bluuebunny/crossref_metadata_2025 huggingface dataset:
Pyoderma Gangrenosum after Fat Grafting in Alloplastic Breast Reconstruction: An Unusual Outcome
Authors: Song Ethan Y. , Wallace Sean J. , Teixeira Robert M. , Mansour Ahmed , Naktin Jaan P. , Miles Marshall , Low Yee Cheng , Wojcik Randolph
Published: January 2021

Pyoderma gangrenosum (PG) is a rare and painful inflammatory skin disorder that has been recently associated with breast surgery. It is commonly mistaken for postoperative ischemia or wound infection and does not show response to antibiotics or debridement. We describe the first case of post-surgical PG (PSPG) after alloplastic breast reconstruction involving fat grafting. A 47-year-old woman underwent bilateral mastectomy and 2-stage alloplastic breast reconstruction, with fat grafting from the abdomen. Two days post-surgery, she developed bilateral erythema with tender grouped pustules that progressed rapidly into necrotic ulcerations. She did not respond to antibiotics and serial debridement. Subsequent biopsy confirmed a diagnosis of PG. She was started on steroid therapy and responded well. She was discharged on a steroid regimen, local wound care, and eventually a T-cell inhibitor. Over the next 12 months, her wounds healed without surgical intervention. PSPG has been observed in a variety of reconstructive breast surgeries, but never reported in the setting of fat grafting. As PG involves subcutaneous fat, fat grafting may accelerate and exacerbate the course of disease. Treatment for PSPG includes systemic steroid therapy or other immunomodulatory agents (or both). Surgical management remains controversial, as serial debridement and reconstruction have shown to exacerbate and stimulate disease progression. A long-term follow-up is recommended to monitor for wound healing. Delayed diagnosis of PG in breast reconstruction patients can lead to severe morbidity and disfigurement. This is first case of PSPG following fat grafting in the literature.
Practical Review of Abdominal and Breast Regional Analgesia for Plastic Surgeons: Evidence and Techniques
Authors: ElHawary Hassan , Joshi Girish P. , Janis Jeffrey E.
Published: January 2021

Regional analgesia has been increasing in popularity due to its opioid- sparing analgesic effects and utility in multimodal analgesia strategies. Several regional techniques have been used in plastic surgery; however, there is a lack of consensus on the indications and the comparative efficacy of these blocks. The goal of this review is to provide evidence-based recommendations on the most relevant types of interfascial plane blocks for abdominal and breast surgery. A systematic search of the PUBMED, EMBASE, and Cochrane databases was performed to identify the evidence associated with the different interfascial plane blocks used in plastic surgery. The search included all studies from inception to March 2020. A total of 126 studies were included and used in the synthesis of the information presented in this review. There is strong evidence for using the transversus abdominis plane blocks in both abdominoplasties as well as abdominally-based microvascular breast reconstruction as evidenced by a significant reduction in post-operative pain and opioid consumption. Pectoralis (I and II), serratus anterior, and erector spinae plane blocks all provide good pain control in breast surgeries. Finally, the serratus anterior plane block can be used as primary block or an adjunct to the pectoralis blocks for a wider analgesia coverage of the breast. All the reviewed blocks are safe and easy to administer. Interfascial plane blocks are effective and safe modalities used to reduce pain and opioid consumption after abdominal and breast plastic surgery.
Superior Pedicle Breast Reduction with Prefiguration of Final Shape: A 10-year Retrospective Study
Authors: Klinger Marco , Klinger Francesco , Maione Luca , Lisa Andrea , Battistini Andrea , Giannasi Silvia , Veronesi Alessandra , Bandi Valeria , Catania Barbara , Barbera Federico , Lozito Alessia , Caviggioli Fabio , Vinci Valeriano
Published: January 2021

Background:

Breast reduction, also defined as reduction mammaplasty, is one of the most common procedures performed in aesthetic surgery. Multiple techniques have been proposed throughout the years and several classification systems have been adopted according to: type of incision, pedicle blood supply (cutaneous, glandular, dermoglandular), extent of undermining, excision area, simultaneous or separate tissue excision (fat/gland, skin, or both), and combination of the aforementioned. In the present article, we share our 10 years’ experience with reduction mammaplasty and we describe our personal technique, a modified superior pedicle breast reduction.

Methods:

We performed a retrospective analysis on 823 consecutive patients undergoing either aesthetic or functional reduction mammaplasty at Humanitas Research Hospital between 2009 and 2018. For each patient, we evaluated the mean resection volume and complication rate. We also assessed patients’ satisfaction (VAS scale) and aesthetic outcome (assessed by independent surgeons, scale from 1 to 5).

Results:

The average patient age was 48, ranging from 17 to 77 years. The average operative time was 77 minutes, ranging from 62 to 123 minutes. After a thorough follow-up of these patients, we can conclude that our technique has a low complication rate, patients’ satisfaction is excellent, and the result is stable over time in terms of shape and symmetry (the mean VAS score was 8.1). Postoperative surgeon’s photographs evaluation scores were 4.5 ± 0.5. Average resected volume was 860gr.

