bluuebunny/crossref_metadata_2025 huggingface dataset:
A not so sweet scenario: impact of perioperative glucose control on regional anesthetic techniques for orthopedic surgery
Authors: Nowrouz Maliha , Buxhoeveden Michael
Published: February 2022

Purpose of review

Diabetes and hyperglycemia are well established risk factors for complications associated with common orthopedic surgeries. In some practice settings, these conditions are also viewed as contraindications to regional nerve catheters. In this article, we aim to present our approach to offering the benefits of this modality in a safe manner for patients with diabetes and even some with preexisting, localized infections.

Recent findings

Evidence suggests that reduction in opioids and avoidance of general anesthesia can be particularly beneficial for patients with diabetes and high blood sugar, who often suffer from comorbid conditions such as obesity and obstructive sleep apnea. On our high volume, high acuity acute pain service, we take a selective approach to nerve catheter placement in this population and even some who already have localized infections. In our experience, with careful monitoring and risk mitigation strategies these patients have improved pain control and an exceedingly low rate of complications associated with nerve catheter use.

Based on our experience and reading of the literature, we advocate for a liberalized approach to use of continuous regional anesthesia for diabetic patients having for orthopedic surgery. A set of consensus guidelines tailored to institutions’ resources and monitoring capabilities can be a useful tool for standardizing care. It may also increase access to the clinical benefits of this modality in a population particularly vulnerable to opioid related adverse effects.
Zonulin Antagonist, Larazotide (AT1001), As an Adjuvant Treatment for Multisystem Inflammatory Syndrome in Children: A Case Series
Authors: Yonker Lael M. , Swank Zoe , Gilboa Tal , Senussi Yasmeen , Kenyon Victoria , Papadakis Lena , Boribong Brittany P. , Carroll Ryan W. , Walt David R. , Fasano Alessio
Published: February 2022

OBJECTIVES:

A recent study suggests that Multisystem Inflammatory Syndrome in Children (MIS-C) is triggered by gastrointestinal breach of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral particles from the gut lumen into systemic circulation. The virus remains in the gut weeks to months after respiratory infection, causing zonulin release from the intestinal epithelial cells. Zonulin loosens tight junctions, permitting trafficking of highly inflammatory viral particles into circulation. Current MIS-C treatments target the subsequent immune hyperactivation, not the causative loss of mucosal barrier integrity. Larazotide, a zonulin inhibitor, prevents breakdown of tight junctions, limiting antigen trafficking.

DESIGN:

Children with MIS-C were treated with larazotide as an adjuvant to steroid/intravenous immunoglobulin therapy. Clinical outcomes, SARS-CoV-2 antigenemia, and cytokine profiles are reported. Outcomes were compared with children with MIS-C receiving steroids and/or IVIG therapy alone.

PATIENTS:

Four children with MIS-C, ages 3–17 years, were enrolled.

INTERVENTIONS:

Patients were treated with open label larazotide 10 mcg/kg (maximum 500 mcg/dose) orally four times daily for 21 days.

MEASUREMENTS AND MAIN RESULTS:

All four patients tolerated larazotide without adverse effects and displayed reduction in Spike antigenemia to undetectable levels. When compared with 22 children with MIS-C receiving steroids and/or intravenous immunoglobulin therapy alone, larazotide-treated patients reported significantly improved time to resolution of gastrointestinal symptoms (p = 0.03), and time to clearance of Spike antigenemia (p = 0.04), plus a trend towards shorter length of stay.

CONCLUSIONS:

Larazotide appears safe and well-tolerated and may offer potential benefit as an adjuvant to immune-targeted therapies. Expansion of clinical trials is urgently needed to ascertain the clinical impact of larazotide on MIS-C.
Exercise Prescription Methods and Attitudes in Cardiac Rehabilitation
Authors: Pack Quinn R. , Shea Meredith , Brawner Clinton A. , Headley Samuel , Hutchinson Jasmin , Madera Hayden , Keteyian Steven J.
Published: February 2022

Purpose:

High-quality exercise training improves outcomes in cardiac rehabilitation (CR), but little is known about how most programs prescribe exercise. Thus, the aim was to describe how current CR programs prescribe exercise.

Methods:

We conducted a 33-item anonymous survey of CR program directors registered with the American Association of Cardiovascular and Pulmonary Rehabilitation. We assessed the time, mode, and intensity of exercise prescribed, as well as attitudes about maximal exercise testing and exercise prescription. Results were summarized using descriptive statistics. Open-ended responses were coded and quantitated thematically.

Results:

Of 1470 program directors, 246 (16.7%) completed the survey. In a typical session of CR, a median of 5, 35, 10, and 5 min was spent on warm-up, aerobic exercise, resistance training, and cooldown, respectively. The primary aerobic modality was the treadmill (55%) or seated dual-action step machine (40%). Maximal exercise testing and high-intensity interval training (HIIT) were infrequently reported (17 and 8% of patients, respectively). The most common method to prescribe exercise intensity was ratings of perceived exertion followed by resting heart rate +20-30 bpm, although 55 unique formulas for establishing a target heart rate or range (THRR) were reported. Moreover, variation in exercise prescription between staff members in the same program was reported in 40% of programs. Program directors reported both strongly favorable and unfavorable opinions toward maximal exercise testing, HIIT, and use of THRR.

