bluuebunny/crossref_metadata_2025 huggingface dataset:
Syndromes Associated with Sexually Transmitted Infections in Lilongwe, Malawi: Burden and Trends, 2006 to 2015
Authors: Matoga Mitch , Chen Jane S. , Kudowa Evaristar , Kamanga Gift , Mapanje Clement , Massa Cecilia , Ndalama Beatrice , Bonongwe Naomi , Nyirenda Naomi , Mathiya Esther , Jere Edward , Ngoma Edith , Chagomerana Maganizo , Phiri Sam , Powers Kimberly A. , Miller William C. , Cohen Myron S. , Hoffman Irving F.
Published: September 2020

Monitoring the burden of and trends in sexually transmitted infection syndromes is useful in informing syndromic management guidelines. Among sexually transmitted infection clinic patients in Lilongwe, Malawi, between 2006 and 2015, genital discharge, lower abdominal pain, and genital ulcer syndromes were common. Prevalence of most syndromes remained stable during the 10-year period.
Camel-Related Deaths—A Forensic Overview
Authors: Gilbert John D. , Byard Roger W.
Published: September 2020

Camels are ungulates of the genus Camelus and have been used for centuries in parts of Asia and Africa for transport and sustenance. Handling of camels is not without its dangers, and 4 cases from South Australia are reported with a review of lethal camel-related issues. Case 1 is a 56-year-old man who died of multiple blunt force injuries after he had attempted to move a 7-year-old female dromedary (Camelus dromedarius). Case 2 is a 65-year-old woman who was crushed by 1 or more camels that she had been training. Case 3 is a 1-year-old girl who died of blunt craniocerebral trauma after the car in which she was traveling rolled when the driver swerved to avoid a herd of camels that had strayed onto the road. Case 4 is a 66-year-old woman who died of ischemic and hypertensive cardiac disease exacerbated by physical activity while rounding up camels. Deaths associated with camels involve kicking, stomping, kneeling or sitting on a victim, or biting and shaking and throwing. Lethal mechanisms include hemorrhage from vascular injuries and internal organ disruption, crush asphyxia, and blunt craniospinal injuries. Death may also follow falls from camels or vehicle collisions. Camels also carry a wide range of zoonotic diseases, the most significant of which is Middle Eastern respiratory syndrome. Handling of camels may also exacerbate underlying organic illnesses such as cardiac disease. Those working with camels should be aware that the size, strength, and temperament of these animals may make them dangerous and that they also carry potentially lethal zoonotic diseases.
Histopathological Differentiation of Antemortem and Postmortem Electrical Burn Mark Produced by Low Voltage
Authors: Behera Chittaranjan , Sikary Asit Kumar , Kumar Vivek , Mridha Asit Ranjan
Published: September 2020

The study was undertaken to differentiate antemortem electrical (AME) and postmortem electrical (PME) burn marks with the help of histopathology. The electrical burn mark was produced on 25 dead bodies. Alongside 25 cases of electrocution deaths were included for comparison. Slides were prepared and stained with hematoxylin-eosin stains. Intraepidermal and subepidermal separation; coagulative necrosis of the epidermis; nuclear elongation and hyperchromasia of epidermal cells; homogenization of the dermis; nuclear elongation and hyperchromasia of hair follicles, sweat glands, sebaceous glands, and blood vessel endothelium were studied for histopathological changes and graded. The findings of the study suggest that the histopathological changes in electrical burn marks are due to the physical effect of heat produced by the electric current. The classical histopathological features of electrical burn mark cannot differentiate between AME and PME burn marks. However, careful evaluation of grading of the dermal changes can be helpful in differentiating AME and PME burn marks. Highest grade of dermal thickness homogenization and highest grade of nuclear elongation of dermal appendages were significantly more in the antemortem electrical burn marks than PME burn marks.
Embolism of Cerebral Tissue to the Lung After Head Trauma
Authors: Bugra Aytul , Das Taner
Published: September 2020

Embolism of cerebral tissue to pulmonary circulation is a rare entity. It can be occur because of penetrating or closed head trauma at any age or during difficult vaginal deliveries at any age. We present a case of cerebral tissue pulmonary embolization after severe head trauma in a male adult. The autopsy revealed multiple skull fractures, subdural hematoma, subarachnoid hemorrhages, and contusions. Microscopically, we observed cerebral tissue inside the branches of the pulmonary arteries. Embolism of cerebral tissue to the pulmonary circulation is a rare condition. It should always be kept in mind in sudden unexpected deaths during delivery and head trauma cases at any age.
Death by Copper Ammonium Complex–Containing Fungicide
Authors: Otter Jenna , Cantrell F Lee
Published: September 2020

There is a paucity of published reports of copper ammonium complex ingestion, as most published data describe overdoses of copper sulfate formulations. We report a case of suicide by ingestion of copper ammonium complex–containing fungicide with an elevated postmortem copper level. A 77-year-old woman was found dead at home by her relative after ingesting a fungicide containing 8% copper ammonium complex solution. Turquoise emesis was found at the scene, and on autopsy, turquoise material was found throughout the gastrointestinal tract. Postmortem central blood copper level was 500 μg/dL. Cause of death was determined to be acute copper toxicity.
Arrhythmogenic Right Ventricular Cardiomyopathy in a Young Athlete
Authors: Rich Lucas , Rarick Joshua , Prahlow Joseph
Published: September 2020

Sudden death in young athletes is rare, with an incidence of 0.61/100,000 person-years in the United States (Circulation. 2009;119(8):1085–1092). Etiologies may be divided into cardiac and noncardiac. We present a case of arrhythmogenic right ventricular cardiomyopathy (ARVC) resulting in sudden death in a high school athlete.