Conclusion:

The proposed technique is safe, fast, and simple with a relatively short learning curve, making it didactic and intuitive for young surgeons.
Prosthetic Facial Reconstruction in a Blast Injury Case
Authors: Tyrell Richard , Willcockson James , Rich Bianca , Tanner Paul , Crum Allison , Gociman Barbu
Published: January 2021

The management of blast and burn injuries to the facial soft tissue and craniomaxillofacial skeleton has been a challenge since the inception of reconstructive plastic surgery. These injuries continue to present complex reconstructive challenges today. While there have been advancements in free tissue transfer and vascularized composite allotransplantation, prosthetics have been used successfully since antiquity until the present day. Prosthetics may achieve acceptable coverage without complex surgery or as an adjunct to reconstructive surgery. Here, we report a case of devastating blast injury to the face that has been managed successfully with orbital prosthetics anchored with osseointegrated implants.
Novel Use of a Custom Fixation Plate in Pediatric Fibrous Dysplasia
Authors: Harbour Patrick W. , Charipova Karina , Dang Danielle , Moores Leon , Baker Stephen B.
Published: January 2021

The authors present a case of a 11-year-old girl with fibrous dysplasia involving the nasal cavity and sphenoid sinus that potentially required a tracheostomy for anesthesia. The tumor was to be approached through both supraorbital and Le Fort I osteotomies. The tumor prevented nasal intubation, and the necessity of maxillomandibular fixation to reduce the osteotomized maxilla with traditional fixation prevented oral intubation. Given the age of the patient and the desire to avoid a tracheostomy scar, a decision was made to utilize custom fixation plates. Virtual surgical planning was utilized to design custom cutting guides with splints for maxillomandibular fixation. These custom maxillary orthognathic plates ensured accurate reduction of the osteotomized maxillary segment and allowed for placement of an oral endotracheal tube. Despite the oral endotracheal tube preventing maxillomandibular fixation, use of custom plates established proper occlusion as determined immediately after extubation and at postoperative visits.
Objective 18-month Comparison of the Tolerability of 2 Dermal Fillers Formulated with Tri-Hyal Technology
Authors: Trevidic Patrick , Andre Pierre , Benadiba Laurent , Deutsch Jean-Jacques , Galatoire Olivier , Garcia Philippe , Grand-Vincent Anne , Boisnic Sylvie , Salomon Catherine , Fanian Ferial
Published: January 2021

Background:

The first phase of this study showed that ART FILLER Universal filler (AFU; FILORGA Laboratories) and ART FILLER Fine lines (AFFL) were non-inferior to JUVÉDERM Ultra 3 (Allergan) and FIRST LINES PureSense (Teoxane), respectively. The clinical benefits of AFU and AFFL on nasolabial folds and crow’s feet persisted until at least Day 180. This article reports results from an open-label extension phase that assessed the tolerability and efficacy of AFU and AFFL for up to 18 months based on clinical evaluation and ultrasound high-frequency imaging.

Methods:

Eligible subjects were enrolled at D180 and assessed on D270, D360, and D540. The primary outcome measured was local tolerability. Secondary outcomes measured included: proportion of subjects in whom the severity of nasolabial folds and crow’s feet remained at least 1 point below the baseline measurement (Lemperle scale); general safety; Global Aesthetic Improvement Scale scores by subjects and investigators; wrinkle volumes; and skin thickness by high-frequency ultrasound.

Results:

Adverse events were consistent with the product information and the initial study. No serious adverse events were recorded. In exploratory analyses, wrinkle correction with AFU and AFFL is sustained for at least 18 months: 48.4% and 98.3% of subjects respectively still showed at least a 1-point decrease in the mean Lemperle score compared with the baseline. The benefits were sustained irrespective of whether subjects received additional injections. Modifications in wrinkle volume and skin thickness at D540 were statistically significant compared with the baseline.

Conclusion:

AFU and AFFL were well tolerated and, in exploratory analyses, showed a sustained efficacy for at least 18 months.
Primary Melanoma of the Breast Parenchyma: An Oncoplastic Approach
Authors: Snashall Emma , Kiernan Tamara , Harper-Machin Aenone , Taghizadeh Rieka
Published: January 2021

Primary melanoma of the breast parenchyma (PMPB) is a rare and aggressive disease, with only a few cases reported in the literature. We present the case of a 50-year old woman who underwent mastectomy and immediate breast reconstruction using a free DIEP flap following recurrence after breast conserving surgery. This report highlights the importance of an oncoplastic approach for this diagnosis and the benefit of immediate autologous breast reconstruction.
Successful Salvage of Pedicled Latissimus Dorsi Flap after Venous Thrombosis by Selective Thrombolytic Therapy
Authors: Maitani Kosuke , Tomita Koichi , Tashima Hiroki , Nomori Michiko , Taminato Mifue , Kubo Tateki
Published: January 2021

