bluuebunny/crossref_metadata_2025 huggingface dataset:
Dermatologic Surgery and Reconstruction Photograph Booklet as a Tool to Improve Informed Consent Before Skin Surgery
Authors: Arujuna Nisha Rishi , Brendling Lisa , DeGiovanni Claudia
Published: April 2018

BACKGROUND

Skin surgery is a high-risk area of litigation and tools to improve consent are welcomed.

OBJECTIVE

This project aimed to strengthen the consenting process for dermatological surgery by introducing a photograph booklet.

MATERIALS AND METHODS

The authors designed a booklet containing skin surgery images. Patients attending surgery completed an anonymous questionnaire immediately after their procedures before the booklet introduction (Group 1). The questionnaire was then repeated (Group 2) with the introduction of the photograph booklet during consent. The authors looked for changes in the following: understanding of procedure, scar, and postoperative care as well as addressing of patients' concerns using a subjective scale of 1 to 5 (1 = poor, 2 = fair, 3 = okay, 4 = good, and 5 = great).

RESULTS

Results indicated greater patient satisfaction among patients in Group 2 who had been shown relevant surgical images compared with Group 1, with improvements from ratings of 3 and 4 on the scale to 5. The difference in the 2 groups for the highest ratings of 5/5 was significant (p < .05) for understanding of procedure and resulting scars.

CONCLUSION

The use of photograph booklets containing simple and relevant images to support the consent process for dermatologic surgery improves patients' understanding, expectations, and experience of skin surgery.
The Safety and Efficacy of Treatment With a 1,927-nm Diode Laser With and Without Topical Hydroquinone for Facial Hyperpigmentation and Melasma in Darker Skin Types
Authors: Vanaman Wilson Monique J. , Jones Isabela T. , Bolton Joanna , Larsen Lisa , Fabi Sabrina Guillen
Published: April 2018

BACKGROUND

The nonablative, fractional, 1,927-nm diode laser is theoretically a safe and effective treatment for hyperpigmentation and melasma in darker skin and may potentiate topical cosmeceutical delivery.

OBJECTIVE

To evaluate the use of a nonablative, fractional, 1,927-nm diode laser with and without topical 2% hydroquinone (HQ) cream for moderate-to-severe facial hyperpigmentation in Fitzpatrick skin Types III–V.

METHODS

Forty adults underwent 4 laser treatments at 2-week intervals and were randomized to daily application of 2% HQ cream or moisturizer. Follow-ups were conducted 4 and 12 weeks after the final laser treatment.

RESULTS

Hydroquinone and moisturizer groups demonstrated Mottled Pigmentation Area and Severity Index improvements of approximately 50% at post-treatment Weeks 4 and 12. Blinded investigator–assessed hyperpigmentation and photodamage improved significantly for both the groups at post-treatment Weeks 4 and 12. Subject satisfaction improved significantly in both the groups by post-treatment Week 4. Although investigator-rated Global Aesthetic Improvement Scale scores were significantly better in the HQ group at post-treatment Week 12, satisfaction was higher among those using moisturizer. No adverse events were noted.

CONCLUSION

The nonablative, fractional, 1,927-nm diode laser produced significant improvement in hyperpigmentation in Fitzpatrick skin Types III–V by 4 weeks, with maintenance of results at 12 weeks after treatment even without HQ.
Prospective Cohort Study Investigating Changes in Body Image, Quality of Life, and Self-Esteem Following Minimally Invasive Cosmetic Procedures
Authors: Sobanko Joseph F. , Dai Julia , Gelfand Joel M. , Sarwer David B. , Percec Ivona
Published: April 2018

BACKGROUND

Minimally invasive cosmetic injectable procedures are increasingly common. However, a few studies have investigated changes in psychosocial functioning following these treatments.

OBJECTIVE

To assess changes in body image, quality of life, and self-esteem following cosmetic injectable treatment with soft tissue fillers and neuromodulators.

METHODS

Open, prospective study of 75 patients undergoing cosmetic injectable procedures for facial aging to evaluate changes in psychosocial functioning within 6 weeks of treatment. Outcome measures included the Derriford appearance scale (DAS-24), body image quality of life inventory (BIQLI), and the Rosenberg self-esteem scale.

RESULTS

Body image dissatisfaction, as assessed by the DAS-24, improved significantly 6 weeks after the treatment. Body image quality of life, as assessed by the BIQLI, improved, but the change did not reach statistical significance. Self-esteem was unchanged after the treatment.

CONCLUSION

Minimally invasive cosmetic injectable procedures were associated with reductions in body image dissatisfaction. Future research, using recently developed cosmetic surgery-specific instruments, may provide further insight into the psychosocial benefits of minimally invasive procedures.
In Vivo Degradation of Crosslinked Hyaluronic Acid Fillers by Exogenous Hyaluronidases
Authors: Shumate Garrett T. , Chopra Rajesh , Jones Derek , Messina Darin J. , Hee Christopher K.
Published: April 2018

BACKGROUND

An advantage of hyaluronic acid (HA)-based fillers is reversibility.

OBJECTIVE

To evaluate the ability of 2 hyaluronidases to degrade 3 HA-based fillers using a novel in vivo model.

MATERIALS AND METHODS

Rats were injected with 3 HA fillers (HYC-24L+, VYC-20L, and RES-L) to create a projecting bolus. After 4 days, recombinant human hyaluronidase (HX) or ovine hyaluronidase (VIT) was administered at (1) varying doses (5 U, 10 U, or 30 U per 0.1 mL filler) or (2) different dilutions (10 U diluted 3-fold). The impact of tissue integration was assessed by administering 10 U/0.1 mL filler 4 weeks after filler injection. Three-dimensional images quantified projection loss over 72 hours.

