bluuebunny/crossref_metadata_2025 huggingface dataset:
Atypical mycobacterial infections – management and when to treat
Authors: Gill Laura Indira , Dominic Catherine , Tiberi Simon
Published: February 2021

Purpose of review

Infections caused by nontuberculous mycobacteria (NTM) are increasing for several reasons, including diagnostic advances, increased awareness and a larger at-risk population. NTM pulmonary disease is surpassing tuberculosis (TB) in some low incidence areas. This review summarizes the latest literature and guidelines and aims to be a concise source outlining treatment and management of NTM lung infections, integrating established treatment paradigms with novel pharmacological interventions.

Recent findings

Recent additions to NTM treatment are inhaled liposomal amikacin and the anti-TB drug bedaquiline. Several other new or repurposed treatments are being explored in vitro, in animal models and in clinical trials, including novel beta-lactamase inhibitor/lactam combinations, dual-lactam combinations, efflux pump inhibitors, novel antimicrobials, inhaled clofazimine suspension and bacteriophages.

Patients with NTM pulmonary disease are mainly female and older with significant delay between diagnosis and treatment being common. Treatment varies according to causative organism, drug susceptibilities, radiological type and disease severity. Underlying chronic conditions, drug intolerances and interactions require careful consideration. In all cases, at least three drugs should be used to minimize acquisition of drug resistance, and all patients should receive a minimum of 12 months of treatment. Expert advice should be taken. NTM treatment is longer than TB treatment, more likely to fail and more likely to cause toxicity. The relatively small numbers of patients affected by each NTM species has limited research. Novel treatments hold promise; nevertheless, it is likely that new solutions for NTM management will stem from the TB pipeline for the foreseeable future.
Severity of liver test abnormalities in coronavirus disease 2019 depends on comorbidities and predicts early in-hospital mortality
Authors: Satapathy Sanjaya K. , Kuntzen Christian , Qiu He , Jiang Yu , Bodenheimer Henry C. , Roth Nitzan C. , Lee Tai-Ping , Hirsch Jamie S. , Trindade Arvind J. , Bernstein David E. ,   for the Northwell Health COVID-19 Research Consortium
Published: February 2021

Background and aims

Liver chemistry abnormalities (LCA) are common in patients with coronavirus disease 2019 (COVID-19), but their causes and clinical impact have not been adequately studied. We assessed the associations between LCA and clinical characteristics, inflammatory serum markers, in-hospital mortality.

Methods

Ten thousand eight hundred fifty-six adult patients with COVID-19 hospitalized in 13 hospitals in New York (1 March to 27 April 2020) were analyzed retrospectively. Abnormalities of liver chemistries [aspartate aminotransferase (AST), alanine aminotransferase, alkaline phosphatase, or total bilirubin] were defined as absent, mild-moderate (at least one value up to four times elevated), or severe.

Results

LCA were mild-moderate in 63.9% and severe in 7.6% at admission. Risk factors for severe LCA were male sex and chronic liver disease. Conversely, hypertension and diabetes mellitus were less likely associated with severe LCA. AST elevation correlated weakly to modestly with inflammatory markers. On adjusted analysis, in-hospital mortality was 1.56 times and 1.87 times increased in patients with mild-to-moderate and severe LCA, respectively. Diabetes, hypertension, male sex, and age greater than 60 years was associated with incremental risk of mortality with increase severity of LCA, especially in the first week of hospitalization. HTN was not associated with increased in-hospital mortality unless LCA was present.

Conclusion

Increasing severity of LCA on hospital admission predicts early in-hospital mortality in COVID-19 patients. Mortality associated with the known risk factors, hypertension, diabetes, male sex, and old age was accentuated in the presence of LCA. AST correlated modestly with inflammatory markers.
Hepatocellular carcinoma in patients coinfected with hepatitis B or C and HIV: more aggressive tumor behavior?
Authors: Saud Lisa R. C. , Chagas Aline L. , Maccali Claudia , Pinto Paulo V. A. , Horvat Natally , Alencar Regiane S. S. M. , Tani Claudia M. , Abdala Edson , Carrilho Flair J.
Published: February 2021

Introduction and objectives

Hepatocellular carcinoma (HCC) is the 6th cause of cancer and hepatitis C (HCV) and B (HBV) viruses are the most frequent risk factors for HCC. Patients coinfected with HCV or HBV and HIV present a faster progression to liver fibrosis and higher incidence of HCC. The aim of this study was to evaluate the survival and clinical outcomes of coinfected patients with HCC comparing with non-HIV patients.

Methods

We conducted a retrospective cohort study, including 267 HCC patients with HCV or HBV infection with or without HIV. The primary endpoint was overall survival. A Kaplan–Meier curve was presented to assess survival function. Clinical and radiologic variables, according to HIV status, were compared by logistic regression.

Results

Among 267 HCC patients, 25 (9.3%) were HIV-positive. In the coinfected group, patients were younger (49.8 vs 61.2 years, P < 0.001), cirrhosis was less predominant (88 vs 96.7%, P = 0.05), a smaller proportion received HCC treatment (60 vs 86.3%, P = 0.001) and the frequency of portal vein tumoral thrombosis was higher (32 vs 11.1%, P = 0.003). The overall mortality rate was higher in the HIV-positive group (92 vs 74.3%), independently of clinical and tumoral variables.

