bluuebunny/crossref_metadata_2025 huggingface dataset:
Endoscopic Versus Microscopic Stapedotomy: A Single-Blinded Randomized Control Trial
Authors: Fan Caleb J. , Kaul Vivian F. , Mavrommatis Maria A. , Schwam Zachary G. , Hu Shirley , Kong Derek K. , Phan Noel M. , Villavisanis Dillan F. , Cosetti Maura K. , Wanna George B.
Published: August 2021

Objective:

To demonstrate non-inferiority of endoscopic stapedotomy to microscopic stapedotomy for the treatment of otosclerosis.

Study Design:

Single-blinded randomized control trial.

Setting:

Tertiary, academic otology-neurotology practice.

Patients:

Adult subjects with a diagnosis of otosclerosis and a preoperative air-bone gap (ABG) more than or equal to 20 dB undergoing primary stapedotomy.

Intervention:

Endoscopic or microscopic stapedotomy.

Main Outcome Measures:

Primary audiometric outcome was postoperative ABG. Secondary audiometric outcomes included speech reception threshold (SRT), word recognition score (WRS), bone- and air-conduction pure tone averages (PTA), change in ABG, and ABG closure rates to less than or equal to 10 dB and less than or equal to 20 dB.

Results:

Twenty-two patients were recruited. Eleven patients underwent endoscopic stapedotomy and 11 underwent microscopic stapedotomy. The endoscopic group was non-inferior to the microscopic group in terms of postoperative audiometric outcomes (endoscope versus microscope, p-value): ABG (8.1 dB versus 8.1 dB, <0.001), SRT (27.7 dB versus 25.9 dB, <0.001), WRS (92% at 65 dB versus 98% at 62 dB, <0.001), air-conduction PTA (33.5 dB versus 30.8 dB, <0.01), and change in ABG (23.0 dB versus 20.7 dB, <0.0001). ABG closure rates to less than or equal to 10 dB (72.7% versus 81.2%, p = 1.0) and less than or equal to 20 dB (90.9% versus 100%, p = 1.0) were not significantly different. There was no significant difference in operative time, necessity of scutum curettage, or postoperative dysgeusia. No patients required chorda tympani sacrifice. Preoperative tinnitus resolved in three patients in each group postoperatively.

Conclusions:

This study is the first randomized control trial to demonstrate non-inferiority of endoscopic to microscopic stapedotomy.
Diabetes and pancreatic cancer: recent insights with implications for early diagnosis, treatment and prevention
Authors: Wu Bechien U.
Published: August 2021

Purpose of review

Recent insights into the complex relationship between diabetes and pancreatic cancer have the potential to help direct future approaches to early detection, treatment and prevention.

Recent findings

Insulin resistance and hyperinsulinemia have been identified as factors that relate to risk of pancreatic cancer among patients with long-standing diabetes. In contrast, weight loss in the setting of new-onset diabetes can help identify patients at an increased risk for harbouring pancreatic-cancer related disturbances in glucose metabolism. Insights into the implications of poor glycaemic control in patients undergoing resection for pancreatic cancer have the potential to improve both surgical and oncologic outcomes. Finally, among antidiabetic medications, metformin continues to be evaluated as a potential adjunctive therapeutic agent, although recent evidence supports the safety of incretins with respect to pancreatic cancer.

This review highlights recent developments in these areas with an emphasis on opportunities for improved early diagnosis, treatment and prevention in pancreatic cancer.
Updates in artificial intelligence in gastroenterology endoscopy in 2020
Authors: Moore Matthew , Sharma Prateek
Published: August 2021

Purpose of review

Artificial intelligence is becoming rapidly integrated into modern technology including medicine. Artificial intelligence has a wide range of potential in gastroenterology, particularly with endoscopy, given the required analysis of large datasets of images. The aim of this review is to summarize the advances of artificial intelligence in gastroenterology (GI) endoscopy over the past year.

Recent findings

Computer-aided detection (CADe) systems during real-time colonoscopy have resulted in increased adenoma detection rate with no significant increase in procedure times. Deep learning techniques have been utilized to accurately assess bowel preparation quality, which would impact surveillance colonoscopy recommendations. For the upper GI tract, CADe systems have been developed to aid in improving the diagnosis of Barrett's neoplasia during real-time endoscopy. Artificial intelligence-assisted real-time endoscopy has been shown to reduce blind spots during EGD.

The application of artificial intelligence in gastroenterology endoscopy remains promising. Advances over the past year include improved detection of GI neoplasia during endoscopy and characterization of lesions. Further research including randomized, multicenter trials are needed to further evaluate the use of artificial intelligence for real-time endoscopy.
Segmental mandibular reconstruction in patients with poor lower extremity perfusion, vessel-depleted necks and/or profound medical frailty
Authors: Rubin Samuel J. , Sayre Kelly S. , Kovatch Kevin J. , Ali S. Ahmed , Hanks John E.
Published: August 2021

Purpose of review

Options for segmental mandibular reconstruction in patients poorly suited to undergo fibula free flap (FFF).

