bluuebunny/crossref_metadata_2025 huggingface dataset:
Association between environmental air pollution and rheumatoid arthritis flares
Authors: Adami Giovanni , Viapiana Ombretta , Rossini Maurizio , Orsolini Giovanni , Bertoldo Eugenia , Giollo Alessandro , Gatti Davide , Fassio Angelo
Published: January 2021

Objectives

Environmental air pollution has been linked to the pathogenesis of RA. Nevertheless, evidence linking higher concentrations of air pollutants with the risk of RA reactivations is missing. The objective of the present study was to determine the association between RA flares and air pollution.

Methods

We collected longitudinal data of patients affected by RA and of the daily concentration of air pollutants in the Verona area. We designed a case-crossover study. We compared the exposure to pollutants in the 30-day and 60-day periods preceding an arthritic flare referent to the 30-day and 60-day preceding a low-disease activity visit.

Results

The study included 888 patients with RA with 3396 follow-up visits; 13 636 daily air pollution records were retrieved. We found an exposure–response relationship between the concentration of air pollutants and the risk of having abnormal CRP levels. Patients exposed to greater concentrations of air pollutants were at higher risk of having CRP levels ≥5 mg/l. Concentrations of CO, NO, NO2, NOx, PM10, PM2.5 and O3 were higher in the 60-day period preceding a flare.

Conclusions

We found a striking association between air pollution and RA disease severity and reactivations in a cohort of patients followed over a 5-year period. The exposure to high levels of air pollutants was associated with increased CRP levels and a higher risk of experiencing a flare of arthritis. This excessive risk was evident at very low levels of exposure.
Identification of novel avian and mammalian deltaviruses provides new insights into deltavirus evolution
Authors: Iwamoto Masashi , Shibata Yukino , Kawasaki Junna , Kojima Shohei , Li Yung-Tsung , Iwami Shingo , Muramatsu Masamichi , Wu Hui-Lin , Wada Kazuhiro , Tomonaga Keizo , Watashi Koichi , Horie Masayuki
Published: January 2021

Hepatitis delta virus (HDV) is a satellite virus that requires hepadnavirus envelope proteins for its transmission. Although recent studies identified HDV-related deltaviruses in certain animals, the evolution of deltaviruses, such as the origin of HDV and the mechanism of its coevolution with its helper viruses, is unknown, mainly because of the phylogenetic gaps among deltaviruses. Here, we identified novel deltaviruses of passerine birds, woodchucks, and white-tailed deer by extensive database searches and molecular surveillance. Phylogenetic and molecular epidemiological analyses suggest that HDV originated from mammalian deltaviruses and the past interspecies transmission of mammalian and passerine deltaviruses. Further, metaviromic and experimental analyses suggest that the satellite–helper relationship between HDV and hepadnavirus was established after the divergence of the HDV lineage from non-HDV mammalian deltaviruses. Our findings enhance our understanding of deltavirus evolution, diversity, and transmission, indicating the importance of further surveillance for deltaviruses.
Opportunities for Improved Potato Late Blight Management in the Republic of Ireland: Field Evaluation of the Modified Irish Rules Crop Disease Risk Prediction Model
Authors: Cucak Mladen , de Andrade Moral Rafael , Fealy Rowan , Lambkin Keith , Kildea Steven
Published: January 2021

Potato late blight remains the most significant disease threat of potato cultivation globally, often requiring expensive, time-consuming, and environmentally unfriendly approaches to disease management. The goal of this research was to evaluate whether an estimation of potato late blight risk based on environmental factors can be reliably used to adjust the standard potato late blight management practices and the role of cultivar resistance under growing conditions and contemporary Phytophthora infestans populations in the Republic of Ireland. The modified Irish Rules model made it possible to reduce fungicide usage by 58.7% on average, compared with current standard practices used by growers and without adversely compromising disease control and yield, with similar results achieved by the half-dose program. Host resistance levels were found to be correlated with a delay in the initiation of the epidemics, final foliar disease levels, and reduction of fungicide usage. Disease levels on the highly resistant cultivars remained low, and a clear selection pattern toward the P. infestans genotypes EU_13_A2 and EU_6_A1 was observed. An increase in the frequency of strains belonging to genotypes EU_13_A2 and EU_6_A1 was also observed to occur in the latter part of the trial growing seasons. Because of the increasingly dynamic nature of the population structure, associated with the continued evolution of the P. infestans population and the arrival of EU_36_A2 in the Republic of Ireland, routine population monitoring is necessary to ensure that potato late blight control strategies remain effective.

[Formula: see text] Copyright © 2021 The Author(s). This is an open access article distributed under the CC BY-NC-ND 4.0 International license .
The Relations Between Auditory Processing Scores and Cognitive, Listening and Reading Abilities
Authors: Seeto Mark , Tomlin Dani , Dillon Harvey
Published: January 2021

Objectives:

To investigate associations between auditory processing abilities, cognitive abilities, listening ability, and reading ability in children.

Design:

This was a cross-sectional study involving 155 children (105 referred for auditory processing assessment and 50 with no reported listening concerns) aged between 7 and 13 years. Each child was assessed on auditory processing tests, cognitive tests, and a reading test. Additional data on reading ability were provided by the reading score from a national test. Questionnaires about the child’s listening ability were completed by a parent, a teacher, and the child.

