bluuebunny/crossref_metadata_2025 huggingface dataset:
A Preliminary Investigation of Accelerometer-Derived Sleep and Physical Activity Following Sport-Related Concussion
Authors: Sufrinko Alicia M. , Howie Erin K. , Elbin R. J. , Collins Michael W. , Kontos Anthony P.
Published: March 2018

Objective:

Describe changes in postconcussion activity levels and sleep throughout recovery in a sample of pediatric sport-related concussion (SRC) patients, and examine the predictive value of accelerometer-derived activity and sleep on subsequent clinical outcomes at a follow-up clinic visit.

Setting:

Outpatient concussion clinic.

Participants:

Twenty athletes aged 12 to 19 years with diagnosed SRC.

Methods:

Prospective study including visit 1 (<72 hours postinjury) and visit 2 (6-18 days postinjury). Linear regressions used to predict scores (ie, neurocognitive, vestibular/oculomotor) at visit 2 from accelerometer-derived data collected 0 to 6 days postinjury. Linear mixed models evaluated changes in activity and sleep across recovery.

Main Measures:

Symptom, neurocognitive, and vestibular/oculomotor scores; sleep and activity data (Actigraph GT3x+)

Results:

The maximum intensity of physical activity increased (P= .009) and time in bed decreased throughout recovery (P= .026). Several physical activity metrics from 0 to 6 days postinjury were predictive of worse vestibular/oculomotor scores at visit 2 (P< .05). Metrics indicative of poor sleep 0 to 6 days postinjury were associated with worse reaction time at visit 2 (P< .05).

Conclusions:

This exploratory study suggests physical activity and sleep change from the acute to subacute postinjury time period in adolescent SRC patients. In our small sample, excess physical activity and poor sleep the first week postinjury may be associated with worse outcomes at follow-up in the subacute stage of recovery. This study further supported the feasibility of research utilizing wearable technology in concussion patients, and future research in a large, diverse sample of concussion patients examined at concise time intervals postinjury is needed.
ACUTE MACULAR NEURORETINOPATHY IN SUSAC SYNDROME: A NEW ASSOCIATION
Authors: Yang Yong-Sheng , Zhang Lily , Asdaghi Negar , Henry Christopher R. , Davis Janet L.
Published: March 2018

Purpose:

To report a case of acute macular neuroretinopathy in a patient with Susac syndrome.

Methods:

Case report.

Results:

A 39-year-old male patient presented with severe headache, photopsias, and a sudden onset of hearing loss in the right ear. Fluorescein angiography of the right eye revealed multiple branch retinal artery occlusions. Clinical presentation of encephalopathy, hearing loss, and branch retinal artery occlusions, along with characteristic magnetic resonance imaging findings, led to a diagnosis of Susac syndrome. Despite aggressive immunosuppression for four months, the patient later presented with acute macular neuroretinopathy in the left eye.

Conclusion:

Acute macular neuroretinopathy and Susac is a new association of two well-defined disorders. The concurrence of both disorders supports retinal ischemia as the proximate cause of acute macular neuroretinopathy and inflammation as a potential etiology.
Corneal Cross-Linking for Pediatric Keratcoconus Review
Authors: Perez-Straziota Claudia , Gaster Ronald N. , Rabinowitz Yaron S.
Published: March 2018

Purpose:

To comprehensively review the available published literature for cross-linking in the pediatric population.

Methods:

Review of the literature published in English in PubMed.

Results:

Two hundred ten publications were considered. One hundred fifteen were considered relevant to this review.

Conclusions:

Studies of cross-linking in pediatric patients are sparse, with relatively short follow-up times, and mostly on small groups of patients. Treatment with cross-linking halts progression of keratoconus in the pediatric population, and early treatment seems to be cost-effective compared with later penetrating keratoplasty. Long-term effects and regression rates remain unclear, and further studies are needed in this population.
Risk of Anterior Segment Complications Associated With the Live Herpes Zoster Vaccine: Evidence From a Health-Claim Database
Authors: Liu Rhuozhou Tom , Yeung Sonia N. , Carleton Bruce , Etminan Mahyar
Published: March 2018

Purpose:

To determine the risk of developing anterior segment complications after receiving the live herpes zoster virus vaccine.

Methods:

This retrospective cohort study included a random sample of 9 million patients registered in a health-claim database in the United States between 2006 and 2016. Herpes zoster-related anterior segment diseases were identified by International Classification of Diseases ninth or tenth edition codes (an event). Patients without any event before index dates were separated into cohorts 1 and 2. Cohort 1 received the live virus vaccine on the index date. Cohort 2 was diagnosed with nonophthalmic zoster on the index date. The recurrent cohorts consisted of those who had an event 6 months or more before the index dates and were separated into cohort 3 and cohort 4 based on the same criteria as cohort 1 and 2, respectively. All cohorts were followed to the first event. Hazard ratios (HRs) of anterior segment complications after vaccine administration were determined.

Results:

There were 72,141 vaccine users and 133,604 nonusers. There were 379 events and 1032 events in cohort 1 and cohort 2, respectively. The adjusted HR was 0.89 (95% confidence interval: 0.77–1.02). Among those with recurrent disease, there were 2679 vaccine users and 9421 nonusers. There were 16 events in cohort 3, compared with 86 events in cohort 4. The adjusted HR was 0.70 (95% confidence interval: 0.40–1.23).