Recent findings

Although FFF is the current ‘gold standard’ for segmental mandibular reconstruction, other reconstructive options must be considered when FFF is contraindicated or disfavoured and/or patient frailty precludes a lengthy anaesthetic. In addition to various nonvascularized and soft tissue only reconstructions, excellent osseous free flap alternatives for functional segmental mandibular reconstruction may be employed. The subscapular system free flaps (SSSFF) may be ideal in frail and/or elderly patients, as SSSFF allows for early mobility and does not alter gait. In extensive and/or symphyseal defects, functional mandibular reconstruction in lieu of a free flap is extremely limited. Pedicled segmental mandibular reconstructions remain reasonable options, but limited contemporary literature highlights unpredictable bone graft perfusion and poor long-term functional outcomes.

There are several excellent free flap alternatives to FFF in segmental mandibular reconstruction, assuming adequate cervical recipient vessels are present. On the basis of the current literature, the optimal mandibular reconstruction for the medically frail, elderly and/or patients with extreme vessel-depleted necks is limited and debatable. In qualifying (i.e. limited, lateral) defects, soft tissue only reconstructions should be strongly considered when osseous free flaps are unavailable.
Recognising and Treating Complicated Fissuring Perianal Crohn Disease
Authors: Burgess Christopher J. , Clark Claire , Khedim Cher‐Antonia , Armstrong Katherine , Henderson Paul , Wilson David C.
Published: August 2021

Fissuring perianal Crohn disease (CD) is not recognised as a perianal phenotype in Montreal/Paris inflammatory bowel disease classifications; however, can occasionally present as complicated disease with severe perianal pain driving increasingly intensive medical therapy despite well controlled luminal disease. We identified a regional cohort of prospectively acquired incident cases of paediatric CD diagnosed <16 years of age in South‐East Scotland over a 19‐year period (1999–2018), and conducted a retrospective review of complicated fissuring perianal CD causing severe pain related to anal sphincter complex spasm at defecation. Two hundred forty‐seven new cases of paediatric CD were diagnosed with complicated fissuring perianal disease identified in 4 described cases (cumulative incidence 1.6%). These patients with marked fissuring and refractory anal sphincter complex spasm required neurostimulation‐guided, 4‐quadrant, anal intrasphincteric botulinum toxin (BT). All experienced immediate success, measured by cessation of spasms, with variable ongoing symptom relief after median (range) 3 (2–5) BT injections.
Pediatric Chronic Myelogenous Leukemia in T-lineage Blast Crisis: A Reminder in Relevance
Authors: Patel Sachit A. , Beck Jill C.
Published: August 2021

Pediatric Philadelphia chromosome positive (Ph+) acute T-cell lymphoblastic leukemia can mimic chronic myelogenous leukemia (CML) in T-lineage blast crisis (BC). Differentiating the 2 is critical in guiding therapy as most children with de novo Ph+ acute T-cell lymphoblastic leukemia are treated with chemotherapy and tyrosine kinase inhibitors, whereas T-lineage BC of CML can include hematopoietic stem cell transplantation. We present a unique case of CML in T-lineage BC. The patient was treated with induction chemotherapy plus imatinib followed by matched unrelated donor hematopoietic stem cell transplantation. She is currently off all medications and in complete disease remission.
Is Monitoring of Cytomegalovirus Disease Required in Nontransplant Pediatric Acute Lymphoblastic Leukemia?
Authors: Şen Semra , Özdemir Hamiyet H. , Karadaş Nihal , Bal Zümrüt Ş. , Göktepe Şebnem Ö. , Ece Dilek , Balkan Can , Aydinok Yeşim , Karapinar Deniz Y.
Published: August 2021

Introduction:

Cytomegalovirus (CMV) infections in developing countries are experienced at an early age. This study was performed to investigate the frequency of reactivation and risk factors of infection acquired at an early age of nontransplant acute lymphoblastic leukemia (ALL) patients receiving immunosuppressive therapy with weekly monitoring of CMV levels in Turkey.

Materials and Methods:

This was a retrospective, single-center study of 172 pediatric patients (102 boys and 70 girls) with ALL. All patients were monitored routinely for CMV-DNA at the initial presentation of leukemia and twice a week during chemotherapy. The CMV immunoglobulin (Ig)M/IgG titers were measured at admission.

Results:

CMV seropositivity at baseline was 90,11%. The overall prevalence of CMV infection (viremia) was 70.34%, 116 of whom were seropositive for CMV IgG and 5 of whom were negative for CMV at the time of ALL diagnosis. Reactivation was more common than de novo CMV infections (P=0.000). CMV seropositivity at the beginning of the leukemia diagnosis was found to be an independent predictor for developing CMV infection (P=0.001). A total of 60 CMV infection episodes were treated with antivirals. Four of these included organ involvement. The duration of CMV-DNA viremia episodes was longer in patients with CMV-DNA ≥1000 copies/mL (n=45) than in those with lower CMV-DNA levels (P=0.002). Infection was shown not to be associated with chemotherapy phase.