Results:

Structural equation models relating auditory processing abilities, cognitive abilities, listening ability, and reading ability were developed. There was evidence that listening and reading abilities were associated with cognitive abilities when adjusting for auditory processing abilities, but little evidence that listening and reading abilities were associated with auditory processing abilities when adjusting for cognitive abilities.

Conclusions:

It should not be assumed that auditory processing tests and cognitive tests measure separate abilities. When investigating the association between auditory processing abilities and real-world abilities, it is important to adjust for cognitive abilities. Children with listening difficulties should undergo cognitive assessments in addition to auditory processing assessments.
Primary Septic Arthritis Among Children 6 to 48 Months of Age: Implications for PCR Acquisition and Empiric Antimicrobial Selection
Authors: Villani Mary C. , Hamilton Elizabeth C. , Klosterman Mary M. , Jo Chanhee , Kang Lisa H. , Copley Lawson A.B.
Published: January 2021

Introduction:

Primary septic arthritis requires unique evaluation and treatment considerations for children in the 6- to 48-month age range because of the spectrum of identified pathogens and high rate of negative cultures. The purpose of this study is to evaluate primary septic arthritis in this age group in order to differentiate children with infection caused by Kingella kingae from those with other confirmed pathogens and those with no identified pathogen.

Methods:

Preschool children who underwent multidisciplinary evaluation and treatment for septic arthritis between 2009 and 2019 were retrospectively studied. Three cohorts were established for comparison of clinical and laboratory features of primary septic arthritis: (1) confirmed K. kingae, (2) confirmed other pathogen, and (3) presumed (without identified pathogen).

Results:

Among 139 children with septic arthritis, 40 (29%) were confirmed K. kingae, 29 (21%) other pathogen, and 70 (50%) presumed. Children with Kingella and those with presumed septic arthritis had significantly lower initial C-reactive protein (4.8 and 4.5 vs. 9.3 mg/dL) and fewer febrile hospital days (0.2 and 0.4 vs. 1.3 d) than children with other confirmed pathogens. Children with other pathogens had higher rates of bacteremia (38% vs. 0%) and positive joint fluid cultures (86% vs. 15%) than that of children with Kingella. The rate of polymerase chain reaction (PCR) acquisition was 38 of 40 (95.0%) Kingella cases, 18 of 29 (62.1%) other pathogen cases, and 33 of 70 (47.1%) presumed cases.

Conclusions:

K. kingae was the most commonly identified pathogen among 6-month to 4-year-old children. The Kingella and other identified pathogens in this study serve to guide empiric antimicrobial recommendations for this age range. Because of similarities between children with septic arthritis because of K. kingae and those with no identified pathogen, it is likely that an unrecognized burden of Kingella resides in culture negative cases, particularly if no PCR is sent. Systematic evaluation, including PCR acquisition, and a high index of suspicion for K. kingae are recommended to thoroughly evaluate septic arthritis in preschool children.

Level of Evidence:

Level III—Retrospective cohort comparison.
The Influence of Body Mass Index in Obese and Morbidly Obese Patients on Complications and 30- and 90-day Readmissions Following Lumbar Spine Fusion
Authors: Chen Xiao T. , Shahrestani Shane , Ballatori Alexander M. , Ton Andy , Buser Zorica , Wang Jeffrey C.
Published: January 2021

Study Design.

Retrospective cohort study using the 2013–2017 National Readmission Database.

Objective.

The aim of this study was to quantify the influence of body mass index (BMI) on complication and readmission rates following lumbar spine fusion.

Summary of Background Data.

Compared to controls, patients with BMI ≥35 had greater odds of readmission, infection, and wound complications following lumbar spine fusion.

Methods.

Patients who underwent elective lumbar spine fusion within the population-based sample were considered for inclusion. Exclusion criteria included nonelective lumbar spine fusions, malnourished, anorexic, or underweight patients, and surgical indications of trauma or neoplasm. Patients were grouped by BMI: 18.5 to 29.9 (controls), 30 to 34.9 (obesity I), 35 to 39.9 (obesity II), and ≥40 (obesity III). Multivariate regression was performed to analyze differences in complications and readmissions between groups. Predictive modeling was conducted to estimate the impact of BMI on 30- and 90-day infection, wound complication, and readmissions rates.

Results.

A total of 86,697 patients were included for analysis, with an average age of 58.9 years and 58.9% being female. The obesity II group had significantly higher odds of infection (odds ratio [OR]: 1.82, 95% confidence interval [CI]: 1.28–2.62, P = 0.001), wound dehiscence (OR: 3.08, 95% CI: 1.70–6.18, P = 0.0006), and 30-day readmission (OR: 1.32, 95% CI: 1.11–1.58, P = 0.002), whereas the obesity III group had significantly higher odds of acute renal failure (OR: 2.14, 95% CI: 1.20–4.06, P = 0.014), infection (OR: 2.43, 95% CI: 1.72–3.48, P < 0.0001), wound dehiscence (OR: 3.76, 95% CI: 2.08–7.51, P < 0.0001), 30-day readmission (OR: 1.62, 95% CI: 1.36–1.93, P < 0.0001), and 90-day readmission (OR: 1.53, 95% CI: 1.31–1.79, P < 0.0001) compared with controls. Predictive modeling showed cumulative increases of 6.44% in infection, 3.69% in wound dehiscence, and 1.35% in readmission within 90-days for each successive BMI cohort.

