bluuebunny/crossref_metadata_2025 huggingface dataset:
A descriptive analysis of end-of-life discussions for high-grade glioma patients
Authors: Chikada Ai , Takenouchi Sayaka , Arakawa Yoshiki , Nin Kazuko
Published: February 2021

Background

End-of-life discussions (EOLDs) in patients with high-grade glioma (HGG) have not been well described. Therefore, this study examined the appropriateness of timing and the extent of patient involvement in EOLDs and their impact on HGG patients.

Methods

A cross-sectional survey was conducted among 105 bereaved families of HGG patients at a university hospital in Japan between July and August 2019. Fisher’s exact test and the Wilcoxon rank-sum test were used to assess the association between patient participation in EOLDs and their outcomes.

Results

In total, 77 questionnaires were returned (response rate 73%), of which 20 respondents replied with refusal documents. Overall, 31/57 (54%) participated in EOLDs at least once in acute hospital settings, and a significant difference was observed between participating and nonparticipating groups in communicating the patient’s wishes for EOL care to the family (48% vs 8%, P = .001). Moreover, >80% of respondents indicated that the initiation of EOLDs during the early diagnosis period with patients and families was appropriate. Most EOLDs were provided by neurosurgeons (96%), and other health care providers rarely participated. Additionally, patient goals and priorities were discussed in only 28% of the EOLDs. Patient participation in EOLDs was not associated with the quality of EOL care and a good death.

Conclusions

Although participation in EOLDs is relatively challenging for HGG patients, this study showed that participation in EOLDs may enable patients to express their wishes regarding EOL care. It is important to initiate EOLDs early on through an interdisciplinary team approach while respecting patient goals and priorities.
Bacterial Superinfections Among Persons With Coronavirus Disease 2019: A Comprehensive Review of Data From Postmortem Studies
Authors: Clancy Cornelius J , Schwartz Ilan S , Kula Brittany , Nguyen M Hong
Published: February 2021

Background

Limited clinical data suggest a ~16% prevalence of bacterial superinfections among critically ill patients with coronavirus disease 2019 (COVID-19).

Methods

We reviewed postmortem studies of patients with COVID-19 published in English through September 26, 2020, for histopathologic findings consistent with bacterial lung infections.

Results

Worldwide, 621 patients from 75 studies were included. The quality of data was uneven, likely because identifying superinfections was not a major objective in 96% (72/75) of studies. Histopathology consistent with a potential lung superinfection was reported in 32% (200/621) of patients (22–96 years old; 66% men). Types of infections were pneumonia (95%), abscesses or empyema (3.5%), and septic emboli (1.5%). Seventy-three percent of pneumonias were focal rather than diffuse. The predominant histopathologic findings were intra-alveolar neutrophilic infiltrations that were distinct from those typical of COVID-19-associated diffuse alveolar damage. In studies with available data, 79% of patients received antimicrobial treatment; the most common agents were beta-lactam/beta-lactamase inhibitors (48%), macrolides (16%), cephalosoprins (12%), and carbapenems (6%). Superinfections were proven by direct visualization or recovery of bacteria in 25.5% (51/200) of potential cases and 8% of all patients in postmortem studies. In rank order, pathogens included Acinetobacter baumannii, Staphylococcus aureus, Pseudomonas aeruginosa, and Klebsiella pneumoniae. Lung superinfections were the cause of death in 16% of potential cases and 3% of all patients with COVID-19.

Conclusions

Potential bacterial lung superinfections were evident at postmortem examination in 32% of persons who died with COVID-19 (proven, 8%; possible, 24%), but they were uncommonly the cause of death.
Risk Factors for Pneumonia and Death in Adult Patients With Seasonal Influenza and Establishment of Prediction Scores: A Population-Based Study
Authors: Miyashita Koichi , Nakatani Eiji , Hozumi Hironao , Sato Yoko , Miyachi Yoshiki , Suda Takafumi
Published: February 2021

Background

Seasonal influenza remains a global health problem; however, there are limited data on the specific relative risks for pneumonia and death among outpatients considered to be at high risk for influenza complications. This population-based study aimed to develop prediction models for determining the risk of influenza-related pneumonia and death.

Methods

We included patients diagnosed with laboratory-confirmed influenza between 2016 and 2017 (main cohort, n = 25 659), those diagnosed between 2015 and 2016 (validation cohort 1, n = 16 727), and those diagnosed between 2017 and 2018 (validation cohort 2, n = 34 219). Prediction scores were developed based on the incidence and independent predictors of pneumonia and death identified using multivariate analyses, and patients were categorized into low-, medium-, and high-risk groups based on total scores.

Results

In the main cohort, age, gender, and certain comorbidities (dementia, congestive heart failure, diabetes, and others) were independent predictors of pneumonia and death. The 28-day pneumonia incidence was 0.5%, 4.1%, and 10.8% in the low-, medium-, and high-risk groups, respectively (c-index, 0.75); the 28-day mortality was 0.05%, 0.7%, and 3.3% in the low-, medium-, and high-risk groups, respectively (c-index, 0.85). In validation cohort 1, c-indices for the models for pneumonia and death were 0.75 and 0.87, respectively. In validation cohort 2, c-indices for the models were 0.74 and 0.87, respectively.