Conclusion:

This study suggests the importance of monitoring for CMV infections in developing countries because of frequent reactivations in seropositive ALL patients. It should be kept in mind that low CMV-DNA levels may also lead to organ involvement.
Vaso-occlusive Pain Crisis Mimicking Mandibular Abscess in an Adolescent with Sickle Cell Disease
Authors: Wu Han-Wei , Rahim Nasiha , Mbadiwe Nina , Khayat Sarah , da Fonseca Marcio A. , Peters Erika , Hsu Lewis L.
Published: August 2021

In people with sickle cell disease (SCD), oral abscesses are concerning clinical conditions and carry a high risk of postoperative sickle cell complications. We present an unusual case of a 14-year-old girl with SCD whose initial presentation of facial swelling, headaches, jaw pain, and paresthesia mimicked an odontogenic abscess. She was diagnosed with vaso-occlusive crisis in the mandibular bone and successfully managed noninvasively. This is among the youngest cases of paresthesia in the lower lip in SCD, which provided a clue that postponing invasive aspiration or biopsy was possible under empiric antibiotics and close observation.
Development and Validation of Pediatric Opioid Analgesia Self-Instruction System (PedOASIS): An Opioid Knowledge Tool for Pediatric Clinicians
Authors: MacDonell-Yilmaz Rebecca E. , Anderson Angela , Hirway Priya , Welch Jennifer G.
Published: August 2021

Background:

Acute pain is common in children and young adults with cancer and sickle cell disease. Current training curricula fail to adequately impart skills for pain management. We sought to develop and validate an education and assessment tool to address the safe effective use of opioids for pain management by pediatrics trainees.

Methods:

The first version of the tool contained 10 case-based, multiple-choice questions. It was pilot tested within a medium-sized pediatric residency program using preintervention and postintervention surveys to assess residents’ knowledge and comfort related to prescribing opioids. Content validation was performed through an expert panel of physicians. Internal reliability was tested by administering the tool to learners and practitioners with varying levels of training.

Results:

Comfort with choosing and converting between opioids increased significantly in pilot testing (P=0.005). Mean objective knowledge scores increased from 51% to 85.9% (P<0.001). The revised tool showed internal reliability within each group (Cronbach alpha 0.71 to 0.78) and significant differences in mean scores between groups (F ratio=9.45, P=0.0002).

Conclusions:

This tool demonstrates validity and internal reliability. Its use was associated with short-term educational gains and it garnered overall favorable feedback from users. Further testing is needed to assess the duration of these gains.
Sphenopalatine Ganglion Block for Postdural Puncture Headaches in a Thrombocytopenic Adolescent Young Adult: A Case Report
Authors: Lo Carl (Yuan-Feng) , Le Sang , Kim Eugene
Published: August 2021

The epidural blood patch is the gold-standard therapy to treat postdural puncture headaches from dural puncture when conservative therapies fail. However, an epidural blood patch is contraindicated in patients with coagulopathy and thrombocytopenia (platelet count of 60,000/µL) due to concerns of an epidural hematoma. We present a case of an adolescent with acute lymphocytic leukemia, thrombocytopenia, and persistent postdural puncture headaches. The patient was successfully treated with a sphenopalatine ganglion nerve block at the bedside without any side effects and complications.
Symptom Clusters, Physical Activity, and Quality of Life
Authors: Hooke Mary C. , Mathiason Michelle A. , Blommer Audrey , Hutter Jessica , Mitby Pauline , Taylor Olga , Scheurer Michael E. , Kunin-Batson Alicia S. , Pan Wei , Hockenberry Marilyn J.
Published: August 2021

Background

Children undergoing treatment for acute lymphocytic leukemia (ALL) report co-occurring symptoms of fatigue, sleep disturbances, and depression as a symptom cluster. Physical activity (PA) may influence symptom severity and quality of life (QOL).

Objectives

This study examined changes in symptoms and QOL during ALL maintenance in children categorized by symptom cluster and explored the influence of PA and symptoms on QOL.

Methods

Self-report of fatigue, sleep disturbance, and depression; QOL; and PA were measured at the beginning and end of maintenance in 42 children aged 3 to 18 years with ALL. Children were categorized into symptom cluster groups based on measurements at the beginning of maintenance.

Results

Two latent classes of symptom clusters (low and high) were identified with significant differences between groups in symptoms at both the beginning and end maintenance (P < .01). Each group’s symptom levels did not change during maintenance. Quality-of-life was different between groups at both time points (P < .01) and did not improve. Children with low symptoms and high PA at the beginning of maintenance had better QOL as treatment ended compared with the physically active high-symptom group and the inactive high-symptom group (P < .01).

Conclusions

Children with higher symptoms did not experience an improvement with time. Symptom and PA levels may influence QOL at the end of treatment.

Implications for Practice

Maintenance therapy is a long time (1.5 years) in a child’s life. Symptom assessment is needed early in maintenance; interventions are needed for children with high levels.
Environmental and Behavioral Factors with Refractive Error in Israeli Boys
Authors: Gordon-Shaag Ariela , Shneor Einat , Doron Ravid , Levine Jonathan , Ostrin Lisa A.
Published: August 2021

SIGNIFICANCE

Evidence supporting the contributions of near work in myopia is equivocal. Findings from this pilot study suggest that a high prevalence of myopia in ultra-Orthodox boys may be attributed to intense near work at school and learning to read in preschool at an early age.

PURPOSE

This study aimed to assess factors that may influence myopia in three groups of Jewish boys with different educational demands.

METHODS

Healthy ultra-Orthodox, religious, and secular Jewish boys (n = 36) aged 8 to 12 years participated. Refractive status, education, time spent reading and writing, and electronic device use were assessed using a questionnaire, and time outdoors and physical activity were assessed objectively using an Actiwatch. Data were analyzed with χ
2 and Kruskal-Wallis tests with Bonferroni post hoc comparisons.