Conclusion.

Progressively higher risks for infection, wound complications, and hospital readmission were found with each progressive BMI level.

Level of Evidence: 3
Cost-Effectiveness of Bariatric Surgery Prior to Posterior Lumbar Decompression and Fusion in an Obese Population with Degenerative Spondylolisthesis
Authors: Paranjape Chinmay S. , Gentry Ryan D. , Regan Conor M.
Published: January 2021

Study Design.

Cost-effectiveness analysis.

Objective.

To determine if bariatric surgery prior to posterior lumbar decompression and fusion (PLDF) for degenerative spondylolisthesis (DS) is a cost-effective strategy.

Summary of Background Data.

Obesity poses significant perioperative challenges for DS. Treated operatively, obese patients achieve worse outcomes relative to non-obese peers. Concomitantly, they fare better with surgery than with nonoperative measures. These competing facts create uncertainty in determining optimal treatment algorithms for obese patients with DS. The role of bariatric surgery merits investigation as a potentially cost-effective optimization strategy prior to PLDF.

Methods.

We simulated a Markov model with two cohorts of obese individuals with DS. 10,000 patients with body mass index (BMI) more than or equal to 30 in both arms were candidates for both bariatric surgery and PLDF. Subjects were assigned either to (1) no weight loss intervention with immediate operative or nonoperative management (“traditional arm”) or (2) bariatric surgery 2 years prior to entering the same management options (“combined protocol”).

Published costs, utilities, and transition probabilities from the literature were applied. A willingness to pay threshold of $100,000/QALY was used. Sensitivity analyses were run for all variables to assess the robustness of the model.

Results.

Over a 10-year horizon, the combined protocol was dominant ($13,500 cheaper, 1.15 QALY more effective). Changes in utilities of operative and nonoperative treatments in non-obese patients, the obesity cost-multiplier, cost of bariatric surgery, and the probability of success of nonoperative treatment in obese patients led to decision changes. However, all thresholds occurred outside published bounds for these variables.

Conclusion.

The combined protocol was less costly and more effective than the traditional protocol. Results were robust with thresholds occurring outside published ranges. Bariatric surgery is a viable, cost-effective preoperative strategy in obese patients considering elective PLDF for DS.

Level of Evidence: 3
Exceptional Conditions for Favorable Neurological Recovery After Laminoplasty in Cases with Cervical Myelopathy Caused by K-line (−) Ossification of Posterior Longitudinal Ligament
Authors: Tsujimoto Takeru , Endo Tsutomu , Menjo Yusuke , Kanayama Masahiro , Oda Itaru , Suda Kota , Fujita Ryo , Koike Yoshinao , Hisada Yuichiro , Iwasaki Norimasa , Takahata Masahiko
Published: January 2021

Study Design.

A retrospective observational study.

Objective.

To clarify the exceptional conditions for a favorable neurological recovery after laminoplasty (LMP) for cervical myelopathy caused by K-line (−) ossification of the posterior longitudinal ligament (OPLL).

Summary of Background Data.

The K-line-based classification of cervical OPLL was developed to predict insufficient neurological recovery after LMP. For patients with K-line (−) OPLL, LMP generally yields the least improvement because of inadequate decompression of the spinal cord; however, there are some exceptional cases wherein LMP promotes favorable neurological recoveries.

Methods.

We retrospectively reviewed the medical records of 106 consecutive patients who underwent LMP for cervical OPLL to determine the demographic data, radiographic findings, and neurological recoveries of the patients as assessed preoperatively and 2 years postoperatively by their Japanese Orthopedic Association (JOA) scores. The factors associated with favorable outcomes after LMP in patients with K-line (−) were then investigated.

Results.

Of 106 total patients, 31 were classified as K-line (−), of whom 21 achieved the least neurological recovery after LMP (JOA recovery rate <50%), while the remaining 10 patients achieved favorable outcomes (JOA recovery rate ≥50%). Among the K-line (−) group patients, those with ext-K-line (+), which changed to K-line (+) in the neck-extended position, and the patients with up-K-line (−), in whom the lesion responsible for myelopathy in the upper cervical spine (C3 or above), showed favorable neurological recoveries after LMP.

Conclusion.

Our data shows that, even for patients with K-line (−) OPLL, a favorable neurological recovery can be expected after LMP in cases in which the OPLL is in the upper cervical spine or the K-line changes to (+) in the neck-extended position. This means that K-line-based predictions of surgical outcomes after LMP should be indicated for patients with OPLL in the middle and lower cervical spine with limited extension mobility.

Level of Evidence: 4
The Feasibility of Anterior Spinal Access
Authors: Ng Julia Poh-Hwee , Scott-Young Matthew , Chan Daniel Nim-Cho , Oh Jacob Yoong-Leong
Published: January 2021

Study Design.

Cross-sectional study.

Objective.

To analyze the feasibility of anterior spinal access to the vascular corridor at the L5–S1 junction, by evaluating three crucial anatomical landmarks. This provides a framework for risk-stratification for the clinician during preoperative evaluation.

Summary of Background Data.