Conclusions

We successfully developed and validated simple-to-use risk prediction models, which would promptly provide useful information for treatment decisions in primary care settings.
Afro-Communitarianism and the Role of Traditional African Healers in the COVID-19 Pandemic
Authors: Cordeiro-Rodrigues Luís , Metz Thaddeus
Published: February 2021

The COVID-19 pandemic has brought significant challenges to healthcare systems worldwide, and in Africa, given the lack of resources, they are likely to be even more acute. The usefulness of Traditional African Healers in helping to mitigate the effects of pandemic has been neglected. We argue from an ethical perspective that these healers can and should have an important role in informing and guiding local communities in Africa on how to prevent the spread of COVID-19. Particularly, we argue not only that much of the philosophy underlying Traditional African Medicine is adequate and compatible with preventive measures for COVID-19, but also that Traditional African Healers have some unique cultural capital for influencing and enforcing such preventive measures. The paper therefore suggests that not only given the cultural context of Africa where Traditional African Healers have a special role, but also because of the normative strength of the Afro-communitarian philosophy that informs it, there are good ethical reasons to endorse policies that involve Traditional Healers in the fight against COVID-19. We also maintain that concerns about Traditional African Healers objectionably violating patient confidentiality or being paternalistic are much weaker in the face of COVID-19.
How Conservatives Lost Confidence in Science: The Role of Ideological Alignment in Political Polarization
Authors: Kozlowski Austin C
Published: February 2021

Confidence in the scientific community became politically polarized in the United States at the turn of the twenty-first century, with conservatives displaying lower confidence in scientists than liberals. Using data from the General Social Survey from 1984 to 2016, I show that moral and economic conservatives played distinct but complementary roles in producing this divide. I find that moral conservatives exhibited low confidence in scientists before any substantial division existed between self-identified political conservatives and liberals on this issue. However, as moral conservatism increasingly consolidated under the label of political conservatism, a negative association between political conservatism and confidence in the scientific community emerged. Economic conservatives, by contrast, previously held disproportionately high confidence in scientists, but this positive relationship wanes in the beginning of the twenty-first century. These findings suggest that interpreting political polarization requires attention to the multiple dimensions along which political attitudes are organized and ideological coalitions are formed.
Altered K-complex morphology during sustained inspiratory airflow limitation is associated with next-day lapses in vigilance in obstructive sleep apnea
Authors: Parekh Ankit , Kam Korey , Mullins Anna E , Castillo Bresne , Berkalieva Asem , Mazumdar Madhu , Varga Andrew W , Eckert Danny J , Rapoport David M , Ayappa Indu
Published: February 2021

Study Objectives

Determine if changes in K-complexes associated with sustained inspiratory airflow limitation (SIFL) during N2 sleep are associated with next-day vigilance and objective sleepiness.

Methods

Data from thirty subjects with moderate-to-severe obstructive sleep apnea who completed three in-lab polysomnograms: diagnostic, on therapeutic continuous positive airway pressure (CPAP), and on suboptimal CPAP (4 cmH2O below optimal titrated CPAP level) were analyzed. Four 20-min psychomotor vigilance tests (PVT) were performed after each PSG, every 2 h. Changes in the proportion of spontaneous K-complexes and spectral characteristics surrounding K-complexes were evaluated for K-complexes associated with both delta (∆SWAK), alpha (∆αK) frequencies.

Results

Suboptimal CPAP induced SIFL (14.7 (20.9) vs 2.9 (9.2); %total sleep time, p < 0.001) with a small increase in apnea–hypopnea index (AHI3A: 6.5 (7.7) vs 1.9 (2.3); p < 0.01) versus optimal CPAP. K-complex density (num./min of stage N2) was higher on suboptimal CPAP (0.97 ± 0.7 vs 0.65±0.5, #/min, mean ± SD, p < 0.01) above and beyond the effect of age, sex, AHI3A, and duration of SIFL. A decrease in ∆SWAK with suboptimal CPAP was associated with increased PVT lapses and explained 17% of additional variance in PVT lapses. Within-night during suboptimal CPAP K-complexes appeared to alternate between promoting sleep and as arousal surrogates. Electroencephalographic changes were not associated with objective sleepiness.

Conclusions

Sustained inspiratory airflow limitation is associated with altered K-complex morphology including the increased occurrence of K-complexes with bursts of alpha as arousal surrogates. These findings suggest that sustained inspiratory flow limitation may be associated with nonvisible sleep fragmentation and contribute to increased lapses in vigilance.
A MATLAB toolbox for modeling genetic circuits in cell-free systems†
Authors: Singhal Vipul , Tuza Zoltan A , Sun Zachary Z , Murray Richard M
Published: February 2021

We introduce a MATLAB-based simulation toolbox, called txtlsim, for an Escherichia coli-based Transcription–Translation (TX–TL) system. This toolbox accounts for several cell-free-related phenomena, such as resource loading, consumption and degradation, and in doing so, models the dynamics of TX–TL reactions for the entire duration of solution phase batch-mode experiments. We use a Bayesian parameter inference approach to characterize the reaction rate parameters associated with the core transcription, translation and mRNA degradation mechanics of the toolbox, allowing it to reproduce constitutive mRNA and protein-expression trajectories. We demonstrate the use of this characterized toolbox in a circuit behavior prediction case study for an incoherent feed-forward loop.
Effect of drying and warming piglets at birth on preweaning mortality
Authors: Vande Pol Katherine D , Tolosa Andres F , Shull Caleb M , Brown Catherine B , Alencar Stephan A S , Ellis Michael
Published: February 2021