Conclusion

Coinfected patients with HCC presented higher mortality, tumor diagnosis in a younger age, less underlying cirrhosis and a higher frequency of tumoral thrombosis. Further studies are warranted to better understand the role of HIV in hepatocarcinogenesis, in order to improve the management of those patients, particularly regarding screening programs.
Design and verification of individualized follow-up strategy of colonoscopy for postoperative patients with colorectal cancer
Authors: Guo Chunmei , Wu Jing , Jiao Yue , Zhang Qian , Wang Canghai , Wang Yadan , Liu Hong , Zhang Shutian , Wei Nan , Lin Wu , Liu Kuiliang , Shi Haiyun
Published: February 2021

Background

Current guidelines do not establish an individual scheme for surveillance colonoscopy in postoperative colorectal cancer (CRC) patients.

Aims

The purpose of the study was to screen possible risk factors for the development of metachronous adenoma in postoperative CRC patients and to develop a risk prediction model and verify it.

Methods

Consecutive postoperative patients with CRC were enrolled from April 2007 to December 2013 as the derivation group. Baseline data of patients and clinicopathological features of the tumor were collected, logistic regression analysis was performed, and clinical model was established and was verified internally. The model was externally validated in an independent cohort (validation group) from January 2014 to October 2017 in the same hospital.

Results

A total of 734 patients were included, with average (64.6 ± 11.5) years old. The overall incidence of metachronous adenoma was 35.4%. There was no significant difference in the incidence of metachronous adenoma between the derivation group and validation group (P > 0.05). Age, diabetes mellitus, right colon cancer, moderately to poorly differentiated adenocarcinoma and synchronous adenoma were independent risk factors for metachronous adenoma. The C-index of the metachronous adenoma line chart model was 0.932, and the index decreased by 0.022 after internal verification. The C-index of external validation was 0.910. The Hosmer–Lemeshow test showed that the P value of metachronous adenoma risk prediction model was 0.247.

Conclusions

Individual surveillance strategies should be designed for postoperative patients with CRC. For high-risk patients, it is appropriate to undergo more than two colonoscopies in 36 months after operation.
Serum fibrosis markers could aid in the prediction of factor for successful oral antiviral treatment in hepatitis C
Authors: Sahin Memduh , Sucu Pinar , Serin Erdinc , Yetim Aylin , Alkim Huseyin , Alkim Canan
Published: February 2021

Background

It has been demonstrated that there may be a relationship between liver fibrosis and serum biomarkers. The aim of this study was to investigate pre- and postoral antiviral therapy levels of these biomarkers and their relationship with other fibrotic parameters in hepatitis C virus (HCV) patients.

Methods

The study group comprised HCV patients who were treated with oral antiviral regimens. Prior to, and 8 months after the treatment, serum biomarkers, including transforming growth factor-β (TGF-β), chitinase-3-like protein 1 (YKL-40), collagen type IV, matrix metalloproteinases (MMPs) and hyaluronic acid levels, were examined and fibrosis-4 (Fib-4) and aspartate aminotransferase to platelet ratio index (APRI) scores were calculated at the same times.

Results

In total, 45 HCV patients (aged between 27 and 86 years) participated. Of these 20 (44.4%) were cirrhotic and 25 (55.6%) were noncirrhotic. The concentrations of YKL-40 (P = 0.01) and TGF-β (P = 0.032) after treatment were significantly higher than the pretreatment values, whereas hyaluronic acid concentrations decreased after treatment (P = 0.001). Noncirrhotic patients had significantly higher (P = 0.03) YKL-40 levels prior to therapy compared to cirrhotic patients. Median MMP-2 concentrations were higher in men than in women (P = 0.001). Prior to treatment, TGF-β, YKL-40 and collagen type IV levels were negatively correlated with Fib-4 scores, whereas only TGF-β and YKL-40 concentrations were negatively correlated with APRI scores.

Conclusion

YKL-40, TGF β and hyaluronic acid may be markers for fibrotic change during oral therapy for HCV. In particular, TGF β concentrations correlated with fibrotic indices. However, these results should be confirmed and validated by further research.
Postcholecystectomy biliary injuries: frequency, and role of early versus late endoscopic retrograde cholangiopancreatography
Authors: Emara Mohamed H. , Ali Reda F. , Mahmoud Ramadan , Mohamed Salem Y.
Published: February 2021

Background and study aim

Bile duct injuries are not infrequently seen during hepatobiliary surgery, particularly after liver transplantation and cholecystectomy. The current study aims to figure out the frequency of postcholecystectomy biliary injuries (PCBI) and the role of early versus late endoscopic retrograde cholangiopancreatography (ERCP) in their management.

Patients and methods

Totally 960 cases operated by both laparoscopic and open cholecystectomy were evaluated in the current study. In total, 942 cases were operated in our institutes, by both laparoscopic (n = 925) and open (n = 17) cholecystectomy, and the frequency of PCBI among patients operated in our institutes was (9/942) 0.95%. Additional 18 cases of PCBI referred to our centers were included in the study. One patient was treated by repair during the surgery, in the remaining 26 patients, ERCP management was attempted. The full details of the 26 patients regarding ERCP management were discussed.

Results

The overall success rate of ERCP management was 88.46% (23/26), whereas 11.54% of cases were treated surgically by choledochal-jejunal anastomosis due to complete common bile duct ligation. There were no differences between patients treated by early (first week) versus late (after the first week) ERCP regarding the needed interventions, type of PCBI, type and diameter of the inserted stents, and the overall success. There were no adverse events associated with ERCP management.