While the use of free flaps has become routine and is associated with a low complication rate, pedicled flaps remain a solid reconstructive option in various clinical situations. Pedicled flaps provide a reliable vascular supply and involve a simple surgical procedure. Although the procedure is advantageous from the standpoint of a low rate of flap ischemia, thrombosis, and total flap loss, these complications are still occasionally observed due to intraoperative pedicle injury, postoperative torsion, or compression. Here we report on a case of severe venous thrombosis in a pedicled latissimus dorsi (LD) flap used for breast reconstruction. The patient was a 52-year-old woman who underwent mastectomy and immediate breast reconstruction with a LD flap for left breast cancer. Postoperatively, the color of the skin paddle became dark blue over time. Emergent surgical exploration revealed kinking and narrowing of the thoracodorsal vessels and extensive venous thrombi. The kinked pedicles were repaired and selective thrombolytic therapy was performed. A thrombolytic agent was administered through the serratus anterior branch of the thoracodorsal artery in retrograde fashion while the thoracodorsal vessels were clamped just cephalad to the bifurcation. This allowed for draining of the thrombolytic agent and thrombi through the serratus anterior branch of the thoracodorsal vein without flowing into the systemic circulation. To the best of our knowledge, this is the first report of selective thrombolysis using a pedicle branch to treat venous thrombosis in a pedicled flap. If major vascular branches are available in a pedicled flap, selective thrombolytic therapy may be possible without disconnecting the pedicle, as in the present case.
Beyond the Hernia Repair: A Review of the Insurance Coverage of Critical Adjuncts in Abdominal Wall Reconstruction
Authors: Naga Hani I. , Mellia Joseph A. , Diatta Fortunay , Othman Sammy , Patel Viren , Janis Jeffrey E. , Heniford B. Todd , Fischer John P.
Published: January 2021

Background:

The prevalence of complex abdominal wall defects continues to rise, which necessitates increasingly sophisticated medical and surgical management. Insurance coverage for reconstructive surgery varies due to differing interpretations of medical necessity. The authors sought to characterize the current insurance landscape for a subset of key adjunctive procedures in abdominal wall reconstruction, including component separation and simultaneous ventral hernia repair with panniculectomy (SVHR-P) or abdominoplasty (SVHR-A), and synthesize a set of reporting recommendations based on insurer criteria.

Methods:

Insurance companies were selected based on their national and state market share. Preauthorization criteria, preauthorization lists, and medical/clinical policies by each company for component separation, SVRH-P, and SVRH-A were examined. Coverage criteria were abstracted and analyzed.

Results:

Fifty insurance companies were included in the study. Only 1 company had clear approval criteria for component separation, while 38 cover it on a case-by-case basis. Four companies had clear approval policies for SVHR-P, 4 cover them on an individual case basis, and 28 flatly do not cover SVHR-P. Similarly, 3 companies had clear approval policies for SVHR-A, 6 cover them case by case, and 33 do not cover SVHR-A.

Conclusions:

Component separation and soft tissue contouring are important adjunctive AWR procedures with efficacy supported by peer-reviewed literature. The variability in SVHR-P and SVHR-A coverage likely decreases access to these procedures even when there are established medical indications. The authors recommend standardization of coverage criteria for component separation, given that differing interpretations of medical necessity increase the likelihood of insurance denials.
Reducing the Cleft Nose Deformity in Bilateral Cleft Lip Repair
Authors: Dhooghe Nicolas S. , Chong David K.
Published: January 2021

Repair of a bilateral cleft lip and nose deformity remains a challenge. The nose remains the main persisting stigma for patients, deserving an equal amount of attention as the lip during the repair. We share 3 technical principles to help achieve the optimal nasolabial result and minimize cleft nose deformity after bilateral cleft lip repair. Firstly, cephalad rotation of C-flaps from the prolabium is used to define the nasolabial angle. Secondly, the nasal base and contour is set before the lip repair, as the vectors and tension of nasal repair differ from the vector and tension of the orbicularis oris muscle closure. Thirdly, different suspension and shaping stitches are used to define alar shape and position after lower lateral cartilage release, avoiding additional scars.
Use of Plasma Metagenomic Next-generation Sequencing for Pathogen Identification in Pediatric Endocarditis
Authors: To Rachel K. , Ramchandar Nanda , Gupta Aamisha , Pong Alice , Cannavino Christopher , Foley Jennifer , Farnaes Lauge , Coufal Nicole G.
Published: January 2021

Pediatric infective endocarditis incurs significant morbidity and generally occurs among children with underlying heart disease. Identification of a pathogen is critical in determining appropriate therapy. However, standard diagnostic testing has limited sensitivity. We describe a case series of children with infective endocarditis in whom plasma next-generation sequencing (Karius, Redwood, CA) identified an organism in 8 of 10 cases.
Botulinum Toxin A for Chronic Exertional Compartment Syndrome Evaluated With Shear Wave Elastography: A Case Report
Authors: Berrigan William A. , Wickstrom Jordan , Farrell Michael , Alter Katharine
Published: January 2021

This case presentation offers supportive evidence that shear wave elastography may provide an alternative method of diagnosis of chronic exertional compartment syndrome (CECS). A 39-year-old female runner presented with bilateral anterior shin pain on exertion. She initially underwent compartmental pressure testing confirming the diagnosis of CECS but declined fasciotomy. When her symptoms recurred, she was referred for botulinum toxin therapy. Shear wave muscle elastography was performed in the bilateral anterior and lateral compartments following symptom provocation treadmill testing and compared with 2 control subjects. At 6 weeks and 7 months after onabotulinumtoxinA injections, she was asymptomatic, and elastography measurements revealed a reduction in muscle stiffness from initial treadmill testing.
Frailty Interdisciplinary Pathway: Compliance and Sustainability in a Level I Trauma Center
Authors: O'Mara Lynne , Palm Katherine , Castillo-Angeles Manuel , Bryant Elizabeth , Moberg Esther , Armstrong Katherine , Patel Nikita , Tulebaev Samir , McDonald Meghan , Tsitos Diane , Cooper Zara
Published: January 2021

Background:

Frailty is a state of physiological vulnerability that predisposes many older adult trauma patients to poor health outcomes. Specialized care pathways for frail trauma patients have been shown to improve outcomes, but the compliance and sustainability of these pathways have not been reported (Bryant et al., 2019
;
Engelhardt et al., 2018).