Conclusions:

Cardiac rehabilitation program directors reported generally consistent exercise time and modes, but widely divergent methods and opinions toward prescribing exercise intensity. Our results suggest a need to better study and standardize exercise intensity in CR.
Adrenal BORDeAux reGistry: Bordeaux single-center study of hypertensive patients with primary hyperaldosteronism
Authors: Benoit Julie , Gaudissard Julie , Doublet Julien , Boulestreau Romain , Robert Grégoire , Brossaud Julie , Gosse Philippe , Cremer Antoine
Published: February 2022

Background:

Primary aldosteronism is responsible for a major cardiovascular risk that can be avoided by specific treatment. A better characterization of the hypertensive population with primary aldosteronism would not only improve the overall diagnosis but also allows a better selection of patients requiring adrenal vein sampling (AVS).

Methods:

Creation of a prospective single-center Bordeaux ABORDAGE study of hypertensive patients with primary aldosteronism who underwent AVS. Primary aldosteronism was diagnosed according to the recommendations of the SFE/SFHTA. Peripheral and central blood pressure measurements were performed with mercury sphygmomanometer, SphygmoCor applanation tonometer and ambulatory blood pressure measurement. An adrenal computed tomography and an unstimulated AVS were performed in each patient.

Results:

One hundred and eighty-eight patients were included in our study. They were mostly men (61.7%), with a mean age of 48.7 ± 10.5 years, BMI of 29.7 ± 5 kg/ m2 and duration of hypertension of 101.5 ± 84 months. AVS was selective in 82.3% of patients and lateralization was concordant with CT in only 35.4% of patients. Lateralized secretion was significantly associated with a marked biological primary aldosteronism and hypertension. In multivariate analysis, no variable specifically differentiated patients with aldosterone lateralization.

Conclusion:

The ABORDAGE population description is consistent with the data found in the literature. These characteristics are ultimately those expected in essential hypertension population, which therefore, could explain part of the underdiagnosis of primary aldosteronism. Only AVS is able to predict the lateralization of secretion with a post adrenalectomy recovery of about 90% in case of lateralization. The generalization of AVS would, therefore, increase the proportion of patients with primary aldosteronism cured.
ANSI 3.1-2014 and the Supplemental Workforce of Radiation Protection Technicians
Authors: Blue Leldon
Published: February 2022

Attrition in the supplemental workforce of radiation protection technicians continues to present challenges in supporting the US nuclear power industry with contract technicians during refueling outages, major projects, and decommissioning. Industry wide adoption of ANSI 3.1-2014, Selection, Qualification, and Training of Personnel for Nuclear Power Plants, can help overcome these challenges by accelerating the training and development of technicians in the supplemental workforce by applying the systematic approach to training (SAT).
COMPARISON BETWEEN ORAL AND INTRAVENOUS ULTRAWIDE-FIELD FLUORESCEIN ANGIOGRAPHY IN THE CLINICAL FOLLOW-UP OF CHILDREN WITH A HISTORY OF RETINOPATHY OF PREMATURITY OR PREMATURITY
Authors: Ling Xiao Chun , Chou Hung-Da , Liu Laura , Wang Nan-Kai , Lai Chi-Chun , Chen Kuan-Jen , Hwang Yih-Shiou , Wu Wei-Chi
Published: February 2022

Purpose:

To compare between oral and intravenous (IV) ultrawide-field fluorescein angiography in pediatric patients with a history of prematurity of retinopathy or prematurity.

Methods:

Pediatric patients (<18 year old; n = 107 patients) who underwent ultrawide-field fluorescein angiography for retinopathy of prematurity were categorized into oral and IV fluorescein angiography (FA) groups. Quality of FA images was graded on the order of retinal vessels visible. Reported outcomes were proportions of graded FA images, peak fluorescein intensity, and the time to first dye appearance and to reach peak fluorescence.

Results:

Image quality analysis revealed that 91.5% of IV FA images had excellent image quality compared with only 55.6% of oral FA images (P < 0.01). There were still 83.3% of oral-contrast images with good or excellent image quality. The average time required for first dye appearance and peak fluorescence were significantly shorter in the IV FA group than in the oral FA group (P < 0.01). Peak intensity was greater in the IV group (141.41 ± 29.09) than in the oral group (111.25 ± 45.68; P < 0.01). Adverse reaction rates were similar between the two groups (P = 0.22).

Conclusion:

Ultrawide-field fluorescein angiography provides excellent-quality imaging of the retina in the pediatric population. Overall, oral FA is still an effective and useful alternative to IV FA in children with prematurity history.
A CASE OF RAPIDLY PROGRESSIVE RETINOPATHY ASSOCIATED WITH PEMBROLIZUMAB IMMUNOTHERAPY FOR METASTATIC UROTHELIAL CARCINOMA
Authors: Sakai Daiki , Hirami Yasuhiko , Sugita Sunao , Maeda Akiko , Matsumiya Wataru , Nakamura Makoto , Kurimoto Yasuo
Published: February 2022

Purpose:

To describe a novel case of bilateral rapidly progressive retinopathy after immunotherapy with pembrolizumab for metastatic urothelial carcinoma.

Methods:

Case report.

Results:

A 64-year-old man undergoing pembrolizumab immunotherapy was referred to our hospital because of bilateral acute vision loss. His best-corrected visual acuity was 20/30 in the right eye and 20/320 in the left eye, and a visual field test revealed central and paracentral scotomas in the right eye and central scotoma in the left eye. We suspected immune-related retinopathy based on the progressive photoreceptor damage with abnormal electroretinogram findings, absence of overt intraocular inflammation, and presence of malignancy. Cessation of pembrolizumab and steroid pulse therapy followed by decreasing oral prednisolone improved visual function and photoreceptor damage, although there was recurrence after pembrolizumab was restarted.

