The “FAST” examination—focused assessment with sonography for trauma—ultrasound scan of the chest and abdomen allows clinicians to assess critical regions for free fluid without use of invasive procedures as quickly and as often as needed. In addition, ultrasonography has a high degree of sensitivity and specificity and is safe during pregnancy. For patients requiring evaluation of the pleura, the “eFAST” (or extended FAST) may be conducted, which may serve to locate pleural effusions, hemothorax, and pneumothorax. However, ultrasound quality is operator dependent and is recommended with other diagnostic measures to provide a complete clinical picture of trauma patients. Ongoing development of ultrasound competency among established clinicians and nurse practitioner students is vital to maintain diagnostic accuracy and ensure quality care for trauma patients in the emergency department.
Are Pelvic Exams Necessary Anymore?
Authors: Tucker Paula , Evans Dian Dowling
Published: November 2019

This article, “Is the pelvic examination still crucial in patients presenting to the emergency department (ED) with vaginal bleeding or abdominal pain when an intrauterine pregnancy is identified on ultrasonography? A randomized controlled trial,” by J. A. Linden et al. (2017) seeks to determine whether excluding a pelvic examination among patients presenting to the ED with first-trimester vaginal bleeding or lower abdominal pain, and indication of intrauterine pregnancy recorded on ultrasound increases morbidity. The findings are discussed in the context of changing practice and patient preference. Emergency nurse practitioners should remain informed about changing practices to ensure that patients receive safe care. Although pelvic examination does provide additional information for specific clinical conditions, the current practice to always include it in the evaluation of a pregnant patient with vaginal bleeding or pelvic pain may no longer be relevant given the improved diagnostic capabilities available within the ED setting.
Donor-host Lymphatic Anastomosis After Murine Lung Transplantation
Authors: Outtz Reed Hasina , Wang Liqing , Kahn Mark L. , Hancock Wayne W.
Published: November 2019

Background.

Establishing lung lymphatic drainage is thought to be important for successful lung transplantation. To date, there has been a complete absence of knowledge of how lymphatic connections are reestablished after lung transplant, despite evidence suggesting that this does indeed occur. The present study aimed to elucidate whether and how lymphatic anastomosis occurs after lung transplant.

Methods.

An orthotopic murine model of lung transplant using lymphatic reporter mice and whole mount immunohistochemistry was used to evaluate the lymphatic vasculature and donor-host connections after lung transplantation.

Results.

Immunohistochemistry of transplanted lungs demonstrated robust lymphatic vessels, and functional assays demonstrated lymphatic drainage in the transplanted lung that was comparable with that in native lungs. Lymphatic vessels in the donor lung exhibited active sprouting toward the host at the anastomosis within the first 3 days after lung transplantation, with more numerous and complex lymphatic sprouting developing thereafter. Donor lymphatic vessels were numerous at the site of anastomosis by day 14 after lung transplantation and formed physical connections with host lymphatic vessels, demonstrating a mechanism by which lymphatic drainage is reestablished in the transplanted lung.

Conclusions.

Lymphatic drainage after lung transplantation is established by active sprouting of donor lymphatic vessels towards the host and the formation of donor-host lymphatic connections at the level of the transplant anastomosis.
Eye Movement Disorders and the Cerebellum
Authors: Shemesh Ari A. , Zee David S.
Published: November 2019

The cerebellum works as a network hub for optimizing eye movements through its mutual connections with the brainstem and beyond. Here, we review three key areas in the cerebellum that are related to the control of eye movements: (1) the flocculus/paraflocculus (tonsil) complex, primarily for high-frequency, transient vestibular responses, and also for smooth pursuit maintenance and steady gaze holding; (2) the nodulus/ventral uvula, primarily for low-frequency, sustained vestibular responses; and (3) the dorsal vermis/posterior fastigial nucleus, primarily for the accuracy of saccades. Although there is no absolute compartmentalization of function within the three major ocular motor areas in the cerebellum, the structural–functional approach provides a framework for assessing ocular motor performance in patients with disease that involves the cerebellum or the brainstem.