Methods:

We retrospectively measured compliance and sustainability during the first 2 years of a frailty pathway for patients 65 years or older at an urban Level I trauma center. Compliance to 19 pathway elements was collected for 279 pathway patients between October 1, 2016, and September 30, 2018. Compliance was analyzed and reported as a percentage of the total possible times each element could have been completed per pathway guidelines. Benchmark compliance was 75% or more.

Results:

Retrospective 2-year mean overall compliance to all pathway elements was 68.2% and improved from Year 1 (65.0%) to Year 2 (71.4%). Seven elements achieved a mean 75% or more compliance over the 2-year period: frailty screening on admission (92.8%), consultation requests for physical therapy (97.9%), geriatrics (96.2%), and nutrition (92.3%), consultant care within 72 hr of admission (78.0%), delirium screening 3 times daily (76.3%), and daily senna administration (76.0%). Compliance to 10 elements significantly improved from Year 1 to Year 2 and significantly worsened in 2 elements.

Conclusion:

Many standardized geriatric care processes for frail older adult trauma patients can be successfully integrated into routine daily inpatient practice and sustained over time. Multicenter studies are needed to demonstrate how to improve compliance and to understand better which pathway elements are most effective.
Injury Severity of Ambulatory Patients Following Motor Vehicle Crash
Authors: Stimson Christopher
Published: January 2021

Background

On-scene ambulatory status following a motor vehicle crash (MVC) serves as an informal marker of physiologic stability. The influence of ambulatory status after an MVC on trauma team activation and injury severity is infrequently studied, yet may alter the clinician's index of suspicion for injury. The purpose of this study is to describe the injury burden of ambulatory on-scene patients following an MVC.

Methods

This is a prospective descriptive study of MVC patients arriving by emergency medical services (EMS), with trauma team activation, to a Midwestern Level I trauma center from July through December 2018. The EMS records were reviewed for wording that indicated the patient's ambulatory status following an MVC. Those denoted as “ambulatory on-scene” were included in this study. Of this subset, Injury Severity Score (ISS), hospital admission status, safety mechanisms utilized, crash scene description, and demographics were collected.

Results

A total of 648 MVC patients with trauma activations were reviewed, of which 308 met criteria for study inclusion. The average ISS was 2.8, with a range of 0 to 30. The cohort was 51.3% male, with a hospital admission rate of 25.9%. Of the 308 trauma activations, six were total, and 302 were partial.

Conclusion

This study of MVC patients with documented on-scene ambulation found that, although the average ISS was low, injuries and hospital admission were present in up to one-quarter of patients. Ambulatory status following an MVC while informative should not be used as a triage mechanism.
Vestibular Function After Bilateral Simultaneous Cochlear Implantation
Authors: Yan Tao , Zong Fangru , Han Xiao , Li Qiuhong , Qiao Ruru , Wang Xiaojing , Zhang Hanbing
Published: January 2021

Objectives:

Thanks to the advantages of hearing-in-noise and spatial orientation, currently bilateral cochlear implantation (CI) became popular for patients with profound hearing loss. The aim of this study was to investigate vestibular function in bilateral simultaneous CI recipients.

Study Design:

Retrospective analysis.

Setting:

University hospital.

Patients:

Sixteen patients with profound hearing loss were included.

Interventions:

Bilateral simultaneous CI with flexible electrode using round window approach.

Main Outcome Measures:

Vestibular function was evaluated using both objective and subjective measures in the subjects preoperatively and 4 months postoperatively. Differences were analyzed preoperatively and postoperatively.

Results:

Preoperative vestibular tests revealed that 8 subjects (50%) had abnormal caloric test results, 11 ears (34.4%) had abnormal ocular vestibular-evoked myogenic potential results, 6 ears (18.8%) had abnormal cervical vestibular-evoked myogenic potential results, 7 ears (21.9%) in the anterior semicircular canal, and 6 ears (18.8%) in the posterior semicircular canal had gain loss. However, surgery significantly decreased the sums of the maximal slow-phase velocities evidenced by caloric test (p < 0.05). Cervical vestibular-evoked myogenic potential abnormal rate significantly increased to 53.1% after surgery (p < 0.05). The postoperative changes regarding ocular vestibular-evoked myogenic potential, video head impulse test (vHIT), and Dizziness Handicap Inventory (DHI) were not significant among all the patients. Patients diagnosed as large vestibular aqueduct syndrome showed significantly higher DHI scores than others (p < 0.05). Spearman's correlation analysis revealed that DHI moderately correlated with the dysfunction of semicircular canals evidenced by vHIT (r = 0.702; p < 0.001), weakly correlated with caloric (r = 0.352; p = 0.048). However, no correlation was found between DHI and VEMPs. The monosyllabic and disyllabic word recognition score significantly improved from 0 to 60.4 ± 14.3% (p < 0.05) and from 0 to 63.3 ± 14.5% (p < 0.05) respectively. There was no correlation between the improvement of word recognition score and the change of vestibular tests.