Conclusions

ERCP was valuable in the treatment of 88.46% of injured cases. There were no differences between early and late ERCP in the treatment of PCBI. Furthermore, ERCP management was not associated with adverse events.
Improving accuracy of 18F-fluorodeoxyglucose PET computed tomography to diagnose nodal involvement in non-small cell lung cancer: utility of using various predictive models
Authors: Mathew Boon , Purandare Nilendu C. , Pramesh C S , Karimundackal George , Jiwnani Sabita , Agrawal Archi , Shah Sneha , Puranik Ameya , Kumar Rajiv , Prakash Agarwal Jai , Prabhash Kumar , Tandon Sandeep , Rangarajan Venkatesh
Published: February 2021

Purpose

To determine predictive models (PM) that could improve the accuracy for identifying metastatic regional nodes in non-small cell lung cancer based on both PET and CT findings seen on 18F-FDG PET CT.

Methods

Three hundred thirty-nine biopsy-proven NSCLC patients who underwent surgical resection and had a staging 18F-FDG PET CT were enrolled. PET parameters obtained were (1) presence of visual PET positive nodes, (2) SUVmax of nodes (NSUV), (3) ratio of node to aorta SUVmax (N/A ratio) and (4) ratio of node to primary tumour SUVmax (N/T ratio). CT parameters obtained were (1) short-axis diameter and (2) Hounsfield units (HU) of PET-positive nodes. PET and CT parameters were correlated with nodal histopathology to find out the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and overall accuracy. Different PM combining these parameters were devised and the incremental improvement in accuracy was determined.

Results

Visual PET positivity showed sensitivity, specificity, PPV, NPV and accuracy of 72.4, 76.1, 30.1, 95.1 and 75.6, respectively. PM2 which combined visual PET positivity, NSUV and HU appears more clinically relevant and showed sensitivity, specificity, PPV, NPV and accuracy of 53.5, 96.5, 68.9, 93.6 and 91.2, respectively. PM6 which combined visual PET positivity, NSUV, N/A ratio and HU showed the maximum PPV (80.0%), specificity (98.3%) and accuracy of (91.9%).

Conclusion

PM combining parameters like nodal SUVmax, N/A ratio, N/T ratio and HU values have shown to improve the PPV, specificity and overall accuracy of 18FDG PET CT in the preoperative diagnosis of nodal metastases.
Is There an Ethical Mandate to Practice Without Proper Personal Protective Equipment?
Authors: Rasmussen Amy , Dambrino Kathryn
Published: February 2021

In the spring of 2020, a novel virus known as COVID-19 (coronavirus disease 2019) was introduced to the human population, and the world faced a global pandemic with far-reaching consequences. One of the most difficult challenges that nurses faced in the midst of the crisis was the lack of proper personal protective equipment (PPE). The lack of PPE left health care professionals with a complicated ethical dilemma: Is there an ethical duty to care for patients in the absence of proper PPE? This article seeks to help the individual nurse (a) understand the ethical dilemma and the tensions that it brings, (b) look to the literature for guidance, and (c) understand how individuals can apply these ethical principles. After careful analysis, the recommendation is for the individual nurse to make a thorough assessment of their personal situation. This will include consideration for their family, community, financial responsibilities, legal protections, organizational policies, and personal health risk. Finally, this article serves as a call to organizations and professional leaders to increase their support of frontline health care workers and provide the individual nurse with the information they need in order to make sound decisions.
Leading Healthcare Change Across the Care Continuum
Authors: Murphy Lyn Stankiewicz , Joseph M. Lindell
Published: February 2021

Kenneth Rempher, PhD, MBA, CENP, RN, is the chief nursing officer for the University of Iowa (UI) Hospitals and Clinics. In his 20-year career, he has distinguished himself as a visionary healthcare leader. Colleagues describe Dr Rempher as a strong, transformational leader, guiding the UI enterprise through a time of uncertainty and change. This interview by the CGEAN provides insight to his leadership style, successes, and ideas on the future of care delivery.
Measuring Nurse Leaders’ and Direct Care Nurses’ Perceptions of a Healthy Work Environment in an Acute Care Setting, Part 1
Authors: Huddleston Penny , Gray Jennifer
Published: February 2021

BACKGROUND:

The American Association of Critical-Care Nurses Healthy Work Environment Assessment tool (AACN HWEAT) was developed as a simple screening assessment for clinical units to quickly get individual feedback on the status of the nurses' work environments based on the AACN standards of a healthy work environment (HWE). Pilot studies were conducted to determine the psychometric properties of the tool after seeking permission from AACN and the Vital Smarts Company.

PURPOSES:

The purposes of these research studies were to assess the psychometric properties of the AACN HWEAT and to measure the nurse leaders' and direct care nurses' perceptions of an HWE in an acute care setting.

METHODS:

Nonexperimental descriptive survey designs were implemented with 3 convenience samples for a total sample of 321 nurse leaders and direct care nurses.

RESULTS:

Cronbach's αs of .97 for nurse leaders and .91 for direct care nurses demonstrated strong reliability or internal consistency of the tool. Face validity demonstrated 13 of 18 items placed in the correct category. The scale content validity index score was 96.63. Concurrent validity demonstrated that items were highly correlated, ranging from 0.42, with 95% confidence interval (CI) of 0.57 to 0.69, to 0.85, with 95% CI of 0.70-0.93, P < .05. Principal component analysis revealed 2 components for the tool.