A 17-year-old adolescent boy with an unremarkable medical history suddenly collapsed while running. Autopsy revealed a 510-g heart with a markedly dilated right ventricle and multifocal areas of wall thinning and apparent fatty infiltration. The left ventricle demonstrated concentric hypertrophy. Coronary arteries were unremarkable, as were the cardiac valves. Microscopic examination revealed right ventricular myocyte loss with replacement by fibrofatty tissue. Remainder of the autopsy was negative except for mild chronic asthmatic changes. Serum and urine drug screens were negative. The cause of death was ARVC. The manner of death was natural.

Arrhythmogenic right ventricular cardiomyopathy is an inherited cardiomyopathy with variable expressivity and incomplete penetrance often resulting in heart failure or sudden cardiac death. It is characterized by segmental and multifocal fibro-fatty replacement of the right ventricle free wall. Arrhythmogenic right ventricular cardiomyopathy accounts for 2.1% to 4.0% of total sudden deaths in young athletes and thus should be considered in similar cases (J Am Coll Cardiol. 2018;72(7):784–804).
Claudin-18 as a Marker for Identifying the Stomach and Pancreatobiliary Tract as the Primary Sites of Metastatic Adenocarcinoma
Authors: Li Wan-Ting , Jeng Yung-Ming , Yang Ching-Yao
Published: September 2020

Identification of the primary site of cancer is essential for the treatment of patients with cancer. Numerous immunohistochemical markers have been developed to determine the differentiation of tumor cells and suggest possible primary sites, but markers of gastric and pancreatic adenocarcinomas are still lacking. Claudin-18 is a tight-junction protein uniquely expressed in gastric epithelial cells and has been shown to be expressed in gastric and pancreatic adenocarcinoma. Whether claudin-18 can be used as a marker for identifying the primary site of cancer is still unclear. In this study, we used the immunohistochemical method to stain claudin-18 in tissue arrays containing 575 carcinomas from different anatomic sites and representative sections of 157 metastatic adenocarcinomas. In the group of primary tumors, claudin-18 was frequently expressed in gastric, pancreatic, and pulmonary mucinous adenocarcinomas. Half of cholangiocarcinomas and ovarian mucinous carcinomas and some colorectal and pulmonary adenocarcinomas were also positive for claudin-18. In the metastatic cohort, 15 of 17 (88%) gastric adenocarcinomas, 18 of 23 (78%) pancreatic adenocarcinomas, and 4 of 7 (57%) cholangiocarcinomas and gallbladder adenocarcinomas were positive for claudin-18. Only 4 tumors that originated outside the stomach and pancreatobiliary tract were positive for claudin-18. After normalization to the tumor frequency, the sensitivity of claudin-18 for identifying the stomach and pancreatobiliary tract as primary tumor sites was 79%, and the specificity was 93%. The positive and negative predictive values were 76% and 94%, respectively. In conclusion, claudin-18 represents a sensitive and specific marker for stomach and pancreatobiliary adenocarcinoma that may be a useful diagnostic tool in routine surgical pathology.
Amyloid-like Fibronectin Deposits in the Liver
Authors: Yasir Saba , Rech Karen L. , Chen Zongming Eric , Torbenson Michael S.
Published: September 2020

Amyloid deposits in the liver are recognized by their hematoxylin and eosin (H&E) findings, consisting of acellular eosinophilic deposits in various compartments of the liver parenchyma, including the stroma, vessels, and rarely the hepatocytes. H&E findings that suggest amyloid are then confirmed by Congo red stains and subtyped when clinically needed. Two cases are reported with sinusoidal deposits of acellular material that closely mimicked amyloid on H&E, but were Congo red negative. Mass spectrometry–based proteomic analysis identified the material as fibronectin. In 1 case, the deposits were located in the sinusoids of a well-differentiated hepatocellular carcinoma and in 1 case in the sinusoids of a benign liver.
The Impact of the Novel Coronavirus on Brazilian PICUs
Authors: Araujo Orlei Ribeiro de , Almeida Carlos Gustavo de , Lima-Setta Fernanda , Prata-Barbosa Arnaldo , Colleti Junior José
Published: September 2020

Objectives:

To study the impact of the coronavirus disease 2019 pandemic, considering the physical distancing and schools closing, on the characteristics of admission and epidemiology on Brazilian PICUs.

Design:

Observational, multicenter, time series analysis, of electronic medical records from 15 PICU in Brazil. Data consisted of all March, April, and May PICU admissions from 2017 to 2020.

Setting:

Fifteen private PICUs in Brazil.

Patients:

Pediatric patients admitted to the PICU from March to May since 2017.

Interventions:

None.

Measurements and Main Results:

The period from March 11, 2020, to March 17, 2020, was considered the “intervention point” studied, corresponding to the suspension of school activities and the beginning of physical distancing in Brazil. During the pandemic period studied, there were 28 cases of coronavirus disease 2019 (one death). The mean age was higher (p = 0.000), the length of stay was shorter (p = 0.000), but mortality rates were similar among the periods (p = 0.36). The model estimated a reduction of 1,483 PICU admissions from March 2020 to May 2020. At the end of May, there was an estimated drop of –146.6 bronchiolitis admissions (95% CI, –242.8 to –50.3; p = 0.016); –71 asthma admissions (95% CI, –93.6 to –48.63; p = 0.000); and –59 community-acquired pneumonia admissions (95% CI, –74.7 to –43.3; p = 0.000) per period. The model showed no effect of the “intervention” (physical distancing) on hospitalization rates for epilepsy, diarrhea, sepsis, bacterial meningitis, or surgery when analyzed individually. When assessed together, the model estimated a reduction of 73.6 admissions (95% IC, –132 to –15.2; p = 0.43).