Conclusion:

The study showed preservation of utricle function, vestibular function at high frequency after bilateral simultaneous CI. However, operation significantly affected vestibular function at low frequency and saccule function. Patients with large vestibular aqueduct syndrome showed dramatically higher DHI scores than others. DHI moderately correlated with vHIT and weakly correlated with caloric.
Point-of-care cardiac ultrasound during cardiac arrest: a reliable tool for termination of resuscitation?
Authors: Reynolds Joshua C. , Del Rios Marina
Published: January 2021

Purpose of review

Point-of-care ultrasound (POCUS) is commonly used during cardiac arrest to screen for potential causes and to inform termination of resuscitation. However, unique biases and limitations in diagnostic and prognostic test accuracy studies lead to potential for misinterpretation. The present review highlights recent evidence regarding POCUS in cardiac arrest, guides the incorporation of POCUS into clinical management, and outlines how to improve the certainty of evidence.

Recent findings

Multiple frameworks organize and direct POCUS during cardiac arrest. Although many are proofs of concept, several have been prospectively evaluated. Indirect evidence from undifferentiated shock suggests that POCUS offers better specificity than sensitivity as a diagnostic aid. The prognostic accuracy of POCUS during cardiac arrest to predict subsequent clinical outcomes is better characterized, but subject to unique biases and confounding. Low certainty direct evidence suggests that POCUS offers better specificity than sensitivity as a prognostic aid.

POCUS findings might indicate a particular diagnosis or encourage the continuation of resuscitation, but absence of the same is not sufficient in isolation to exclude a particular diagnosis or cease resuscitation. Until the evidence to support POCUS during cardiac arrest is more certain, it is best characterized as a diagnostic and prognostic adjunct.
Gut–kidney axis in oxalate homeostasis
Authors: Alshaikh Altayeb E. , Hassan Hatim A.
Published: January 2021

Purpose of review

The gut–kidney axis plays a critical role in oxalate homeostasis, and better understanding of oxalate transport regulatory mechanisms is essential for developing novel therapies.

Recent findings

Oxalate potentially contributes to chronic kidney disease (CKD) progression, CKD - and end stage renal disease (ESRD)-associated cardiovascular diseases, polycystic kidney disease (PKD) progression, and/or poor renal allograft survival, emphasizing the need for plasma and urinary oxalate lowering therapies. One promising strategy would be to enhance the bowel's ability to secrete oxalate, which might be facilitated by the following findings. Oxalobacter formigenes (O. formigenes)-derived factors recapitulate O. formigenes colonization effects by reducing urinary oxalate excretion in hyperoxaluric mice by inducing colonic oxalate secretion. Protein kinase A activation stimulates intestinal oxalate transport by enhancing the surface expression of the oxalate transporter SLC26A6 (A6). Glycosylation also stimulates A6-mediated oxalate transport. The colon adapts to chronic acidosis in rats through increased colonic oxalate secretion as previously reported in CKD rats, and A6-mediated enteric oxalate secretion is critical in reducing the body oxalate burden in CKD mice. Intestinal oxalate transport is negatively regulated by proinflammatory cytokines and cholinergic, purinergic, and adenosinergic signaling.

These findings could facilitate the development of novel therapeutics for hyperoxalemia, hyperoxaluria, and related disorders if similar regulatory mechanisms are confirmed in humans.
Immunotherapy in cholangiocarcinoma
Authors: Al-Rajabi Raed , Sun Weijing
Published: January 2021

Purpose of review

Cholangiocarcinoma is an aggressive heterogeneous group of cancers of the biliary epithelium and most patients are detected with advanced metastatic disease with poor prognosis. The therapeutic options are limited, and the current standard care as systemic therapy is still cytotoxic chemotherapy. With the understanding of the complex immune microenvironment in the liver and these cancers arising in the milieu of chronic inflammation, recent advances in immune oncology have transformed the landscape of cancer management with breakthroughs in the treatment of several solid tumors.

Recent findings

With the advances of genome sequencing, subgroups of cholangiocarcinoma with hyper mutated status and rich in cancer neoantigen production may be susceptible to immunotherapies like cancer vaccines and immune checkpoint inhibitors by eliciting a host immune response resulting in tumor rejection or overcoming the immunosuppressive local tumor microenvironment

In this review, we look at the most recent evidence behind immunotherapy and its application in the treatment of cholangiocarcinoma. Though its utility is still in early development it shows great promise in improving response rates that may translate to durable disease control and improve clinical outcomes in this aggressive disease.
Grant monitoring after intestinal transplantation
Authors: Venick Robert S.
Published: January 2021

Purpose of review

The current review aims to describe in detail the most common practices utilized to monitor graft function in intestinal transplant (ITx) recipients. In addition, to discussing the role of endoscopy and stool studies it will examine the use of other potential biomarkers which have been utilized. Data will be discussed from contemporary publications in the field, the Intestinal Transplant Registry as well as detailed data from a large, ITx single-center.

Recent findings

Significant improvements have been made in early outcomes following ITx, yet long-term survival remains challenged by infection and rejection, both of which can present with diarrhea. While endoscopy and stool studies are the gold-standard for graft monitoring, calprotectin, citrulline, measurements of immunoreactivity and donor-specific antibodies have been investigated in the field and are herein reviewed.