RESULTS

Ultra-Orthodox (n = 14) and religious (n = 13) children had greater myopia prevalence compared with secular children (n = 9; P = .01), despite no differences in parental myopia. Actigraph data showed that there were no differences in activity (P = .52) or time spent outdoors (P = .48) between groups. Ultra-Orthodox children learned to read at a younger age and spent more hours at school (P < .001 for both). All groups engaged in a similar amount of near work while not in school (P = .52). However, ultra-Orthodox boys had less electronic device use than did religious (P = .007) and secular children (P < .001).

CONCLUSIONS

This pilot study demonstrates that ultra-Orthodox, religious, and secular children have distinct educational demands but similar time outdoors, physical activity, and near work while not in school. The findings suggest that near work at school and/or learning to read in preschool at an early age may contribute to previously reported differences in refractive error between groups. However, conclusions should be confirmed in a larger sample size.
The Effects of Mindfulness-Based Stress Reduction on the Association Between Autonomic Interoceptive Signals and Emotion Regulation Selection
Authors: Ardi Ziv , Golland Yulia , Shafir Roni , Sheppes Gal , Levit-Binnun Nava
Published: August 2021

Objective

The ability to select the most adaptive regulatory strategy as a function of the emotional context plays a pivotal role in psychological health. Recently, we showed that mindfulness-based interventions (MBIs) can improve the sensitivity of regulatory strategy selection to emotional intensity. However, the mechanisms underlying this improvement are unclear. In this study, we tested the hypothesis that MBIs support adaptive regulatory selection by increasing sensitivity to interoceptive signals associated with the emotional stimuli.

Methods

Participants (n = 84, mean [standard deviation {SD}] age = 30.9 [8.3] years; 54% women) were randomized to either a mindfulness-based stress reduction (MBSR) program or a wait-list control condition. Before and after the MBSR program, physiological measures for autonomic nervous system activity were obtained, and participants performed a task examining emotion regulation selections (reappraisal versus distraction) when confronted with low or high negative intensity images. They also completed a battery of mindfulness, interoception, and well-being self-report measures. A cross-classified model was used for the main analyses.

Results

The participants assigned to the MBSR were overall more likely to choose reappraisal than distraction (b = 0.26, posterior SD = 0.13, 95confidence interval = 0.02–0.52) after the program. Interoceptive signals in response to negative images were associated with subsequent regulatory selections (b = 0.02, posterior SD = 0.01, 95% confidence interval = 0.01–0.03) in the MBSR group. Specifically, lower cardiac reactivity was associated with the choice to reappraise, whereas higher cardiac reactivity was related to the choice to distract. Greater differences in cardiac reactivity between states that prompt reappraisal and states that prompt distraction were associated with higher well-being (Satisfaction With Life Scale, Pearson r (29) = 0.527, p = .003).

Conclusions

Mindfulness seems to increase the sensitivity of regulatory selections to interoceptive signals, and this is associated with subjective well-being. This may be a central pathway through which MBIs exert their positive effects on mental health and resilience.
A Roadmap to Implementing Venous Thromboembolism Risk Stratification and Mitigation
Authors: Glassman Gabriella E. , Zhang Michael Z. , Patrinely James R. , Lee Elizabeth , Drolet Brian C. , Perdikis Galen
Published: August 2021

Introduction

Venous thromboembolism (VTE) is a life-threatening postoperative complication that carries high morbidity and mortality for plastic surgery patients. In 2011, the American Society of Plastic Surgeons recommended the adoption of a VTE risk stratification and mitigation; however, successful implementation of VTE prophylaxis protocols has not been well described. To address and reduce the VTE burden at our academic center, a risk assessment protocol was implemented for patients undergoing outpatient plastic surgery procedures.

Method

All patients who received outpatient plastic surgery between August 2018 and July 2019 were eligible for the VTE modified Caprini risk assessment screening. Sampling of practice patterns was done by chart review from the first week of each month. The study was divided into 3 phases to assess the relationship of screening compliance rates with each protocol change. Compliance was defined as completion of VTE Caprini screening with documentation in patients' charts.

Results

Over the 12-month study period, 277 patients met the inclusion criteria. From August to November 2018 (phase 1), patients were screened at the initial clinic visit with an average compliance rate of 11.1%. In December 2018 (phase 2), patients were screened on the day of surgery, with an average compliance rate of 47.1%. From January to July 2019 (phase 3), surgeons recorded the numerical Caprini score into the patient's electronic medical record with a subsequent compliance rate of 61.3%. The overall compliance during the 12 months was 44.8%. The median calculated Caprini score for this population was 4 (range, 1–7).