Conclusions:

The coronavirus disease 2019 pandemic strongly affected Brazilian PICUs, reducing admissions, length of stay, and the epidemiological profile. The measures to oppose the coronavirus disease 2019 pandemic may have prevented thousands of PICU hospitalizations across the country.
Crohn Disease Presenting as the Cutaneous Rash of Pyoderma Gangrenosum
Authors: Harris Corrie Ann , Lehto Elizabeth M. , Laneiwcz Megan Bryce
Published: September 2020

Pyoderma gangrenosum (PG) is a rare pediatric diagnosis, occurring in 3 to 10 patients per million per year, and most commonly seen in individuals between ages 20 and 50 years. This severe ulcerating skin rash is typically associated with an underlying systemic inflammatory condition. The appearance of PG often coincides with exacerbation of the underlying disease. In the absence of systemic symptoms, misdiagnosis of PG can occur, resulting in delay of appropriate treatment. The disease's visual similarity to soft tissue infections, which have dramatically increased in recent years (Ann Emerg Med. 2008;51,3:291–98), makes isolated dermatologic presentations particularly problematic. We present a case of Crohn disease presenting as the inflammatory rash of PG in the absence of significant bowel symptoms. This case highlights the importance of keeping PG in the differential for inflammatory lesions presenting to the emergency department.
Radiation-Free Diagnosis of Pediatric Appendicitis
Authors: Davis Joshua , Chima Melissa , Kasmire Kathryn
Published: September 2020

Introduction

Appendicitis is a common pediatric surgical emergency, and it can often be difficult to diagnose. Computed tomography is commonly used as a diagnostic criterion standard, but herein, we describe the accuracy of a “radiation-free” diagnostic algorithm using point-of-care ultrasonography (POCUS) and magnetic resonance imaging (MRI) to diagnose pediatric appendicitis.

Methods

This was a retrospective chart review of all patients who had a POCUS ordered for evaluation of pediatric appendicitis. Results of POCUS and MRI were classified as positive, negative, or equivocal using previously described cutoffs and criterion standard of surgery/pathology or clinical follow-up. Diagnostic accuracy was calculated using traditional methods.

Results

We identified 209 patients for inclusion. The sensitivity and specificity of POCUS were 100% and 95.2%, respectively, in addition to 86 equivocal examinations, 6 of which had appendicitis. The sensitivity and specificity of MRI were 94.4% and 96.5%, respectively, in addition to 27 equivocal examinations, 2 of which had appendicitis.

Conclusions

Using POCUS and MRI for the diagnosis of pediatric appendicitis is a highly accurate way to avoid ionizing radiation in children. In our study, POCUS is as accurate as MRI, although this is limited by being mostly done by a single provider and a high number of equivocal examinations.
Seated Position Does Not Change Lumbar Dimensions Compared With Lateral Position
Authors: Long Michael T. , Del Re Angelo M. , Uya Atim , Kanegaye John T. , Nguyen Margaret B.
Published: September 2020

Objective

The infant lumbar puncture (LP) can be a technically challenging procedure. Understanding the anatomical lumbar dimensions may optimize LP conditions. Data from preterm neonates, older children, and adults indicate measurements of the lumbar spine in the seated LP position may be superior when compared with the lateral position. We use point-of-care ultrasound (US) to determine if the seated position, when compared with the lateral decubitus position, significantly affected the lumbar dimensions of infants 12 months or younger presenting to the pediatric emergency department.

Methods

We conducted a prospective observational study of a convenience sample of patients 12 months or younger. We used US to obtain 3 still images oriented longitudinally in the midline over the L3 to L4 interspace in the lateral decubitus and seated positions. A US fellowship-trained emergency physician, blinded to patient position, measured interspinous space, subarachnoid space width, and spinal canal depth. We then compared the means of all 3 dimensions in the lateral and seated positions.

Results

From 50 subjects, 49 subjects provided 46 evaluable sets of images for each measure. Interspinous space, spinal canal depth, and subarachnoid space width did not differ significantly between positions. Mean differences did not exceed 0.02 cm for any of the measured dimensions. We report no significant differences in the 3 lumbar dimensions at the seated position when compared with the lateral decubitus position.

Conclusions

For infants younger than 12 months, sonographic measurements of lumbar dimensions did not differ between the positions commonly used for LP.
Characteristics of Upper Limb Osteoarticular Infections at the Emergency Department of a Tertiary University Hospital in Spain
Authors: Martín Espín Irene , Murias Loza Sara , Lacasta Plasin Clara , Niño Saco María Dolores , Alcolea Sánchez Alida , de Ceano-Vivas la Calle María
Published: September 2020

Objectives

Osteoarticular infections are infrequent in pediatric patients, although their incidence seems to be increasing. They usually affect children younger than 5 years and tend to localize in the lower limbs. Because of their nonspecific symptoms, especially at onset, a timely diagnosis is difficult to achieve, with the subsequent risk of a delay in treatment. We hereby report the management of osteoarticular infections in our pediatric emergency department.