Despite a number of tests which are currently available for monitoring ITx recipients, a strong need exists for improved noninvasive, timely and accurate biomarkers to help improve ITx graft and patient survival.
Safety of Biological Therapy in Children With Inflammatory Bowel Disease
Authors: D’Arcangelo Giulia , Distante Manuela , Raso Tonia , Rossetti Danilo , Catassi Giulia , Aloi Marina
Published: January 2021

Objectives:

Retrospective, observational, single-center, cohort study investigating the safety profile of biological therapy in children with inflammatory bowel disease (IBD).

Methods:

Retrospective, observational, cohort study of pediatric patients with IBD, receiving infliximab, adalimumab, vedolizumab, or ustekinumab for at least 2 months. Data related to the immediate and delayed adverse events (AEs) were collected, focusing on the reaction type and severity, the time of onset, the outcome and the temporary or definitive therapy discontinuation secondary to the AE. Number of suspected and confirmed coronavirus disease-209 (COVID-19) cases and their outcomes, as well as flu vaccination coverage were collected.

Results:

One hundred eighty-five children were included (101 [55%] CD, 82 [44%] UC, and 2 [1%] IBDU): 149 received infliximab (IFX) (81%), 88 (48%) adalimumab (ADA), 18 (21%) vedolizumab, and 4 (2%) ustekinumab. The overall AE rates were 49%, 67% of whom likely medication-related. Eleven (6%) patients experienced more than 1 AE, 18 patients (10%) presented an immediate reaction, and 82 (45%) a delayed AE. Among the 90 patients experiencing at least 1 AE, 97% had mild-to-moderate AEs. Only 4 SAEs were reported (4%). Treatment discontinuation because of AE occurred in 25 patients (14%). Four COVID-19 cases were reported, all with a mild course.

Conclusions:

Our findings confirm a good safety profile of biologics. Infusion reactions to IFX administration remain one of the main issues, significantly linked to its immunogenicity and consequently with an impact on its efficacy and durability.
Ethical Implications of COVID-19
Authors: Parekh de Campos Amisha , Daniels Susan
Published: January 2021

Outbreaks of COVID-19 among nursing homes, assisted living facilities, and other long-term care facilities in the United States have had devastating effects on residents. Restrictions such as banning visitors, sequestering residents, and testing health care staff have been implemented to mitigate the spread of the virus. However, consequences include a decline in mental and physical health, decompensation, and a sense of hopelessness among residents. We present and explore a case study at an assisted living facility addressing the ethical issues in balancing the management of the community versus the resident's right to autonomy and self-determination. A team of palliative care experts was brought into assisted living facilities to manage patients, care for well residents, and provide input in advance care planning and symptom management. The principles of self-determination and autonomy, stewardship, and distributive justice were explored. The use of nursing skills in triage and assessment, principles in public health, and the 8 domains of palliative care provided a comprehensive framework for structuring emergency operations. Palliative interventions and the role of palliative care nurses played an integral part in addressing ethical challenges in the containment of the virus and the deleterious effects of social isolation among the elderly.
Extragenital Testing for Neisseria gonorrhoeae and Chlamydia trachomatis in a Large HIV Clinic in the US South: Implementation and Epidemiology
Authors: Pottorff Alexandra , Duarte Piper , Chow Jeremy , Luque Amneris , Nijhawan Ank E.
Published: January 2021

Background

Rectal and oral Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) infections are common among people with HIV, especially men who have sex with men (MSM); however, GC/CT testing rates remain low in many HIV clinics. We evaluated the real-world implementation and results of extragenital nucleic acid amplification testing for GC/CT in an urban HIV clinic.

Methods

Electronic health records were reviewed for all patients 18 years or older with ≥1 outpatient visit to an HIV clinic in Dallas, TX, from February 2016 to May 2019. Extragenital nucleic acid amplification testing became available in February 2017, which was followed by active interventions to increase testing.

Results

Overall, 5564 individual patients were included in the preintervention period (February 2016–January 2017), 5067 in the intervention period (February 2017–August 2017), and 7030 in the postintervention period (September 2017–May 2018). Tailored education was provided to patients, and nursing and medical providers, and a self-collection protocol was implemented beginning in spring 2017. A sustained increase in extragenital GC/CT testing among MSM patients, from 70% to 87% (P < 0.01), was observed. Among MSM, overall GC positivity increased from 3.2% to 8.5% and CT positivity increased from 3.9% to 8.3%. N. gonorrhoeae/C. trachomatis infections were highest among young (<35 years) MSM, and approximately 50% of GC/CT infections diagnosed were detected by oral and rectal tests.