RESULTS

Complete loss of projection was achieved for all fillers with the highest HX and VIT doses; lower doses achieved less degradation. No difference in degradation was observed between HYC-24L+ and VYC-20L using HX or VIT. RES-L was slightly more degraded with 10 U VIT but not with 10 U HX. Enzyme dilution resulted in less degradation. Tissue integration did not impact the degree of degradation.

CONCLUSION

This model incorporates the biological system while controlling variables including filler depth and volume and location of hyaluronidase delivery. Hyaluronic acid filler degradation by exogenous hyaluronidase was not hindered by differences among fillers.
Topical Botulinum Toxin Type A Liposomal Cream for Primary Axillary Hyperhidrosis: A Double-Blind, Randomized, Split-Site, Vehicle-Controlled Study
Authors: Lueangarun Suparuj , Sermsilp Chairat , Tempark Therdpong
Published: April 2018

BACKGROUND

Despite its effectiveness in treating primary axillary hyperhidrosis (PAH), topical botulinum toxin type A (BTX-A) is highly resistant to transdermal absorption. Topical BTX-A liposomal cream is recommended as a novel, noninvasive modality to enhance skin penetration.

OBJECTIVE

To evaluate the efficacy and safety of topical BTX-A liposomal cream in comparison with liposomal vehicle cream alone in the treatment of PAH.

MATERIALS AND METHODS

A prospective, randomized, double-blinded, split-site study was conducted in 20 subjects, aged 18 to 50 years, all of whom had symmetrical axillary sweating with Hyperhidrosis Disease Severity Scale scores between 2 to 4. All subjects were double-blinded to treatment regimens and randomly given 2 bottles, one containing topical BTX-A liposomal cream and one containing the vehicle cream without BTX-A, to be applied consistently to the same axilla nightly for 7 consecutive days. Clinical improvement and adverse reactions were evaluated at every follow-up visit.

RESULTS

Axillary skin treated with topical BTX-A demonstrated superior sweat reduction and patient satisfaction to vehicle cream–treated axillary skin, with clinical and statistical significance, at baseline, weeks 2, 4, 6, and 8 of follow-up, without adverse effects.

CONCLUSION

Topical BTX-A liposomal cream pharmaceutically enhances drug delivery, is painless, cost-effective, and overall an innovative treatment of PAH.
Liposarcoma Preoperatively Diagnosed as Lipoma: 10-Year Experience at a Single Institution
Authors: Sato Daisuke , Suga Hirotaka , Takushima Akihiko
Published: April 2018

BACKGROUND

On rare occasions, a lesion preoperatively diagnosed as a lipoma is ultimately diagnosed as a liposarcoma. It is important to differentiate liposarcomas from lipomas preoperatively.

OBJECTIVE

To examine characteristic features of liposarcomas preoperatively diagnosed as lipomas.

METHODS

Patients (n = 637) who underwent resection of tumors preoperatively diagnosed as lipomas from January 2006 to October 2016 were retrospectively reviewed.

RESULTS

Based on pathological examination, 8 of 637 lesions were diagnosed as liposarcomas postoperatively. All the liposarcomas were well-differentiated liposarcomas. The rate of male patients was higher (87.5% vs 38.9%) and the size of tumors was larger (8.75 vs 4.64 cm) in these cases than in accurately diagnosed lipoma cases. On imaging, nonfatty septa were more frequently observed (71.4% vs 20.0%) and were thicker (2.22 vs 1.33 mm) than in true lipoma cases.

CONCLUSION

If the patient with a lipomatous tumor is male and the tumor is large, we should consider the possibility of it being a liposarcoma. A thick internal septum in the image findings is a good predictor of malignancy.
Malar Reconstruction with Anterior Bilobed Cheek Flap
Authors: Ueda Koichi , Akamatsu Jun , Sugita Naoya , Nuri Takashi , Otsuki Yuki
Published: April 2018

A 66-year-old man had developed a tumor on his right cheek. A biopsy revealed basal cell carcinoma. The ulcerative cancer and zygomatic bone were resected. We designed an anterior bilobed cheek flap to reconstruct the cheek skin defect. The postoperative clinical course was uneventful.
A Systematic Review of Surgical Management of Melanoma of the External Ear
Authors: Sawyer Justin D. , Wilson Morgan L. , Neumeister Michael W.
Published: April 2018

Background:

Historically, external ear melanomas have been treated aggressively, due to early perceptions suggesting they had poor prognosis and aggressive biological behavior. More recent evidence has not supported these notions.

Methods:

We completed a complete review of the literature involving malignant melanoma of the external ear. We then completed a quantitative analysis on seventy-three cases from 8 reports that contained case-level data, assessing factors that influence recurrence, and assessing characteristics of the melanomas based on histological subtype. Baseline and outcomes data for all 20 studies were then compiled but not statistically evaluated.

Results:

In our subanalysis, patients who had recurrence were significantly more likely to have had wedge resection versus wide-local excision, and those with no recurrence were more likely to have undergone wide local excision. Nodular tumors had significantly greater thickness. Overall, conservative excisions provided excellent outcomes.