Conclusions:

Data from a large health-claim database suggest that the live zoster virus vaccine is not associated with a higher risk of anterior segment complications.
Infant Human Immunodeficiency Virus–free Survival in the Era of Universal Antiretroviral Therapy for Pregnant and Breastfeeding Women
Authors: Chi Benjamin H. , Mutale Wilbroad , Winston Jennifer , Phiri Winifreda , Price Joan T. , Mwiche Angel , Ayles Helen , Stringer Jeffrey S. A.
Published: March 2018

Background:

Lifelong antiretroviral therapy (ART) is now recommended for all human immunodeficiency virus (HIV)-infected pregnant and breastfeeding women; however, few have described overall infant outcomes in this new era for the prevention of mother-to-child HIV transmission (PMTCT).

Methods:

As part of an assessment of PMTCT program impact, we enrolled a prospective cohort study in 4 predominantly rural districts in Zambia. HIV-infected mothers and their newborns (≤30 days old) were recruited and followed at 6 weeks, 6 months and 12 months postpartum; infant specimens were tested via HIV DNA polymerase chain reaction. In Kaplan–Meier analyses, we estimated overall infant HIV-free survival and then stratified by district, community and maternal ART use. We investigated the relationship between community-level 12-month, self-reported maternal ART use and infant HIV-free survival via linear regression.

Results:

From June 2014 to November 2015, we enrolled 827 mother–infant pairs in 33 communities. At 12 months, small proportions of infants had died (2.8%), were HIV-infected (3.0%) or were lost to follow-up (4.3%). Overall, infant HIV-free survival was 99.0% [95% confidence interval (CI): 98.0%–99.5%] at 6 weeks, 97.5% (95% CI: 96.1%–98.4%) at 6 months and 96.3% (95% CI: 94.8%–97.4%) at 12 months. Women reporting ART use at enrollment had higher infant HIV-free survival than those who did not (97.4% vs. 89.0%, P = 0.01). Differences were noted at the district and site levels (P = 0.01). In community-level analysis, no relationship was observed between 12-month infant HIV-free survival and self-reported maternal ART use (P = 0.65).

Conclusion:

Although encouraging, these findings highlight the need for rigorous monitoring and evaluation of PMTCT services at the population level.
Epidemiology and Clinical Relevance of Toxic Shock Syndrome in US Children
Authors: Gaensbauer James T. , Birkholz Meghan , Smit Michael A. , Garcia Roger , Todd James K.
Published: March 2018

Introduction:

It is important for clinicians to recognize the contribution of toxic shock syndrome (TSS) to the overall burden of pediatric septic shock because the clinical features, optimal therapy and prognosis differ from non-TSS septic shock.

Methods:

We analyzed cases of pediatric septic shock reported to the Pediatric Health Information Systems database between 2009 and 2013 to define the clinical and demographic characteristics of pediatric TSS in the United States. Using a validated International Classification of Diseases, 9th revision, coding strategy, we identified patients with infectious shock among inpatients age 1–18 years and classified cases of staphylococcal and streptococcal TSS for comparison with non-TSS cases.

Results:

Of 8,226 cases of pediatric septic shock, 909 (11.1%) were classified as TSS and 562 (6.8%) were possible TSS cases. Staphylococcal TSS represented the majority (83%) of TSS cases and occurred more commonly in females and at an older age. Compared with non-TSS septic shock, TSS had significantly lower fatality rates, disease severity and length of hospital stay and was present more often at the time of admission (P < 0.001 for each). Streptococcal TSS was associated with poorer outcomes than staphylococcal TSS. Treatment for TSS differed from non-TSS septic shock in use of more clindamycin, vancomycin and Intravenous Immunoglobulin and less need for vasopressors.

Conclusions:

Results demonstrate a significant contribution of TSS to the burden of pediatric septic shock in the United States. The findings emphasize the importance of inclusion of TSS diagnostic and therapeutic considerations in sepsis treatment protocols for children.
Hospital-Acquired Infections in Children
Authors: Alvares Paula Andrade , Arnoni Mariana Volpe , da Silva Cely Barreto , Sáfadi Marco Aurélio Palazzi , Mimica Marcelo Jenné
Published: March 2018

Hospital-acquired infections account for high mortality rates and hospital costs. We analyzed pediatric data from a tertiary teaching hospital and found that most of the cases occurred in the intensive care unit and had significant association with invasive devices. Bloodstream infections were the main site of infection, and Gram-negative bacteria were the predominant etiology.
National Incidence of Pediatric Mastoiditis in the United States, 2000–2012
Authors: King Laura M. , Bartoces Monina , Hersh Adam L. , Hicks Lauri A. , Fleming-Dutra Katherine E.
Published: March 2018

Between 2000 and 2012, the national estimated incidence rate of pediatric mastoiditis, a rare but serious complication of acute otitis media, was highest in 2006 (2.7/100,000 population) and lowest in 2012 (1.8/100,000 population). This measure provides a baseline for public health surveillance in the pneumococcal conjugate vaccine era as stewardship efforts target antibiotic use in acute otitis media.
The Influence of β-Adrenergic Receptor Kinase-1 on Stroke-induced Immunodeficiency Syndrome
Authors: Ross Amy Miner , Lee Christopher S. , Lutsep Helmi , Clark Wayne M.
Published: March 2018

Background:

Immunodeficiency in acute ischemic stroke (AIS) is thought to be a result of norepinephrine suppression of the lymphoid tissue. The possible differences in the distribution of lymphocytes after stroke may be due to differences in responsiveness of lymphocyte β-adrenergic receptors to their kinase (BARK-1).