Piglets are susceptible to hypothermia early after birth, which is a major predisposing factor for preweaning mortality (PWM). Drying and warming piglets at birth has been shown to reduce early postnatal temperature decline. This study evaluated the effect of drying and warming piglets at birth on PWM and weaning weight (WW) under commercial conditions. A completely randomized design was used with 802 sows/litters (10,327 piglets); sows/litters were randomly allotted at start of farrowing to one of two Intervention Treatments (applied at birth): Control (no drying or warming); Drying+Warming (dried with a cellulose-based desiccant and placed in a box under a heat lamp for 30 min). Piglets were weighed at birth and weaning; PWM was recorded. Rectal temperature was measured at 0 and 30 min after birth on all piglets in a subsample of 10% of litters. The effect of farrowing pen temperature (FPT) on WW and PWM was evaluated by comparing litters born under COOL (<25°C) to those born under WARM (≥25°C) FPT. The effect of birth weight on WW and PWM was evaluated by comparing three birth weight categories (BWC; Light: <1.0 kg, Medium: 1.0 to 1.5 kg, or Heavy: >1.5 kg). PROC GLIMMIX and MIXED of SAS were used to analyze mortality and other data, respectively. Litter was the experimental unit; piglet was a subsample of litter. The model included fixed effects of Intervention Treatment, and FPT or BWC as appropriate, the interaction, and the random effects of litter. Piglet rectal temperature at 30 min after birth was greater (P ≤ 0.05) for the Drying+Warming than the Control treatment (+2.33°C). Overall, there was no effect (P > 0.05) of Intervention Treatment on PWM or WW, and there were no Intervention Treatment by BWC interactions (P > 0.05) for these measurements. There was an Intervention Treatment by FPT interaction (P ≤ 0.05) for PWM. Drying and warming piglets reduced (P ≤ 0.05) PWM under COOL (by 2.4 percentage units) but not WARM FPT. In addition, WW were lower (P ≤ 0.05) under WARM (by 0.79 kg) than COOL FPT; however, there was no interaction (P > 0.05) with Intervention Treatment. In conclusion, this study suggests that drying and warming piglets at birth increases rectal temperature and may reduce PWM under cooler conditions, which are typically experienced in temperate climates during the majority of the year.
Development-Dependent Plasticity in Vasoactive Intestinal Polypeptide Neurons in the Infralimbic Cortex
Authors: Collins Stuart A , Ninan Ipe
Published: February 2021

The onset of several neuropsychiatric disorders including anxiety disorders coincides with adolescence. Consistently, threat extinction, which plays a key role in the regulation of anxiety-related behaviors, is diminished during adolescence. Furthermore, this attenuated threat extinction during adolescence is associated with an altered synaptic plasticity in the infralimbic medial prefrontal cortex (IL-mPFC), a brain region critical for threat extinction. However, the mechanism underlying the altered plasticity in the IL-mPFC during adolescence is unclear. Given the purported role of vasoactive intestinal polypeptide expressing interneurons (VIPINs) in disinhibition and hence their potential to affect cortical plasticity, we examined whether VIPINs exhibit an adolescence-specific plasticity in the IL-mPFC. We observed an increase in GABAergic transmission and a decrease in excitability in VIPINs during adolescence. Male mice show a significantly higher VIPIN-pyramidal neuron GABAergic transmission compared with female mice. The observed increase in GABAergic transmission and a decrease in membrane excitability in VIPINs during adolescence could play a role in the altered plasticity in the adolescent IL-mPFC. Furthermore, the suppression of VIPIN-mediated GABAergic transmission in females might be relevant to sex differences in anxiety disorders.
Take-Home Naloxone and the Need for a Publicly Funded Naloxone Supply
Authors: Kim Howard S. , Aks Steven E.
Published: February 2021

The opioid crisis continues to exact a heavy toll on the United States, and overdose deaths have only increased during the current global pandemic. One effective intervention to reduce overdose deaths is to distribute the opioid antagonist naloxone directly to persons actively using opioids (ie, “take-home naloxone”), especially at touchpoints with the potential for significant impact such as emergency departments and jails. A number of hospital emergency departments have recently sought to implement individual take-home naloxone programs; however, programmatic success has been inconsistent due primarily to the inability to secure reliable funding for a naloxone supply. In this commentary, we establish the argument for a publicly funded naloxone supply to support take-home naloxone distribution in emergency department settings. We posit that the complex billing and reimbursement system for medication dispensing is impossibly burdensome during emergency care for an acute opioid overdose, and that the mounting death toll from this public health crisis demands a strong commitment to harm reduction. A publicly financed naloxone supply would demonstrate this commitment and make a measurable impact in saving lives. Ultimately, provision of naloxone should be coupled with other comprehensive treatment services and medications for opioid use disorder to meaningfully reduce harms associated with opioid use.
Guided growth using a tension-band plate in Blount’s disease
Authors: Maré Pieter Herman , Thompson David Mungo , Marais Leonard Charles
Published: February 2021