Conclusions:

Conservative treatment for external ear melanoma produces satisfactory outcomes. There is no evidence to support the use of radical amputation and little evidence to support the removal of cartilage or perichondrium. Sentinel lymph node biopsy is warranted only with positive nodes. There is no role for elective neck dissection. The roles for chemo/radiation therapy are unclear and guidelines for other cutaneous melanomas should be followed.
Does Distal Radio-ulnar Joint Configuration Affect Postoperative Functional Results after Ulnar Shortening Osteotomy?
Authors: Gilbert Fabian , Jakubietz Rafael G. , Meffert Rainer H. , Jakubietz Michael G.
Published: April 2018

Background:

Reverse oblique distal radio-ulnar joint (DRUJ) configuration is assumed to show inferior postoperative results in ulnar-shortening osteotomy due to osteoarthritis, as the joint force pressure in the DRUJ may be increased. An evaluation and comparison of the postoperative functional results with regard to clinical and radiographic signs of arthritis among different DRUJ configurations was carried out retrospectively.

Methods:

Sixty-two patients after ulnar shortening osteotomy were included. The minimum follow-up was 5 years. Preoperative x-rays were assessed for the DRUJ configuration according to the Tolat classification, whereas postoperative radiographs were evaluated with regard to signs of osteoarthritis using the Kallgren-Lawrence-Score. Functional results were evaluated using the disabilities of the arm, shoulder and hand (DASH) and Mayo Wrist Score and measuring range of motion and grip strength.

Results:

Significantly better functional results were found in patients with parallel configuration of the DRUJ (Tolat type 1 configuration) with regard to DASH score, grip strength, and supination compared with nonparallel configurations. In the Tolat type 1, configurated DRUJ mean DASH score was 9 compared with 18 in the Tolat type 2 and 3 groups. Apart from supination, no differences were observed in range of motion among groups.

Conclusion:

Although long-term postoperative range of motion failed to display statistically significant differences between DRUJ configurations except for supination, better results regarding grip strength and DASH scores were seen in a parallel-aligned DRUJ configuration. Although onset of osteoarthritis does not seem to become apparent within the observation period, nonparallel aligned configuration predisposes to inferior results.
PHOTODYNAMIC THERAPY AS PRIMARY TREATMENT FOR SMALL CHOROIDAL MELANOMA
Authors: Turkoglu Elif B. , Pointdujour-Lim Renelle , Mashayekhi Arman , Shields Carol L.
Published: April 2018

Purpose:

To report outcomes of photodynamic therapy (PDT) as primary treatment for small amelanotic choroidal melanoma.

Methods:

Retrospective interventional case series of 12 patients with small choroidal melanoma treated with standard-fluence PDT (83 seconds; 50 J/cm2) using verteporfin.

Outcome measures:

Tumor regression, subretinal fluid resolution, best-corrected visual acuity, and PDT complications.

Results:

There were 12 eyes with melanoma, demonstrating amelanotic (10 [83%]) or lightly pigmented (n = 2, 17%) appearance. The mean tumor thickness was 2.7 mm (median, 2.8; range 1.8–3.7 mm). After PDT, mean follow-up was 56 months (median, 53; range, 14–91). Outcomes revealed complete tumor regression after 1 session (n = 3, 25%), 2 sessions (n = 3, 25%), and 3 sessions (n = 2, 17%) of PDT, reduced to mean thickness of 2.1 mm (median, 2.0; range 1.2–3.4 mm). Tumors that failed to regress (n = 4, 33%) were further controlled with transpupillary thermotherapy (n = 1) or plaque brachytherapy (n = 3). Subretinal fluid, present in six eyes, demonstrated resolution (n = 5) or progression (n = 1), and one tumor developed new subretinal fluid after PDT (n = 1). Visual outcome was stable (n = 11 eyes) or improved (n = 1). Photodynamic therapy complications included local retina pigment epithelium atrophy at the site of treatment in 3 (25%) eyes, with no effect on macular or optic nerve function.

Conclusion:

Primary PDT resulted in complete tumor regression of small amelanotic choroidal melanoma in 67% at mean 5 years, with no major effect on visual acuity.
ACCURACY AND PRECISION OF INTRAVITREAL INJECTIONS OF ANTI–VASCULAR ENDOTHELIAL GROWTH FACTOR AGENTS IN REAL LIFE
Authors: Loewenstein Itamar , Goldstein Michaella , Moisseiev Joseph , Moisseiev Elad
Published: April 2018

Purpose:

To evaluate the accuracy and precision of anti–vascular endothelial growth factor volume delivery by intravitreal injections in the clinical setup.

Methods:

Volume output was measured in 669 intravitreal injections administered to patients, calculated from the difference in syringe weight before and after expelling the drug. Three groups were included: prefilled bevacizumab 1.0 mL syringe (Group 1, n = 432), pre-filled ranibizumab in a small-volume syringe with low dead-space plunger design (Group 2, n = 125), and aflibercept drawn and injected using a 1.0-mL syringe (Group 3, n = 112). Accuracy was analyzed by mean absolute percentage error, and precision by coefficient of variation.

Results:

Volume outputs in all 3 groups were significantly different from the target of 50 μL (P < 0.0001 for all), and mean absolute percentage error values were 12.25% ± 5.92% in Group 1, 13.60% ± 8.75% in Group 2, and 24.69% ± 14.84% in Group 3. No difference was found between groups 1 and 2, but both were significantly more accurate than Group 3 (P < 0.0001 for both).