Objective:

The objective was to quantify the influence of lymphocyte BARK-1 on stroke-induced immunodeficiency in AIS patients.

Methods:

A prospective clinical cohort study was conducted (N = 44). Measures included age, gender, race, risk factors for stroke, stroke severity, comorbidities, presence of infection, white blood cell counts and differential proportions, and lymphocyte BARK-1. Student t tests, effect sizes, and linear and logistic regressions were conducted to test the study objective. The study was approved by the Oregon Health & Science University Institutional Review Board.

Results:

There were significant changes in all white blood cells and differential proportions and in the National Institutes of Health Stroke Scale from admission to 48 hours after onset of stroke deficits. Higher BARK-1 influenced the lower lymphocyte proportion at 48 hours, independent of age, P < .0001. Furthermore, BARK-1 also was associated with an increase in the likelihood of having sustained or stroke-induced immunodeficiency at 48 hours: odds ratio, 2.41; 95% confidence interval, 1.10–5.25; P = .027, and odds ratio, 2.79; 95% confidence interval, 1.03–7.52; P = .043, respectively. In all backward stepwise selection of factors, BARK-1 was the only factor consistently retained in the models.

Conclusions:

β-Adrenergic receptor kinase-1 has a significant quantifiable influence on lymphocyte proportion at 48 hours and on the classification of sustained stroke-induced immunodeficiency.

Clinical Implications:

β-Adrenergic stimulation influences immunodeficiency in AIS.
Seasonal Work and Cardiovascular Risk Factors in Farmers
Authors: Schulz Paula S. , Zimmerman Lani , Johansson Patrik
Published: March 2018

Background:

Cardiovascular disease is the leading cause of death and hospitalization in the rural United States. Midwestern farmers are integral to rural communities, but little is known about the effect of occupational variability of seasonal work and technology use on their cardiovascular disease risk.

Aims:

This study describes the relationships of health behaviors and cardiovascular disease risk in 40 Midwestern farmers during peak and off-peak farming seasons.

Methods:

Objectively measured physical activity and self-report of demographics, diet, and health-related quality of life were collected during each farming season.

Results and Conclusions:

Farmers in this study were physically active, ate consistent diets, and reported high health status ratings throughout the year. Cardiovascular disease risk was positively correlated with age and body mass index (P < .01), and half of young and middle-age farmers reported anxiety and depression problems. Cardiovascular disease risk reduction interventions for farmers should address both physical and emotional aspects of farming.
Low Bone Mineral Density in Elite Female Athletes With a History of Secondary Amenorrhea in Their Teens
Authors: Nose-Ogura Sayaka , Yoshino Osamu , Dohi Michiko , Kigawa Mika , Harada Miyuki , Kawahara Takashi , Osuga Yutaka , Saito Shigeru
Published: March 2018

Objective:

To determine whether secondary amenorrhea during teenage years influences bone mineral density (BMD) in female athletes in their 20s.

Design:

Original research.

Setting:

Japan Institute of Sports Sciences.

Participants:

Two hundred ten elite female athletes older than 20 years were included in the study.

Main Outcome Measures:

Information on the participants' past (ie, during their teenage years) and current menstrual cycle, training time, history of stress fractures, and blood tests for hormones received was obtained. Bone mineral density of the lumbar spine was evaluated by dual-energy x-ray absorptiometry; low BMD was defined as a Z-score ≤−1. We investigated the correlation factors for low BMD in athletes in their 20s by univariable and multivariable logistic regression analysis.

Results:

A total of 39 (18.6%) female athletes had low BMD. Secondary amenorrhea in their teens [odds ratio (OR), 7.11, 95% confidence interval (CI), 2.38-21.24; P < 0.001] and present body mass index (BMI) (OR, 0.56, 95% CI, 0.42-0.73; P < 0.001) were independent correlation factors for low BMD in the multivariable logistic regression analysis. The average Z-score for those with secondary amenorrhea in their teens and 20s, secondary amenorrhea in their 20s only, and regular menstruation was −1.56 ± 1.00, −0.45 ± 1.21, and 0.82 ± 1.11 g/cm2, respectively.

Conclusions:

Secondary amenorrhea for at least 1 year during teenage years in female athletes and BMI at present was strongly associated with low BMD in their 20s.
Test–Retest Reliability and the Effects of Exercise on the King-Devick Test
Authors: Eddy Ryan , Goetschius John , Hertel Jay , Resch Jacob
Published: March 2018

Objective:

To determine the test–retest reliability and the influence of exercise on King-Devick (K-D) test performance.

Design:

Crossover study design.

Setting:

Controlled laboratory.

Participants:

Participants consisted of 63 (39 women and 24 men) healthy, recreationally active college students who were 21.0 + 1.5 years of age.

Independent Variables:

Participants completed the K-D test using a 2-week, test–retest interval. The K-D test was administered before and after a counterbalanced exercise or rest intervention. Reliability was assessed using testing visits (visit 1 and visit 2) as the independent variables. Exercise or rest and time (baseline, postintervention) were used as independent variables to examine the influence of exercise.