Our observational study’s objective was to determine how effective guided growth with tension-band plates was to correct the deformity in Blount’s disease. We reviewed the records of 14 children (18 limbs) with Blount’s disease who were treated with tension-band plates as the only surgical intervention at a single institution over eight years. Five children (seven limbs) had infantile Blount’s disease with Langenskiöld stage ≤2. Nine children (11 limbs) had late-onset Blount’s disease. The mean age at operation was 7.2 years (SD, 3.1, range, 2.9–11.8). The tension-band plate effectively corrected the varus deformity in 78% (14/18) of limbs. Correction to normal mechanical alignment was achieved in 67% (n = 12) of limbs at a mean of 18 months (SD, 7, range, 9–31). Failure to achieve correction of the mechanical axis was due to delayed implant removal and overcorrection in 11% (2/18), mechanical failure due to screw fixation failure in 11% (2/18) and in 6% (1/18) due to a misplaced epiphyseal screw. There was a greater magnitude of correction in the Infantile Blount’s disease group (mean, 26°, SD, 9°) when compared to the children with late-onset Blount’s disease (13°, SD, 4°) (P = 0.021). The mean correction rate was 1.8°/month in the Infantile Blount’s disease group and 0.7°/month in the late-onset Blount’s disease group, respectively (P = 0.014). Our findings support the use of tension-band plating in Blount’s disease. Further research is required to determine the ideal indications and to investigate the long-term outcome of guided growth in Blount’s disease. Level of evidence: Level 4.
Effects of positive end-expiratory pressure/recruitment manoeuvres compared with zero end-expiratory pressure on atelectasis in children
Authors: Zhu Change , Zhang Saiji , Dong Junli , Wei Rong
Published: February 2021

BACKGROUND

Atelectasis is a common postoperative complication. Peri-operative lung protection can reduce atelectasis; however, it is not clear whether this persists into the postoperative period.

OBJECTIVE

To evaluate to what extent lung-protective ventilation reduces peri-operative atelectasis in children undergoing nonabdominal surgery.

DESIGN

Randomised, controlled, double-blind study.

SETTING

Single tertiary hospital, 25 July 2019 to 18 January 2020.

PATIENTS

A total of 60 patients aged 1 to 6 years, American Society of Anesthesiologists physical status 1 or 2, planned for nonabdominal surgery under general anaesthesia (≤2 h) with mechanical ventilation.

INTERVENTIONS

The patients were assigned randomly into either the lung-protective or zero end-expiratory pressure with no recruitment manoeuvres (control) group. Lung protection entailed 5 cmH2O positive end-expiratory pressure and recruitment manoeuvres every 30 min. Both groups received volume-controlled ventilation with a tidal volume of 6 ml kg−1 body weight. Lung ultrasound was conducted before anaesthesia induction, immediately after induction, surgery and tracheal extubation, and 15 min, 3 h, 12 h and 24 h after extubation.

MAIN OUTCOME MEASURES

The difference in lung ultrasound score between groups at each interval. A higher score indicates worse lung aeration.

RESULTS

Patients in the lung-protective group exhibited lower median [IQR] ultrasound scores compared with the control group immediately after surgery, 4 [4 to 5] vs. 8 [4 to 6], (95% confidence interval for the difference between group values −4 to −4, Z = -6.324) and after extubation 3 [3 to 4] vs. 4 [4 to 4], 95% CI −1 to 0, Z = −3.161. This did not persist from 15 min after extubation onwards. Lung aeration returned to normal in both groups 3 h after extubation.

CONCLUSIONS

The reduced atelectasis provided by lung-protective ventilation does not persist from 15 min after extubation onwards. Further studies are needed to determine if it yields better results in other types of surgery.

TRIAL REGISTRATION

Chictr.org.cn (ChiCTR2000033469).
Physostigmine for prevention of postoperative delirium and long-term cognitive dysfunction in liver surgery
Authors: Spies Claudia D. , Knaak Cornelia , Mertens Mandy , Brockhaus Wolf-Rüdiger , Shadenok Anna , Wiebach Janine , Kunzmann Kevin , Feldheiser Aarne , Pratschke Johann , Müller Olga , Kipping Valesca , Fabian Maria , Abels Wiltrud , Borchers Friedrich , Akyüz Levent , Ely E. Wesley , Wernecke Klaus-Dieter , Menon David Krishna , Piper Sophie K.
Published: February 2021

BACKGROUND

Anecdotally, cholinergic stimulation has been used to treat delirium and reduce cognitive dysfunction.

OBJECTIVE

The aim of this investigation was to evaluate whether physostigmine reduced the incidence of postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) in patients undergoing liver resection.

DESIGN

This was a double-blind, randomised, placebo-controlled trial. Between 11 August 2009 and 3 March 2016, patients were recruited at the Charité – Universitätsmedizin Berlin in Germany. Follow-ups took place at 1 week (T1), 90 days (T2) and 365 days (T3) after surgery.

SETTING

This single-centre study was conducted at an academic medical centre.

PARTICIPANTS

In total, 261 participants aged at least 18 years scheduled for elective liver surgery were randomised. The protocol also included 45 non-surgical matched controls to provide normative data for POCD and neurocognitive deficit (NCD).

INTERVENTION

Participants were allocated to receive either intravenous physostigmine, as a bolus of 0.02 mg kg−1 body weight followed by 0.01 mg kg−1 body weight per hour (n = 130), or placebo (n = 131), for 24 h after induction of anaesthesia.

MAIN OUTCOMES AND MEASURES

Primary outcomes were POD, assessed using the Diagnostic and Statistical Manual of Mental Disorders (DSM-4-TR) twice daily up to day 7 after surgery, and POCD assessed via the CANTAB neuropsychological test battery, and two paper pencil tests on the day before surgery, and on postoperative days 7, 90 and 365.