Conclusion:

The current practices used for intravitreal injections are highly variable, with overdelivery of the anti–vascular endothelial growth factor drugs measured in most cases, but underdelivery in 16.3% of injections. Use of a prefilled syringe was associated with improved accuracy, and low dead-space plunger design may improve precision.
Frontalis Muscle Flap Versus Maximal Anterior Levator Resection as First Option for Patients With Severe Congenital Ptosis
Authors: Medel Ramón , Molina Salvador , Vasquez Luz Maria , Visa Josep , Wert Ana , Wolley-Dod Charlotte
Published: April 2018

Purpose:

To compare 2 surgical techniques (frontalis flap versus maximal anterior levator resection) as first surgical options for the treatment of congenital ptosis with poor levator function in patients younger than 2 years of age with a follow up of 10 years.

Methods:

A retrospective study of 58 patients (71 eyelids) with severe ptosis and poor levator function who underwent frontalis muscle flap (FMF = 47) or maximal anterior levator resection (ALR = 24) for correction of their ptosis. Eyelid measurements were taken at baseline, 1, 5, and 10 years after surgery. The presence of complications, need for reoperations, and palpebral contour were evaluated.

Results:

Most patients in both groups required only one surgical procedure with a stable average margin-reflex distance 1 over the 10-year follow-up period in both groups, with no statistically significant difference between the 2 techniques in achieving an adequate palpebral height after one single procedure. Eleven eyelids treated with FMF (23%) and 12 treated with ALR (50%) needed a reoperation, with a statistically significant difference between the 2 techniques. Five ALR patients (21%) and 6 FMF patients (13%) had alterations of eyelid contour. Pop-eyelid and eyelash ptosis were observed in 8% of patients operated with FMF.

Conclusion:

Good functional and aesthetic results were obtained with both surgical techniques. FMF required fewer reoperations compared with maximal ALR, offering a better long-term result without residual ptosis.
Orbital Inflammatory Syndrome Secondary to Flea Bite
Authors: Prospero Ponce Claudia M. , Malik Amina I. , Vickers Aroucha , Chevez-Barrios Patricia , Lee Andrew G.
Published: April 2018

A 34-year-old previously healthy Hispanic male presented to the emergency room complaining of progressive left upper eyelid swelling and pain for more than 2 weeks. He was previously diagnosed and treated for a “pink eye” but failed to improve. He reported a previous “bug bite” around the left lateral canthus a few weeks prior to admission. Computer tomography orbit with contrast showed left exophthalmos, an enhancing left lacrimal gland and orbital inflammatory signs suggestive of possible intraorbital abscess. Intravenous antibiotics did not improve his symptoms. Surgical debridement showed no abscess but inflamed soft tissues and lacrimal gland. Intravenous steroids failed to improve his symptoms. On postoperative day 3, the patient reported that an insect had “jumped” out from his left orbit. Identification of the specimen proved to be a mature flea. Biopsy of the lacrimal gland showed degranulation of eosinophils and foreign body material consistent with probable insect leg parts.
Similarity in Bilateral Isolated Internal Orbital Fractures
Authors: Chen Hung-Chang , Cox Jacob T. , Sanyal Abanti , Mahoney Nicholas R.
Published: April 2018

Purpose:

In evaluating patients sustaining bilateral isolated internal orbital fractures, the authors have observed both similar fracture locations and also similar expansion of orbital volumes. In this study, we aim to investigate if there is a propensity for the 2 orbits to fracture in symmetrically similar patterns when sustaining similar trauma.

Methods:

A retrospective chart review was performed studying all cases at our institution of bilateral isolated internal orbital fractures involving the medial wall and/or the floor at the time of presentation. The similarity of the bilateral fracture locations was evaluated using the Fisher’s exact test. The bilateral expanded orbital volumes were analyzed using the Wilcoxon signed-rank test to assess for orbital volume similarity.

Results:

Twenty-four patients with bilateral internal orbital fractures were analyzed for fracture location similarity. Seventeen patients (70.8%) had 100% concordance in the orbital subregion fractured, and the association between the right and the left orbital fracture subregion locations was statistically significant (P < 0.0001). Fifteen patients were analyzed for orbital volume similarity. The average orbital cavity volume was 31.2 ± 3.8 cm3 on the right and 32.0 ± 3.7 cm3 on the left. There was a statistically significant difference between right and left orbital cavity volumes (P = 0.0026).

Conclusions:

The data from this study suggest that an individual who suffers isolated bilateral internal orbital fractures has a statistically significant similarity in the location of their orbital fractures. However, there does not appear to be statistically significant similarity in the expansion of the orbital volumes in these patients.
Congenital Accessory Palpebral Fissure and Eyelid in a Newborn: A Case Report
Authors: Bokman Christine L. , Lo Christopher C. , Eichhorn Knut , Goldberg Robert A.
Published: April 2018

The occurrence of an accessory palpebral fissure and eyelid is an extremely rare phenomenon. An isolated accessory palpebral fissure and eyelid have been reported only twice in the literature, and in one case as an extension of Delleman syndrome, or oculocerebrocutaneous syndrome. The authors report a case of a full-term newborn who presented with an accessory palpebral fissure and eyelid associated with microcornea, skin polyps and tags, cutis dysplasia, and hypoplasia of the corpus callosum with an otherwise normal systemic workup and negative genetic screening. Detailed surgical management and histopathological analysis of the accessory findings are also described.
Effects of Human Papillomavirus Awareness and Knowledge on Psychological State of Women Referred to Cervical Cancer Screening
Authors: Markovic-Denic Ljiljana , Djuric Olivera , Maksimovic Natasa , Popovac Svetlana , Kesic Vesna
Published: April 2018

Objective

The aim of the study was to assess the impact of human papillomavirus (HPV) awareness and knowledge on physiological state and quality of life of women referred to colposcopy and/or HPV testing.