Main Outcome Measures:

Intraclass correlation (ICC) coefficients with 95% confidence intervals were calculated between visits to assess reliability of K-D test completion time. A repeated-measure 2 x 2 analysis of variance (intervention × time) with post hoc pairedttests was used to assess the influence of exercise on K-D test performance.

Results:

The K-D test was observed to have strong test–retest reliability [ICC2,1= 0.90 (0.71, 0.96)] over time. No significant intervention-by-time interaction (P= 0.55) or intervention main effects (P= 0.68) on K-D time were observed. Mean differences of −1.5 and −1.7 seconds (P< 0.001) were observed between baseline and rest and exercise interventions for K-D test performance, respectively. Up to 32% (20/63) of participants were observed to have a false-positive K-D test performance before and after each intervention.

Conclusions:

Although strong test–retest reliability coefficients were observed using clinically relevant time points, a high false-positive rate warrants caution when interpreting the K-D test.
Pediatric Collagenous Gastritis and Colitis
Authors: Matta Judy , Alex George , Cameron Donald J.S. , Chow Chung W. , Hardikar Winita , Heine Ralf G.
Published: March 2018

Introduction:

Collagenous gastritis is a rare disease characterized by the subepithelial deposition of collagen bands. Two phenotypes of the disease have been described: a pediatric‐onset and an adult‐onset type. The adult‐onset form is associated with collagenous colitis and autoimmune disorders. No effective treatment has been identified to date.

Objective:

We aim to describe the clinical features and outcomes of patients in our cohort and provide a summary of published pediatric cases with collagenous gastritis and colitis reported to date to gather information that will contribute to improved knowledge of this rare condition.

Methods:

A retrospective chart review of all patients with collagenous gastritis and/or colitis who were treated at the Royal Children's Hospital, Melbourne, was performed. A literature review was also conducted.

Results:

A total of 12 cases of collagenous gastritis were reviewed. Three of 12 (25%) patients had associated collagenous colitis. The most common clinical presentation was iron deficiency anemia. Nine (75%) patients were followed up, and repeat endoscopies were performed in 8 (67%). Iron deficiency anemia resolved in all patients on oral iron supplementation. Histologic improvement was only identified in one patient with the adult phenotype who had been treated with oral corticosteroids and azathioprine.

Conclusions:

Collagenous gastritis is a rare condition in children. A small proportion of children develop features of the “‘adult” phenotype at a very young age. Patients with collagenous gastritis require long‐term follow‐up and monitoring of their disease. Further randomized clinical trials are needed to establish an effective therapeutic strategy.
Multivariate Model for the Prediction of Severity of Acute Pancreatitis in Children
Authors: Izquierdo Yojhan E. , Fonseca Eileen V. , Moreno Luz Á. , Montoya Rubén D. , Guerrero Rafael
Published: March 2018

This study aimed to develop a severity prediction system for pediatric patients with acute pancreatitis (AP) based on clinical and laboratory parameters recorded at disease onset. A retrospective cohort study including 130 patients with AP, aged 0 to 18 years, was conducted. Correlations between severe AP (SAP) and clinical and laboratory data were established. Parameters with a significant statistical correlation (P ⩽ 0.05) were incorporated in logistic regression models, and receiver operating characteristic curves were generated. The best‐performance cutoff points were calculated to propose a severity prediction score, for which sensitivity and specificity were determined. Thirty‐eight cases (29.2%) were consistent with SAP. A value of ≥1 point yielded a sensitivity of 81.5% and specificity of 64.1% for SAP prediction, when using a score including blood urea nitrogen ≥12.5 mg/dL (1 point) or hemoglobin <13 mg/dL (1 point) as variables. The proposed severity score showed good performance in predicting SAP.
Sustainable Eating Patterns Should Be Part of the Dietary Guidelines for Americans
Authors: Oshiro Jordan , Adyatni Irma , O’Connor Lauren , Savaiano Dennis
Published: March 2018

Promoting sustainable eating patterns is an approach to limiting the environmental impact of resource-intensive food production. Incorporating the concept of sustainable eating patterns into the Dietary Guidelines for Americans (DGA) would be congruent with established federal policy goals, but societal, economic, and agricultural impacts also need to be considered. The healthy eating patterns established in the 2015–2020 DGA are not markedly different than the proposed sustainable eating patterns. Introducing sustainable eating patterns in the DGA would be a convenient and efficient strategy to align US nutrition policy with related global and national food and agriculture policies. The DGA is an appropriate medium for introducing sustainable eating patterns into US nutrition policy to create awareness that consumers’ food purchasing behaviors affect the environment.
Use of Oral Fluid With a Rapid Treponemal Test for Syphilis Evaluation
Authors: Bristow Claire C. , Shannon Chelsea , Herbst de Cortina Sasha , Klausner Jeffrey D.
Published: March 2018

We aimed to determine if rapid treponemal tests intended for whole-blood specimens could be used to detect treponemal antibody in oral fluid. We found a high sensitivity of oral fluid rapid testing, which increased with increasing rapid plasma reagin titer, suggesting potential for the development of accurate rapid oral syphilis tests.
Chikungunya in a Pediatric Traveler
Authors: Thomas Vanessa A. , Murray Kristy O. , Crouse Heather L.
Published: March 2018