Methods

This is a retrospective descriptive study of patients diagnosed with osteoarticular upper limb infection in the pediatric emergency department of a tertiary hospital from January 2011 to December 2016.

Results

From an initial global sample of 170 patients diagnosed with osteomyelitis or septic arthritis at any location at the pediatric emergency department, 32 children (18.82%) with upper limb involvement were included in the study. Of them, 22 were male and the mean age at diagnosis was 14.5 months (interquartile range, 2–106). Eighteen patients (56%) were diagnosed with septic arthritis, and 14 (44%) had a diagnosis of osteomyelitis.

The most frequent symptom was pain (50%). More than one third of patients (11) had received a different diagnosis in a previous hospital visit. A traumatic etiology was suspected in 7 cases (21%).

Regarding acute phase reactants, the mean value for C-reactive protein was 21.3 mg/L, and erythrocyte sedimentation rate was elevated in 27 cases (84%). In 28 patients, blood cultures were obtained, 24 of which came back negative. All children received antibiotic treatment and achieved a full recovery.

Conclusions

One third of patients were misdiagnosed at the first consultation, which stresses the importance of a high clinical suspicion to avoid delays in diagnosis and treatment of osteoarticular infections. This study also shows a lower mean age of children with upper limb infection as compared with those with lower limb infection. All patients recovered fully with oral antibiotics.
Which Clinical Features of Children on Initial Presentation to the Emergency Department With Head Injury Are Associated With Clinically Important Traumatic Brain Injury, Classification as Abuse, and Poor Prognosis?
Authors: Burns James , Rohl Stephen , Marth Daniel , Proctor Drexel , Amin Raid , Sekhon Carol
Published: September 2020

Background

Pediatric traumatic brain injury (TBI) and abusive head trauma (AHT) are leading causes of morbidity and mortality. Clinicians may not be aware of AHT at presentation to the emergency department (ED).

Objective

The objective of this study was to determine which clinical features associated with head injury in children on initial presentation to the ED trauma bay predict 3 outcomes including clinically important TBI (CiTBI), classification as confirmed abuse by Child Protection Team (CPT), and poor neurologic status on hospital discharge.

Participants and Setting

Inclusion for this study were children 3 years or younger, presenting to the ED with significant TBI. In addition, presentations where the mechanism of injury was not verifiable such as with falls, being struck by object, or no mechanism of injury reported by caregiver were included.

Methods

Researchers used 3 sources of information for this analysis: a regional trauma registry, hospital records, and the CPT database. Clinical features included demographics, mechanisms of injury, physical, radiological findings, and CPT classification.

Results

On pairwise analysis, seizures, apnea, and no mechanism of injury reported by caregiver were the only clinical features related to all 3 outcomes (P < 0.001). Rib fractures (relative risk [RR], 3.3; P < 0.001), long bone fractures (RR, 3.1; P < 0.001), retinal hemorrhages (RR, 3.0; P < 0.001), seizures (RR, 3.6; P < 0.001), apnea (RR, 4.4; P < 0.001), and younger than 6 months (RR, 1.8; P < 0.001) were related to AHT. On multivariable logistic regression, no mechanism of injury reported by caregiver and seizures remained significantly related to CiTBI; seizures and retinal hemorrhage remained significantly related to classification as abuse by CPT, and no mechanism of injury by the caregiver, apnea, and seizures were significantly related to poor outcome on hospital discharge.

Conclusions

No mechanism of injury reported by the caregiver, seizures, and apnea at the time of presentation to the ED are important features associated with CiTBI, classification as AHT, and poor prognosis. In addition, younger age, retinal hemorrhage, rib, and long bone fractures were found to be important clinical features associated with AHT.
Lung Point-of-Care Ultrasound in Pediatric COVID-19
Authors: Kennedy Thomas M. , Malia Laurie , Dessie Almaz , Kessler David O. , Ng Lorraine , Chiang Elaine L. , Rabiner Joni E.
Published: September 2020

Lung point-of-care ultrasound (POCUS) has been shown to be useful for identifying pulmonary pathology in adult patients with coronavirus disease 2019 (COVID-19). However, pediatric literature for POCUS in COVID-19 is limited. The objective of this case series was to describe lung POCUS findings in pediatric patients with COVID-19. Three patients with COVID-19 who had lung POCUS performed in a pediatric emergency department were included. Point-of-care ultrasound revealed bilateral abnormalities in all patients, including pleural line irregularities, scattered and coalescing B-lines, consolidations, and pleural effusions. Additional pediatric studies are necessary to gain a broader understanding of COVID-19's sonographic appearance in this age group and to determine whether POCUS may be helpful to facilitate diagnosis and expedite management decisions.
COVID-19
Authors: Isba Rachel , Edge Rhiannon , Auerbach Marc , Cicero Mark X. , Jenner Rachel , Setzer Erika , Broughton Emily , Keegan Thomas
Published: September 2020

Introduction

This cross-sectional study looked at the impact of the SARS-CoV-2/COVID-19 pandemic on pediatric emergency department (PED) attendances and admissions (as a proxy for severity of illness) in the United States and United Kingdom.

Methods

Data were extracted for children and adolescents, younger than 16 years, attending Royal Manchester Children's Hospital (RMCH, United Kingdom), and Yale New Haven Children's Hospital (YNHCH, United States). Attendances for weeks 1 to 20 of 2020 and 2019 were compared, and likelihood of admission was assessed via calculation of odds ratios, using week 13 (lockdown) as a cutoff.