Materials and Methods

A cross-sectional study was carried out at University Hospital, Belgrade, Serbia. The women with abnormal Pap test results obtained at the primary care centers requiring colposcopy and/or HPV testing were included. Before gynecological examination, participants filled the questionnaire on demographic characteristics, gynecological history, questionnaire for the evaluation of HPV awareness and HPV knowledge level, a set of self-report questionnaires assessing the anxiety level, quality of life, and concern about the smear and colposcopy results and perceived risk of developing cervical cancer.

Results

Of 324 women, 196 (60.5%) were aware of HPV. They reported higher concern about test results (p< .001), perceived risk of developing cervical cancer (p< .001), and had significantly lower quality of life (p= .004) than women who did not hear anything about this virus. On contrary, better knowledge correlated with younger age (p< .001) and better quality of life (p< .0001) and was associated with lower anxiety, lower concern about smear test results, and lower perceived risk of developing cancer.

Conclusions

Human papillomavirus awareness and knowledge have different impact on psychological state and quality of life. Being aware of HPV is not enough for reducing the stress and anxiety and increasing the coverage of screening. Therefore, it is necessary to increase women's knowledge through more detailed information about HPV in different public health messages and education programs.
Repeated Audiometry After Bacterial Meningitis: Consequences for Future Management
Authors: Rodenburg-Vlot Marian B. A. , Ruytjens Liesbet , Oostenbrink Rianne , van der Schroeff Marc P.
Published: April 2018

Objective:

Sensorineural hearing loss is a common sequela of bacterial meningitis. The objective of this study is to delineate the incidence and course of hearing loss after bacterial meningitis.

Study Design:

Retrospective cohort study.

Setting:

Tertiary referral center.

Patients:

Data of 655 patients who suffered from bacterial meningitis between 1985 and 2015 were analyzed.

Interventions:

None.

Main Outcome Measurements:

Availability of audiometric data, incidence of hearing loss, and onset and course of hearing loss.

Results:

In this cohort the incidence of hearing loss (>25 dB) was 28% (95% confidence interval 23–34%). The incidence of profound hearing loss (>80 dB) was 13% (95% confidence interval 10–18%). Normal hearing at the first assessment after treatment for meningitis remained stable over time in all these patients. In 19 of the 28 patients with diagnosed hearing loss, the hearing level remained stable over time. Hearing improved in six patients and deteriorated in two patients. One patient showed a fluctuating unilateral hearing loss.

Conclusion:

Audiological tests in patients with bacterial meningitis, especially children, should be started as soon as possible after the acute phase is over. As we found no deterioration of initial normal hearing after bacterial meningitis, repeated audiometry seems indicated only for those with diagnosed hearing loss at first assessment.
Intravenous Immunoglobulin and Methylprednisolone for Clozapine-Associated Perimyocarditis
Authors: Cheng Albert , Ahmed Mohanned , Shuaib Waqas
Published: April 2018

Clinical Features:

Cardiotoxicity is a rare but serious side effect of clozapine. We present a case of a psychiatric patient on chronic clozapine 75 mg daily, who presented with congestive heart failure secondary to the cardiotoxic effects of the psychiatric medication.

Therapeutic Challenge:

Conventional heart failure treatment failed to improve symptoms.

Solution:

A course of 40 mg of intravenous immunoglobulin and 125 mg of steroids was implemented, after which the patient made a full recovery. We hope to raise awareness of concurrent clozapine-induced pericarditis and myocarditis and propose a role of intravenous immunoglobulin and steroids in the treatment of drug-induced cardiomyopathy.
Enhancing Lesbian, Gay, Bisexual, and Transgender Cultural Competence in a Midwestern Primary Care Clinic Setting
Authors: Felsenstein Denise R.
Published: April 2018

The process of initiating lesbian, gay, bisexual, and transgender (LGBT) cultural competencies and educational interventions developed to increase staff knowledge on LGBT culture and health issues is discussed, including a computer-based module and panel discussion. The module intervention showed a statistically significant increase (p = .033) of staff LGBT knowledge from pretest to posttest scores. An evaluation after the panel discussion showed that 72% of staff indicated they were more prepared for LGBT patient care.
When a Child Dies Unexpectedly
Authors: Callanan Deborah L. , McClain William D.
Published: April 2018

Sudden death of a child beyond infancy is a rare event. We report a child who presented to the emergency care system with asystole and the caregiver's report of an asthma attack as the preceding event. After unsuccessful attempts at resuscitation, an autopsy was performed by the medical examiner. Despite only scattered bruises with no clear-cut signs of abuse, aortic rupture and spinal fractures were found. This case highlights the crucial role of the medical examiner in evaluating sudden childhood death, even in the setting of underlying illness.
Functional Status Change Among Children With Extracorporeal Membrane Oxygenation to Support Cardiopulmonary Resuscitation in a Pediatric Cardiac ICU: A Single Institution Report*
Authors: Beshish Asaad G. , Baginski Mathew R. , Johnson Thomas J. , Deatrick Barry K. , Barbaro Ryan P. , Owens Gabe E.
Published: April 2018

Objectives:

The purpose of this study is to describe the functional status of survivors from extracorporeal cardiopulmonary resuscitation instituted during in-hospital cardiac arrest using the Functional Status Scale. We aimed to determine risk factors leading to the development of new morbidity and unfavorable functional outcomes.