The anterior lumbar interbody fusion (ALIF) offers many advantages for fusion at the L5–S1 junction. However, the variant iliac vasculature may preclude safe anterior access.

Methods.

Five hundred magnetic resonance imaging (MRI) images of the L5–S1 level were identified, with 379 meeting inclusion criteria. We graded the anterior access into three grades, namely, easy, advanced, or difficult by looking at three important anatomical landmarks—the vascular corridor (narrow if ≤25 mm, medium if 25–35 mm [inclusive], and wide if >35 mm), the left common iliac vein (LCIV) location (grades A–D based on the relative position of the LCIV to the L5–S1 disc space), and the presence or absence of a fat plane.

Results.

Our results showed that 43.27% of the patients had wide corridor for the anterior access, 19.26% of patients had no fat plane, and 7.65% had a LCIV that extended past the midline of the disc (Grade C, D: >50%). By combining these three factors, 37.20% would have easy anterior access, while a minority (1.85%) would have a difficult anterior access.

Conclusion.

The ALIF at L5–S1 offers significant benefits to the patient. The surgeon should be aware of the dangers in an anterior access by looking at three crucial factors to determine whether the access is easy, advanced, or difficult. Patients with a difficult access should be attempted by experts, vascular access surgeons, or consider an alternative approach to L5–S1.

Level of Evidence: 3
Effects of the Level and Duration of Mobilization Therapy in the Surgical ICU on the Loss of the Ability to Live Independently: An International Prospective Cohort Study
Authors: Scheffenbichler Flora T. , Teja Bijan , Wongtangman Karuna , Mazwi Nicole , Waak Karen , Schaller Stefan J. , Xu Xinling , Barbieri Silvia , Fagoni Nazzareno , Cassavaugh Jessica , Blobner Manfred , Hodgson Carol L. , Latronico Nicola , Eikermann Matthias
Published: January 2021

OBJECTIVES:

It is unclear whether early mobilization in the surgical ICU helps improve patients’ functional recovery to a level that enables independent living. We assessed dose of mobilization (level + duration). We tested the research hypotheses that dose of mobilization predicts adverse discharge and that both duration of mobilization and maximum mobilization level predict adverse discharge.

DESIGN:

International, prospective cohort study.

SETTING:

Study conducted in five surgical ICUs at four different institutions.

PATIENTS:

One hundred fifty patients who were functionally independent before admission (Barthel Index ≥ 70) and who were expected to stay in the ICU for greater than or equal to 72 hours.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

Mobilization was quantified daily, and treatments from all healthcare providers were included. We developed and used the Mobilization Quantification Score that quantifies both level and duration of mobilization. We assessed the association between the dose of mobilization (level + duration; exposure) and adverse discharge disposition (loss of the ability to live independently; primary outcome). There was wide variability in the dose of mobilization across centers and patients, which could not be explained by patients’ comorbidity or disease severity. Dose of mobilization was associated with reduced risk of adverse discharge (adjusted odds ratio, 0.21; 95%CI, 0.09–0.50; p < 0.001). Both level and duration explained variance of adverse discharge (adjusted odds ratio, 0.28; 95% CI, 0.12–0.65; p = 0.003; adjusted odds ratio, 0.14; 95% CI, 0.06–0.36; p < 0.001, respectively). Duration compared with the level of mobilization tended to explain more variance in adverse discharge (area under the curve duration 0.73; 95% CI, 0.64–0.82; area under the curve mobilization level 0.68; 95% CI, 0.58–0.77; p = 0.10).

CONCLUSIONS:

We observed wide variability in dose of mobilization treatment applied, which could not be explained by patients’ comorbidity or disease severity. High dose of mobilization is an independent predictor of patients’ ability to live independently after discharge. Duration of mobilization sessions should be taken into account in future quality improvement and research projects.
Faculty Perceptions: A Qualitative Study of the Perceived Need, Opportunities, and Challenges of Developing “One Health-One Medicine” in the Medical, Veterinary, and Public Health Curricula
Authors: Roopnarine Rohini , Regan Julie-Anne
Published: January 2021

Introduction:

The conceptual framework of One Health (OH) provides a strategy for promoting collaboration across the nexus of animal, human, and environmental health, which is essential for tackling emerging disease threats, such as COVID-19. However, there is no accreditation requirement for OH to prepare students across the professions for collaborative practice. This study aimed to explore the perspectives of faculty across the medical, veterinary, and public health programs about the need, opportunities, and challenges of developing OH in the curricula.

Methods:

In this qualitative study, faculty across the three disciplines were invited to participate in audio-recorded, focus group interviews. Recordings were transcribed verbatim and analyzed using inductive and deductive thematic analysis.

Results:

All participants recognized the need for OH as a critical concept for preparing students for collaborative practice. Opportunities were identified for shared learning and research across the disciplines, particularly through the use of interprofessional education. The lack of an accreditation mandate for OH in the medical curriculum was perceived to be the greatest challenge, leading to an anticipation of significant resistance among medical educators and students.

