bluuebunny/crossref_metadata_2025_split huggingface dataset:
Impact of Transportation Interventions on Health Care Outcomes
Authors: Solomon Eli M. , Wing Holly , Steiner John F. , Gottlieb Laura M. 
Published: January 2020

Introduction:
Lack of reliable transportation can be a barrier to keeping appointments or accessing other health care services. Increasingly, insurers and health care delivery systems subsidize transportation services for patients. This systematic review synthesizes existing research on nonemergency medical transportation interventions.

Methods:
We searched 3 databases (Embase, PubMed, Google) for studies of health care sector-sponsored programs that provided patients assistance with nonemergency transportation and directly assessed the impact of transportation assistance on health and health care utilization outcomes. Studies meeting inclusion criteria were graded for quality using standard grading criteria.

Findings:
Eight studies met all inclusion criteria. Most were rated as low quality. All studies included examined process or health care utilization outcomes, such as uptake of transportation services, return for follow-up, or missed appointment rates; only 1 included health outcomes, such as illness severity and blood pressure. Results were mixed. More rigorous studies showed low patient uptake of transportation services and inconsistent impacts on health and utilization outcomes.

Conclusions:
Despite considerable interest in subsidizing transportation services to improve health for patients facing transportation barriers, little rigorously conducted research has demonstrated the impact of transportation services on health or health care utilization. Some extant literature suggests that transportation assistance is more likely to be effective when offered with other interventions to reduce social and economic barriers to health.
Prognostic and Predictive Role of CXC Chemokine Receptor 4 in Metastatic Colorectal Cancer Patients
Authors: Ottaiano Alessandro , Scala Stefania , Normanno Nicola , Botti Gerardo , Tatangelo Fabiana , Di Mauro Annabella , Capozzi Monica , Facchini Sergio , Tafuto Salvatore , Nasti Guglielmo 
Published: January 2020

Background:
Colorectal cancer (CRC) is the third leading cause of cancer-related death worldwide. About 30% of patients present with metastatic disease involving predominantly the liver and a similar percentage will develop distant metastases later after removal of the primary tumor. In metastatic CRC, chemotherapies and biological drugs have prolonged survival for up to 30 months. However, there is a great need for biomarkers predictive of response and prognosis to optimize treatments. CXC chemokine receptor 4 (CXCR4) is a chemokine receptor; it binds to CXCL12 and plays a central role in colon cancer cells’ growth and dissemination.

Materials and Methods:
CXCR4 was evaluated in CRC primary tissues by immunohistochemistry. Formalin-fixed, paraffin-embedded 4-μm tissue sections were immunostained using a biotin-streptavidin-peroxidase method and categorized into 2 semiquantitative classes: (i) absence of staining, ≤50% positive cells (negative/low) and (ii) >50% positive cells (high). Associations between clinic-pathologic variables and CXCR4 expression were evaluated using the χ2 test. The Kaplan-Meier product-limit method was applied to graph overall survival (OS). OS was defined as the time elapsed from diagnosis to death from any cause. Univariate analysis was carried out using the log-rank test. Cox proportional hazards regression was used to analyze the effect of several risk factors on OS.

Results:
Seventy-eight primary adenocarcinomas were analyzed; 26 were categorized as negative/low and 52 as high. Age, sex, performance status, site of metastases, KRAS mutational status, type of first-line therapy, and a number of therapy lines did not correlate with CXCR4 expression. Although not significant (P=0.0533), high CXCR4 expression was more frequently localized on the right side of the colon. Significant correlations were detected with grading (P=0.0041) and response to first-line anti-epidermal growth factor receptors agents (P<0.0001), bevacizumab (P=0.0029), and chemotherapy alone (P=0.0260). At a median follow-up of 53 months, 77 deaths have been registered. Grading [hazard ratio (HR): 1.42; confidence interval (CI): 0.89-2.28; P<0.0001], KRAS mutational status (HR: 1.73; CI: 1.03-290; P=0.0133), response to first-line chemotherapy (HR: 3.39; CI: 2.10-5.48; P<0.0001), and CXCR4 expression (HR: 3.18; CI: 2.01-5.02; P<0.0001) showed prognostic power at univariate and multivariate analyses.

Conclusion:
In the present report, we show that CXCR4 expression on the primary tumor is an independent prognostic factor and correlates with response to first-line chemotherapy in metastatic CRC patients.
Addition of CORES to the I-PASS Handoff: A Resident-led Quality Improvement Study
Authors: Tufts Lauren M. , Damron Christopher L. , Flesher Susan L. 
Published: January 2020

Introduction:
Quality patient handoff is vital in patient care and attainable with structured handoff systems, such as the I-PASS mnemonic. This paper describes a continuous quality improvement study occurring after the implementation of the I-PASS handoff bundle. Our objectives were to (1) determine compliance with the inclusion of I-PASS elements during handoff and (2) determine whether the addition of CORES, an electronic tool that generates a patient list designed for use with I-PASS, would improve compliance and sustainability.