Design:

This was a single-center retrospective chart review abstracting patient characteristics/demographic data, duration of cardiopulmonary resuscitation, duration of extracorporeal membrane oxygenation support, as well as maximum lactate levels within 2 hours before and after extracorporeal cardiopulmonary resuscitation. Cardiac arrest was defined as the administration of chest compressions for a nonperfusing cardiac rhythm. Extracorporeal cardiopulmonary resuscitation was defined by instituting extracorporeal membrane oxygenation during active chest compressions. Functional Status Scale scores were calculated at admission and on hospital discharge for patients who survived.

Setting:

Patients admitted in the pediatric cardiac ICU at C.S. Mott Children’s Hospital from January 1, 2005, to December 31, 2015.

Patients:

Children less than 18 years who underwent extracorporeal cardiopulmonary resuscitation.

Interventions:

Not applicable.

Measurements and Main Results:

Of 608 extracorporeal membrane oxygenation events during the study period, 80 were extracorporeal cardiopulmonary resuscitation (14%). There were 40 female patients (50%). Median age was 40 days (interquartile range, 9–342 d). Survival to hospital discharge was 48% (38/80). Median Functional Status Scale score at admission was 6 (interquartile range, 6–6) and at hospital discharge 9 (interquartile range, 8–11). Out of 38 survivors, 19 (50%) had a change of Functional Status Scale score greater than or equal to 3, that is consistent with new morbidity, and 26 (68%) had favorable functional outcomes with a change in Functional Status Scale score of less than 5.

Conclusions:

This is the first extracorporeal cardiopulmonary resuscitation report to examine changes in Functional Status Scale from admission (baseline) to discharge as a measure of overall functional outcome. Half of surviving patients (19/38) had new morbidity, while 68% (26/38) had favorable outcomes. Lactate levels, duration of cardiopulmonary resuscitation, and duration of extracorporeal membrane oxygenation were not found to be risk factors for the development of new morbidity and poor functional outcomes. Functional Status Scale may be used as a metric to monitor improvement of extracorporeal cardiopulmonary resuscitation outcomes and help guide research initiatives to decrease morbidity in this patient population.
A Pilot Randomized Controlled Trial of an Intervention to Promote Psychological Well-Being in Critically Ill Children: Soothing Through Touch, Reading, and Music*
Authors: Rennick Janet E. , Stremler Robyn , Horwood Linda , Aita Marilyn , Lavoie Tanya , Majnemer Annette , Antonacci Marie , Knox Alyssa , Constantin Evelyn
Published: April 2018

Objectives:

To examine the feasibility and acceptability of a PICU Soothing intervention using touch, reading, and music.

Design:

Nonblinded, pilot randomized controlled trial.

Setting:

The PICU and medical-surgical wards of one Canadian pediatric hospital.

Patients:

Twenty PICU patients age 2–14 years old and their parents, randomized to an intervention group (n = 10) or control group (n = 10).

Intervention:

PICU Soothing consisted of: 1) parental comforting (touch and reading), followed by 2) a quiet period with music via soft headbands, administered once daily throughout hospitalization.

Measurements and Main Results:

Acceptability and feasibility of the intervention and methods were assessed via participation rates, observation, measurement completion rates, semistructured interviews, and telephone calls. Psychological well-being was assessed using measures of distress, sleep, and child and parent anxiety in the PICU, on the wards and 3 months post discharge. Forty-four percent of parents agreed to participate. Seventy percent and 100% of intervention group parents responded positively to comforting and music, respectively. Most intervention group parents (70%) and all nurses felt children responded positively. All nurses found the intervention acceptable and feasible. Measurement completion rates ranged from 70% to 100%. Pilot data suggested lower intervention group child and parent anxiety after transfer to hospital wards.

Conclusions:

PICU Soothing is acceptable and feasible to conduct. Results support the implementation of a full-scale randomized controlled trial to evaluate intervention effectiveness.
Association of Academic Physiatrists Federal Funding of Disability and Rehabilitation Research Position Statement
Authors: Whyte John
Published: April 2018

The Association of Academic Physiatrists seeks to advocate for policies that are supportive of academic rehabilitation, with elected officials, agency leaders, and other policy makers. Accordingly, the Association of Academic Physiatrists' Public Policy Committee identifies policy issues of importance to the organizational mission, conducts background research on those issues, and develops position statements that articulate the organization's position. These position statements require approval by the Board of Trustees and are used to support advocacy efforts by Association of Academic Physiatrists' members. Federal funding for disability and rehabilitation research is an important issue for the Association of Academic Physiatrists and its members. This position statement addresses the need for greater federal funding in this area, better coordination of the agencies providing funding, and an appropriate balance of merit-based funding with funding targeted to building capacity in critical rehabilitation-relevant methodology and content areas.
Femoral Artery Blood Flow and Microcirculatory Perfusion During Acute, Low-Level Functional Electrical Stimulation in Spinal Cord Injury
Authors: Barton Thomas J. , Low David A. , Janssen Thomas W.J. , Sloots Maurits , Smit Christof A.J. , Thijssen Dick H.J.
Published: April 2018

Objective

Functional electrical stimulation (FES) may help to reduce the risk of developing macrovascular and microvascular complications in people with spinal cord injury. Low-intensity FES has significant clinical potential because this can be applied continuously throughout the day. This study examines the acute effects of low-intensity FES using wearable clothing garment on vascular blood flow and oxygen consumption in people with spinal cord injury.

Design

This was a cross-sectional observation study.

Methods

Eight participants with a motor complete spinal cord injury received four 3-min unilateral FES to the gluteal and hamstring muscles. Skin and deep femoral artery blood flow and oxygen consumption were measured at baseline and during each bout of stimulation.