Chikungunya is a mosquito-transmitted virus found primarily in Africa and Asia. In late 2013, chikungunya virus emerged in the Western hemisphere, spreading from the Caribbean to South, Central, and North America (MMWR Morb Mortal Wkly Rep. 2014;63:1121–1128). Symptoms can be similar to nonspecific viral presentations including fever, joint pain, joint swelling, and rash. The diagnosis of infectious tropical diseases in the emergency department often requires a high index of suspicion, given the nonspecific early findings that characterize many of these tropical diseases. This report presents a case of chikungunya in a pediatric patient traveling from Guatemala to the United States. Proper recognition of infection and diagnosis are vital from a public health perspective. Considering patients will remain viremic for up to a week and potentially expose local mosquitoes to infection, it is important to educate the patient on mosquito bite prevention in geographic areas of the United States where competent mosquito vectors exist as a means of avoiding further spread.
Extracellular Vesicles in Cancer
Authors: Clancy James , D’Souza-Schorey Crislyn
Published: March 2018

Extracellular vesicles refer collectively to a heterogeneous group of membrane-bound vesicles released from cells and loaded with bioactive proteins, nucleic acids, and lipids. The concept of extracellular vesicles has rapidly evolved from once being viewed as cellular debris to their recognition as packets of cellular information with considerable promise for clinical applications as biomarker platforms and therapeutic vehicles. These shed vesicles have emerged as critical mediators of intercellular communication in both local and distant microenvironments during normal physiological processes, as well as in orchestrating systemic pathophysiological events in disease. This mode of cellular crosstalk is particularly relevant to modulating the tumor microenvironment and orchestrating paths of least resistance during metastases. Here, we describe recent advances for the roles of extracellular vesicles in tumor progression and their potential as disease biomarkers.
Molecular Profiling of Liquid Biopsy Samples for Precision Medicine
Authors: Campos Camila D.M. , Jackson Joshua M. , Witek Małgorzata A. , Soper Steven A.
Published: March 2018

In the context of oncology, liquid biopsies consist of harvesting cancer biomarkers, such as circulating tumor cells, tumor-derived cell-free DNA, and extracellular vesicles, from bodily fluids. These biomarkers provide a source of clinically actionable molecular information that can enable precision medicine. Herein, we review technologies for the molecular profiling of liquid biopsy markers with special emphasis on the analysis of low abundant markers from mixed populations.
Mechanosensitive Ion Channels
Authors: Hope Jacob M. , Greenlee Joshua D. , King Michael R.
Published: March 2018

Cancer metastasis is the second leading cause of death in the United States. Despite its morbidity, metastasis is an inefficient process that few cells can survive. However, cancer cells can overcome these metastatic barriers via cellular responses to microenvironmental cues, such as through mechanotransduction. This review focuses on the mechanosensitive ion channels TRPV4 and P2X7, and their roles in metastasis, as both channels have been shown to significantly affect tumor cell dissemination. Upon activation, these channels help form tumor neovasculature, promote transendothelial migration, and increase cell motility. Conversely, they have also been linked to forms of cancer cell death dependent upon levels of activation, implying the complex functionality of mechanosensitive ion channels. Understanding the roles of TRPV4, P2X7 and other mechanosensitive ion channels in these processes may reveal new possible drug targets that modify channel function to reduce a tumor’s metastatic potential.
Breast Cancer following Augmentation Mammaplasty: A Case-Control Study
Authors: Sosin Michael , Devulapalli Chaitan , Fehring Charles , Hammond Edward R. , Willey Shawna C. , Tousimis Eleni A. , Spear Scott L. , Nahabedian Maurice Y. , Feldman Elizabeth D.
Published: March 2018

Background:

The purpose of this study was to determine whether augmentation mammaplasty, implant type, and implant location affect breast cancer detection, stage, and treatment.

Methods:

An institutional case-control study was performed of patients with prior breast augmentation undergoing breast cancer treatment from 2000 to 2013. Controls were propensity matched and randomized, and data were retrospectively reviewed.

Results:

Forty-eight cases and 302 controls were analyzed. Palpable lesions were detected at a smaller size in augmentation patients (1.6 cm versus 2.3 cm;p< 0.001). Fewer lesions in augmented patients were detected by screening mammography (77.8 percent of cases versus 90.7 percent of controls;p= 0.010). Patients with implants were more likely to undergo an excisional biopsy for diagnosis (20.5 percent versus 4.4 percent;p< 0.001), rather than image-guided core needle biopsy (77.3 percent versus 95.3 percent;p< 0.001). Earlier staging in augmented patients approached but did not reach statistical significance (p= 0.073). Augmented patients had higher mastectomy rates (74.5 percent versus 57.0 percent) and lower rates of breast-conservation therapy (25.5 percent versus 43 percent;p= 0.023). Neither implant fill type nor anatomic location affected method of diagnosis, stage, or treatment.

Conclusions:

Palpable detection of breast cancer is more likely at a smaller size in augmented patients, yet it is less likely on screening mammography than in controls. Augmentation breast cancer patients have a comparable disease stage and are more likely to undergo mastectomy rather than lumpectomy. Both silicone and saline implants, whether placed submuscularly or subglandularly, have comparable effects on breast imaging, biopsy modality, and surgical intervention.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
5000 Free Flaps and Counting: A 10-Year Review of a Single Academic Institution’s Microsurgical Development and Outcomes
Authors: Carney Martin J. , Weissler Jason M. , Tecce Michael G. , Mirzabeigi Michael N. , Wes Ari M. , Koltz Peter F. , Kanchwala Suhail K. , Low David W. , Kovach Stephen J. , Wu Liza C. , Serletti Joseph M. , Fosnot Joshua
Published: March 2018

Background:

The establishment of an effective clinical and academic culture within an institution is a multifactorial process. This process is cultivated by dynamic elements such as recruitment of an accomplished and diverse faculty, patient geographic outreach, clinical outcomes research, and fundamental support from all levels of an institution. This study reviews the academic evolution of a single academic plastic surgery practice, and summarizes a 10-year experience of microsurgical development, clinical outcomes, and academic productivity.