Methods:
We developed an aim statement: 90% of handoffs would include all 6 I-PASS elements within 6 months of the addition of CORES. Two plan–do–study–act (PDSA) cycles were conducted. In PDSA 1, we implemented CORES. In PDSA 2, we reeducated residents on I-PASS elements and the importance of a quality handoff. We used a checklist to evaluate the inclusion of I-PASS elements. Following PDSA 2, we administered a survey regarding CORES to involved residents.

Results:
During PDSA 1, illness severity, diagnosis, patient summary, contingency planning, action list, and receiver synthesis were present in 13%, 62%, 52%, 87%, 42%, and 25% of handoffs, respectively. Overall compliance was 47%. During PDSA 2, illness severity remained stable at 13% whereas the remainder increased to 84%, 82%, 93%, 91%, and 37%. Overall compliance increased to 67%. Following PDSA 2, 100% of survey respondents reported improved handoff with CORES.

Conclusions:
In this study, we show that neither implementation of CORES nor resident reeducation resulted in the return to high postintervention compliance observed after implementation of the I-PASS handoff bundle.
Implementation of Febrile Infant Management Guidelines Reduces Hospitalization
Authors: Foster Lauren Z. , Beiner Joshua , Duh-Leong Carol , Mascho Kira , Giordani Victoria , Rinke Michael L. , Trasande Leonardo , Wiener Ethan , Rosenberg Rebecca E. 
Published: January 2020

Introduction:
The clinical management of well-appearing febrile infants 7−60 days of age remains variable due in part to multiple criteria differentiating the risk of a serious bacterial infection. The purpose of this quality improvement study was to standardize risk stratification in the emergency department and length of stay in the inpatient unit by implementing an evidence-based clinical practice guideline (CPG).

Methods:
The Model for Improvement was used to implement a CPG for the management of well-appearing febrile infants, with collaboration between pediatric emergency medicine and pediatric hospital medicine physicians. Interventions included physician education, process audit/feedback, and development of an electronic orderset. We used statistical process control charts to assess the primary aims of appropriate risk stratification and length of stay.

Results:
Over a 34-month period, 168 unique encounters (baseline n = 65, intervention n = 103) were included. There was strong adherence for appropriate risk stratification in both periods: the proportion of low-risk patients admitted inappropriately decreased from 14.8% to 10.8%. Among admitted high-risk patients, the mean length of stay decreased from 49.4 to 38.2 hours, sustained for 18 months.

Conclusion:
CPG implementation using quality improvement methodology can increase the delivery of evidence-based care for febrile infants, leading to a reduction in length of stay for high-risk infants.
The Current State of Gender-Affirming Surgery Training in Plastic Surgery Residency Programs as Reported by Residency Program Directors
Authors: Magoon Katie L. , LaQuaglia Rebecca , Yang Robin , Taylor Jesse A. , Nguyen Phuong D. 
Published: January 2020

Background:
The purpose of this Web-based survey was to elucidate the current perspectives of plastic surgery residency program directors on training residents to perform gender-affirming surgery.

Methods:
Web-based surveys were distributed to 79 plastic surgery program directors. Demographic information and perspectives on training of gender-affirming surgery in plastic surgery residency were queried.

Results:
Of 79 distributed surveys, there were 43 responses (54 percent). Overall, program directors reported that their trainees were prepared to address plastic surgery–related transgender concerns (67 percent), and believe plastic surgeons are the most appropriate specialty referral for each type of gender-affirming surgery (top/chest, 98 percent; facial, 95 percent; and bottom/genital, 79 percent). Ninety-three percent of program directors noted that transgender surgery is becoming more accepted and/or practiced in their referral area, with 26 percent reporting a dedicated clinic experience. There was a mixed response on the need for additional fellowship training for gender-affirming surgery. Residents are exposed to significantly more bottom (p = 0.0018), top (p = 0.0013), and facial operations (p = 0.00005) if they rotate through a “gender” clinic.

Conclusions:
Of the queried program directors, the majority feel their residents are well-trained in gender-affirming surgery. However, residents have more clinical exposure in facial and top (chest) gender-affirming surgery as compared to bottom (genital) surgery. Although most program directors agree that plastic surgeons are the most important referral for top, bottom, and facial operations, there is less consensus over the role of fellowship training. Most program directors reported a desire to devote additional CME time to the topic in the coming years.
Prepectoral Two-Stage Implant-Based Breast Reconstruction with and without Acellular Dermal Matrix: Do We See a Difference?
Authors: Manrique Oscar J. , Huang Tony Chieh-Ting , Martinez-Jorge Jorys , Ciudad Pedro , Forte Antonio J. , Bustos Samyd S. , Boughey Judy C. , Jakub James W. , Degnim Amy C. , Galan Ricardo 
Published: January 2020

Background:
Prepectoral implant-based breast reconstruction has gained popularity because of advantages over the subpectoral technique. Acellular dermal matrix use with implant-based breast reconstruction has become common because of its perceived superior aesthetic outcome. Matrices are expensive, however, and recent evidence has pointed to several potential complications. This article reports a series of prepectoral implant-based breast reconstructions with and without acellular dermal matrix and compared their outcomes.