Results

Femoral artery blood flow increased by 18.1% with the application of FES (P = 0.02). Moreover, femoral artery blood flow increased further during each subsequent block of FES (P = 0.004). Skin perfusion did not change during an individual block of stimulation (P = 0.66). Skin perfusion progressively increased with each subsequent bout (P < 0.001). There was no change in femoral or skin perfusion across time in the nonstimulated leg (all P > 0.05).

Conclusion

Low-intensity FES acutely increased blood flow during stimulation, with a progressive increase across subsequent FES bouts. These observations suggest that continuous, low-intensity FES may represent a practical and effective strategy to improve perfusion and reduce the risk of vascular complications.
Evolution in Monitoring of Free Flap Autologous Breast Reconstruction after Nipple-Sparing Mastectomy: Is There a Best Way?
Authors: Frey Jordan D. , Stranix John T. , Chiodo Michael V. , Alperovich Michael , Ahn Christina Y. , Allen Robert J. , Choi Mihye , Karp Nolan S. , Levine Jamie P.
Published: April 2018

Background:

Free flap monitoring in autologous reconstruction after nipple-sparing mastectomy remains controversial. The authors therefore examined outcomes in nipple-sparing mastectomy with buried free flap reconstruction versus free flap reconstruction incorporating a monitoring skin paddle.

Methods:

Autologous free flap reconstructions with nipple-sparing mastectomy performed from 2006 to 2015 were identified. Demographics and operative results were analyzed and compared between buried flaps and those with a skin paddle for monitoring.

Results:

Two hundred twenty-one free flaps for nipple-sparing mastectomy reconstruction were identified: 50 buried flaps and 171 flaps incorporating a skin paddle. The most common flaps used were deep inferior epigastric perforator (64 percent), profunda artery perforator (12.1 percent), and muscle-sparing transverse rectus abdominis myocutaneous flaps (10.4 percent). Patients undergoing autologous reconstructions with a skin paddle had a significantly greater body mass index (p = 0.006). Mastectomy weight (p = 0.017) and flap weight (p < 0.0001) were significantly greater in flaps incorporating a skin paddle. Comparing outcomes, there were no significant differences in flap failure (2.0 percent versus 2.3 percent; p = 1.000) or percentage of flaps requiring return to the operating room (6.0 percent versus 4.7 percent; p = 0.715) between groups. Buried flaps had an absolute greater mean number of revision procedures per nipple-sparing mastectomy (0.82) compared with the skin paddle group (0.44); however, rates of revision procedures per nipple-sparing mastectomy were statistically equivalent between the groups (p = 0.296).

Conclusion:

Although buried free flap reconstruction in nipple-sparing mastectomy has been shown to be safe and effective, the authors’ technique has evolved to favor incorporating a skin paddle, which allows for clinical monitoring and can be removed at the time of secondary revision.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
The Cost of Contralateral Prophylactic Mastectomy in Women with Unilateral Breast Cancer
Authors: Billig Jessica I. , Duncan Anthony , Zhong Lin , Aliu Oluseyi , Sears Erika D. , Chung Kevin C. , Momoh Adeyiza O.
Published: April 2018

Background:

Contralateral prophylactic mastectomy may be unnecessary from an oncologic perspective; therefore, the debate persists about the value of contralateral prophylactic mastectomy in women with early-stage unilateral breast cancer. Given finite health care resources, this study aims to evaluate the cost of contralateral prophylactic mastectomy and breast reconstruction.

Methods:

Women with unilateral breast cancer undergoing either unilateral mastectomy or unilateral mastectomy with contralateral prophylactic mastectomy and immediate breast reconstruction were selected from the Truven MarketScan databases between 2009 and 2013. Demographic and treatment data were recorded, and over an 18-month follow-up period, the treatment cost was tallied. A log-transformed linear model was used to compare cost between the groups.

Results:

A total of 2343 women were identified who met our inclusion criteria, with 1295 undergoing unilateral mastectomy and 1048 undergoing contralateral prophylactic mastectomy. Complication rates within 18 months were similar for women undergoing unilateral mastectomy and contralateral prophylactic mastectomy (39 percent versus 42 percent; p = 0.17). Management with unilateral mastectomy with reconstruction required an adjusted cumulative mean cost of $33,557. Contralateral prophylactic mastectomy with reconstruction was an additional $11,872 in expenditure (p < 0.001). The cost of initial procedures (mean difference, $6467) and secondary procedures (mean difference, $2455) were the greatest contributors to cost.

Conclusions:

In women with unilateral breast cancer, contralateral prophylactic mastectomy with reconstruction is more costly. The increased monetary cost of contralateral prophylactic mastectomy may be offset by improved quality of life. However, this financial reality is an important consideration when ongoing efforts toward reimbursement reform may not pay for contralateral prophylactic mastectomy if outcomes data are not presented to justify this procedure.
Aseptic Freeze-Dried versus Sterile Wet-Packaged Human Cadaveric Acellular Dermal Matrix in Immediate Tissue Expander Breast Reconstruction: A Propensity Score Analysis
Authors: Hanson Summer E. , Meaike Jesse D. , Selber Jesse C. , Liu Jun , Li Liang , Hassid Victor J. , Baumann Donald P. , Butler Charles E. , Garvey Patrick B.
Published: April 2018

Background:

Although multiple acellular dermal matrix sources exist, it is unclear how its processing impacts complication rates. The authors compared complications between two preparations of human cadaveric acellular dermal matrix (freeze dried and ready-to-use) in immediate tissue expander breast reconstruction to analyze the effect of processing on complications.