RESULTS

In total, 261 patients were randomised, 130 to the physostigmine and 131 to the placebo group. The incidence of POD did not differ significantly between the physostigmine and placebo groups (20 versus 15%; P = 0.334). Preoperative cognitive impairment and POCD frequencies did not differ significantly between the physostigmine and placebo groups at any time. Lower mortality rates were found in the physostigmine group compared with placebo at 3 months [2% (95% confidence interval (CI), 0 to 4) versus 11% (95% CI, 6 to 16), P = 0.002], and 6 months [7% (95% CI, 3 to 12) versus 16% (95% CI, 10 to 23), P = 0.012] after surgery.

CONCLUSION

Physostigmine had no effect on POD and POCD when applied after induction of anaesthesia up to 24 h.

TRIAL REGISTRATION

DOI 10.1186/ISRCTN18978802, EudraCT 2008-007237-47, Ethics approval ZS EK 11 618/08 (15 January 2009).
Low-dose aspirin in pregnancy: who? when? how much? and why?
Authors: Mather Andrew R. , Dom Aaron M. , Thorburg Loralei L.
Published: February 2021

Purpose of review

The use of low dose aspirin (LDA) has become routine in prenatal care for a variety of diagnoses, most importantly in women with a history of preeclampsia and associated poor pregnancy outcomes. Although LDA is currently indicated in patients considered to be at risk for development of preeclampsia, optimal dosing, timing of treatment initiation, and persons of benefit are under investigation. Several studies have also looked at LDA treatment and its effect on other maternal and fetal outcomes. This review summarizes the current guidelines for the use of LDA, incorporating the most recent research findings, and offers possible future implications of LDA treatment.

Recent findings

Over 10 years ago, the American College of Obstetricians and Gynecologists, the World Health Organization, and the United States Preventive Service Task Force began publishing guidelines focused on the use of LDA in pregnancy. Since the release of these guidelines, several large studies have re-evaluated the use of LDA with a focus on initiation of treatment and dosing. The combined results of these studies suggest a decreased rate of preeclampsia at aspirin doses >100 mg when treatment is initiated prior to 16 weeks of gestation.

Overall, early initiation of LDA has been shown to decrease the development of preeclampsia in patients considered at increased risk. Current literature suggests increasing the recommended dose to >100 mg to optimize these risk reductions. Although LDA use seems promising for other outcomes like preterm delivery and intrauterine growth restriction, further studies to strengthen recommendations are warranted.
Edwardsiella tarda as a Cause for Limb- and Life- threatening Soft Tissue Infections: What All Plastic Surgeons Need to Know
Authors: Hamidian Jahromi Alireza , Jing Xi Lin , Luce Edward
Published: February 2021

Edwardsiella tarda (ET), a Gram-negative bacterium, causes an extremely uncommon, yet highly aggressive, soft tissue infection. Although plastic surgeons are frequently involved in the primary care, debridement, and secondary reconstruction of difficult soft tissue infections, infections caused by ET have received scant attention in the plastic surgery literature, perhaps because of the rarity of occurrence. We present a case of a 58-year-old man with alcohol abuse and hepatitis C who developed an upper extremity soft tissue infection after a catfish injury, which rapidly deteriorated to cause multiorgan failure and death within 5 days of admission. We will discuss the management of this rare but potentially lethal infection as well as the review of the current literature.
Comparative Photographic, Retrospective Analysis of Nonsyndromic Cleft Noses Treated with or without NAM
Authors: Wolff Klaus-Dietrich , Grill Florian D. , Ritschl Lucas M.
Published: February 2021

Background:

Long-term results and efficacy of nasoalveolar molding (NAM) on the perinasal region are reported controversially in the literature. With this study, we demonstrate our experiences, contribute to the ongoing discussion, and describe our decision-making when NAM is indicated or not.

Methods:

Conventional pre- and postinterventional photographs of patients with nonsyndromic unilateral and bilateral cleft lip and palate (UCLP and BCLP) were analyzed. The 2 independent raters were blinded to therapy (NAM versus non-NAM), and 7 parameters were measured. Intraclass correlation coefficient for intra- and interrater reliability was calculated. The Mann–Whitney U test was performed to compare therapy- and appearance-matched pairs. Finally, 30 specialists in cranio-maxillofacial surgery performed a subjective, blinded rating of matched NAM and non-NAM cases.

Results:

Thirty-six patients, 16 UCLP and 20 BCLP, were enrolled. The intraclass correlation coefficients for intra- and interrater reliability were excellent for all measurements, except for nasal sill (0.77 intrarater and 0.80 interrater). Height-to-width ratio (P = 0.012) was significantly different in the comparison of non-NAM and NAM-treated severe cases with UCLP. Thirty blinded raters evaluated NAM-treated cases with severe UCLP better than matched non-NAM cases. Non-NAM-treated cases with moderate UCLP and BCLP were rated better than matched NAM cases.