Conclusion:

We reported a case of rapidly progressive retinopathy that may have been triggered by pembrolizumab immunotherapy for metastatic urothelial carcinoma. High-dose corticosteroid pulse therapy was effective in reversing photoreceptor damage.
Longitudinal Change in Symptom Clusters in Patients With Ovarian Cancer
Authors: DAN Xin , TIAN Yalin , ZHOU Li , DU Juan , HE Yalin
Published: February 2022

Background

The symptoms of patients with ovarian cancer at a specific time point during the treatment process have been investigated in previous studies. However, only a few longitudinal studies have been conducted in China to determine the symptom cluster of patients with ovarian cancer before surgery, after surgery, and during the initial stage of chemotherapy.

Purpose

This study was carried out to identify the symptom clusters in patients with ovarian cancer at different stages of treatment.

Methods

A longitudinal survey was designed, and 430 patients with ovarian cancer who had undergone surgical operation combined with chemotherapy were recruited as participants. Exploratory factor analysis was conducted to identify the components of symptom cluster at three different time points: 3 days before surgery (T1), 2 days after surgery (T2), and the first day after the completion of chemotherapy cycle 1 (T3).

Results

The symptom clusters varied across the three time points. Notably, the pain-related, emotional, cognitive, and disease-related symptom clusters occurred at T1 and persisted through T2 and T3; the treatment-related symptom cluster occurred at T2 and persisted through T3; and the numbness symptom and gastrointestinal symptom clusters were observed at T3.

Conclusions

Priority symptom management interventions should be provided according to the most severe symptom clusters such as the emotional symptom cluster at T1, the treatment-related symptom cluster at T2, and the gastrointestinal symptom cluster at T3.
Electronic Resources for Children Explaining COVID and Vaccinations
Authors: Bayless Katy R.
Published: February 2022

As parents are forced to become experts of a new virus, it is helpful to know there are resources to help navigate the conversation with children. There are now countless e-books for all ages explaining the virus, illness, social distancing, and even the vaccine. Below are suggestions for especially helpful and fun e-books to aid parents in having these conversations.
A Comparison of ECochG With the Subjective Sound Perception During Cochlear Implantation Under Local Anesthesia—A Case Series Study
Authors: Linder Pia , Iso-Mustajarvi Matti , Dietz Aarno
Published: February 2022

Objective:

Intraoperative electrocochleography (ECochG) has been proposed for cochlear monitoring to minimize trauma during the insertion of the electrode of a cochlear implant (CI). CI surgery is normally performed under general anesthesia, which is why intraoperative ECochG measurements have never been validated against the patient's subjective sound perception. The main objectives of this study were to investigate the feasibility of cochlear monitoring based on the patients hearing and to validate it against intraoperative ECochG measurements during CI surgery under local anesthesia.

Study Design:

Prospective case series study.

Setting:

Tertiary referral center.

Patients:

Patients eligible for cochlear implantation with residual hearing (pure-tone threshold averages [PTA] 2501000 Hz ≤ 75 dB HL). Additionally, patients should be able to hear ECochG stimuli at 250, 500, or 1000 Hz at less than or equal to 100 dB (HL).

Interventions:

Cochlear implantation under local anesthesia without conscious sedation. Intraoperative ECochG monitoring.

Main Outcome Measures:

The development of ECochG amplitudes and the patients’ subjective perception to the sound stimuli.

Results:

In all patients, monitoring based on their subjective sound perception was feasible, whereas, reliable ECochG responses could be measured in seven patients. Sixty percent of the registered declines in ECochG amplitude were associated with a concomitant attenuation of the subjectively perceived sound.

Conclusions:

The developments in the ECochG responses matched well with the changes of the sound stimulus perceived by the patients, which supports the applicability of ECochG for preventing insertion trauma. Monitoring of the patients subjective hearing appears to be more reliable than ECochG but requires surgery under local anesthesia without conscious sedation.
Role of muscle-targeted nutritional therapy: new data
Authors: Cereda Emanuele , Veronese Nicola , Caccialanza Riccardo
Published: February 2022

Purpose of review

To provide an updated overview of recent efficacy data on the use of muscle-targeted nutritional therapy, which should consider the optimization of protein and essential amino acids intakes, possibly in combination with supplementation with vitamin D (correction of deficiency/insufficiency status) and v-3 fatty acids.

Recent findings

Intervention studies conducted in the last years in different healthcare settings and heterogeneous patient populations support the use of muscle-targeted oral nutritional supplementation to improve muscle mass, function and physical performance in patients with sarcopenia. Higher efficacy is likely to be achieved in combination with individually tailored resistance exercise training programs and when nutritional therapy and the provision of specific nutrients result in an adequate protein-calorie balance. However, not only a reactive but also a pro-active application of this therapy could be proposed as evidence exists on the maintenance of or improvement in the same outcome variables in patients at risk of losing skeletal muscle mass.

Based on available efficacy data, both a reactive and pro-active use of muscle-targeted nutritional therapy are promising and should be proposed. However, future research should be directed toward the management of patient populations characterized by substantial muscle wasting, as these have been frequently excluded from previous trials, perhaps to avoid confounding.
Prenatal imaging for the diagnosis of congenital Zika syndrome
Authors: Herrera Tania , Cubilla-Batista Idalina , Goodridge Amador
Published: February 2022

Introduction:

We aim to synthesize the best available evidence on the accuracy of prenatal imaging for the diagnosis of congenital Zika syndrome due to maternal Zika virus (ZIKV) infection. Specifically, we explored the factors that may influence diagnosis accuracy, such as geographic area, endemicity of ZIKA, operator, gestational age, and type of reference standard used.