Methods:

A 10-year retrospective institutional review was performed from fiscal years 2006 to 2016. Microsurgical flap type and operative volume were measured across all microsurgery faculty and participating hospitals. Microvascular compromise and flap salvage rates were noted for the six highest volume surgeons. Univariate and multivariable predictors of flap salvage were determined.

Results:

The 5000th flap was performed in December of 2015 within this institutional study period. Looking at the six highest volume surgeons, free flaps were examined for microvascular compromise, with an institutional mean take-back rate of 1.53 percent and flap loss rate of 0.55 percent across all participating hospitals. Overall, 74.4 percent of cases were breast flaps, and the remaining cases were extremity and head and neck flaps.

Conclusions:

Focused faculty and trainee recruitment has resulted in an academically and clinically productive practice. Collaboration among faculty, staff, and residents contributes to continual learning, innovation, and quality patient care. This established framework, constructed based on experience, offers a workable and reproducible model for other academic plastic surgery institutions.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Trends in Physician Payments for Breast Reconstruction
Authors: Sheckter Clifford C. , Yi Day , Panchal Hina J. , Razdan Shantanu N. , Pusic Andrea L. , McCarthy Colleen M. , Cordeiro Peter G. , Disa Joseph J. , Mehrara Babak , Matros Evan
Published: March 2018

Background:

Prosthetic breast reconstruction rates have risen in the United States, whereas autologous techniques have stagnated. Meanwhile, single-institution data demonstrate that physician payments for prosthetic reconstruction are rising, while payments for autologous techniques are unchanged. This study aims to assess payment trends and variation for tissue expander and free flap breast reconstruction.

Methods:

The Blue Health Intelligence database was queried from 2009 to 2013, identifying women with claims for breast reconstruction. Trends in the incidence of surgery and physician reimbursement were characterized by method and year using regression models.

Results:

There were 21,259 episodes of breast reconstruction, with a significant rise in tissue expander cases (incidence rate ratio, 1.09; p < 0.001) and an unchanged incidence of free flap cases (incidence rate ratio, 1.02; p = 0.222). Bilateral tissue expander cases reimbursed 1.32 times more than unilateral tissue expanders, whereas bilateral free flaps reimbursed 1.61 times more than unilateral variants. The total growth in adjusted tissue expander mean payments was 6.5 percent (from $2232 to $2378) compared with −1.8 percent (from $3858 to $3788) for free flaps. Linear modeling showed significant increases for tissue expander reimbursements only. Surgeon payments varied more for free flaps (the 25th to 75th percentile interquartile range was $2243 for free flaps versus $987 for tissue expanders).

Conclusions:

The incidence of tissue expander cases and reimbursements rose over a period where the incidence of free flap cases and reimbursements plateaued. Reasons for stagnation in free flaps are unclear; however, the opportunity cost of performing this procedure may incentivize the alternative technique. Greater payment variation in autologous reconstruction suggests the opportunity for negotiation with payers.
An Update on the Safety and Efficacy of Outpatient Plastic Surgery: A Review of 26,032 Consecutive Cases
Authors: Rohrich Rod J. , Mendez Bernardino M. , Afrooz Paul N.
Published: March 2018

Background:

Outpatient surgery offers many advantages, including cost-containment, privacy, and convenience. However, patient safety must take precedence over these benefits. Limited well-designed studies exist in the plastic surgery literature on patient safety in the outpatient setting, particularly those that identify risk factors for adverse outcomes.

Methods:

A retrospective review was performed on 26,032 consecutive cases completed by board-certified plastic surgeons at an accredited outpatient surgical center between 1995 and 2017. All cases were reviewed for potential morbidity and mortality events, and variables were analyzed to determine potential risk factors for postoperative complications and inpatient admission.

Results:

A total of 26,032 cases were performed over a 23-year period. There were a total of 203 complications (0.78 percent). Compared with the control population, the 12 patients (0.05 percent) that sustained venous thromboembolic events demonstrated higher body mass indexes (p < 0.01), greater lipoaspirate amounts (p = 0.04), longer operative times (p < 0.01), and were more likely to have undergone a combined procedure (p < 0.01). In addition, the 22 patients (0.08 percent) that were transferred to inpatient facilities demonstrated greater body mass index (p < 0.01) and longer operative times (p = 0.01).

Conclusions:

Plastic surgery is safe to perform in an accredited outpatient facility for a majority of patients. According to the authors’ data, postoperative monitoring in a nursing facility should be considered for the following high-risk patients: those with a body mass index greater than 30 kg/m2, operative times greater than 4 hours, lipoaspirate volumes greater than 3 liters, and those undergoing combined procedures.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, III.
Predictors for Unfavorable Projection of the Constructed Auricle following Ear Elevation Surgery in Microtia Reconstruction
Authors: Lee Kyeong-Tae , Oh Kap Sung
Published: March 2018

Background:

Nagata’s two-stage technique for microtia reconstruction using autologous costal cartilage consists of the implantation of a fabricated cartilage framework and the elevation of the constructed auricle. Achieving long-lasting, sufficient projection of the auricle is a goal of second-stage surgery; however, unfavorable outcomes have been seen in some patients, with suboptimal long-term elevation. The present study aimed to investigate prognostic factors that might contribute to adverse outcomes following the ear elevation operation.