Conclusions:

Children with severe UCLP may benefit from NAM therapy in the sense of better symmetry and a more homogenous appearance. Patients with moderate UCLP and BCLP did not benefit, and the risk of the burden of care increased.
Ultrasound-guided Hydro-dissection Facilitates Tissue Expander Placement and Components Separation in Complex Ventral Hernia Repair
Authors: Maroney Jenna , Taylor George A. , Lo Alexis , Golpanian Samuel , Prus Nelson W. , Livelsberger Jon , Gassman Andrew A.
Published: February 2021

Summary: Tissue expanders are known adjuncts in ventral hernia repair, used in a staged approach where tissue closure or coverage of the defect is preferred but inadequate. Placement of tissue expanders in the correct tissue plane can be difficult, especially in thin patients or with loss of domain. This case series describes a technique in which tissue expander placement is facilitated by ultrasound-guided hydro-dissection, following the placement of a transversus abdominis plane (TAP) block. In short, after induction of anesthesia, the same needle used for the ultrasound-guided TAP block can be repositioned by the anesthesiologist to instill tumescent solution into the fascial plane between the internal and external oblique muscles. This allows for identification of the fascial planes in the ensuing operation. Our technique may prove to be an alternative tool in the placement of tissue expanders for ventral hernia repair, or in other procedures requiring device placement.
Laparoscopically Assisted Transperineal Approach in the Management of a Giant Pelvic Lipoma
Authors: Baccarani Alessio , Bonetti Elisa , Pedone Antonio , De Santis Giorgio , Pappalardo Marco , Romano Alberto , Sighinolfi Chiara , Rocco Bernardo
Published: February 2021

Giant lipomas affecting the retroperitoneum and pelvis are quite rare. The surgical management of these lesions may be technically demanding and controversies exist with respect to diagnosis, competences being involved, type of surgical approach, radicality, and timing. A unique case presentation of a giant lipoma occupying the whole pelvis and the gluteal region is presented. Due to its size, many anatomical areas are involved, requiring the expertise of multiple specialists to treat. After multidisciplinary counseling, the lesion is radically resected in one stage by using a new videolaparoscopically assisted transperineal access to the pelvis. This type of surgical approach may be of interest for resecting pelvic tumors in women and men.
Percutaneous Transluminal Ballooning Angioplasty for Flap Salvage in a Complex Lower Extremity Reconstruction
Authors: Lee Seung Yeol , Seong Ik Hyun , Park Bo Young
Published: February 2021

The treatment of lower extremity trauma with extensive soft tissue defects requires a multidisciplinary approach. Following precise bone fixation, appropriate soft tissue reconstruction is a major requisite. We present a case of a severe lower extremity injury caused by an excavator bucket that fell on the patient’s foot, which was reconstructed with multiple perforator flaps after concise bone fixation. During the treatment, we repeatedly experienced threatened flaps, which could not be recovered with emergent re-explorations. Although vascular occlusion after a free flap surgery may be rare, it poses a major challenge. It necessitates urgent re-exploration, but there are logistical challenges with providing sufficient resources for endovascular revascularization. We attempted an immediate postoperative angioplasty after the failure of surgical re-exploration as a salvage option and achieved successful flap survival. As the flap completely survived without complications, the patient could walk, with bearing his full weight without the use of any orthosis. Despite the development of new techniques for flap revision, which have increased the possibility of limb salvage, immediate postoperative endovascular revascularization can be considered as a salvage option in cases of a compromised flap.
Surgical Nasoalveolar Molding: A Rational Treatment for Bilateral Cleft Lip Nose and Systematic Review
Authors: Rossell-Perry Percy , Olivencia-Flores Claudia , Delgado-Jimenez Maria Pia , Ormeño-Aquino Ruben
Published: February 2021

Background:

The purpose of this study was to evaluate the surgical outcome after using primary surgery to address bilateral cleft lip nose and palate deformities. In addition, the authors performed a systematic review to evaluate the effects of the nasoalveolar molding on non-syndromic bilateral cleft lip and palate.

Methods:

A prospective cohort study on a surgeon’s surgical outcome of 25 consecutively performed primary bilateral cleft lip nasal deformity repairs was conducted and a systematic review of the literature for studies published until December 2019 was done to evaluate the effect of presurgical NAM on nasolabial aesthetics and alveolar gap.

Results:

Since 2014, 25 consecutive patients with complete bilateral cleft have undergone primary anatomical repair of the cleft nasal deformity using primary cheilorhinoplasty. The average columella length was 4.3 ± 1.3 mm. The average ratio of the columella height to nasal height was 0.48 mm 1 year postoperatively and 0.52 mm 5 years postoperatively. Statistically significant differences have been observed between the pre and postoperative alveolar and palatal gaps after using primary cheiloplasty or bilateral lip adhesion. After systematic literature searching, 14 identified studies were qualified for the final analysis, which included 433 patients. The overall study quality according to Oxford CEBM and GRADE scale was low.

Conclusions:

The results of this study suggest that the proposed primary cheilorhinoplasty is a good alternative to improve nose appearance and alveolar gap in patients with primary bilateral cleft lip nose and palate deformity. Based on the available scientific evidence, definitive conclusions about the effectiveness of presurgical Naso Alveolar Molding on nasolabial aesthetics cannot be drawn. Quality of the included articles were too low to make a conclusion.
Breast Implant-associated Anaplastic Large Cell Lymphoma: A Canadian Surgical Oncology Survey
Authors: Azzi Alain J. , Chocron Yehuda , Ponnudurai Nirros , Meterissian Sarkis , Davison Peter G.
Published: February 2021

Background:

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) awareness has increased, resulting in concerns regarding the safety of implant-based reconstruction. Breast cancer patients are first seen by surgical oncologists, who are therefore potentially the first health-care professionals to encounter concerns regarding BIA-ALCL. We therefore surveyed surgical oncologists on their understanding of BIA-ALCL to better assess potential effects on plastic surgery practice.