Methods and analysis

Study selection criteria:

All types of observational studies were included, that examined pregnant women with ZIKV infection (positive real time polymerase chain reaction or immunoglobulin M (IgM) serological tests and plaque neutralization reduction test). The index tests included prenatal imaging studies (ultrasound and/or magnetic resonance imaging). The reference standard was defined as follows: 1) perinatal death, including stillbirth and neonatal death within the first 48 h of birth, 2) neonatal intensive care unit admission, and 3) composite adverse perinatal outcomes. Case reports will be excluded if they only included fewer than five case.

Sources of information:

PubMed, Scopus, ISI Web of Science, and Google Scholar will be search from inception to March 2021. Two researchers will independently screen study titles and abstracts for eligibility, followed by full-text assessment. Data extraction will include population, settings, timing, and use of the index test and reference standard used. We will assess the methodological quality of the included studies and a meta-analysis will be performed to estimate summary statistics. Bivariate and hierarchical summary receiver operating characteristic modeling will be used to evaluate the diagnostic performance. The quality of evidence will be assessed by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) metholody.

Sources:

This systematic review is funded by Secretaria Nacional de Ciencia y Tecnología-Panama.

Ethics and dissemination:

Ethical approval will not be necessary. Results will be published in a peer review scientific journal.

Systematic review registration number in Prospero:

CRD42020162914
Aspiration of zinc tablet leading to chemical burn of the airway
Authors: Qian Edward T. , Lentz Robert J. , Johnson Joyce , Maldonado Fabien
Published: February 2022

Rationale:

Zinc supplementation has been considered a safe prophylactic measure against COVID-19 infection, but the risks have not been well established.

Patient concerns:

We describe a 73-year-old patient who presented with bronchoscopy 10 days after zinc tablet aspiration.

Diagnoses:

Circumferential Chemical Airway Burn leading to Airway Stenosis

Interventions:

Bronchoscopy with bronchodilation

Outcomes:

After the initial bronchoscopy, the patient was administered a course of steroids, but on repeat bronchoscopy, significant airway stenosis was encountered, and balloon dilationwas performed.

Lessons:

Zinc tablet aspiration is a previously unreported risk of zinc prophylaxis and requires prompt bronchoscopic evaluation for foreign body removal.
Papillary thyroid carcinoma with maxillary metastasis
Authors: Awny Shadi , Halim Amal A.F. , Khedr Doaa , Agamy Ahmed , Salah Heba , Abdo Islam , Fareed Ahmed M. , Attia Esam , Roshdy Mohamed , Elzayat Sara , Setit Ahmed , Zeid Amir
Published: February 2022

Introduction:

The incidence of distant metastasis in papillary thyroid carcinoma (PTC) is less than5%. Most such metastases occur in the lungs and bones. More than 80% of bone metastases are located in the axial skeleton. Metastasis to the facial bones is extremely rare.

Patient concerns:

A 36-year-old man presented with intermittent attacks of epistaxis, nasal obstruction, right-sided facial swelling, and a progressive headache without fever or preceding dental trauma. He had undergone total thyroidectomy with neck dissection for PTC in 2017.

Diagnosis:

Computed axial tomography and magnetic resonance imaging of the head and neck region showed a well-defined mass occupying the right maxillary sinus with bony erosion, measuring approximately 5.8 × 3.2 × 5.3 cm. Biopsy revealed metastatic PTC, which was confirmed using immunohistochemistry.

Interventions:

The patient underwent debulking surgery in the form of partial maxillectomy and reconstruction of the mucosal defect using a buccal pad of fat. A post operative therapeutic dose of radioactive iodine (TDRI) was administered.

Outcomes:

A whole-body iodine scan performed 5 days after the dose revealed multiple metastases affecting the right maxilla, both lungs, and left tibia. The patient was discharged on the fifth day following TDRI and resumed thyroid suppressive therapy. The patient was scheduled for another TDRI six months later.

Conclusion:

Maxilla metastasis of PTC is rare, usually occurs in women, and is usually associated with other metastases. When maxillary bone metastasis occurs, physicians, dentists, and pathologists should not exclude the possibility of metastatic PTC.
Microgranulomas at Diagnosis Are Associated With Need for Antitumor Necrosis Factor Escalation in Pediatric Crohn Disease
Authors: Moran Christopher J. , Pankaj Amaya , Kaplan Jess L. , Deshpande Vikram
Published: February 2022

Introduction:

Granulomas are a pathologic hallmark of Crohn disease (CD) although they are found in only a subset of patients. Well‐formed granulomas are associated with an aggressive phenotype although it is unknown if microgranulomas confer a similar phenotype. This study sought to define the incidence of microgranulomas in pediatric CD and compare the clinical course with cases with granulomas and those without granulomatous inflammation.

Methods:

We performed a single‐center, retrospective study of pediatric CD patients who had at least 3 years of follow‐up. initial diagnostic biopsies were systematically re‐examined by a gastrointestinal pathologist. A priori definitions of granuloma (10+ histiocytes) and microgranuloma (4–9 histiocytes) were used. Disease outcomes of hospitalization, development of complicated disease behavior, perianal disease, and the use of anti‐tumor necrosis factor (anti‐TNF) therapy were assessed by Kaplan‐Meier survival plots.