Discussion:

Successful development of OH in all three curricula is vital to prepare students for current and future threats to global health. The role of accreditation bodies in ensuring medical, veterinary, and public health curricula prepare students for these threats is crucial. Implications for practice include strategies for persuading medical educators and medical students to embrace OH in the curriculum and promote a culture of shared learning.
Cosinor-rhythmometry for 24-h urinary sodium, potassium, creatinine excretion in the Chinese adult population
Authors: Peng Ya-Guang , Feng Jing-Jing , Zhang Ying , Li Kun , Cai Si-Yu , Yan Ruo-Hua , Peng Xiao-Xia
Published: January 2021

Background:

The low accuracy of equations predicting 24-h urinary sodium excretion using a single spot urine sample contributed to the misclassification of individual sodium intake levels. The application of single spot urine sample is limited by a lack of representativity of urinary sodium excretion, possibly due to the circadian rhythm in urinary excretion. This study aimed to explore the circadian rhythm, characteristics, and parameters in a healthy young adult Chinese population as a theoretical foundation for developing new approaches.

Methods:

Eighty-five participants (mean age 32.4 years) completed the 24-h urine collection by successively collecting each of the single-voided specimens within 24 h. The concentrations of the urinary sodium, potassium, and creatinine for each voided specimen were measured. Cosinor analysis was applied to explore the circadian rhythm of the urinary sodium, potassium, and creatinine excretion. The excretion per hour was computed for analyzing the change over time with repeated-measures analysis of variance and a cubic spline model.

Results:

The metabolism of urinary sodium, potassium, and creatinine showed different patterns of circadian rhythm, although the urinary sodium excretion showed non-significant parameters in the cosinor model. A significant circadian rhythm of urinary creatinine excretion was observed, while the circadian rhythm of sodium was less significant than that of potassium. The circadian rhythm of urinary sodium and creatinine excretion showed synchronization to some extent, which had a nocturnal peak and fell to the lowest around noon to afternoon. In contrast, the peak of potassium was observed in the morning and dropped to the lowest point in the evening. The hourly urinary excretion followed a similar circadian rhythm.

Conclusion:

It is necessary to consider the circadian rhythm of urinary sodium, potassium, and creatinine excretion in adults while exploring the estimation model for 24-h urinary sodium excretion using spot urine.
Pandemic of the aging society — sporadic cerebral small vessel disease
Authors: Lau Alexander Yuk Lun , Ip Bonaventure Yiu Ming , Ko Ho , Lam Bonnie Yin Ka , Shi Lin , Ma Karen Ka Yan , Au Lisa Wing Chi , Soo Yannie Oi Yan , Leung Thomas Wai Hong , Wong Adrian , Mok Vincent Chung Tong
Published: January 2021

Age-related sporadic cerebral small vessel disease (CSVD) has gained increasing attention over the past decades because of its increasing prevalence associated with an aging population. The widespread application of and advances in brain magnetic resonance imaging in recent decades have significantly increased researchers’ understanding in the in vivo evolution of CSVD, its impact upon the brain, its risk factors, and the mechanisms that explain the various clinical manifestation associated with sporadic CSVD. In this review, we aimed to provide an update on the pathophysiology, risk factors, biomarkers, and the determinants and spectrum of the clinical manifestation of sporadic CSVD.
Unique Associations Between Specific Attention-Deficit Hyperactivity Disorder Symptoms and Related Functional Impairments
Authors: Zoromski Allison K. , Epstein Jeffery N. , Ciesielski Heather A.
Published: January 2021

Objective:

The purpose of this study was to explore the unique relationships between specific attention-deficit hyperactivity disorder (ADHD) symptoms and functional impairment in school-age children using parent and teacher ratings.

Methods:

Parents and teachers rated ADHD symptoms and comorbidities (internalizing and oppositional behaviors) as well as impairments (academic, relationship, and classroom behavior) for 8689 children using the Vanderbilt ADHD Diagnostic Rating Scales. Stepwise regression was used to determine which of the 18 ADHD symptom items were most associated with specific domains of impairment with relevant demographic and clinical characteristics used as covariates (e.g., sex, comorbidities, medication status, and age).

Results:

“Careless mistakes” and “avoids tasks” significantly predicted academic impairment across content areas and across parent- and teacher-rating models. ADHD symptoms accounted for limited variance in impairment in the family and peer relationship domains or in organized activities when oppositional symptoms were entered as a covariate. Regarding teacher-rated classroom behavior, the strongest predictor of impairment was “talks too much.”

Conclusion:

The findings indicate that the symptoms that were most predictive of impairment varied by domain of impairment.
Chlorhexidine Hypersensitivity: A Case Report of Delayed Reactions Associated with Epidermal Preparations
Authors: Bhardwaj Priya , Bekeny Jenna C. , Zolper Elizabeth G. , Nigam Manas , Sher Sarah R.
Published: January 2021