Methods:

An anonymous web-based survey consisting of 9 multiple-choice questions was sent to breast surgical oncologists that are members of the Canadian Society of Surgical Oncology (n = 135).

Results:

Forty-two members responded (n = 42/135, 31%) and all participants were aware of BIA-ALCL. All participants reported that BIA-ALCL has not deterred them from referring patients for implant-based reconstruction. Twenty-two respondents (52%) discuss BIA-ALCL with their patients and 21% (n = 9) believe that BIA-ALCL typically follows a metastatic course. Eight respondents (19%) reported having a poor understanding of BIA-ALCL, while 14% (n = 6) were unable to identify the link to textured implants. There were no statistical differences based on case-load volume.

Conclusions:

Approximately half of the respondent Canadian breast surgical oncologists discuss BIA-ALCL with their patients, yet there is a knowledge gap in terms of the epidemiology and clinical-pathological course of BIA-ALCL. It is of utmost importance to ensure that the plastic surgery community aims at including surgical oncologist colleagues in educational platforms regarding BIA-ALCL to ensure collaboration and unity in an effort to offer the most accurate information to patients, and prevent misinformation that may deter patients from seeking implant-based reconstruction.
A Comparison of 28 Published Augmentation/Mastopexy Techniques Using Photographic Measurements
Authors: Swanson Eric
Published: February 2021

Background:

Numerous augmentation/mastopexy methods have been described in the literature, including those reported in 16 publications in 2019. However, objective measurements of breast dimensions are lacking, leaving little information on which to base treatment selection. The goal is to increase upper pole projection using an implant and correct ptosis by elevating the lower pole with the mastopexy.

Methods:

A PubMed search was conducted to identify published augmentation/mastopexy methods. Lateral photographs were matched for size and orientation and then compared using a 2-dimensional measurement system. Measurements were compared for 5 common approaches—vertical; periareolar; inverted-T, central mound; inverted-T, superior pedicle; and inverted-T, inferior pedicle. Four publications not fitting these 5 groups were also evaluated. Measurement parameters included breast projection, upper pole projection, lower pole level, breast mound elevation, nipple level, area, and breast parenchymal ratio.

Results:

A total of 106 publications were identified; 32 publications included lateral photographs suitable for comparison. Twenty-eight publications fitting 1 of the 5 groups were compared. All published augmentation/mastopexy methods increased breast projection and upper pole projection, although not significantly for inverted-T methods. Vertical augmentation/mastopexy was the only method that significantly raised the lower pole level (P < 0.05). The vertical technique also significantly (P < 0.01) increased the breast parenchymal ratio. Periareolar; inverted-T, central mound; and inverted-T, inferior pedicle methods produced nonsignificant increments in the breast parenchymal ratio.

Conclusions:

Breast implants increase breast projection and upper pole projection. Only vertical augmentation/mastopexy significantly elevates the lower pole. This method also significantly increases the breast parenchymal ratio, achieving the surgical objectives.
Reconstruction of Full-thickness Soft Tissue Defects with Integra: Risk Factors and Treatment Algorithm
Authors: Scalise Alessandro , Torresetti Matteo , Di Benedetto Giovanni
Published: February 2021

Background:

Despite the fact that dermal substitutes are widely used in reconstructive surgery, there have been no studies focused on predictors of complications or delayed matrix take. We propose an algorithm for management of soft tissue reconstruction with Integra dermal matrix, based on our 5-year-long clinical experience.

Methods:

An estimated 111 patients who underwent Integra reconstruction of full-thickness soft tissue defects of different anatomical sites and etiology were enrolled, and dichotomized in two groups according to complications. Participants were further studied according to the wound healing strategy: healing by secondary intention, skin graft (STSG), and flap surgery. A regression analysis was conducted in the whole sample to identify possible predictors of complications.

Results:

No significant differences according to complications were observed. The between-group statistical analysis showed significant differences in age, comorbidities, defect area, diagnosis, and defect site. The regression analysis revealed that the timing of split-thickness skin graft (STSG) was not influenced by age, comorbidities, body mass index (BMI), defect area, site, wound etiology, and risk factors in the subjects who underwent a two-step reconstruction. Healing by secondary intention is recommended for small post-oncological defects of the head, especially in elderly and multimorbid patients. Variables that may interfere with dermal substitutes’ incorporation are independent of the timing of STSG placement; therefore, no predictors of complications or delayed matrix take were identified.

Conclusions:

Our findings showed that Integra can be used in a wide range of patients regardless of their general features, thus acting as a useful alternative to conventional reconstructive techniques in selected cases.
Feasibility and Perception of Cross-sex Face Transplantation to Expand the Donor Pool
Authors: Sosin Michael , Robinson Isabel S. , Diep Gustave K. , Alfonso Allyson R. , Maliha Samantha G. , Ceradini Daniel J. , Levine Jamie P. , Staffenberg David A. , Saadeh Pierre B. , Rodriguez Eduardo D.
Published: February 2021

Background:

A major challenge in face transplantation (FT) is the limited donor allograft pool. This study aimed to investigate the feasibility of cross-sex FT (CSFT) for donor pool expansion by: (1) comparing craniomaxillofacial metrics following CSFT versus same-sex FT (SSFT); and (2) evaluating the public and medical professionals’ perception of CSFT.