Results

Attendance numbers for each PED decreased in 2020 compared with 2019 (RMCH, 29.2%; YNHCH, 24.8%). Odds of admission were significantly higher after lockdown than in 2019—RMCH (odds ratio, 1.26; 95% confidence interval, 1.08–1.46) and YNHCH (odds ratio, 1.60; 95% confidence interval, 1.31–1.98).

Conclusions

Although the absolute numbers of children and adolescents attending the PED and being admitted decreased after lockdown, the acuity of illness of those attending appears to be higher.
Solitary Fibrous Tumor of the Vulva: Case Report of a Rare Entity and Review of Literature
Authors: Tandon Nidhi
Published: September 2020

Solitary fibrous tumor (SFT) is an uncommon mesenchymal tumor of fibroblastic origin, which shows a prominent hemangiopericytoma-like branching pattern. It may be found at any location and can rarely involve the female genital tract with the vulva being the most common site of involvement. This is a case report of vulvar SFT in a 47-yr-old female who presented with a slow growing vulvar mass for 3 yr. Histologic examination showed a neoplasm composed of ovoid to spindle shaped cells with hypocellular and hypercellular areas in a collagenous background. Prominent hemangiopericytoma-like vessels were identified. Immunohistochemistry showed positive staining of the tumor cells for CD34, STAT6, ER, PR, and vimentin. Immunoshistochemical staining for desmin, SMA, and S100 was negative. The majority of SFTs have a NAB2-STAT6 gene fusion on chromosome 12, resulting in nuclear STAT6 overexpression, which is a sensitive and specific immunohistochemical marker for its diagnosis. Only 25 cases of vulvar SFT have been reported in the English literature and it should be considered in the differential diagnosis of spindle cell lesions at this site.
Expanding the Morphologic, Immunohistochemical, and HPV Genotypic Features of High-grade Squamous Intraepithelial Lesions of the Vulva With Morphology Mimicking Differentiated Vulvar Intraepithelial Neoplasia and/or Lichen Sclerosus
Authors: Griesinger Laurie M. , Walline Heather , Wang Grace Y. , Lorenzatti Hiles Guadalupe , Welch Kathryn C. , Haefner Hope K. , Lieberman Richard W. , Skala Stephanie L.
Published: September 2020

Squamous cell carcinoma of the vulva can arise through 2 pathways: human papillomavirus (HPV)-dependent high-grade squamous intraepithelial lesions (previously termed usual vulvar intraepithelial neoplasia) or HPV-independent (differentiated vulvar intraepithelial neoplasia, dVIN). Distinguishing between the 2 types can be clinically and histologically difficult. A subset of high-grade squamous intraepithelial lesions with superimposed chronic inflammation mimicking dVIN has recently been reported; p53 shows characteristic mid-epithelial staining (with basal sparing) in such cases. The pathology databases of 2 academic institutions were searched for vulva specimens with corresponding p53 and p16 immunohistochemical stains, yielding 38 specimens (from 27 patients). In situ hybridization and multiplex polymerase chain reaction-MassArray for high-risk HPV were performed on at least 1 block from each patient. All cases resembled dVIN or lichen sclerosus morphologically, but with a higher degree of atypia. All but 1 case demonstrated mid-epithelial p53 staining with basal sparing by immunohistochemistry. All cases showed block positivity for p16 and at least patchy positivity by HPV in situ hybridization. Of the 23 cases with valid HPV DNA polymerase chain reaction results, 15 were positive and 8 were negative. Of the positive cases, HPV16 was identified in 10 cases, with other high-risk types in the remaining 5. To our knowledge, this is the largest cohort of high-grade squamous intraepithelial lesions mimicking dVIN reported to date. Prior studies reported positivity for HPV16 in all cases tested, however, we found HPV16 in only 67% of HPV positive cases. This case series highlights the importance of immunohistochemistry, and occasionally HPV in situ hybridization, for accurate diagnosis, and expands the spectrum of associated HPV types.
Perineal Clear Cell Hidradenoma: A GATA3-positive Neoplasm With Potential for Misdiagnosis
Authors: Hudacko Rachel , Anderson Patrick , Guerrieri Claudio
Published: September 2020

We report a case of clear cell hidradenoma of the perineum that was initially misinterpreted as a papillary urothelial carcinoma, either metastatic or of Bartholin gland origin, on initial excisional biopsy. The misinterpretation may have been due to the pseudopapillary architecture and GATA3-positivity of the biopsy tissue. Clear cell hidradenomas often show a range of histologic growth patterns and cellular differentiation and are one of many tumors that react immunohistochemically with GATA3. Although rare, these tumors can occur in the genital region and can mimic malignant tumors such as metastatic renal cell carcinoma and carcinomas of the genitourinary tract. This report details the morphologic and immunohistochemical pitfalls that make accurate diagnosis of clear cell hidradenoma in this unusual location challenging.
Uterine Cellular Blue Nevus Arising in Mullerian and Pelvic Dendritic Melanocytosis: Case Report of a Rare Phenomenon to Be Distinguished From Uterine Melanoma
Authors: Cunningham Christopher J. , Fleischman Anna , Buckingham Lindsey , O’Connor Siobhan , Gehrig Paola A. , Googe Paul B.
Published: September 2020