Methods:

Outcomes of patients with congenital microtia who underwent auricular reconstruction with a modified Nagata technique between January of 2007 and June of 2015 were reviewed. Unfavorable elevation was defined as cases with an auriculocephalic angle less than 20 degrees or with a shallow auricular sulcus requiring revision operations. Univariate and multivariate analyses were conducted to identify independent predictors for the unfavorable elevation.

Results:

A total of 309 patients representing 323 cases were analyzed with a median follow-up period of 26 months. The mean age of the patients was 15.1 years. The majority of cases had lobule-type microtia. Hemifacial microsomia was present in 114 cases. Canalplasty was performed in 117 cases before the auricular elevation. Unfavorable elevation was observed in 72 cases (22.3 percent). Multivariate analyses showed that the presence of hemifacial microsomia and performance of canalplasty less than or equal to 12 months before the ear elevation operation were independent risk factors for the unfavorable elevation.

Conclusion:

Several preoperative factors, including combined anomalies and operative timing and sequences, might influence the outcomes of the ear elevation operation.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, III.
Incidence of Cranial Base Suture Fusion in Infants with Craniosynostosis
Authors: Mazzaferro Daniel M. , Naran Sanjay , Wes Ari M. , Runyan Christopher M. , Vossough Arastoo , Bartlett Scott P. , Taylor Jesse A.
Published: March 2018

Background:

Cranial base sutures are important drivers of both facial and cranial growth. The purpose of this study was to compare the incidence and location of cranial base suture fusion among three groups: nonaffected controls, patients with nonsyndromic craniosynostosis, and patients with syndromic craniosynostosis.

Methods:

Patients and computed tomographic scans were accrued from the authors’ prospective craniofacial database. Computed tomographic scans were graded on the frequency of cranial vault and cranial base suture/synchondrosis fusion (0, open; 1, partially/completely fused) by an attending craniofacial surgeon and neuroradiologist. Statistical comparisons were conducted on location and rates of fusion, age, and diagnosis.

Results:

One hundred forty patients met inclusion criteria: 55 syndromic, 64 nonsyndromic, and 21 controls. Average age at computed tomography of syndromic patients (3.6 ± 3.1 months) was younger than that of nonsyndromic patients (5.4 ± 3.1 months; p = 0.001) and control subjects (5.1 ± 3.2 months; p = 0.058). Syndromic craniosynostotic patients had over three times as many cranial base minor sutures fused (2.2 ± 2.5) as nonsyndromic craniosynostosis patients (0.7 ± 1.2; p < 0.001) and controls (0.4 ± 0.8; p = 0.002), whose rates of fusion were statistically equivalent (p = 0.342). Syndromic craniosynostosis patients had a greater frequency of cranial base suture fusion in the coronal branches, squamosal arch, and posterior intraoccipital synchondrosis (p < 0.05).

Conclusions:

Patients with syndromic craniosynostosis have higher rates of cranial base suture fusion in infancy, especially in the coronal arches, and this may have significant implications for both cranial and facial growth. In contrast, patients with nonsyndromic craniosynostosis have similar rates and sites of cranial base suture fusion as controls. Interestingly, there is a low, “normal,” rate of cranial base suture/synchondrosis closure in infancy, the implications of which are unknown.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, III.
Learning from an Unsuccessful Study Idea: Reflection and Application of Innovative Techniques to Prevent Future Failures
Authors: Fujihara Yuki , Saito Taichi , Huetteman Helen E. , Sterbenz Jennifer M. , Chung Kevin C.
Published: March 2018

A well-organized, thoughtful study design is essential for creating an impactful study. However, pressures promoting high output from researchers can lead to rushed study proposals that overlook critical weaknesses in the study design that can affect the validity of the conclusions. Researchers can benefit from thorough review of past failed proposals when crafting new research ideas. Conceptual frameworks and root cause analysis are two innovative techniques that can be used during study development to identify flaws and prevent study failures. In addition, conceptual frameworks and root cause analysis can be combined to complement each other to provide both a big picture and detailed view of a study proposal. This article describes these two common analytical methods and provides an example of how they can be used to evaluate and improve a study design by critically examining a previous failed research idea.
A New Composite Eyeball-Periorbital Transplantation Model in Humans: An Anatomical Study in Preparation for Eyeball Transplantation
Authors: Siemionow Maria , Bozkurt Mehmet , Zor Fatih , Kulahci Yalcin , Uygur Safak , Ozturk Can , Djohan Risal , Papay Frank
Published: March 2018

Background:

Vascularized composite allotransplantation offers a new hope for restoration of orbital content and perhaps vision. The aim of this study was to introduce a new composite eyeball-periorbital transplantation model in fresh cadavers in preparation for composite eyeball allotransplantation in humans.