Results:

This study included 138 subjects with an average follow‐up of 4.6 years. Granulomas were seen in 38 of 138 subjects (27.5%) and an additional 38 subjects (27.5%) had at least 1 microgranuloma (in the absence of granulomas). Escalation to anti‐TNF therapy was higher in CD with granulomas (P = 0.001) and microgranulomas (P = 0.0001) compared with those without granulomatous inflammation.

Conclusions:

A significant subset of pediatric CD patients have microgranulomas (in the absence of well‐defined granulomas). Children with CD who have microgranulomas are escalated to anti‐TNF therapy more frequently than those without granulomatous inflammation (and at a similar rate to those with granulomas). Pathologists should have a low threshold to report microgranulomas as they may help to predict disease behavior.
A Case With New-Onset Neuromyelitis Optica Spectrum Disorder Following COVID-19 mRNA BNT162b2 Vaccination
Authors: Caliskan Ilay , Bulus Eser , Afsar Nazire , Altintas Ayse
Published: February 2022

Introduction:

In the midst of the coronavirus disease of 2019 pandemic, active immunization by effective vaccination gained utmost importance in terms of global health. The messenger RNA (mRNA) vaccines are novel strategies requiring clinical surveillance for adverse events.

Case Report:

We report a 43-year-old previously healthy female with an optic neuritis attack 24 hours following immunization with the second dose of coronavirus disease of 2019 mRNA BNT162b2 vaccine. A second transverse myelitis attack together with an elevated anti-AQP-4 antibody titer confirmed the diagnosis of neuromyelitis optica spectrum disorder.

Conclusion:

Our case identifies the BNT162b2 vaccine as a possible trigger for neuromyelitis optica spectrum disorder. This rare and potentially coincidental event has no implications for vaccine administration practices. However, further research is needed to elucidate the effects of mRNA vaccines on humoral and cell-mediated immunity.
Intra- and Interrater Reliability of the Spanish Version of the Gross Motor Function Measure (GMFM-SP-88)
Authors: Ferre-Fernández Marina , Murcia-González María Antonia , Ríos-Díaz José
Published: February 2022

Purpose:

To assess intra- and interrater reliability of the Spanish version of the 88-item Gross Motor Function Measure (GMFM-SP-88), and its correlation to age and severity of children with cerebral palsy.

Methods:

Six raters assessed 50 videotapes and 4 viewed 50 recordings to determine intra- and interrater reliability, respectively. Intraclass correlation coefficients (ICCs), standard error of measurement (SEm), smallest real difference (SRD), and limits of agreement (LoA) were calculated.

Results:

Intra- and interrater reliability were excellent for both total (ICC2,1 = 1.00, 95% confidence interval [CI] 0.99-1.00) and dimension scores (ICC2,1 = 0.99, 95% CI 0.99-1.00). The SEm and the SRD for the total score were acceptable (1.60 and 3.14, respectively). The average differences in dimension scores were below 1 and 0.1 points (95% LoA: −1.65 to 1.94, −1.06 to 0.86 for intra- and interrater reliability, respectively).

Conclusions:

The results support the potential use of the GMFM-SP-88 as a reliable tool, having correlation with age and severity.

What this adds to the evidence:

The GMFM-SP-88 is a reliable outcome measure to assess gross motor function in cerebral palsy. The GMFM-SP is the only tool available in Spanish to assess gross motor function in children and adolescents with cerebral palsy. The GMFM-SP-88 is a valuable resource for both Spanish physical therapists and researchers.
Reconstructive Surgeons as Essential Operative Consultants: Quantifying the True Value of Plastic Surgeons to an Academic Medical Center
Authors: Vartanian Emma D. , Ebner Peggy J. , Liu Alice , Wilson Todd A. , Wong Alex K. , Carey Joseph N. , Urata Mark M. , Patel Ketan M.
Published: February 2022

Background:

The revenue generated by plastic surgeons assisting other surgical services is poorly captured by hospital accounting systems, which categorize solely by attending physician of record. The financial impact of reconstructive surgery is thus systematically underestimated. The authors sought to quantify the overlooked value of plastic surgeons as consultants who facilitate complex and profitable operations.

Methods:

Hospital billing data were reviewed for inpatient operations over a 3-year fiscal period (2015 to 2017). Cases in which a plastic surgeon assisted were identified. Case mix index, a measure of complexity that correlates with profit, and contribution margin, defined as revenue minus cost, were obtained for each case.

Results:

Five hundred fifty-four cases required a reconstructive surgeon; 18,904 nonconsultation cases were identified for comparison. Average net revenue per case involving a consultation was 1.79 times greater than for control cases (p < 0.0001). Average contribution margin was 1.73 times greater (p < 0.005). The highest contribution margins stemmed from joint cases with cardiothoracic surgery and neurosurgery. Case mix index was significantly higher for consultation cases than for controls (4.5 versus 3.9; p < 0.0001). In 434 cases (78 percent), plastic surgery assisted with an integral aspect of the operation, meaning the surgery could not have been technically performed without reconstructive assistance.

Conclusions:

The authors’ findings demonstrate that cases involving plastic surgeons have a higher profit margin than those performed by any department alone. However, this revenue is not appropriately attributed because of oversimplified financial metrics. The skill set of reconstructive surgeons is an undervalued resource for both patient care and hospital economics.
Law of Diminishing Returns in Ventral Hernia Repair: Fact or Fiction?
Authors: Patel Viren , Jia Hanna , Rios-Diaz Arturo J. , Christopher Adrienne N. , Morris Martin P. , Diatta Fortunay , Cunning Jessica R. , Broach Robyn B. , Fischer John P.
Published: February 2022

Background:

Repeated ventral hernia repair is associated with increased risk of complications and recurrence. The authors present the first study looking at how repeated ventral hernia repair affects quality of life, and whether there is a relationship between the number of prior repairs and quality-of-life improvement after surgery.