Chlorhexidine is a topical antiseptic that is generally well tolerated in patients, making it a common preparatory substance in various surgical settings. Sparse case reports have identified immediate hypersensitivity reactions after exposure to this substance, especially in patients with a history of atopy. The purpose of this case report is to describe 3 unique presentations of delayed hypersensitivity to epidermal chlorhexidine preparation. Patients undergoing breast surgery by a single surgeon between December 2018 and January 2019 were retrospectively reviewed for incidence of dermatologic complications. Medical and surgical history of patients as well as dermatologic hypersensitivity course were collected. Three patients presented with a delayed hypersensitivity to the epidermal chlorhexidine surgical preparation, ChloraPrep. Each patient developed an erythematous, pruritic maculopapular rash in the distribution of the chlorhexidine application. This occurred beyond the immediate postoperative period—ranging from postoperative days 5 to 35. Initial treatment included the use of 1% hydrocortisone along with a systemic antihistamine. If there was no improvement in symptoms after 3 days, we transitioned patients to 0.5% triamcinolone ointment. If there was no improvement after 5 days on triamcinolone, the patient was reexamined and systemic steroids were prescribed. In each of our cases, all skin changes had resolved within 7–10 days of initial symptoms. Our findings highlight a series of delayed adverse reactions to epidermal chlorhexidine occurring beyond the intraoperative and immediate postoperative period. This case report serves to recognize a unique presentation pattern to ensure that all patients are accurately diagnosed and promptly treated via a systematic treatment algorithm.
Sternal Tumor Resection and Reconstruction Using Iliac Crest Autograft
Authors: Drinnon Kyle D. , Sherali Samir , Cox Cameron T. , MacKay Brendan J.
Published: January 2021

Background:

Primary malignant tumors of the sternum are rare among bone tumors. Even with radical resection, the survival rate for sternal tumors remains low. Resection often results in significant bone defects in the chest wall, and reconstruction must provide adequate protection for pulmonary and respiratory structures. Flexible materials have historically been used for sternal reconstructions following failed sternotomies in cardiac surgery. Although these have had some success, they fail to provide adequate support for patients undergoing reconstruction secondary to tumor resection, who are otherwise healthy and active. Although rigid materials offer greater protection, they frequently cause chronic pain and respiratory complications. More recently, bone grafts have been used to reconstruct sternal defects, and the limited published reports are promising.

Methods:

We present the case of a patient diagnosed with an extramedullary solitary bone plasmacytoma who underwent a sternal resection and reconstruction with an autogenous bone graft taken from the iliac crest and secured in place with 5 plates (3 sternal and 2 mandibular).

Results:

At 9-month follow-up, bone marrow biopsy showed no evidence of multiple myeloma. X-ray, computed tomography, and Pulmonary Function Test (PFT) scans confirmed graft stability, and the patient has returned to normal activities.

Conclusions:

Sternal resection and reconstruction is an effective method for treating extramedullary solitary plasmacytoma when radiation is ineffective. In cases of significant segmental defects, iliac crest bone graft may be a viable option for repairing sternal defects following tumor resection.
Barriers to Gender-affirming Surgery Consultations in a Sample of Transmasculine Patients in Boston, Mass.
Authors: Tabaac Ariella R. , Jolly Divya , Boskey Elizabeth R. , Ganor Oren
Published: January 2021

Background:

Gender diverse people are increasingly pursuing gender-affirming surgery, but little is known about their experiences on accessing care. As part of the baseline assessment for an ongoing longitudinal study, we examined the types of barriers and self-reported out-of-pocket costs associated with gender-affirming surgery most commonly endorsed by transmasculine chest (top) and genital (bottom) surgery patients at their initial surgical consultation.

Methods:

A brief survey was administered to a clinical sample of transmasculine patients (n = 160; age ≥15 years) seeking a gender-affirming surgery at the Center for Gender Surgery in Boston, Mass. from April 2018 to February 2020.

Results:

The barriers most commonly endorsed by top surgery patients were insurance coverage and age. For bottom surgery patients, the most commonly endorsed barriers were getting mental health letters and readiness for surgery. Bottom surgery patients were also more likely to report barriers of readiness for surgery and cost of/access to hair removal, than top surgery patients (Ps < 0.05). Bottom surgery patients were more likely to report out-of-pocket costs related to hair removal, surgical consultation, and surgery (Ps < 0.05), whereas top surgery patients were more likely to report hormone treatment costs (P = 0.01). Average out-of-pocket costs were high (mean = 2148.31) and significantly higher for bottom surgery patients (b = 4140.30; β = 0.64; 95% confidence interval, 3064.6–5216.0).

Conclusions:

Transmasculine patients experience a variety of barriers when seeking gender-affirming surgery. Presurgical requirements, insurance access, and high out-of-pocket costs may hinder access to care for many transmasculine people seeking bottom surgery.
Treatment of Deliberate Self-harm Scars with Rotated Thin-skin Graft and Minced-skin Graft
Authors: Takaya Kento , Hayashi Ruka , Aramaki-Hattori Noriko , Okabe Keisuke , Sakai Shigeki , Asou Toru , Kishi Kazuo
Published: January 2021

Background:

Scars developing after wrist cutting (a deliberate action of self-harm) have various patterns and are difficult to treat. In addition, they can occur at anatomically prominent sites and are easily recognized as caused by self-harm; thus, scars can cause lifelong regrets. However, there are no standard treatment guidelines for wounds inflicted through self-harm. This study aimed to evaluate the effectiveness of our novel technique using 90-degree rotated skin grafts, which were thinly collected at a thickness of 250 μm from a wound site, together with minced-skin grafts.

Methods:

Five regions on the forearm of 5 Japanese women (age, 19–29 years) were treated from July 2011 to April 2012. The skin at the scar site was cut with an electric dermatome at a thickness of 250 μm. The scar contained therein was excised, and the skin was rotated 90 degree and transplanted. The scar remaining in the dermis of the wound was resected and resurfaced. At the site where the skin graft was insufficient, the skin was processed into a minced shape and then transplanted (minced-skin graft).