Conclusions

Clinic-wide education and self-collection of extragenital specimens were associated with increased GC/CT testing and detection in a large HIV clinic.
Primary Peritoneal Mesothelioma With Clear Cell Morphology Presenting With Multiple Liver Masses: Report of a Case With a Unique VHL Y98fs*24 Mutation and Indolent Clinical Course
Authors: Saeed Omer A. M. , Armutlu Ayşe , Zhang Xin , Saxena Romil
Published: January 2021

Malignant peritoneal mesothelioma represents less than a quarter of all malignant mesothelioma cases. Malignant mesothelioma can be classified based on morphology into epithelioid, sarcomatoid, or mixed types. Peritoneal epithelioid mesothelioma with predominant clear cell features is very rare and mimics various malignancies posing a diagnostic challenge. Here we report a rare case of primary peritoneal mesothelioma with clear cell features presenting with liver masses. A 68-year-old man who had multiple liver nodules on imaging was admitted for worsening abdominal pain. He complained of intermittent abdominal pain for more than 10 years. Longitudinal follow-up of the patients' abdominal images over 10 years showed slowly progressive liver lesions. Microscopic examination of resected tumors revealed pleomorphic epithelioid neoplasm with clear cytoplasm, distinct cell borders, optically clear chromatin, and prominent nucleoli embedded in a vascular stroma. Immunostaining showed that the tumor cells were positive for AE1/3, vimentin, carbonic anhydrase IX, TFE1/33, and Gata3, whereas they were negative for PAX-8, arginase-1, hepatocyte specific antigen, inhibin, S100, DOG1, CD117, CD31, TTF-1, p63, smooth muscle actin, and HMB45. CancerType ID testing favored the diagnosis of mesothelioma with 90% probability, a diagnosis that was further confirmed by calretinin and WT1 positivity. Foundation genomic testing showed VHL Y98fs*24 mutation, a unique genetic mutation that, to our knowledge, was never described before. In summary, this is a rare case of primary peritoneal mesothelioma with clear cell features presenting as liver masses. The tumor had a unique genetic mutation and behaved in an indolent manner in contrast to what is commonly seen in mesotheliomas.
Collision Tumor Composed of Renal Oncocytoma and Mucinous Tubular and Spindle Cell Carcinoma: Not a Rare Occurrence
Authors: Lin Michelle S. , Jacobi Elizabeth M. , Mullick Seema S. , Nguyen Christopher V. , Thomas Jessica S. , Olsen Randall J. , Shen Steven S. , Ayala Alberto G. , Ro Jae Y.
Published: January 2021

Primary renal collision tumors have been rarely reported in the literature. Our institution reported the first case of a renal collision tumor that comprised oncocytoma and mucinous tubular and spindle cell carcinoma (MTSCC). In this study, upon review of this index case and a second case encountered in our practice, we performed molecular characterization of each component using next-generation sequencing, which did not detect any somatic mutations. In addition, we reviewed resection cases of oncocytomas for previously undetected MTSCC components. While no additional definitive oncocytoma-MTSCC collision tumor cases were identified, 2 cases with entrapped tubules within the central scar of the oncocytoma that possessed some features of MTSCC were encountered, raising the differential diagnosis of oncocytoma-MTSCC collision tumors versus entrapped renal tubules. We propose the following histomorphologic criteria to distinguish a true MTSCC component: (1) expansile mass lesion greater than 0.5 cm; (2) dense proliferation of tubules lined by plump cells; and (3) background of loose myxoid collagenous stroma. In contrast, entrapped tubules tend to form a smaller, stellate-shaped area with atrophic tubules within a dense collagenous stroma. Nevertheless, the occurrence of the 2 described cases provides evidence that the incidence of this collision tumor may not be extremely rare. Therefore, we recommend careful examination and generous sampling of oncocytomas, particularly from the central scarred region or in cases exhibiting atypical gross appearance. Further studies with additional cases are required to better document the relationship and molecular pathogenesis of MTSCC from the central scars of oncocytomas.
The Women Physiatrists Facebook Group
Authors: Capizzi Allison N. , Larson Allison R. , Silver Julie K. , Verduzco-Gutierrez Monica
Published: January 2021

This study evaluated Women Physiatry Facebook group members’ perceptions of the value of an online community. The authors hypothesized that members would find the group protective against burnout, and early career participants would be more likely to use the group for education and networking. This was a cross-sectional survey study of women physicians in the field of physical medicine and rehabilitation primarily in the United States. The survey consisted of 51 questions covering demographic information, work/life satisfaction, and physician burnout.

There were 310 respondents. Those at an earlier career stage accessed the Women Physiatrists Facebook page significantly more often (P = 0.038). Most respondents were neutral regarding the group reducing burnout. Across all career stages, the group was most often used as an educational tool to review patient cases (82.2%). Mid- to late-career members were more likely to use the group to learn about maintenance of certification or continuing medical education requirements (P = 0.019) and searching for a physiatrist in another part of the county (P = 0.016). This study suggests that closed Facebook groups can be useful educational tools across career stages.
Exercise as Treatment for Youth With Major Depression: The Healthy Body Healthy Mind Feasibility Study
Authors: GILES ADRIANA , NASSTASIA YASMINA , BAKER AMANDA , KELLY BRIAN , DASCOMBE BEN , HALPIN SEAN , HIDES LEANNE , CALLISTER ROBIN
Published: January 2021