Methods:

The composite eyeball-periorbital transplantation flap borders included the inferior border, outlined by the infraorbital rim; the medial border, created by the nasal dorsum; the lateral border, created by the lateral orbital rim; and the superior border, created by the superior part of the eyebrow. The pedicle of the flap included the facial artery, superficial temporal artery, and external jugular vein. The skin and subcutaneous tissues of the periorbital region were dissected and the bony tissue was reached. A coronal incision was performed and the frontal lobe of the brain was reached by means of frontal osteotomy. Ophthalmic and oculomotor nerves were also included in the flap. After a “box osteotomy” around the orbit, the dissection was completed. Methylene blue and indocyanine green injection (SPY Elite System) was performed to show the integrity of the vascular territories after facial flap harvest.

Results:

Adequate venous return was observed within the flap after methylene blue dye injection. Laser-assisted indocyanine green angiography identified a well-defined vascular network within the entire composite eyeball-periorbital transplantation flap.

Conclusions:

For the first time, a novel composite eyeball-periorbital transplantation model in human cadavers was introduced. Good perfusion of the flap confirmed the feasibility of composite eyeball-periorbital transplantation in the clinical setting. Although harvesting of the flap is challenging, it introduces a new option for reconstruction of the periorbital region including the eyeball.
Patient-Reported Outcome Measures Used in Gender Confirmation Surgery: A Systematic Review
Authors: Andréasson My , Georgas Konstantinos , Elander Anna , Selvaggi Gennaro
Published: March 2018

Background:

The usefulness of patient-reported outcome measures is emphasized along with the development of patient-centered care. When implementing patient-reported outcome measures, evidence of the instrument’s validity, reliability, and responsiveness in the target population is necessary to secure accurate reporting of the patient’s experience. The aim of this study was to identify the literature in which structured patient-reported outcome measures have been used to evaluate the results of gender confirmation surgery, and to systematically evaluate the validity of these instruments.

Methods:

A systematic review of the current literature was performed to identify structured patient-reported outcome measures used to evaluate the outcome of gender confirmation surgery. The identified instruments’ validity in the transgender population was assessed for adherence to international guidelines for development and validation of health outcomes instruments.

Results:

A total of 110 instruments were identified: 64 ad hoc; six generic; 24 evaluating psychiatric, social, or psychosocial aspects; nine evaluating function but only valid in other patient groups; five ad hoc with some formal development/validation; and two specific for gender dysphoria.

Conclusions:

There is a lack of patient-reported outcome measures that are valid for the transgender population and concurrently sensitive enough to evaluate gender confirmation surgery without the influence of other gender confirming interventions. Basing research on instruments without confirmed validity decreases the validity of the study itself; thus, previous research using patient-reported outcome measures to evaluate gender confirmation surgery can be considered to have a low level of evidence. To obtain valid patient-reported outcome measures, specific for evaluating the results of gender confirmation surgery, development of new instruments or adaptation of existing instruments is needed.
Inner Scar Umbilicus: New Horizons for Vertical Abdominoplasty
Authors: Mendes Flavio H. , Viterbo Fausto , Luna Ana L. A. P.
Published: March 2018

Background:

It is reasonable that deflated tissue in massive weight loss patients may demand not only lifting but also some extent of central body tightening, by the fleur-de-lis procedure. Although achieving nice contouring results, poor visible scars, including umbilical complications, have restricted the indications for the anterior vertical approach. The purpose of this article is to present the authors’ experience with the inner scar umbilical reconstruction, reflecting overall results in vertical abdominoplasties.

Methods:

Massive weight loss patients who underwent fleur-de-lis abdominoplasties with the inner scar umbilicus were reviewed retrospectively. The original stalk was resected along with the surgical specimen, and two marked parallel skin flaps were kept and sutured against each other into the deep medial fascia, to reconstruct the umbilical base. Additional sutures were made to approximate fat tissue immediately under and above it, enhancing a deepening effect. Conventional upper and lower vertical closure helped to establish the tridimensional shape of the new navel.

Results:

One hundred ten consecutive patients were studied, and 52 (47 percent) presented small inflammatory exudate arising from the inner suture, which resolved with conservative dry dressings. No further umbilical complications such as infection, necrosis, dehiscence, widening, or stenosis were reported, and all patients showed natural and scarless new navels with nice shapes and correct position.

Conclusions:

The inner scar umbilicus is a simple, safe, and reproducible technique, presenting low complication rates with sustainable and natural results. High-quality navel reconstruction favors the indication of vertical abdominoplasties, especially for post–bariatric surgery body contouring.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
How to Diagnose and Treat Breast Implant–Associated Anaplastic Large Cell Lymphoma
Authors: Clemens Mark W. , Brody Garry S. , Mahabir Raman C. , Miranda Roberto N.
Published: March 2018

Learning Objectives:

After reading this article, the participant should be able to: 1. Describe the diagnostic criteria for breast implant–associated (BIA) anaplastic large cell lymphoma (ALCL). 2. Appropriately evaluate a patient with suspected BIA-ALCL, including appropriate imaging, laboratory tests, and pathologic evaluation. 3. Understand the operative treatment of BIA-ALCL, and indications for systemic chemotherapy and/or radiation therapy in advanced disease. 4. Understand treatment outcomes and prognosis based on stage of disease.

The goal of this continuing medical education module is to present the assessment of a patient with suspected breast implant–associated anaplastic large cell lymphoma, the evaluation and diagnosis, the preoperative oncologic workup, the formation and execution of a surgical treatment plan, and the inclusion of adjunct treatments when indicated. In addition, staging and disease progression for treatment of breast implant–associated anaplastic large cell lymphoma are discussed.