A 37-yr-old woman presented to the gynecology clinic with abnormal uterine bleeding in the setting of known, large uterine fibroids. Preoperative endometrial biopsy identified atypical melanocytic cells concerning for uterine melanoma. Care was transferred to the gynecologic oncology service for hysterectomy. Intraoperative findings included macular, blue-black pigmentation of the peritoneum of the bladder and cervix, which was resected and sent for frozen section, confirming melanocytic neoplasia. The hysterectomy revealed multiple tan leiomyomas up to 12 cm, and a distinct 3 cm black, incompletely circumscribed mass in the endomyometrium composed of bland spindled cells with delicate melanin granules. The tumor cells were positive for Sox-10, BAP1, and Mart-1 (Melan-A) and negative for PRAME, PD-L1, and BRAFV600E by immunostains. Microscopic elements of similar melanocytes and melanophages were found in the cervix and bladder peritoneum. Molecular analysis of the uterine tumor identified a GNA11 mutation but no TERT or BAP1 mutation. The uterine melanocytic tumor has characteristic findings of a cellular blue nevus arising in association with dendritic melanocytosis of Mullerian and pelvic tissues, a rarely seen benign phenomenon that should be distinguished from malignant melanoma of the upper genital tract.
A Cadaveric Study of the Buccal Fat Pad: Implications for Closure of Palatal Fistulae and Donor-Site Morbidity
Authors: Echlin Kezia , Whitehouse Harry , Schwaiger Michael , Nicholas Rebecca , Fallico Nefer , Atherton Duncan D.
Published: September 2020

Background:

For the cleft surgeon, palatal fistulae after cleft palate repair remain a difficult problem, with a paucity of local tissue options to aid closure. Small clinical series have described the use of the buccal fat pad flap to repair palatal fistulae; however, there is no literature detailing the anatomical coverage of the flap. This study delineates the anatomy of the buccal fat pad flap to guide surgeons in patient selection and examines the residual buccal fat after flap harvest to provide new information with regard to possible effects on the donor site.

Methods:

Buccal fat pad flaps were raised in 30 hemicadavers. The reach of the flap across the midline, anteriorly and posteriorly, was recorded. In 18 hemicadavers, the entire buccal fat pad was then exposed to determine the effects of flap harvest on movement and volume of the residual fat.

Results:

All buccal fat pad flaps provided coverage from the soft palate to the posterior third of the hard palate and all across the midline. Approximately three-fourths of flaps would cover the mid hard palate. The flap constitutes 36 percent of the total buccal fat pad on average, and a series of retaining ligaments were identified that may prevent overresection.

Conclusions:

The buccal fat pad flap is a useful tool for coverage of fistulae in the soft palate to the posterior third of the hard palate. In most cases, it will also reach the middle third; however, it is not suitable for more anterior defects. On average, two-thirds of the buccal fat pad remains within the cheek after flap harvest, which may protect against unwanted alteration in aesthetics.
A Novel Absorbable Stapler Provides Patient-Reported Outcomes and Cost-Effectiveness Noninferior to Subcuticular Skin Closure: A Prospective, Single-Blind, Randomized Clinical Trial
Authors: Malard Olivier , Duteille Franck , Darnis Eric , Espitalier Florent , Perrot Pierre , Ferron Christophe , Planche Lucie , Hardouin Jean-Benoit , Tessier Philippe , Bellanger Martine , Dert Cécile
Published: September 2020

Background:

Deep dermal suturing is critical for scar quality outcomes. The authors evaluated a new, fast medical device for dermal suturing, with the hypothesis of noninferiority with regard to clinical scar and cost-effectiveness.

Methods:

A prospective, patient-blind, randomized, multicenter noninferiority study in 26 French hospitals was conducted. Patients were randomized 1:1 to suturing with conventional thread or a semiautomatic stapler. The Patient Scar Assessment Scale was rated at 3 months for primary endpoint effectiveness. Secondary endpoints were cost-effectiveness of the two suturing methods, prevalence of complications, suturing/operating time, Observer Scar Assessment Scale and Patient Scar Assessment Scale score, scar aesthetic quality 18 months after surgery, and occupational exposure to blood during surgery.

Results:

Six hundred sixty-four patients were enrolled, 660 were randomized, and 649 constituted the full analysis (stapler arm, n = 324; needle arm, n = 325). Primary endpoint Patient Scar Assessment Scale score in the stapler arm was not inferior to that in the needle arm at 3 months or after 18 months. The mean operating time was 180 minutes in the stapler arm and 179 minutes in the needle arm (p = not significant). The mean suturing time was significantly lower in the stapler arm (p < 0.001). There were seven occupational exposures to blood in the needle arm and one in the stapler arm. The two arms did not differ significantly in terms of complications (p = 0.41). The additional cost of using the device was €51.57 for the complete-case population.

Conclusion:

Wound healing outcome was no worse than with conventional suturing using a semiautomatic stapler and associated with less occupational exposure to blood.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, I.
Incidence of Major Arterial Abnormality in Patients with Wound Dehiscence after Lower Extremity Orthopedic Procedures
Authors: Zolper Elizabeth G. , Kotha Vikas S. , Walters Elliot T. , Nigam Manas , Lakhiani Chrisovalantis X. , Fortman Emilie C. , Janhofer David E. , Steinberg John S. , Attinger Christopher E. , Evans Karen K.
Published: September 2020

Background:

Surgical dehiscence can occur after lower extremity orthopedic procedures. Underlying vascular aberrancy and localized ischemia contribute to chronic wound development requiring advanced techniques such as free tissue transfer. Localized vascular abnormality is an underrecognized contributing factor to such dehiscence. The authors reviewed their lower extremity free tissue transfer experience in this population to analyze the incidence of arterial abnormality and outcomes.