The goals of this study were to determine the feasibility of engaging youth with major depressive disorder (MDD) in a multimodal exercise intervention (Healthy Body Healthy Mind) plus usual care and to evaluate the magnitude of its effects on psychological, physical fitness, and biomarker outcomes to inform a future randomized controlled trial. Youth (15 to 25 y of age) with MDD diagnosed using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) were eligible to participate. Feasibility measures included recruitment, retention, and program adherence rates. The exercise program consisted of a single session of motivational interviewing to enhance exercise adherence, then 1-hour, small-group supervised exercise sessions 3 times per week for 12 weeks. Assessments were administered at baseline and at 12 weeks. Depression symptoms were assessed using the Beck Depression Inventory (BDI-II). Physical fitness and blood biomarkers were also measured. Three males and 10 females with MDD, who were 18 to 24 years of age, participated. Retention at 12 weeks was 86%, and attendance at exercise sessions averaged 62%±28%. After 12 weeks, 69% of participants experienced a remission of MDD based on the SCID. Mean BDI-II scores decreased from 31.9±9.1 to 13.1±10.1 [Cohen d effect size (ES)=1.96]. Improvements were observed in upper (ES=0.64) and lower (ES=0.32) body muscular endurance. Exercise session attendance was moderately correlated with changes in BDI-II scores (Pearson r=0.49). It appears feasible to attract and engage some youth with MDD in an exercise intervention. The positive impact on depression symptoms justifies further studies employing exercise interventions as an adjunct to routine care for young people with MDD.
The Association Between Health Care Staff Engagement and Patient Safety Outcomes: A Systematic Review and Meta-Analysis
Authors: Janes Gillian , Mills Thomas , Budworth Luke , Johnson Judith , Lawton Rebecca
Published: January 2021

Objectives

Despite decades of research, improving health care safety remains a global priority. Individual studies have demonstrated links between staff engagement and care quality, but until now, any relationship between engagement and patient safety outcomes has been more speculative. This systematic review and meta-analysis therefore assessed this relationship and explored if the way these variables were defined and measured had any differential effect.

Methods

After systematic searches of Medline, CINAHL, PsycInfo, Embase, Cochrane Library, and National Institute for Health Research Journals databases, narrative and random-effects meta-analyses were completed, with pooled effect sizes expressed as Pearson r.

Results

Fourteen studies met the inclusion criteria, 11 of which were suitable for meta-analysis. Meta-analyses indicated a small but consistent, statistically significant relationship between staff engagement and patient safety (all outcomes; 11 studies; r = 0.22; 95% confidence interval [CI], 0.07 to 0.36; n = 30,490) and 2 patient safety outcome categories: patient safety culture (7 studies; r = 0.22; 95% CI, 0.01 to 0.41; n = 27,857) and errors/adverse events (4 studies; r = −0.20; 95% CI, −0.26 to −0.13; n = 2633). The specific approach to conceptualizing engagement did not affect the strength of the findings.

Conclusions

This is the first review to demonstrate a significant relationship between engagement and both safety culture scores and errors/adverse events. Despite a limited and evolving evidence base, we cautiously conclude that increasing staff engagement could be an effective means of enhancing patient safety. Further research is needed to determine causality and clarify the nature of the staff engagement/patient safety relationship at individual and unit/workgroup levels.
A Rare Case of Tongue Neoplasia Treated Successfully in a Patient With B-Cell Acute Lymphoblastic Leukemia Following Allogeneic Hematopoietic Stem Cell Transplantation
Authors: Qiu Xi , Yu Teng , Xu Yang
Published: January 2021

Abnormal change on the tongue is a potential complication after allogeneic hematopoietic stem cell transplantation (allo-HSCT). The exact pathogenesis remains unclear and several risk factors include chemoradiotherapy, infection, graft-versus-host disease, disease relapse, and secondary malignancy. Our case described a 42-year-old woman with B-cell acute lymphoblastic leukemia treated by allo-HSCT 2 months later followed by a rare and atypical tongue neoplasia without oral pain, dysphagia, and dysgeusia. The biopsy was operated which showed granulation tissue with no evidence on typical graft-versus-host disease or malignancy, and no specific infection had been identified. Cyclosporine and mycophenolate mofetil, which were used for immunosuppression after allo-HSCT accompanying with the rapid growth of the tongue neoplasia, was then replaced by sirolimus. One month later, the patient underwent a complete remission unexpectedly.
The Effects of Intervening With Synonasal Changes on Headaches in Migraine Patients Using Endonasal Surgery
Authors: Ertekin Ayfer , Yasar Murat
Published: January 2021

Objective:

Some anatomical changes might trigger headaches in people who have migraine, and that surgical applications eliminating the structural problems in treatment-resistant migraine patients are effective in pain treatment.

Methods:

A total of 36 patients, who did not respond to different treatment options without aura migraine and chronic migraine that were showing synonasal and anatomical changes in synonasal nasal endoscopy and/or paranasal sinus CT screening, responding insufficiently and/or approximately one year period also did not respond to different treatment options, were included in this study between June 2016 and September 2019.

Results:

The relation between migraine episodes and synonasal symptoms was found to be statistically significant. A significant difference was detected between nasal congestion and obstruction, postnasal discharge, and runny nose in patients with attacks compared to patients without attacks. The difference between mean pain severity values was statistically significant when compared to preoperative values (3.0(3.0∼4.0)) and post-operative values (1.0(0∼1.0)). When the pain severity after the operation (1.0(1.0∼2.75)) was compared with the severity of pain before the operation (5.0 (3.0∼5.0)), it was determined that there was a significant decrease in pain severity in patients diagnosed with chronic migraine, the difference between the mean pain severity values was statistically significant, and the prevalence of pain decreased at a significant level after the operation.

Conclusion:

The results of the present study indicate that the elimination of synonasal structural changes, which were hypothesized to trigger pain in migraine patients, could have a pain-reducing effect on the frequency and severity of the pain.