Methods:

Seven cadaveric FTs were performed, resulting in both CSFT and SSFT. Precision of bony and soft tissue inset was evaluated by comparing pre- versus post-operative cephalometric and anthropometric measurements. Fidelity of the FT compared to the virtual plan was assessed by imaging overlay techniques. Surveys were administered to medical professionals, medical students, and general population to evaluate opinions regarding CSFT.

Results:

Five CSFTs and 2 SSFTs were performed. Comparison of recipients versus post-transplant outcomes showed that only the bigonial and medial intercanthal distances were statistically different between CSFT and SSFT (P = 0.012 and P = 0.010, respectively). Of the 213 survey participants, more were willing to donate for and undergo SSFT, compared with CSFT (donate: 59.6% versus 53.0%, P = 0.001; receive: 79.5% versus 52.3%, P < 0.001). If supported by research, willingness to receive a CSFT significantly increased to 65.6% (P < 0.001). On non-blinded and blinded assessments, 62.9% and 79% of responses rated the CSFT superior or equal to SSFT, respectively.

Conclusions:

Our study demonstrates similar anthropometric and cephalometric outcomes for CSFT and SSFT. Participants were more reticent to undergo CSFT, with increased willingness if supported by research. CSFT may represent a viable option for expansion of the donor pool in future patients prepared to undergo transplantation.
The Umbilicus Free Flap
Authors: Hallock Geoffrey G.
Published: February 2021

Summary: The morbidly obese patient has few reliable options if a single free flap is required for large surface area coverage. Usually, a latissimus dorsi muscle would be the primary option. If unavailable, a transverse-oriented abdominal flap based on deep inferior epigastric perforators as either a perforator flap or a muscle sparing type 2 transverse rectus abdominis musculocutaneous flap would be an alternative. A central panniculectomy type approach allows primary donor site closure by the cephalad advancement of the intentionally retained ptotic portion of the panniculus. Inclusion of the umbilicus with the free flap, which in this patient subgroup often is at risk for complications if excluded, mitigates against the need for undermining of the upper abdomen. The umbilicus free flap, as part of a panniculectomy, not only minimizes intrinsic flap risks, but also those of the abdominal donor site.
Outcomes and Complications of the Mustardé Otoplasty: A “Good–Fast–Cheap” Technique for the Prominent Ear Deformity
Authors: Boroditsky Matthew L. , Van Slyke Aaron C. , Arneja Jugpal S.
Published: February 2021

Background:

The Mustardé otoplasty is a commonly used procedure for the correction of the prominent ear deformity. Complication rates related to suture extrusion and long-term outcomes are variable in the literature. The study’s purpose was to examine the efficacy and safety of the Mustardé otoplasty and its resource utilization, using an “iron triangle” methodology incorporating quality, time, and cost.

Methods:

Retrospective data were collected on patients under 18 years who underwent primary Mustardé otoplasty between 2009 and 2018. Patient demographics, intraoperative details, complications, follow-up, and satisfaction were collected and analyzed.

Results:

There were 119 Mustardé otoplasties performed on 68 patients, with a median follow-up of 72 weeks (24–476 weeks). In total, 51 of the 68 patients underwent bilateral procedures. The median operative time was 95 minutes (31–133 minutes), translating to a facility case cost of $2046. A total of 24 complications were reported in 17 patients. Minor complications included the following: suture extrusion (n = 20), hematoma (n = 1), and suture abscess (n = 1). Major complications included reoperation (n = 2). The series had a revision rate of 1.7% (n = 2). No additional procedures were documented at other hospitals in the province. The majority (97%) of ear outcomes demonstrated both patient and surgeon satisfaction.

Conclusions:

The Mustardé otoplasty demonstrated a high efficacy in the correction of the prominent ear, with low reoperation rates and high patient and surgeon satisfaction. The procedure demonstrated intriguing results in resource utilization, with brief operative times, a “knife and fork” supply chain, and minimal overall case costs. This technique qualifies as a good, fast, and cheap outpatient otoplasty option.
Splinting Technique for Venous Anastomosis in Lower Limb Free Flap Reconstruction
Authors: Khashaba Haitham A. , Khadim Muhammad F. , Chapman Thomas W.
Published: February 2021

Lower limb reconstruction of the distal third following tumor extirpation or trauma is a complex procedure. The use of free flaps to cover lower limb defects is a common practice in our department. Vascular kinking or compression resulting in thrombosis is the leading cause of venous congestion and free flap failure in lower limb reconstruction. We describe a simple and inexpensive technique to avoid venous kinking during microvascular anastomosis in free flap reconstructions in the lower leg, which has proved safe in a cohort of patients.
Lymphovenous Anastomosis for Treating Lymphedema in IgG4-Related Disease
Authors: Lin Ying-Sheng , Yang Feng-Jung
Published: February 2021

Immunoglobin G4-related disease (IgG4RD) is a multi-organ immune-mediated condition, and lymphoplasmacytic infiltration is one of the main pathologic features.
1,2
Lower extremity lymphedema is likely to occur if the infiltration involves multiple inguinal lymph nodes and thus disrupting lymphatic transport. Lymphovenous anastomosis (LVA) is a surgical procedure used to treat obstructive lymphedema in extremities
3,4
or in the head and neck area.
5
It basically reroutes the obstructed lymph flow into patent venous system by making microsurgical anastomosis between lymphatic duct and vein over the swollen area. Herein, we reported a patient with recalcitrant lower extremity lymphedema caused by IgG4RD, whose lymphedema subsided after being treated with LVA.