Conclusions

Standardization of VTE risk assessment is vital for patient safety and outcomes. Successful implementation and long-term protocol sustainability are not a simple goal. In this study, protocol compliance greatly improved after tailoring the guidelines to the specific institutional needs and workflow. These results reinforce the importance of continuous protocol review and modification to ensure optimal departmental buy-in and sustainability.
Temporoparietal Fascial Free Flap
Authors: Horen Sydney R. , Hamidian Jahromi Alireza , Konofaos Petros
Published: August 2021

The temporoparietal fascial flap (TPFF) is a versatile tool used in head and neck reconstructive surgeries as well as distal upper and lower extremity reconstructions. Depending on the anatomical location and characteristics of the recipient site soft tissue defects, harvesting techniques for TPFF retrieval may include elevation as a pedicle or a free flap, inclusion of the temporalis muscle and/or adjacent calvarial bone as a composite flap. The TPFF as a free flap is not only used for soft tissue coverage of various defects, and it can be used as a joint gliding surface with coverage of nerve and tendons after repair or trauma. This article includes a systematic search of the medical literature for indications, historical background, techniques, current perspective, and complications along with the pros and cons of the free TPFF compared with other potential reconstructive options.
Anatomical Location of Lymphatic Pathways in the Posterior Thigh
Authors: Sakai Hayahito , Kageyama Takashi , Tsukuura Reiko , Yamamoto Takumi
Published: August 2021

Background

It is necessary for treating lower extremity lymphedema to understand the lymphatic pathways in the extremities. This study aimed to clarify the anatomical locations of lymph vessels in the posterior thigh using indocyanine green (ICG) lymphography.

Methods

Medical records of cancer survivors who underwent ICG lymphography for secondary lymphedema screening from February 2019 to November 2020 were reviewed. Nonlymphedematous limbs without dermal backflow pattern on ICG lymphography (ICG stage 0) were included. Indocyanine green (0.1 mL) was injected intradermally at 2 points in the midlateral thigh, at the levels of one third and two thirds from the popliteal fossa to the gluteal fold in a prone position. Locations of the posterior thigh collecting lymph vessels visualized by ICG lymphography were marked on the skin surface with a pen, and distances from the popliteal fossa to the collecting lymph vessels were measured at the posterior midline in percentage, with the popliteal fossa set as 0% and the gluteal fold as 100%. Based on ICG lymphography findings, the number of the collecting lymph vessels shown as linear pattern and anatomical locations at the posterior thigh midline were investigated.

Results

Twenty limbs of 20 cancer survivors were included. Linear pattern was identified in all lower extremities; average number was 2.3 ± 0.7 (range, 1–3). Most collecting lymph vessels shown on ICG lymphography, 26.7% (12 of 45) lymph vessels, were located within 40% to 50% of the region, and 24.4% (11 of 45) lymph vessels within 30% to 40% of the region.

Conclusions

There are 1 or more collecting lymph vessels in the posterior thigh by midlateral thigh ICG injection, which can be addressed for posterior thigh lymphedema.
Versatility of the Peroneal Perforator Propeller Sural Flap for Various Types of Injuries in the Ankle and Foot Regions
Authors: Tapan Mehmet , Özkan Özlenen , Özkan Ömer
Published: August 2021

Objectives

The goals of soft tissue reconstruction in the distal lower extremities are to provide a functional limb and to help patients return to a normal life with the capability of wearing shoes or boots. A peroneal perforator propeller sural flap is a combination of a sural flap and a peroneal propeller perforator flap. This article presents the versatility of this flap in the foot and ankle regions.

Patients and Methods

Eleven peroneal perforator propeller sural flaps were harvested to reconstruct the ankle and foot regions. There were 9 male and 2 female patients, with ages ranging from 9 to 64 years. The flaps were used for 7 different defect types including avulsion, gunshot, crush injury, diabetic foot, defect secondary to orthopedic surgery, tumor resection, and electrical burn. The flaps included 3 different insetting types and 2 different utilizations of the sural nerve.

Results

Eight direct propeller flaps, 2 interpolation propeller flaps, and 1 passing-through-style propeller flap were harvested as flap insetting types. In 1 patient, sural nerve coaptation was used, and in 2 patients, an additional posterior tibial artery perforator flap was used. One patient underwent surgery at the time of the injury. Only 2 patients had complications related to the type of injury. There was no need for debulking surgery for patients to wear their own shoes or boots.

Conclusions

The peroneal perforator propeller sural flap can be harvested as a sensory flap with sural nerve coaptation, a passing-through- style, an interpolation style, an extended style, or as a component of double perforator flaps. This type of flap provides various options in the challenging field of reconstructive surgery.
Revision Rates of Left and Right Breast Reconstruction Differ With DIEP Flaps
Authors: Jo Taehee , Han Hyun Ho , Eom Jin Sup
Published: August 2021

Background

The internal mammary system provides the recipient vessel of choice in free autologous tissue breast reconstruction. However, left internal mammary veins (IMVs) are smaller than right IMVs, thus raising questions about their reliability. Here we analyzed right and left breast deep inferior epigastric perforator (DIEP) flap reconstruction performed by an experienced versus less experienced surgeon and hypothesized that less experienced surgeons might encounter difficulty in cases of smaller left IMVs.

Methods

We respectively reviewed the charts of 714 DIEP flap breast reconstructions performed by an experienced surgeon (>15 years' DIEP flap experience) and 231 performed by a relatively inexperienced surgeon (<4 years' DIEP flap experience). Reconstructions requiring microvascular revisions were compared with nonrevision controls, and left-side reconstructions were compared with right-side controls.

Results

Preoperative risk factors were not significantly different between the left and right cohorts for either surgeon. The experienced surgeon performed 17 microvascular revisions (2.4%), including 9 left (52.9%) and 8 right (47.1%). The less experienced surgeon performed 7 microvascular revisions (3.0%), all left. The left- and right-side revision rates were 2.4% and 2.3% for the experienced surgeon versus 6.1% and 0% for the less experienced surgeon, respectively, with a higher rate for the left side (P = 0.0299).