CONCLUSIONS:

As a result of these findings, an opportunity was identified to develop additional tools to measure an HWE for nurses at all levels in acute care settings.
Breakthrough Thinking in Nursing Education
Authors: Godfrey Nelda , Martin David
Published: February 2021

A deliberate emphasis on breakthrough thinking led to a radically new, evidence-based model for baccalaureate generalist nursing education known as the Baccalaureate Big 5. This semistructured brainstorming process then led to wider application in other settings, creating new nursing education and practice opportunities state wide and nationally. How this was accomplished and how it can be duplicated by others is the intent of this publication.
Caregiver Fatigue
Authors: Smith-Miller Cheryl A. , Harden Jacqueline , Seaman Christa W. , Li Yin , Blouin Ann Scott
Published: February 2021

Fatigue negatively affects healthcare workers’ health and well-being, decreases patient safety, and negatively impacts the work environment. Although individual lifestyle choices influence fatigue levels, much responsibility lies with nursing administrators to prevent situations that may result in sleep deprivation or overwork. This article, the 2nd in a 2-part series, describes the results that were achieved from a fatigue reduction intervention.
G2 Research Radically Invasive Projectile
Authors: Zhang Xin , Cain Matthew D. , Williams Christian D. , Spears Timothy A. , Poulos Christopher K.
Published: February 2021

Many fragmenting and frangible projectiles have been developed in the course of firearm history. In addition, partially because of the concerns of range and environmental contamination, bullets constructed without lead have become increasingly common. A case regarding a unique projectile that incorporates both features, the G2 Research Radically Invasive Projectile ammunition, is discussed in this article. Here we report a 25-year-old woman who died of multiple gunshot wounds caused by G2 Research Radically Invasive Projectile ammunition. Because of the bullet's unique design, the wounds demonstrated characteristic radiographic patterns and unique autopsy findings. Familiarity with these findings is important to forensic pathologists in terms of case documentation, projectile recovery, and personal safety.
Predictive Patterns of Glutamine Synthetase Immunohistochemical Staining in CTNNB1-mutated Hepatocellular Adenomas
Authors: Sempoux Christine , Gouw Annette S.H. , Dunet Vincent , Paradis Valérie , Balabaud Charles , Bioulac-Sage Paulette
Published: February 2021

Some hepatocellular adenoma (HCA) subtypes are characterized by different CTNNB1 mutations, leading to different beta-catenin activation levels, hence variable immunostaining patterns of glutamine synthetase (GS) expression, and different risks of malignant transformation. In a retrospective multicentric study of 63 resected inflammatory (n=33) and noninflammatory (n=30) molecularly confirmed CTNNB1-mutated b-(I)HCA, we investigated the predictive potential of 3 known GS patterns as markers for CTNNB1 exon 3, 7/8 mutations. Pattern 1 (diffuse homogenous) allowed recognition of 17/21 exon 3 non-S45 mutated b-(I)HCA. Pattern 2 (diffuse heterogenous) identified all b-(I)HCA harboring exon 3 S45 mutation (20/20). Pattern 3 (focal patchy) distinguished 12/22 b-(I)HCA with exon 7/8 mutations. In exon 3 S45 and 7/8 mutations, both b-HCA and b-IHCA showed a GS+/CD34− rim with diffuse CD34 positivity in the center of the lesion. Interobserver reproducibility was excellent for exon 3 mutations. Comparative analysis of GS patterns with molecular data showed 83% and 80% sensitivity (b-HCA/b-IHCA) and 100% specificity for exon 3 non-S45. For exon 3 S45, sensitivity was 100% for b-(I)HCA, and specificity 93% and 92% (b-HCA/b-IHCA). For exon 7/8, sensitivity was 55% for both subtypes and specificity 100% and 96% (b-HCA/b-IHCA). Preliminary data from 16 preoperative needle biopsies from the same patients suggest that this panel may also be applicable to small samples. In surgically resected HCA, 2 distinct GS patterns can reliably predict CTNNB1 exon 3 mutations, which are relevant because of the higher risk for malignant transformation. The third pattern, although specific, was less sensitive for the identification of exon 7/8 mutation, but the GS+/CD34− rim is a valuable aid to indicate either an exon 3 S45 or exon 7/8 mutation.
Crowdsourced Assessment of Aesthetic Outcomes after Breast Reconstruction
Authors: Teotia Sumeet S. , Alford Jake A. , Kadakia Yash , Haddock Nicholas T.
Published: February 2021

Background:

Evaluating the aesthetic success of breast reconstruction can be difficult. Patients, surgeons, and the general population may differ in what constitutes a successful outcome. Recently, crowdsourcing has emerged to accumulate and analyze data on a massive scale. The authors propose that crowdsourcing can be a useful tool to reliably rate aesthetic outcomes of breast reconstruction.

Methods:

One hundred one deidentified photographs of patients at various stages of breast reconstruction were gathered. Assessment tools included a five-point Likert scale and the transverse rectus abdominis myocutaneous (TRAM) visual assessment scale. Anonymous crowd workers and a group of expert reconstructive surgeons rated an identical set of photographs on the Likert scale. Crowd workers also rated the set of photographs on the TRAM scale.