Methods:

The authors conducted a retrospective review of 64 lower extremity free tissue transfers performed for chronic wounds after orthopedic procedures from 2011 to 2018. The primary outcome was major arterial abnormality as identified on angiography. Secondary outcomes were flap success, limb salvage, and ambulation status.

Results:

The median age was 58 years, and 44 were men (69 percent). Comorbidities included osteomyelitis (77 percent), diabetes (39 percent), and peripheral vascular disease (17 percent). The incidence of arterial abnormality on angiography was 47 percent. Defect location correlated with angiosome of arterial abnormality in 53 percent. The flap success rate was 92 percent. Limb salvage and ambulation rates were 89 and 89 percent, respectively, at an average follow-up of 17.6 months. Men demonstrated an increased rate of limb salvage (p = 0.026). Diabetes (p = 0.012), arterial abnormality (p = 0.044), and arterial flap complication (p = 0.010) correlated with amputation.

Conclusions:

The high incidence of arterial abnormality in this population highlights the importance of expedient multidisciplinary care, including vascular and plastic surgery. Diagnostic angiography is important for identifying major arterial abnormality and the need for free tissue transfer for definitive coverage.
Osseointegration of Extremity Prostheses: A Primer for the Plastic Surgeon
Authors: Souza Jason M. , Mioton Lauren M. , Harrington Colin J. , Potter Benjamin K. , Forsberg Jonathan A.
Published: September 2020

Interest in amputation surgery has increased in conjunction with rising public awareness about amputee care. To date, plastic surgeons have impacted the quality of life and functional potential of amputees through novel strategies for sensory feedback and prosthesis control and various techniques for neuroma treatment and prevention. Osseointegration, which involves the direct skeletal attachment of a prosthesis to bone, has the ability to further maximize amputee function. There exists a critical role for plastic surgeons to help optimize techniques for extremity osseointegration through improved wound care and soft-tissue management. An overview of current osseointegrated prostheses and their associated limitations, and potential avenues through which plastic surgeons can help mitigate these challenges, are discussed in this article.
Diffuse Venous Malformations of the Upper Extremity (Bockenheimer Disease): Diagnosis and Management
Authors: Ali Barkat , Panossian Andre , Taghinia Amir , Mulliken John B. , Alomari Ahmad , Adams Denise M. , Fishman Stephen J. , Upton Joseph
Published: September 2020

Background:

Diffuse venous malformations that involve all tissues in the upper limb and ipsilateral chest wall are known as “phlebectasia of Bockenheimer.” The authors describe their experience with management of this uncommon vascular anomaly.

Methods:

The authors’ Vascular Anomalies Center registry comprised 18,766 patients over a 40-year period. This review identified 2036 patients with venous malformations of the extremities (10.8 percent), of whom only 80 (0.43 percent) had Bockenheimer disease. The authors retrospectively analyzed patient characteristics, diagnostics, treatments, and complications.

Results:

The venous malformation was first noted at birth or within the first few years of life with slow and gradual progression. Pain was related to engorgement of the limb. Thromboses and phleboliths were common, but diffuse intravascular coagulopathy occurred in only 12 patients (15 percent). Skeletal involvement was demonstrated as lytic lesions, cortical scalloping, osteopenia, and pathologic fractures. Management included compression garments (100 percent), sclerotherapy (27.5 percent), and resection of symptomatic areas in 35 percent of patients. Adjunctive pharmacologic medication was given in 7.5 percent. Following resection, 17 patients (60 percent) had one or more complications: hematoma, wound dehiscence, flap loss, contracture, and psychosis. There were no deaths. Symptoms improved in all patients with useful functional outcomes.

Conclusions:

The decision to pursue compression, sclerotherapy, pharmacologic treatment, or resection alone or in combination was made by an interdisciplinary team. Although extensive venous malformations cannot be completely ablated, debulking of symptomatic regions, resection of neuromas, and noninvasive treatments improve the quality of life. Despite the bulk and weight of the arm, forearm, and hand, and the ominous appearance on magnetic resonance imaging, these patients remain functional.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, V.
Three-Dimensional Facial Scanning at the Fingertips of Patients and Surgeons: Accuracy and Precision Testing of iPhone X Three-Dimensional Scanner
Authors: Rudy Hayeem L. , Wake Nicole , Yee Judy , Garfein Evan S. , Tepper Oren M.
Published: September 2020

Background:

The iPhone X (Apple, Inc., Cupertino, Calif.) is the first smartphone to be released with a high-fidelity three-dimensional scanner. At present, half of all U.S. smartphone users use an iPhone. Recent data suggest that the majority of these 230 million individuals will upgrade to the iPhone X within 2 years. This represents a profound expansion in access to three-dimensional scanning technology, not only for plastic surgeons but for their patients as well. The purpose of this study was to compare the iPhone X scanner against a popular, portable three-dimensional camera used in plastic surgery (Canfield Vectra H1; Canfield Scientific, Inc., Parsippany, N.J.).

Methods:

Sixteen human subjects underwent three-dimensional facial capture with the iPhone X and Canfield Vectra H1. Results were compared using color map analysis and surface distances between key anatomical landmarks. To assess repeatability and precision of the iPhone X three-dimensional scanner, six facial scans of a single participant were obtained and compared using color map analysis. In addition, three-dimensionally–printed facial masks (n = 3) were captured with each device and compared.