Conclusions

The left-side microvascular revision rate was higher for the less experienced surgeon. Considering that left IMVs are smaller, less experienced surgeons should carefully perform left-side free flap breast reconstructions and be prepared to convert to thoracodorsal recipient vessel use.
The Craniofacial Collaboration UK: Developmental Outcomes in 3-Year-Old Children With Metopic Synostosis
Authors: Culshaw Laura , Piggott Katie , Care Helen , Dalton Louise , Denly Susie , Horton Jo , Kennedy-Williams Patrick , Pinckston Molly , Rooney Natasha , Thornhill Hannah , Parks Christopher , Kearney Anna
Published: August 2021

The Craniofacial Collaboration UK (CC-UK) has been established across the 4 highly specialized craniofacial centers in the UK since 2015. This joint collective aims to address the current limitations within developmental craniofacial research, using robust clinical data from a homogenous sample of children. This paper presents the third wave of findings from the CC-UK, with consideration to developmental and behavioral parent-report measures. Whilst previous data for sagittal synostosis have been presented, this article summarizes the analysis of these outcomes for children with metopic synostosis (MS) at 3 years who have undergone primary corrective surgery. Results highlight similar patterns to that of earlier CC-UK work, with the majority of children falling within 1 standard deviation of the population normative means across all measures. However, statistically significant difficulties were found between group means for children with MS on various developmental and behavioral domains. Prosocial skills and peer difficulties were reported as the greatest areas of behavioral concern for parents, with prosocial skills found to be below the level expected for their chronological age. In order to further understand the developmental trajectory of children with MS, longitudinal examination of individual diagnostic and specific age groups with single-suture craniosynostosis is crucial. The continuation of the CC-UK provides an opportunity to attain this goal.
Modified Cephalic Index Measured at Superior Levels of the Cranium Revealed Improved Correction With Helmet Therapy for Patients With Sagittal Suture Craniosynostosis
Authors: Abernethy Lisa M. , England Dwiesha L. , Price Ciera A. , Stevens Phillip M. , Wurdeman Shane R.
Published: August 2021

Objective:

Historically, studies have shown that cranial remolding therapy improves surgical correction and protects against regression for patients with sagittal suture craniosynostosis. This study aimed to define the most responsive cranial height for measuring cephalic index (CI) following cranial remolding therapy for infants with sagittal suture craniosynostosis.

Methods:

The authors performed a retrospective analysis of data between January 2018 and August 2019. The outcomes measured were CI-3 (level of glabella) through CI-7 (superior to eurions), where each value was defined as the width at levels 3 through 7 divided by the length at level 3. Differences between baseline- and post-treatment measurements were assessed using a 5 × 2 repeated measures analysis of variance.

Results:

Data from thirty-four patients (19 males, 15 females, and mean age 2.79 months) were analyzed. Mean treatment duration was 4.59 ± 1.86 months. There was a significant increase between baseline and posttreatment measurements (baseline: 72.60% ± 0.70%, post: 76.30% ± 0.80%; F1,33 = 27.74, P < 0.001). The interaction effect for CI level ∗ baseline-post was also significant (F1.43,
47.16 = 6.75, P = 0.006). Post hoc analyses revealed the posttreatment measures were significantly greater than baseline measures at every CI level. The magnitude of the measured differences systematically decreased from CI-7 to CI-3, with a greater effect size at the most superior level (ie CI-7) of 0.961 compared to 0.778 at the traditional level (ie CI-3).

Conclusions:

The CI measurement at level 7 demonstrated the greatest responsiveness to treatment, whereas the traditional CI measurement taken at level 3, the current standard, proved the least responsive.
A Novel Approach to Provide Long-Term Tip Projection and Rotation Stability: Lateral Columellar Strut Graft
Authors: Yücel Sercan , Akyol Gözde , Ünverdi Ömer Faruk
Published: August 2021

One of the methods applied to ensure the long-term continuity of the desired result in rhinoplasty is to detect it by placing columellar strut between the medial crus. Columellar strut helps to increase tip support and projection. However, the placement of the strut between the medial crus can disrupt the divergence angle and prevent the tip rotation to be at the desired level due to the interaction of the septum with the caudal. in this study, the data obtained by fixing the columellar strut to the lateral faces of the medial crus are shared. in 51 primary rhinoplasty patients who underwent open rhinoplasty, the medial crus was dissected and released. The distance between the footplates and the new domes was measured and the length of the columellar struts was determined. Grafts obtained from cartilage septum were shaped. After symmetry was achieved between the medial crus, the prepared grafts were fixed to the lateral face of the medial crus. Preoperative and postoperative 12th month images were transferred to computer- aided program and nasolabial angles were measured. The obtained data were transferred to SPSS 22.0 (IBM Corp., Armonk, New York, USA) program and statistical comparisons were made. Fifty one patients were included in the study. Thirty eight of the patients were female and 13 were male. The mean age of the patients included in the study was 29.2 years. The mean preoperative nasolabial angle was 90.2 degrees postoperatively, and the average nasolabial angle was 104.2 degrees at 6 months. A statistically significant difference was found between preoperative and postoperative measurements (P 
< 0.05). Lateral columellar strut is an effective and reliable and novel method for increasing the stability of medial crus, maintaining tip support in postoperative period and increasing tip rotation.
Management of Mandible Angle Fractures With a Right Angle Drill: Description of Technique
Authors: Anderson Spencer R. , Wolsefer Nicholas S. , Miremadi A. Reza
Published: August 2021