Methods:

A retrospective chart review was conducted of patients undergoing ventral hernia repair between August of 2017 and August of 2019, who completed at least one preoperative and postoperative Abdominal Hernia-Q. Patients were split into four cohorts based on number of prior repairs (zero, one, two, or three or more). Categorical data were compared using chi-square and Fisher’s exact tests, and continuous data were analyzed using Kruskal-Wallis tests.

Results:

Ninety-three patients met inclusion criteria, with 19 (20 percent), 45 (48 percent), 15 (16 percent), and 14 patients (15 percent) in each cohort, ranging from zero to three or more prior repairs. Patients with more prior repairs were significantly more likely to be readmitted and undergo reoperation (p = 0.04 and p = 0.01, respectively), in addition to significantly higher cost of care (p = 0.004). Patients with three or more prior repairs had significantly lower preoperative quality of life when compared to patients with two or fewer prior repairs (p = 0.04). However, all patients reported a similar absolute level of quality of life postoperatively, irrespective of prior repairs (p = 0.34).

Conclusions:

Treatment of recurrent hernia remains a challenge because of poor clinical outcomes and higher risk of recurrence. This study shows that patients with multiple prior ventral hernia repairs report similar postoperative quality of life as patients undergoing primary repair. This information is valuable in determining appropriate surgical candidates and improving preoperative counseling.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, II.
Incidence and Nerve Distribution of Symptomatic Neuromas and Phantom Limb Pain after Below-Knee Amputation
Authors: Chang Brian L. , Mondshine Josh , Fleury Christopher M. , Attinger Christopher E. , Kleiber Grant M.
Published: February 2022

Background:

Patients with major lower limb amputations suffer from symptomatic neuromas and phantom-limb pain due to their transected nerves. Peripheral nerve surgery techniques, such as targeted muscle reinnervation and regenerative peripheral nerve interface, aim to physiologically prevent this nerve-specific pain. No studies have specifically reported on which nerves most frequently cause chronic pain. The authors studied the nerve-specific incidence of symptomatic neuroma formation and phantom limb pain in patients undergoing a below-knee amputation, to better tailor use of targeted muscle reinnervation and regenerative peripheral nerve interface.

Methods:

This was a retrospective review of all patients undergoing a below-knee amputation from January 1, 2013, to December 31, 2018, at MedStar Georgetown University Hospital. All below-knee amputations were performed with a posterior skin flap, myotenodesis, and traction neurectomies of all nerves. Postoperative notes were reviewed for the presence of a symptomatic neuroma, defined as localized pain and a Tinel sign over a known sensory nerve, and nerve-specific phantom limb pain, defined as pain of the missing limb corresponding to a known dermatome.

Results:

One hundred ninety-eight patients were included in this study. The rate of symptomatic neuroma formation was 14.6 percent (29 of 198), with the superficial peroneal and saphenous nerves most often involved. Diabetes and obesity were protective against symptomatic neuroma formation. The rate of nerve-specific phantom limb pain was 12.6 percent (25 of 198) and highly correlated with the presence of a symptomatic neuroma.

Conclusion:

To optimize outcomes for amputees, it is critical that surgeons best understand what nerves are more likely to form symptomatic neuromas and lead to nerve-specific phantom limb pain, so that surgeons can best tailor primary or secondary management of the major sensory nerves.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, III.
Uncontrolled HIV and inflammation is associated with intracranial saccular aneurysm presence
Authors: Dugue Rachelle , Schnall Rebecca , Liu Minghua , Brickman Adam M. , Pavol Marykay , Porra Tiffany , Gutierrez Jose
Published: February 2022

Objective:

To study biomarkers of inflammation in cerebrovascular disease, exploring modifiable and non-modifiable biochemical and clinical risk factors associated with the presence of intracranial saccular aneurysms (ISAs) in an HIV-positive cohort.

Design:

A cross-sectional community-based study was used to study blood biomarkers of inflammation as predictors of cerebrovascular disease, specifically the presence of ISAs in persons with HIV. Potential biochemical and clinical predictors of ISA presence were identified.

Methods:

Time of flight magnetic resonance angiography and magnetic resonance imaging data identified the presence of ISAs in an HIV-positive cohort. Quantitative assays for neuroinflammatory biomarkers were performed on plasma blood samples. Lasso regression models were used to identify neuroinflammatory biomarkers and clinical risk factors associated with ISAs.

Results:

Eight of 72 participants had radiographically identified ISAs. ISAs were more common in non-Hispanic black participants (18.5% vs. 0% presence in nonblack patients). Participants with well controlled HIV (defined as CD4+ count >200 cells/ml and undetectable viral load at time of magnetic resonance imaging) had lower odds of ISAs (odds ratio: 0.19, 95% confidence interval 0.05–0.79) independent of age, sex, ethnicity and vascular risk factors. Macrophage inflammatory protein-1 p, an HIV- suppressive factor detected in participant blood samples, was inversely associated with aneurysm presence.