Results:

For the experiments, average root mean square was 0.44 mm following color map analysis and 0.46 mm for surface distance between anatomical landmarks. For repeatability and precision testing, average root mean square difference following color map analysis was 0.35 mm. For the three-dimensionally–printed facial mask comparison, average root mean square difference was 0.28 mm.

Conclusions:

The iPhone X offers three-dimensional scanning that is accurate and precise to within 0.5 mm when compared to a commonly used, validated, and expensive three-dimensional camera. This represents a significant reduction in the barrier to access to three-dimensional scanning technology for both patients and surgeons.
40 Years of Total Extracorporeal Septal Reconstruction: The Past, Present, and Future
Authors: Gubisch Wolfgang , Hacker Stefan , Neumann Jens , Haack Sebastian
Published: September 2020

Background:

Even today, severe septal deformities are a challenging problem for any rhinoplasty surgeon. Standard techniques are often not able to achieve satisfactory long-term results regarding function or aesthetic form. In such severe cases, a partial or total extracorporeal septal reconstruction may be used, as these techniques provide reliable and lasting results.

Methods:

The aim of this work is to present the authors’ experience with the technique of total extracorporeal septal reconstruction and its development to today’s standard and to prove its effectiveness in the long-term follow-up.

Results:

This article presents 40 years of clinical experience in this field and describes the technical changes that have evolved. Low complication rates, safe techniques, and favorable long-term outcomes of the total extracorporeal septal reconstruction show the benefits of this technique.

Conclusion:

The indication for a total extracorporeal septal reconstruction has been limited by the development of less complex surgical procedures, but it still represents the best technique to achieve long-term functional and aesthetic results in patients with very complex septal deformities.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, V.
Routine Bedside Use of Obstetric Early Warning System in the Postnatal Ward to Identify Maternal Morbidity Among High-Risk Women
Authors: Hoppu Sanna , Hannola Katja , Mennander Susanna , Huhtala Heini , Rissanen Maria , Tulensalo Eveliina , Laivuori Hannele , Tihtonen Kati
Published: September 2020

Objective

Several authorities have recommended the use of an obstetric early warning system (OEWS) to prevent severe morbidity and mortality. Data on the accuracy of OEWS in different clinical settings and maternal populations are still scarce. Our aim was to validate OEWS to detect maternal morbidity among high-risk women in the postnatal ward.

Methods

An OEWS was assigned to women with a body mass index >35 kg/m2, postpartum hemorrhage (PPH) >1500 mL, preeclampsia, concern over the maternal condition, chorioamnionitis, or type 1 diabetes. Morbidity was defined as worsening preeclampsia, action on hemorrhage, thromboembolia, diabetic ketoacidosis, puerperal infections, transfer to the intensive care unit, cardiopulmonary dysfunction, or death during the stay in the postnatal ward. The use of OEWS was implemented on November 1, 2016, and the study period ended on April 30, 2018.

Results

The study group included 827 women. The incidence of maternal morbidity was 29%. Women with PPH (odds ratio [OR], 6.4 [95% confidence interval, 3.5–11.6]) and preeclampsia (OR, 5.7 [3.5–9.6]) had the highest risk for morbidity. The sensitivity of OEWS for any morbidity was 42% (35%–48%), the specificity was 83% (80%–86%), the positive predictive value was 50% (44%–56%), and the negative predictive value was 78% (76%–80%). Systolic (OR, 6.8 [4.0–11.5]) and diastolic (OR, 3.3 [1.8–6.0]) blood pressure as well as pulse (OR, 2.1 [1.1–4.2]) predicted morbidity the most.

Conclusions

In high-risk women, OEWS revealed one-half of the morbidity. Women with PPH and preeclampsia benefited most from it. Abnormal blood pressure and pulse had the strongest associations with morbidity.
Give Intravenous Bolus Overdose a Brake: User Experience and Perception of Safety Device
Authors: Ng Yasmin Yen Yen , Wan Paul Weng , Chan Kim Poh , Sim Guek Gwee
Published: September 2020

Objectives

Drugs can come in concentrated solutions that require dilution before intravenous bolus administration. Upon dilution, the syringe can contain more than the required amount of drug. The user may mistakenly administer the full contents of the syringe, resulting in an overdose. In this cross-sectional study, we evaluated user experience and perception of Syringe Brake, a dosage flow restrictor device, as part of the intravenous morphine bolus administration workflow.

Methods

From December 2018 to January 2019, doctors and nurses working in the emergency department of 3 public tertiary hospitals in Singapore were invited to complete a paper-based 11-item 5-point Likert scale survey questionnaire after 3 months of Syringe Brake implementation.

Results

Overall, 77.5% (290/374; 4.11 ± 0.83) of participants were satisfied with the use of Syringe Brake to prevent medication error. Our survey results showed that the top features of Syringe Brake were ease of setting the desired volume to be administered (86.1%; 4.21 ± 0.72), allowing the drug to be titrated safely (84.8%; 4.26 ± 0.77), and giving users the confidence to avoid overdosing the patient (82.1%; 4.21 ± 0.78). Those with hands-on experience with Syringe Brake rated significantly higher for all survey statements except on the perceived ability to prevent error arising from miscommunication (adjusted odds ratio, 1.58 [0.98–2.57]; P = 0.062).

Conclusions

Syringe Brake shows promising potential for adoption to prevent medication errors. The device serves as a constraint to prevent accidental overdose, caused by user unfamiliarity or autopilot administration.