Results:

The authors obtained 901 anonymous, layperson evaluations on both Likert and TRAM scales. Crowdsourced assessment data collection took 28.6 hours. Expert assessment took 15 months. Expert and crowdsourced scores were equivalent on the Likert scale (overall interrater reliability, κ = 0.99; 95 percent CI, 0.98 to 0.99). Intrarater reliability among each subcomponent was highly reproducible for the crowd (r = 0.98; 95 percent CI, 0.97 to 0.99) and experts (r = 0.82; 95 percent CI, 0.77 to 0.87). Breast contour and positioning were most predictive of overall aesthetic result. Skin patch and scar were least predictive of overall aesthetic appearance.

Conclusions:

Aesthetic outcomes rated by crowds were reliable and correlated closely with those by expert surgeons. Crowdsourcing can be a rapid, reliable, and valid way to assess aesthetic outcomes in the breast reconstruction patient.
Splitting the Difference: Using Synthetic and Biologic Mesh to Decrease Cost in Prepectoral Immediate Implant Breast Reconstruction
Authors: Karp Nolan S. , Salibian Ara A.
Published: February 2021

Prepectoral breast reconstruction has minimized morbidity and dynamic deformities associated with submuscular implant-based breast reconstruction. However, reliance on implant coverage with acellular dermal matrix in immediate implant reconstruction remains limited by high material costs. The authors describe a technique in which anterior implant coverage in prepectoral reconstruction is split into acellular dermal matrix inferolaterally and synthetic, absorbable mesh superiorly. Use of acellular dermal matrix inferiorly provides coverage and reinforces the inframammary fold, whereas the absorbable mesh is trimmed and sutured to the acellular dermal matrix at the appropriate tension to support the implant and relieve pressure on mastectomy flaps. A retrospective review was performed on all consecutive prepectoral one-stage breast reconstructions using this technique at a single institution. Patient demographics, mastectomy and reconstruction characteristics, reconstructive outcomes, and cost of support materials were queried and analyzed. Eleven patients (21 breasts) underwent prepectoral immediate implant reconstruction with Vicryl and acellular dermal matrix anterior coverage. Average mastectomy weight was 775.8 g. Smooth, round cohesive implants were used in all cases and average implant size was 514.5 ml. Overall complication rates were low and included one minor infection (4.8 percent) and one case of minor mastectomy flap and partial nipple necrosis each (4.8 percent). Calculated cost savings of Vicryl and acellular dermal matrix anterior coverage was up to $3415 in unilateral and $6830 in bilateral cases. Prepectoral breast reconstruction using acellular dermal matrix inferiorly and Vicryl mesh superiorly is a safe technique that decreases material costs associated with support materials and allows the surgeon to precisely control the implant pocket and position.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Robin Sequence: 5-Year Speech Outcomes—A Case-Control Study
Authors: Schwaiger Michael , Cook Hannah , Jordan Zoe , Edmondson Sarah-Jayne , Mischak Irene , Wallner Jürgen , Atherton Duncan , Haers Piet , Timoney Norma , Ferguson Louisa
Published: February 2021

Background:

Pierre Robin sequence (Robin sequence) is defined as the triad of micrognathia, glossoptosis, and airway obstruction. It is frequently associated with palatal clefting. In recent years, increased interest in speech outcomes of cleft patients diagnosed with Robin sequence has been shown.

Methods:

Speech outcomes of cleft patients with Robin sequence were assessed at age 5 in comparison with a cleft palate–only cohort. Speech parameters were evaluated according to the Cleft Audit Protocol for Speech-Augmented and analyzed using the National Audit Standards for Speech (United Kingdom). All patients were treated in the same institution during the same period (2005 to 2012). Subjects who needed nasopharyngeal airway support and those whose airway was managed by positioning only were eligible.

Results:

Fifty-one cleft patients diagnosed with Robin sequence were included in this study. Outcomes were compared to those of 128 nonsyndromic cleft palate–only patients.

Patients with Robin sequence were shown to present with a significantly higher rate of cleft speech characteristics in comparison to the reference cohort (p = 0.001). Furthermore, it was shown that Robin sequence is associated with a significantly higher rate of secondary speech surgery for velopharyngeal dysfunction before the age of 5 (p = 0.016). Robin sequence patients with a nasopharyngeal airway presented with a higher rate of cleft speech characteristics compared to Robin sequence patients managed with positioning only.

Conclusion:

Cleft patients with Robin sequence are more likely to need further surgery to correct velopharyngeal dysfunction before the age of 5 and are more prone to present with cleft speech characteristics at the age of 5.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, II.
Four-Step Spreader Flap: The Pull-Twist-Turn Technique
Authors: Rohrich Rod J. , Durand Paul D.
Published: February 2021

The spreader (or autospreader) flap offers an alternative to the traditional spreader graft in reconstructing the dorsal midvault and preserving internal valve function. This is of particular importance after an aggressive dorsal hump reduction, which has the potential to result in an inverted-V deformity, dorsal narrowing, or saddle-nose deformity. In this article, the authors describe a four-step spreader flap technique that offers a simple, reproducible method of shaping the dorsal midvault while preserving internal valve function.
The Effect of Depressor Anguli Oris Muscle Block on Facial Symmetry in Synkinetic Facial Paralysis Patients and Its Role in Preoperative Assessment
Authors: Krag Andreas E. , Glick Samuel , Hembd Austin , Rozen Shai M.
Published: February 2021

Background:

Depressor anguli oris muscle hypertonicity in synkinetic facial paralysis patients may have an overpowering antagonistic effect on facial symmetry. Depressor anguli oris muscle block is a crucial diagnostic test before any treatment planning. Presented is the largest patient cohort analysis to date on static and dynamic facial symmetry changes after depressor anguli oris muscle block.