Conclusion:

Well controlled HIV is associated with fewer ISAs. The identification of non-modifiable and modifiable risk factors contributing to ISA formation may provide valuable insight to impact clinical practice and inform the pathophysiology underlying ISA formation.
A Rare Case of Front Mandible Orthokeratinized Odontogenic Cyst – Surgical Management with Preventive Rigid Osteosynthesis
Authors: Zadrozny Łukasz , Rogus Pawel , Pyzlak Michał , Tallarico Marco , Cicciu Marco
Published: February 2022

Purpose:

Cysts and other intrabony lesions can grow asymptomatic until being diagnosed by occasionally done radiologic examination. Missing tooth and malposition of adjacent teeth should induce clinicians to perform X-Ray diagnostic.

Methods:

A 37-year-old, male patient was admitted with a hopeless tooth 36, to be extracted and replaced with an implant. Clinical examination revealed also missing one of lower incisors and malposition of remaining lower incisors. Cone-beam computed tomography revealed horizontally impacted lower incisor surrounded by bone defect −15 × 20 × 8 mm with the bone thickness remaining only 3.5 mm in the narrowest area. The basis on strong masticatory muscles and low thickness of bone after surgical removal of tooth and lesion, prophylactic osteosynthesis was planned. To explain the surgery to the patient model of the mandible was 3D printed.

Results:

Two treatment plans were presented to the patient: 1. custom plate production according to the bone defect and the shape of remaining bone and 2. choosing a standard plate and adjusting it on the 3D printed model. Costs of the material were 10 times higher in a custom solution. Plan 2 was then accepted. 1.2 mm straight plate was prebend on the model and sterilized. Lesion and impacted tooth were removed in local anesthesia. Prepared plates were fixed.

Conclusions:

In the presented case custom 3D printed osteosynthesis plate was about 10 times more expensive compared to the standard osteosynthesis plate used. 3D printing of bone model may be helpful for prebending chosen standard plate and planning the surgery.
Application of Segmented Template in Three-Dimensionally Guided Mandibular Angle Osteotomy
Authors: Zhou Sizheng , Yu Zheyuan , Duan Huichuan , Jiang Taoran , Li Dong , Yuan Jie , Gao Jiaman , Wei Min , Xu Liang
Published: February 2022

Background:

The procedure of mandibular angle osteotomy (MAO) via an intraoral approach is challenging and experience-dependent due to the limited field of view and inadequate operational space. Uncertainty about the osteotomy line and plane can lead to severe complications. A three-dimensional printed guidance template based on a computer-assisted preoperative simulation is a potential solution to this problem. The current study aims to retrospectively investigate the feasibility and accuracy of using a custom-made segmented template to guide the osteotomy plane during the procedure.

Methods:

Sixty patients who had segmented template-guided MAO were included in the study. Preoperative simulation using the custom-designed template and postoperative computed tomography were collected and parameters, including mandibular angle, gonion distance, and the mandibular plane angle were measured. A paired t tests and intraclass correlation coefficients (ICCs) were used to evaluate the efficacy, accuracy, and symmetry of the results. All complications were reviewed.

Results:

The patients had a significantly larger mandibular angle and narrower gonion distance postoperatively. Preoperative simulations and postoperative outcomes were compared; ICCs were larger than 95% indicating significant agreement. Bilateral postoperative comparisons of the mandible also demonstrated excellent agreement (ICC > 95%). Numbness in the chin area was the most frequent complication but all recovered by 3 months postoperatively.

Conclusions:

The custom-made template can guide the osteotomy plane during the MAO procedure and achieve favorable accuracy and symmetry. Direct contact of the saw with the guidance template not only facilitates control of the osteotomy line but also the oblique angle of the osteotomy plane. This methodology may be a feasible and effective tool for mandibular contouring.
Colonoscopic-Assisted Laparoscopic Wedge Resection for Colonic Lesions
Authors: Leicher Laura W , Huisman Jelle F. , van Grevenstein Wilhelmina M. U. , Didden Paul , Backes Yara , Offerhaus G. Johan A. , Laclé Miangela M. , Moll Freek C. P. , Geesing Joost M. J. , Smakman Niels , Droste Jochim S. Terhaar Sive , Verdaasdonk Emiel G. G. , ter Borg Frank , Talsma A. Koen , Erkelens G. Willemien , van der Zaag Edwin S. , Schrauwen Ruud WM. , van Wely Bob J. , Schot Ingrid , Vermaas Maarten , van Bergeijk Jeroen D. , Sietses Colin , Hazen Wouter L. , Wasowicz Dareczka K. , Ramsoekh Dewkoemar , Tuynman Jurriaan B. , Alderlieste Yasser A. , Renger Rutger-Jan , Oort Frank A. , Bilgen Ernst Jan Spillenaar , Vleggaar Frank P. , Vasen Hans F. A. , de Vos tot Nederveen Cappel Wouter H. , Moons Leon M. G. , van Westreenen Henderik L.
Published: February 2022

Objective:

The aim of this study was to evaluate the safety and efficacy of a modified CAL-WR.

Summary Background Data:

The use of segmental colectomy in patients with endoscopically unresectable colonic lesions results in significant morbidity and mortality. CAL-WR is an alternative procedure that may reduce morbidity.

Methods:

This prospective multicenter study was performed in 13 Dutch hospitals between January 2017 and December 2019. Inclusion criteria were (1) colonic lesions inaccessible using current endoscopic resection techniques (judged by an expert panel), (2) non-lifting residual/recurrent adenomatous tissue after previous polypectomy or (3) an undetermined resection margin after endoscopic removal of a low-risk pathological T1 (pT1) colon carcinoma. Thirty-day morbidity, technical success rate and radicality were evaluated.