Management of mandible angle fractures can be challenging within the confines of the oral cavity where the use of linear instruments may result in structural weakness or malalignment secondary to improper placement. A right angle drill can facilitate a more ergonomic approach, with direct perpendicular placement of the instrument over the angle fracture. In addition, local soft tissue strain is minimized, and the need for a transcutaneous exposure can be avoided for additional plate placement. The right angle drill technique is simple, reproducible, and can be easily incorporated into routine mandible angle fracture management.
A New Time-Window Prediction Model For Traumatic Hemorrhagic Shock Based on Interpretable Machine Learning
Authors: Zhao Yuzhuo , Jia Lijing , Jia Ruiqi , Han Hui , Feng Cong , Li Xueyan , Wei Zijian , Wang Hongxin , Zhang Heng , Pan Shuxiao , Wang Jiaming , Guo Xin , Yu Zheyuan , Li Xiucheng , Wang Zhaohong , Chen Wei , Li Jing , Li Tanshi
Published: August 2021

Early warning prediction of traumatic hemorrhagic shock (THS) can greatly reduce patient mortality and morbidity. We aimed to develop and validate models with different stepped feature sets to predict THS in advance. From the PLA General Hospital Emergency Rescue Database and Medical Information Mart for Intensive Care III, we identified 604 and 1,614 patients, respectively. Two popular machine learning algorithms (i.e., extreme gradient boosting [XGBoost] and logistic regression) were applied. The area under the receiver operating characteristic curve (AUROC) was used to evaluate the performance of the models. By analyzing the feature importance based on XGBoost, we found that features in vital signs (VS), routine blood (RB), and blood gas analysis (BG) were the most relevant to THS (0.292, 0.249, and 0.225, respectively). Thus, the stepped relationships existing in them were revealed. Furthermore, the three stepped feature sets (i.e., VS, VS + RB, and VS + RB + sBG) were passed to the two machine learning algorithms to predict THS in the subsequent T hours (where T = 3, 2, 1, or 0.5), respectively. Results showed that the XGBoost model performance was significantly better than the logistic regression. The model using vital signs alone achieved good performance at the half-hour time window (AUROC = 0.935), and the performance was increased when laboratory results were added, especially when the time window was 1 h (AUROC = 0.950 and 0.968, respectively). These good-performing interpretable models demonstrated acceptable generalization ability in external validation, which could flexibly and rollingly predict THS T hours (where T = 0.5, 1) prior to clinical recognition. A prospective study is necessary to determine the clinical utility of the proposed THS prediction models.
Sepsis-Induced Myopathy and Gut Microbiome Dysbiosis: Mechanistic Links and Therapeutic Targets
Authors: Mankowski Robert T. , Laitano Orlando , Darden Dijoia , Kelly Lauren , Munley Jennifer , Loftus Tyler J. , Mohr Alicia M. , Efron Philip A. , Thomas Ryan M.
Published: August 2021

Sepsis is currently defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. The skeletal muscle system is among the host organ systems compromised by sepsis. The resulting neuromuscular dysfunction and impaired regenerative capacity defines sepsis-induced myopathy and manifests as atrophy, loss of strength, and hindered regeneration after injury. These outcomes delay recovery from critical illness and confer increased vulnerability to morbidity and mortality. The mechanisms underlying sepsis-induced myopathy, including the potential contribution of peripheral organs, remain largely unexplored. The gut microbiome is an immunological and homeostatic entity that interacts with and controls end-organ function, including the skeletal muscle system. Sepsis induces alterations in the gut microbiota composition, which is globally termed a state of “dysbiosis” for the host compared to baseline microbiota composition. In this review, we critically evaluate existing evidence and potential mechanisms linking sepsis-induced myopathy with gut microbiota dysbiosis.
Therapeutic Effects of Hyaluronic Acid Against Cytotoxic Extracellular Vesicles Released During Pseudomonas Aeruginosa Pneumonia
Authors: Naito Yoshifumi , Kato Hideya , Zhou Li , Sugita Shinji , He Hongli , Zheng Justin , Hao Qi , Sawa Teiji , Lee Jae-Woo
Published: August 2021

Extracellular vesicles (EVs) have now been recognized as important mediators of cellular communication during injury and repair. We previously found that plasma EVs isolated from ex vivo perfused human lungs injured with Escherichia coli bacterial pneumonia were inflammatory, and exogenous administration of high molecular weight (HMW) hyaluronic acid (HA) as therapy bound to these EVs, decreasing inflammation and injury. In the current study, we studied the role of EVs released during severe Pseudomonas aeruginosa (PA) pneumonia in mice and determined whether intravenous administration of exogenous HMW HA would have therapeutic effects against the bacterial pneumonia. EVs were collected from the bronchoalveolar lavage fluid (BALF) of mice infected with PA103 by ultracentrifugation and analyzed by NanoSight and flow cytometry. In a cytotoxicity assay, administration of EVs released from infected mice (I-EVs) decreased the viability of A549 cells compared to EV isolated from sham control mice (C-EVs). Either exogenous HMW HA or an anti-CD44 antibody, when co-incubated with I-EVs, significantly improved the viability of the A549 cells. In mice with PA103 pneumonia, administration of HMW HA improved pulmonary edema and bacterial count in the lungs and decreased TNF-α and caspase-3 levels in the supernatant of lung homogenates. In conclusion, EVs isolated from BALF of mice with P. aeruginosa pneumonia were cytotoxic and inflammatory, and intravenous HMW HA administration was protective against P. aeruginosa pneumonia.
Which Septic Shock Patients With Non-Overt DIC Progress to DIC After Admission? Point-of-Care Thromboelastography Testing
Authors: Kim Sang-Min , Kim Sang-Il , Yu Gina , Kim Youn-Jung , Kim Won Young
Published: August 2021