Results:

In all cases, skin grafting was performed. The scar was successfully camouflaged and transformed into a socially acceptable appearance. At the wound site, the skin texture was reproduced. Following skin grafting, nodules, pigmentation, and redness around the graft transiently occurred, which then disappeared over time. No scar contractures were observed.

Conclusion:

A combination of thin-skin graft rotated 90 degrees and minced-skin graft is useful in camouflaging a wide variety of deliberate self-harm scars.
Average Models and 3-dimensional Growth Patterns of the Healthy Infant Cranium
Authors: Kuwahara Kosuke , Hikosaka Makoto , Takamatsu Ako , Miyazaki Osamu , Nosaka Shunsuke , Ogawa Rei , Kaneko Tsuyoshi
Published: January 2021

Background:

Treatment of cranial deformity is often performed during infancy in cases such as craniosynostosis and deformational plagiocephaly. To acquire morphologic standards for the treatment goals of these conditions, we created cranial average models and elucidated the growth patterns of the cranium of healthy infants in 3-dimension (3D) using homologous modeling.

Methods:

Homologous modeling is a technique that enables mathematical analysis of different 3D objects by converting the objects into homologous models that share the same number of vertices with the same spatial relationships. Craniofacial computed tomographic data of 120 healthy infants ranging in age from 1 to 17 months were collected. Based on the computed tomographic data, we created 120 homologous models. Six average 3D models (20 individuals each for 6 different age groups) were created by averaging the vertices of the models. Three-dimensional growth patterns of the cranium were clarified by comparing the 6 average models.

Results:

We successfully created 6 average models and visualized the growth patterns of the cranium. From 1-month-old to 5-month-old infants, the entire cranium except for the occipital region grows, and the cranium tended to be brachycephalic (cephalic index at 4–5 months: 87.1–97.3), but the growth was thereafter localized to specific areas.

Conclusions:

Three-dimensional growth patterns of the cranium of healthy infants were clarified. These findings will support the understanding and treatment of the conditions that cause cranial deformity. To our knowledge, this is the first report to visualize the growth patterns of the entire cranium of healthy infants in 3D.
Analysis of Cell-seeded, Collagen-rich Hydrogel for Wound Healing
Authors: Sotelo Leon Daniel , Williams Tokoya , Wang Zhen , Leyden Jacinta , Franklin Austin , Kaizawa Yukitoshi , Chang James , Fox Paige M.
Published: January 2021

Background:

Our laboratory has previously developed a novel collagen-rich hydrogel (cHG), which significantly increases the speed of wound healing in diabetic rats.

Methods:

In this study, we examine the in vitro survival and migration of fibroblasts, endothelial cells, and adipose-derived stem cells in a novel cHG. Furthermore, we test the ability of adipose-derived stem cell–seeded cHG to support cell survival and accelerate healing in vivo.

Results:

In vitro, cell survival within the cHG was retained for 25 days. We were unable to detect cellular migration into, out of, or through cHG. In the in vivo model, bioluminescence of stem cells seeded within the cHG in diabetic rat wounds was detected until day 10. Rate of wound closure was higher for cHG plus adipose-derived stem cells versus control from day 2 until day 16 and significant on days 6, 8, and 12 (P < 0.05). This significant difference was also observed on day 16 by histology (P ≤ 0.05).

Conclusions:

We conclude that cHG is a good candidate for delivering adipose-derived stem cells, endothelial cells, and fibroblasts to wounds. Future studies will determine whether the delivery of combinations of different cell lines in cHG further enhances wound healing.
An Innovative Autologous Breast Reconstruction Option: Musculo-derma-glandular, Axio-perforator, Bipedicled Flap
Authors: Kalender Vagif , Guliyeva Gunel
Published: January 2021

Following a mastectomy, patients frequently seek breast reconstruction. Although there are several options for reconstruction, none of them are considered ideal. Taking patients’ psychological and physical condition into account, we created a new flap technique with a low postoperative morbidity and short operation time. We harvested the flap composed of skin, breast tissue, and pectoralis major muscle with a base in the parasternal line from the contralateral breast. To display our results, we presented 2 case examples. The mean follow-up was 12 months, and no postoperative complications were observed. At follow-ups, patients answered the question, “How satisfied are you with the results of the surgery?” using a 5-point Likert-like scale (5, very satisfied; 4, somewhat satisfied; 3, undecided; 2, somewhat dissatisfied; and 1, very dissatisfied). The mean score was 4. Our study showed that this surgical approach is a safe and cost-effective alternative for immediate and delayed breast reconstruction.
Traumatic Radial Artery Pseudoaneurysm: Vein Graft Repair through a Single Incision
Authors: Simmons Michael T. , Beckett Allison R. , Cato Philip J. , Lightfoot Robert W. , Brooks Ronald M.
Published: January 2021