Methods:

The authors retrospectively reviewed all alloplastic breast reconstructions with freeze-dried or ready-to-use human acellular dermal matrices between 2006 and 2016. The primary outcome measure was surgical-site occurrence defined as seroma, skin dehiscence, surgical-site infection, or reconstruction failure. The two groups were compared before and after propensity score matching.

Results:

The authors included 988 reconstructions (freeze-dried, 53.8 percent; ready-to-use, 46.2 percent). Analysis of 384 propensity score–matched pairs demonstrated a slightly higher rate of surgical-site occurrence (21.4 percent versus 16.7 percent; p = 0.10) and surgical-site infection (9.6 percent versus 7.8 percent; p = 0.13) in the freeze-dried group than in the ready-to-use group, but the difference was not significant. However, failure was significantly higher for the freeze-dried versus ready-to-use group (7.8 percent versus 4.4 percent; p = 0.050).

Conclusions:

This is the largest study comparing the outcomes of alloplastic breast reconstruction using human acellular dermal matrix materials prepared by different methods. The authors demonstrated higher early complications with aseptic, freeze-dried matrix than with sterile ready-to-use matrix; reconstructive failure was the only outcome to achieve statistical significance. The authors conclude that acellular dermal matrix preparation has an independent impact on patient outcomes in their comparison of one company’s product.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Pediatric Zygomaticomaxillary Complex Fracture Repair: Location and Number of Fixation Sites in Growing Children
Authors: Luck J. D. , Lopez Joseph , Faateh Muhammad , Macmillan Alexandra , Yang Robin , Davidson Edward H. , Nam Arthur J. , Grant Michael P. , Tufaro Anthony P. , Redett Richard J. , Manson Paul N. , Dorafshar Amir H.
Published: April 2018

Background:

Relatively few reports have been published investigating the operative management of pediatric zygomaticomaxillary complex fractures. The purpose of this study was to assess pediatric zygomaticomaxillary complex fracture management and associated complications, and potentially describe a standard treatment paradigm for these cases.

Methods:

A retrospective cohort review was performed of all patients younger than 15 years presenting to a single institution with zygomaticomaxillary complex fractures from 1990 to 2010. Patient demographics, concomitant injuries, management details, and complications were recorded. Complications were compared among patients by dentition stage, number of fixation points, and identity of fixation sites.

Results:

A total of 36 patients with 44 unique zygomaticomaxillary complex fractures met the authors’ inclusion criteria. Thirty-two fractures exhibited at least 2.0 mm of diastasis along at least one buttress (73 percent), and all but one of these were managed operatively. Among operatively managed patients with deciduous dentition, two-point fixation was associated with a lower overall complication rate compared with one- and three-point fixation (0 percent versus 75 percent and 75 percent;p= 0.01). Furthermore, rigid plate-and-screw fixation at the zygomaticomaxillary buttress was not associated with an increased complication rate in operatively managed patients with deciduous dentition (40 percent versus 50 percent;p= 0.76).

Conclusions:

The authors’ results suggest that two-point fixation is an effective management strategy for repair of displaced zygomaticomaxillary complex fractures in children. In addition, rigid plate-and-screw fixation at the zygomaticomaxillary buttress in children with deciduous dentition appears to be safe and effective when performed.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Methodological Aspects for Preclinical Evaluation of Gadolinium Presence in Brain Tissue
Authors: Robert Philippe , Frenzel Thomas , Factor Cécile , Jost Gregor , Rasschaert Marlène , Schuetz Gunnar , Fretellier Nathalie , Boyken Janina , Idée Jean-Marc , Pietsch Hubertus
Published: April 2018

Gadolinium (Gd)-based contrast agents (GBCAs) are pharmaceuticals that have been approved for 30 years and used daily in millions of patients worldwide. Their clinical benefits are indisputable. Recently, unexpected long-term presence of Gd in the brain has been reported by numerous retrospective clinical studies and confirmed in preclinical models particularly after linear GBCA (L-GBCA) compared with macrocyclic GBCA (M-GBCA). Even if no clinical consequences of Gd presence in brain tissue has been demonstrated so far, in-depth investigations on potential toxicological consequences and the fate of Gd in the body remain crucial to potentially adapt the clinical use of GBCAs, as done during the nephrogenic systemic fibrosis crisis. Preclinical models are instrumental in the understanding of the mechanism of action as well as the potential safety consequences. However, such models may be associated with risks of biases, often related to the protocol design. Selection of adequate terminology is also crucial. This review of the literature intends to summarize and critically discuss the main methodological aspects for accurate design and translational character of preclinical studies.
Prostate-Specific Membrane Antigen–Negative Metastases—A Potential Pitfall in Prostate-Specific Membrane Antigen PET
Authors: Noto Benjamin , Auf der Springe Katharina , Huss Sebastian , Allkemper Thomas , Stegger Lars
Published: April 2018

68Ga-PSMA-11 PET/CT was performed in a 74-year-old man because of biochemical recurrence of prostate cancer following radiation therapy of the prostate gland 24 months earlier. Besides focal nuclide accumulation in the prostate gland suggestive of local recurrence, PET scan revealed no further pathologic uptake. However, CT showed multiple pulmonic nodules suggestive of metastases. Thoracotomy and pathologic examination revealed the nodules to be prostate cancer metastasis. Furthermore, immunohistochemical staining with PSMA antibodies demonstrated a virtual lack of PSMA expression. This case demonstrates the possibility of PSMA-negative metastases of prostate cancer an important pitfall that should be known to physicians interpreting PSMA PET.