Methods:

Unilateral synkinetic patients with depressor anguli oris muscle hypertonicity were included. Resting symmetry and smile modiolus angle, excursion, and exposure of teeth were measured on both synkinetic and healthy hemifaces before and after depressor anguli oris muscle block using Emotrics and FaceGram photographic analyses.

Results:

Thirty-six patients were included. Before depressor anguli oris block, resting modiolus height was elevated on the synkinetic side (p = 0.047). During open-mouth smile, reduced modiolus angle (p < 0.0001), modiolus excursion (p < 0.0001), and exposure of teeth (p < 0.0001) were observed on the synkinetic hemiface. After depressor anguli oris block, resting modiolus height became symmetric (p = 0.64). During open-mouth smile, modiolus angle and exposure of teeth significantly increased (both p < 0.0001); excursion did not improve on the synkinetic side (p = 0.13) but unexpectedly improved in open-mouth smile on the healthy side (p = 0.0068).

Conclusions:

Depressor anguli oris muscle block improved resting symmetry and modiolus angle and exposure of teeth during smile, demonstrating the inhibitory mimetic role of a hypertonic depressor anguli oris muscle in synkinesis. It is a critical diagnostic and communication tool in the assessment and treatment planning of depressor anguli oris muscle hypertonicity, suggesting the potential effects of future depressor anguli oris myectomy.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Free Flap Reconstruction of Posterior Trunk Soft-Tissue Defects: Single-Institution Experience and Systematic Literature Review
Authors: Akdeniz-Dogan Zeynep , Roubaud Margaret S. , Kapur Sahil K. , Liu Jessie , Yu Peirong , Selber Jesse C. , Mericli Alexander F.
Published: February 2021

Background:

The posterior trunk is a technically demanding location for microvascular free tissue transfer. In this study, the authors report their own institutional experience with soft-tissue free flap reconstruction of the posterior trunk and provide a systematic review of the literature regarding this uncommon clinical scenario.

Methods:

A systematic review was performed using the PubMed database in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A single-institution retrospective review was also performed including all patients who received a soft-tissue free flap for a posterior trunk defect between 1990 and 2019.

Results:

The database search yielded 15 articles, representing 61 patients; the most commonly used flap was the latissimus dorsi (45.9 percent) and the most commonly reported defect location was the lumbosacrum (42.3 percent). Retrospective review of the authors’ database identified 26 patients, with the latissimus dorsi being the most common flap and the sacrum the most common defect site. The authors’ institutional case series showed a 30.7 percent major complication rate and 7.7 percent total flap loss rate; 38.4 percent of flaps required vein grafting.

Conclusions:

In this study, the authors provided a systematic literature review and described their own long-term institutional experience with these rare and difficult reconstructions. Although the overall complication rate is high, these reconstructions are frequently necessary, and an algorithmic approach can improve outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Linear Modeling to Reduce Bias in Plastic Surgery Residency Selection
Authors: Elmaraghi Shady , Rao Venkat K. , Christie Brian M.
Published: February 2021

Background:

Consistently selecting successful, productive applicants from an annual candidate pool is the goal of all resident selection practices. Efforts to routinely identify high-quality applicants involve scrutiny of multiple factors and formulation of an ordinal rank list. Linear modeling offers a quantified approach to applicant selection that is strongly supported by decades of psychological research.

Methods:

For the 2019 residency application process, the University of Wisconsin Plastic Surgery Residency Program used linear modeling in their evaluation and ranking process. A linear model was developed using United States Medical Licensing Examination Step 1 and Step 2 scores, letters of recommendation, publications, and extracurricular activities as inputs.

Results:

The applicant’s total score was calculated from a maximum total score of 100. The mean and median scores were 49 and 48, respectively, and applicants were ranked according to total score. A separate rank list was maintained using our program’s standard methodology for applicant ranking, which involves global intuitive scoring during the interview process. The Spearman rank correlation coefficient between the two lists was 0.532, and differences between the rank lists were used as a fulcrum for discussion before making the final rank list.

Conclusions:

This article presents the first known instance of the use of linear modeling to improve consistency, increase fairness, and decrease bias in the plastic surgery residency selection process. Transparent sharing of methodology may be useful to other programs seeking to optimize their own ranking methodology. Furthermore, it indicates to applicants that they are being evaluated based on fair, quantifiable criteria.
The eternal dilemma of antitoxin antibiotics for skin and soft tissue infection
Authors: Burillo Almudena , Bouza Emilio
Published: February 2021

Purpose of review

In standard clinical practice, combined antibiotic treatment is used to treat severe skin and soft tissue infections (SSTIs), whereby one of the drugs is usually a protein synthesis inhibitor antibiotic. However, evidence for this practice is only based on data from ‘in vitro’ studies, animal models and case reports. There are no randomized controlled trials. In the light of several new drugs marketed for the treatment of these infections, there is a need to revise the state of the art.

Recent findings

New reviews and systematic appraisals of the literature exist on the use of protein synthesis inhibitor antibiotics to treat severe SSTI. Several ‘in vitro’ studies have assessed the efficacy of some of the new drugs.