Radial artery pseudoaneurysms are rare clinical entities usually occurring after penetrating trauma or iatrogenic injury. The radial artery is the least common location for peripheral artery pseudoaneurysms, and no clear standard of treatment exists. We present a case of an adolescent male who developed a radial artery pseudoaneurysm after slitting his wrists. Using a single incision, the radial artery pseudoaneurysm was excised and repaired using a reversed venae comitantes interposition graft. This single incision technique for radial artery pseudoaneurysm repair preserves the dual arterial supply to the hand, which is of particular importance in young patients.
Telemedicine in the Wake of the COVID-19 Pandemic: Increasing Access to Surgical Care
Authors: Dekker Paige K. , Bhardwaj Priya , Singh Tanvee , Bekeny Jenna C. , Kim Kevin G. , Steinberg John S. , Evans Karen K. , Song David H. , Attinger Christopher E. , Fan Kenneth L.
Published: January 2021

Background:

The COVID-19 pandemic has brought seismic shifts in healthcare delivery. The objective of this study was to examine the impact of telemedicine in the disadvantaged population.

Methods:

All consecutive patients with outpatient appointments amongst 5 providers in the Plastic and Reconstructive Surgery Department between March 2, 2020, and April 10, 2020, were retrospectively reviewed. Appointment and patient characteristics collected include visit modality, reason for visit, new or established patient, history of recorded procedure, age, sex, race, insurance provider, urban/rural designation of residence, Social Vulnerability Index, and income. The primary outcome of interest was whether or not a patient missed their appointment (show versus no-show).

Results:

During the study period, there were a total of 784 patient appointments. Before the COVID-19 pandemic, patients with a higher Social Vulnerability Index were more likely to have a no-show appointment (0.49 versus 0.39, P = 0.007). Multivariate regression modeling showed that every 0.1 increase in Social Vulnerability Index results in 1.32 greater odds of loss to follow-up (P = 0.045). These associations no longer held true after the lockdown.

Conclusions:

This study indicates a reduction in disparity and an increase in access following the dramatically increased use of telemedicine in the wake of the COVID-19 pandemic. Although drawbacks to telemedicine exist and remain to be addressed, the vast majority of literature points to an overwhelming benefit—both for patient experience and outcomes—of utilizing telemedicine. Future studies should focus on improving access, reducing technological barriers, and policy reform to improve the spread of telemedicine.
Outcomes following Microvascular Mandibular Reconstruction in Pediatric Patients and Young Adults
Authors: Malloy Shannon M. , Dronkers Wouter J. , Firriolo Joseph M. , Nuzzi Laura C. , Koudstaal Maarten J. , Padwa Bonnie L. , Taghinia Amir H. , Labow Brian I.
Published: January 2021

Background:

The etiology and treatment of complex mandibular defects in children differ markedly from those of adults, although treatment with free bone flaps is historical in both groups. While adult outcomes and complication rates are well known, few pediatric data exist, especially for patients with congenital deficiencies. This study reports early and late outcomes from a cohort of young, primarily syndromic patients undergoing microvascular mandibular reconstruction.

Methods:

This is a retrospective case series of patients who underwent microvascular mandibular reconstruction between 1995 and 2016.

Results:

Thirteen patients received a total of 13 fibula transfers and 1 medial femoral condyle transfer. Most patients carried a congenital diagnosis (77%), and the average age during surgery was 11.7 ± 5.7 years. The median (interquartile range) [IQR] length of follow-up was 6.3 (5.7) years. There was a 100% flap survival rate, although 86% of all patients experienced at least one complication. Half of all procedures resulted in an early complication. Nine patients (69%) developed late complications, of which temporal mandibular joint ankylosis was the most common (n = 5; 38%).

Conclusions:

This study is one of few detailing outcomes following mandibular reconstruction by free flap transfer in pediatric patients. These patients were primarily syndromic with appreciable complication rates higher than in other adult and pediatric studies. Some complications are manageable or self-resolving, but others lead to functional problems that may require late operative interventions to correct. Microsurgical treatment should be reserved for children with large, complex mandibular defects when other options are unavailable or have been exhausted.
Non-surgical Correction of Congenital Ear Anomalies: A Review of the Literature
Authors: Feijen Michelle M.W. , van Cruchten Cas , Payne Phileemon E. , van der Hulst Rene R. W. J.
Published: January 2021

Congenital ear anomalies have been known to cause lasting psychosocial consequences for children. Congenital ear anomalies can generally be divided into malformations (chondro-cutaneous defect) and deformations (misshaped pinna). Operative techniques are the standard for correction at a minimal age of 5–7, exposing the children to teasing and heavy complications. Ear molding is a non-operative technique to treat ear anomalies at a younger age. Having been popularized since the 1980s, its use has increased over the past decades. However, uncertainties about its properties remain. Therefore, this review was conducted to look at what is known and what has been newly discovered in the last decade, comparing different treatment methods and materials. A literature search was performed on PubMed, and 16 articles, published in the last decade, were included. It was found that treatment initiated at an early age showed higher satisfactory outcome rates and a shorter duration of treatment. A shorter duration of treatment also led to higher satisfactory rates, which might be attributable to age at initiation, individual moldability, and treatment compliance. Complications were minor in all articles. Recurrence rate was low and mostly concerned prominent ears, which proved to be the most difficult to correct deformity as well. Malformations, however, were even more difficult to treat than deformations. Our analysis shows ear molding to be a successful treatment method for ear anomalies with a preference for early diagnosis and treatment.