Results:

Of the 118 patients included (56% male, mean age 66 years, standard deviation ± 8 years), 66 (56%) had complex lesions unsuitable for endoscopic removal, 34 (29%) had non-lifting residual/recurrent adenoma after previous polypectomy and 18 (15%) had uncertain resection margins after polypectomy of a pT1 colon carcinoma. CAL-WR was technically successful in 93% and R0 resection was achieved in 91% of patients. Minor complications (Clavien-Dindo i-ii) were noted in 7 patients (6%) and an additional oncologic segmental resection was performed in 12 cases (11%). Residual tissue at the scar was observed in 5% of patients during endoscopic follow-up.

Conclusions:

CAL-WR is an effective, organ-preserving approach that results in minor complications and circumvents the need for major surgery. CAL-WR, therefore, deserves consideration when endoscopic excision of circumscribed lesions is impossible or incomplete.
Favorable Outcomes After Retro-Rectus (Rives-Stoppa) Mesh Repair as Treatment for Noncomplex Ventral Abdominal Wall Hernia, a Systematic Review and Meta-analysis
Authors: Hartog Floris P. J. den , Sneiders Dimitri , Darwish Es F. , Yurtkap Yağmur , Menon Anand G. , Muysoms Filip E. , Kleinrensink Gert-Jan , Bouvy Nicole D. , Jeekel Johannes , Lange Johan F.
Published: February 2022

Objective:

To assess prevalence of hernia recurrence, surgical site infection (SSI), seroma, serious complications, and mortality after retro-rectus repair.

Summary Background Data:

Ventral abdominal wall hernia is a common problem, tied to increasing frailty and obesity of patients undergoing surgery. For noncomplex ventral hernia, retro-rectus (Rives-Stoppa) repair is considered the gold standard treatment. Level-1 evidence confirming this presumed superiority is lacking.

Methods:

Five databases were searched for studies reporting on retro-rectus repair. Single-armed and comparative randomized and non-randomized studies were included. Outcomes were pooled with mixed-effects, inverse variance or random-effects models.

Results:

Ninety-three studies representing 12,440 patients undergoing retro-rectus repair were included. Pooled hernia recurrence was estimated at 3.2% [95% confidence interval (CI): 2.2%–4.2%, n = 11,049] after minimally 12months and 4.1%, (95%CI: 2.9%–5.5%, n = 3830) after minimally 24 months. Incidences of SSI and seroma were estimated at respectively 5.2% (95%CI: 4.2%–6.4%, n = 4891) and 5.5% (95%CI: 4.4%–6.8%, n = 3650). Retro-rectus repair was associated with lower recurrence rates compared to onlay repair [odds ratios (OR): 0.27, 95%CI: 0.15–0.51, P < 0.001] and equal recurrence rates compared to intraperitoneal onlay mesh (IPOM) repair (OR: 0.92, 95%CI: 0.75–1.12, P = 0.400). Retro-rectus repair was associated with more SSI than IPOM repair (OR: 1.8, 95%CI: 1.03 –3.14, P = 0.038). Minimally invasive retro-rectus repair displayed low rates of recurrence (1.3%, 95%CI: 0.7%–2.3%, n = 849) and SSI (1.5%, 95%CI: 0.8%–2.8%, n = 982), albeit based on non-randomized studies.

Conclusions:

Retro-rectus (Rives-Stoppa) repair results in excellent outcomes, superior or similar to other techniques for all outcomes except SSI. The latter rarely occurred, yet less frequently after IPOM repair, which is usually performed by laparoscopy.
Genomic differentiation within East Asian Helicobacter pylori
Authors: You Yuanhai , Thorell Kaisa , He Lihua , Yahara Koji , Yamaoka Yoshio , Cha Jeong-Heon , Murakami Kazunari , Katsura Yukako ,   TEAMHp, Kobayashi Ichizo , Falush Daniel , Zhang Jianzhong
Published: February 2022

The East Asian region, including China, Japan and Korea, accounts for half of gastric cancer deaths. However, different areas have contrasting gastric cancer incidences and the population structure of

Helicobacter pylori

in this ethnically diverse region is yet unknown. We aimed to investigate genomic differences in

H. pylori

between these areas to identify sequence polymorphisms associated with increased cancer risk. We analysed 381 

H

.

pylori

genomes collected from different areas of the three countries using phylogenetic and population genetic tools to characterize population differentiation. The functional consequences of SNPs with a highest fixation index (Fst) between subpopulations were examined by mapping amino acid changes on 3D protein structure, solved or modelled. Overall, 329/381 genomes belonged to the previously identified hspEAsia population indicating that import of bacteria from other regions of the world has been uncommon. Seven subregional clusters were found within hspEAsia, related to subpopulations with various ethnicities, geographies and gastric cancer risks. Subpopulation-specific amino acid changes were found in multidrug exporters (hefC), transporters (frpB-4), outer membrane proteins (hopI) and several genes involved in host interaction, such as a catalase site, involved in H2O2 entrance, and a flagellin site mimicking host glycosylation. Several of the top hits, including frpB-4, hefC, alpB/hopB and hofC, have been found to be differentiated within the Americas in previous studies, indicating that a handful of genes may be key to local geographic adaptation.

H. pylori

within East Asia are not homogeneous but have become differentiated geographically at multiple loci that might have facilitated adaptation to local conditions and hosts. This has important implications for further evaluation of these changes in relation to the varying gastric cancer incidence between geographical areas in this region.