Combination therapy, including an adjuvant protein synthesis inhibitor antibiotic for toxin suppression, should be used both in patients with severe SSTI and in those with moderate infection and risk factors for methicillin-resistant positive- or Panton–Valentine leukocidin positive-Staphylococcus aureus infection.
Interventions for Informal Caregivers of Stroke Survivors: Is There Racial and Ethnic Representation in Stroke Caregiver Studies?
Authors: Lopez Janet , Stacciarini Jeanne-Marie , Scarton Lisa , Uphold Constance R.
Published: February 2021

Purpose

The specific aims of this scoping review of the literature are to (1) map the current scope of literature regarding nonpharmacological interventions for informal stroke caregivers and (2) explore the degree to which racial/ethnic minority groups were represented in nonpharmacological interventions for stroke caregivers in the United States.

Design and Methods

Arksey and O’Malley’s methodological framework was used to conduct this scoping review. The framework entails formulating research questions, developing criteria for selecting relevant studies, charting the data, and synthesizing results.

Findings

The scoping review yielded 11 studies that varied in intervention design, methods of implementation, and outcome measurements. The review indicated that racial and ethnic minorities were less likely to be represented in nonpharmacological intervention studies for stroke caregivers.

Conclusion

Currently, there is sparse research that focuses on interventions with family caregivers of varying racial/ethnic groups in the United States.
Overexpression of the MSK1 Kinase in Patients With Chronic Lung Allograft Dysfunction and Its Confirmed Role in a Murine Model
Authors: Nemska Simona , Daubeuf François , Obrecht Adeline , Israel-Biet Dominique , Stern Marc , Kessler Romain , Roux Antoine , Tavakoli Reza , Villa Pascal , Tissot Adrien , Danger Richard , Reber Laurent , Durand Eugénie , Foureau Aurore , Brouard Sophie , Magnan Antoine , Frossard Nelly ,   the COLT consortium
Published: February 2021

Background.

Chronic lung allograft dysfunction (CLAD) and its obstructive form, the obliterative bronchiolitis (OB), are the main long-term complications related to high mortality rate postlung transplantation. CLAD treatment lacks a significant success in survival. Here, we investigated a new strategy through inhibition of the proinflammatory mitogen- and stress-activated kinase 1 (MSK1) kinase.

Methods.

MSK1 expression was assessed in a mouse OB model after heterotopic tracheal allotransplantation. Pharmacological inhibition of MSK1 (H89, fasudil, PHA767491) was evaluated in the murine model and in a translational model using human lung primary fibroblasts in proinflammatory conditions. MSK1 expression was graded over time in biopsies from a cohort of CLAD patients.

Results.

MSK1 mRNA progressively increased during OB (6.4-fold at D21 posttransplantation). Inhibition of MSK1 allowed to counteract the damage to the epithelium (56% restoration for H89), and abolished the recruitment of MHCII+ (94%) and T cells (100%) at the early inflammatory phase of OB. In addition, it markedly decreased the late fibroproliferative obstruction in allografts (48%). MSK1 inhibitors decreased production of IL-6 (whose transcription is under the control of MSK1) released from human lung fibroblasts (96%). Finally, we confirmed occurrence of a 2.9-fold increased MSK1 mRNA expression in lung biopsies in patients at 6 months before CLAD diagnosis as compared to recipients with stable lung function.

Conclusions.

These findings suggest the overall interest of the MSK1 kinase either as a marker or as a potential therapeutic target in lung dysfunction posttransplantation.
Impact of Pretransplant and New-Onset Diabetes After Transplantation on the Risk of Major Adverse Cardiovascular Events in Kidney Transplant Recipients: A Population-based Cohort Study
Authors: Lim Wai H. , Lok Charmaine E. , Kim S. Joseph , Knoll Greg , Shah Baiju R. , Naylor Kyla , Luo Bin , Vinegar Marlee , Dixon Stephanie N. , Hawley Carmel , Ooi Esther , Viecelli Andrea , Wong Germaine
Published: February 2021

Background.

Pretransplant diabetes and new-onset diabetes after transplant (NODAT) are known risk factors for vascular events after kidney transplantation, but the incidence and magnitude of the risk of major adverse cardiovascular events (MACE) and cardiac deaths remain uncertain in recent era.

Methods.

A population cohort study of kidney transplant recipients identified using data from linked administrative healthcare databases from Ontario, Canada. The incidence rates of MACE (expressed as events with 95% confidence interval [95% CI] per 1000 person-years were reported according to diabetes status of pretransplant diabetes, NODAT, or no diabetes. Extended Cox regression model was used to examine the association between diabetes status, MACE, and cardiac death.

Results.

Of 5248 recipients, 1973 (38%) had pretransplant diabetes, and 799 (15%) developed NODAT with a median follow-up of 5.5 y. The incidence rates (95% CI) of MACE for recipients with pretransplant diabetes, NODAT, and no diabetes between 1 and 3 y posttransplant were 38.1 (32.1-45.3), 12.6 (6.3-25.2), and 11.8 (9.2-15.0) per 1000 person-years, respectively. Compared with recipients with pretransplant diabetes, recipients with NODAT experienced a lower risk of MACE (adjusted hazard ratio, 0.59; 95% CI, 0.47-0.74) but not cardiac death (adjusted hazard ratio, 0.97; 95% CI, 0.61-1.55). The rate of MACE and cardiac death was lowest in patients without diabetes.