Background:

Disseminated intravascular coagulation (DIC) is a life-threatening complication of septic shock; however, risk factors for its development after admission are unknown. Thromboelastography (TEG) can reflect coagulation disturbances in early non-overt DIC that are not detected by standard coagulation tests. This study investigated the risk factors including TEG findings as early predictors for DIC development after admission in septic shock patients with non-overt DIC.

Methods:

This retrospective observation study included 295 consecutive septic shock patients with non-overt DIC at admission between January 2016 and December 2019. DIC was defined as an International Society on Thrombosis and Hemostasis (ISTH) score ≥ 5. The primary outcome was non-overt DIC at admission that met the ISTH DIC criteria within 3 days after admission.

Results:

Of the 295 patients with non-overt DIC, 89 (30.2%) developed DIC after admission. The DIC group showed a higher ISTH score and 28-day mortality rate than the non-DIC group (2 vs. 3, P < 0.001; 13.6% vs. 27.0%, P = 0.008, respectively). The DIC rate increased with the ISTH score (7.7%, 13.3%, 15.8%, 36.5%, and 61.4% for scores of 0, 1, 2, 3, and 4, respectively). Among TEG values, the maximum amplitude (MA) was higher in the non-DIC group (P < 0.001). On multivariate analysis, an MA < 64 mm was independently associated with DIC development (odds ratio, 2.311; 95% confidence interval, 1.298–4.115).

Conclusions:

DIC more often developed among those with admission ISTH scores ≥ 3 and was associated with higher mortality rates. An MA < 64 mm was independently associated with DIC development in septic shock patients.
Overcoming COVID-19
Authors: Coleman Dawn M. , Perrone Erin E. , Dombrowski Janet , Dossett Lesly A. , Sears Erica D. , Sandhu Gurjit , Telem Dana A. , Waljee Jennifer F. , Newman Erika A. ,   on behalf of the Michigan Women's Surgical Collaborative
Published: August 2021

Sex inequity in academic achievement was well documented before the COVID-19 pandemic, and evolving data suggest that women in academic surgery are disproportionately disadvantaged by the pandemic. This perspective piece reviews currently accepted solutions to the sex achievement gap, with their associated shortcomings. We also propose innovative strategies to overcoming barriers to sex equity in academic medicine that broadly fall into three categories: strategies to mitigate inequitable caregiving responsibilities, strategies to reduce cognitive load, and strategies to value uncompensated, impactful work. These approaches address inequities at the system-level, as opposed to the individual-level, lifting the burden of changing the system from women.
Early Prediction of a Serious Postoperative Course in Perihilar Cholangiocarcinoma
Authors: Kawakatsu Shoji , Yamaguchi Junpei , Mizuno Takashi , Watanabe Nobuyuki , Onoe Shunsuke , Igami Tsuyoshi , Yokoyama Yukihiro , Uehara Kay , Nagino Masato , Matsuo Keitaro , Ebata Tomoki
Published: August 2021

Objective:

The aim of this study was to visualize the postoperative clinical course using the comprehensive complication index (CCI) and to propose an early alarming sign for subsequent serious outcomes in perihilar cholangiocarcinoma.

Background:

Surgery for this disease carries a high risk of morbidity and mortality. The developmental course of the overall morbidity burden and its clinical utility are unknown.

Methods:

Patients who underwent major hepatectomy for perihilar cholan-giocarcinoma between 2010 and 2019 were reviewed retrospectively. All postoperative complications were evaluated according to the Clavien-Dindo classification (CDC), and the CCI was calculated on a daily basis until postoperative day 14 to construct an accumulating graph as a trajectory. Group-based trajectory modeling was conducted to categorize the trajectory into clinically distinct patterns and the predictive power of early CCI for a subsequent serious course was assessed.

Results:

A total of 4230 complications occurred in the 484 study patients (CDC grade I, n = 27; II, n = 132; IlIa, n = 290; IIIb, n = 4; IVa, n = 21; IVb, n = 1; and V, n = 9). The trajectory was categorized into 3 patterns: mild (n = 209), moderate (n = 235), and severe (n = 40) morbidity courses. The 90-day mortality rate significantly differed among the courses: 0%, 0.9%, and 17.5%, respectively (P<0.001). The cutoff values of the CCI on postoperative days 1, 4, and 7 for predicting a severe morbidity course were 15.0, 28.5, and 40.6 with areas under the curves of 0.780, 0.924, and 0.984, respectively.

Conclusions:

The CCI could depict the chronological increase in the overall morbidity burden, categorized into 3 patterns. Early CCI potentially predicted sequential progression to serious outcomes.