Conclusions.

Patients with pretransplant diabetes incur the greatest rate of MACE and cardiac deaths after transplantation. Having NODAT also bears high burden of vascular events compared with those without diabetes, but the magnitude of the increased rate remains lower than recipients with pretransplant diabetes.
Automated En Masse Machine Learning Model Generation Shows Comparable Performance as Classic Regression Models for Predicting Delayed Graft Function in Renal Allografts
Authors: Jen Kuang-Yu , Albahra Samer , Yen Felicia , Sageshima Junichiro , Chen Ling-Xin , Tran Nam , Rashidi Hooman H.
Published: February 2021

Background.

Several groups have previously developed logistic regression models for predicting delayed graft function (DGF). In this study, we used an automated machine learning (ML) modeling pipeline to generate and optimize DGF prediction models en masse.

Methods.

Deceased donor renal transplants at our institution from 2010 to 2018 were included. Input data consisted of 21 donor features from United Network for Organ Sharing. A training set composed of ~50%/50% split in DGF-positive and DGF-negative cases was used to generate 400 869 models. Each model was based on 1 of 7 ML algorithms (gradient boosting machine, k-nearest neighbor, logistic regression, neural network, naive Bayes, random forest, support vector machine) with various combinations of feature sets and hyperparameter values. Performance of each model was based on a separate secondary test dataset and assessed by common statistical metrics.

Results.

The best performing models were based on neural network algorithms, with the highest area under the receiver operating characteristic curve of 0.7595. This model used 10 out of the original 21 donor features, including age, height, weight, ethnicity, serum creatinine, blood urea nitrogen, hypertension history, donation after cardiac death status, cause of death, and cold ischemia time. With the same donor data, the highest area under the receiver operating characteristic curve for logistic regression models was 0.7484, using all donor features.

Conclusions.

Our automated en masse ML modeling approach was able to rapidly generate ML models for DGF prediction. The performance of the ML models was comparable with classic logistic regression models.
The role of innate immune genes in Alzheimer's disease
Authors: Griciuc Ana , Tanzi Rudolph E.
Published: February 2021

Purpose of review

The aim of this study was to provide an update on the role of the innate immune system and neuroinflammation in the pathogenesis of Alzheimer's disease, with an emphasis on microglial receptors CD33 and TREM2.

Recent findings

Genome-wide association studies (GWAS) have identified many Alzheimer's disease risk genes related to immune response and microglia including the phagocytic receptors CD33 and TREM2. Recent GWAS and pathway analyses emphasize the crucial role of the innate immune system and neuroinflammation in the pathogenesis of Alzheimer's disease. Disease-associated microglia have been characterized by TREM2-dependent upregulation of phagocytic and lipid metabolism genes. Impaired microglial phagocytosis results in amyloid beta (Aβ) accumulation leading to neuroinflammation that is the primary cause of neurodegeneration. CD33 and TREM2 modulate neuroinflammation in Alzheimer's disease and have emerged as therapeutic targets in Alzheimer's disease. Progress has been made to inhibit CD33 by gene therapy, small molecules or immunotherapy, and to increase TREM2 activity by immunotherapy. Finally, mAbs against CD33 and TREM2 have entered clinical trials and may reduce neuroinflammation in Alzheimer's disease brain.

Targeting neuroinflammation via CD33 inhibition and/or TREM2 activation may have important implications for neurodegeneration in Alzheimer's disease and may be an addition to monoclonal anti-Aβ antibody treatments that remove plaques without reducing neuroinflammation.
Prevalence, Risk Factors, and Impact of Preoperative Seizures in Neonates With Congenital Heart Disease
Authors: Pittet Marie P. , Marini Davide , Ly Linh , Au-Young Stephanie H. , Chau Vann , Seed Mike , Miller Steven P. , Hahn Cecil D.
Published: February 2021

Purpose:

The purpose of this study was to assess the prevalence, risk factors, and impact of electrographic seizures in neonates with complex congenital heart disease before cardiac surgery.

Methods:

A cohort of 31 neonates with congenital heart disease monitored preoperatively with continuous video-EEG (cEEG) was first reviewed for electrographic seizure burden and EEG background abnormalities. Second, cEEG findings were correlated with brain MRI and 18-month outcomes.

Results:

Continuous video-EEG was recorded preoperatively for a median duration of 20.5 hours (range, 2.5–93.5 hours). The five neonates (16%; 95% confidence interval, 5.5% to 34%) with seizures detected on cEEG in the preoperative period had a diagnosis of transposition of the great arteries or similar physiology, detected in four of five postnatally. None of the 157 recorded electrographic seizures had a clinical correlate. The median time to first seizure was 65 minutes (range, 6–300 minutes) after cEEG hookup. The median maximum hourly seizure burden was 12.4 minutes (range, 7–23 minutes). Before the first electrographic seizure, a prolonged interburst interval (>10 seconds) was not associated with seizures (coefficient 1.2; 95% confidence interval, −1.1 to 3.6). MRI brain lesions were three times more common in neonates with seizures. Sharp wave transients on cEEG were associated with delayed opercular development.

Conclusions:

In this cohort, preoperative electrographic seizures were common, were all subclinical, and were associated with MRI brain injury and postnatal diagnosis of transposition of the great arteries. The findings motivate further study of the mechanisms of preoperative brain injury, particularly among neonates with a postnatal diagnosis of transposition of the great arteries.