Methods:
This is a single-surgeon retrospective review of patients who underwent staged prepectoral implant-based breast reconstruction following nipple-sparing mastectomy over two periods. Patients with well-perfused mastectomy skin flaps with a homogeneous thickness underwent reconstruction with acellular dermal matrix initially. On evolution of the practice, it was not used. Patient demographics, operative data, and complications were analyzed. Aesthetic outcome was measured by the BREAST-Q survey and the Aesthetic Item Scale. A cost analysis was also performed.

Results:
Forty patients were included (acellular dermal matrix group, n = 19; non–acellular dermal matrix group, n = 21). The nonmatrix group had one case (5 percent) of seroma and one case (5 percent) with hematoma; there were none in the acellular dermal matrix group. Average BREAST-Q and Aesthetic Item Scale scores were 82.3 versus 81.6 (p = 0.954) and 20.98 versus 20.43 (p = 0.640) for the matrix and nonmatrix groups, respectively. The direct cost savings for the authors’ institution over 1 year if matrix was not used in all cases of implant-based breast reconstruction would be estimated at $3,105,960 to $6,211,920 for unilateral and bilateral cases, respectively, for Medicare reimbursement.

Conclusions:
With adequate patient selection, acellular dermal matrix is not always required during two-stage prepectoral implant-based breast reconstruction for good aesthetic outcomes. The economic burden on patients and the health care system could be lessened with selective matrix use.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, III.
The Effect of Sequential Compression Devices on Fibrinolysis in Plastic Surgery Outpatients: A Randomized Trial
Authors: Swanson Eric 
Published: January 2020

Background:
Sequential compression devices are often considered a mainstay of prophylaxis against deep venous thromboses in surgical patients. The devices are believed to produce a milking action on the deep veins to prevent venous stasis. A systemic fibrinolytic effect has also been proposed, adding a second mechanism of action. The plasma levels of tissue plasminogen activator and plasminogen activator inhibitor-1 reflect fibrinolytic activity.

Methods:
A randomized trial was conducted among 50 consecutive plastic surgery outpatients undergoing cosmetic surgery performed by the author under total intravenous anesthesia and without paralysis. Patients were randomized to receive calf-length sequential compression devices or no sequential compression devices during surgery. Blood samples were obtained from the upper extremity preoperatively and at hourly intervals until the patient was discharged from the postanesthesia care unit. Tissue plasminogen activator and plasminogen activator inhibitor-1 levels were measured. Ultrasound surveillance was used in all patients. There was no outside funding for the study.

Results:
All patients agreed to participate (inclusion rate, 100 percent). No patient developed clinical signs or ultrasound evidence of a deep venous thrombosis. There were no significant changes in tissue plasminogen activator levels or plasminogen activator inhibitor-1 levels from the preoperative measurements at any hourly interval and no differences in levels comparing patients treated with or without sequential compression devices.

Conclusions:
No significant change in systemic fibrinolytic activity occurs during outpatient plastic surgery under total intravenous anesthesia. Sequential compression devices do not affect tissue plasminogen activator or plasminogen activator inhibitor-1 levels, suggesting no fibrinolytic benefit.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, I.
Preventing Lateral Canthal Malposition in Modern Blepharoplasty
Authors: Rohrich Rod. J. , Mohan Raja 
Published: January 2020

Summary:
Current goals in lower eyelid blepharoplasty include blending the lower eyelid-cheek junction, which is highlighted in the authors’ six-step lower lid blepharoplasty technique. One major question in lower lid blepharoplasty is how to prevent lower lid malposition and ectropion, because these are untoward outcomes after an aesthetic procedure. In the authors’ technique, they perform a superficial lateral retinacular canthopexy that is effective and safe and also prevents lower lid malposition or ectropion. A retrospective review of 104 patients who underwent six-step lower lid blepharoplasty was performed. In the authors’ series, there was no significant difference between preoperative and postoperative intercanthal angles (p < 0.05), and the lateral canthal position did not change significantly from its preoperative position. The authors’ six-step blepharoplasty technique addresses signs of midfacial aging, and the lateral canthopexy technique has been shown to have a minimal complication rate and maintains canthal position.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, IV.
The Reducing Opioid Use in Children with Clefts Protocol: A Multidisciplinary Quality Improvement Effort to Reduce Perioperative Opioid Use in Patients Undergoing Cleft Surgery
Authors: Lee Alfred , Chang Brian L. , Yan Chen , Fox Justin P. , Magee Leanne , Scott Michelle , Maguire Meg Ann , Ross Karen , Rakow Cara , Drake Francesca , McGinnis Andrea , Watson Adam , Burlingame Caroline , Kraemer F. Wickham , Muhly Wallis T. , Ruby Jordan , Jackson Oksana A. 
Published: January 2020

Background:
Cleft repair requires multiple operations from infancy through adolescence, with repeated exposure to opioids and their associated risks. The authors implemented a quality improvement project to reduce perioperative opioid exposure in their cleft lip/palate population.

Methods:
After identifying key drivers of perioperative opioid administration, quality improvement interventions were developed to address these key drivers and reduce postoperative opioid administration from 0.30 mg/kg of morphine equivalents to 0.20 mg/kg of morphine equivalents. Data were retrospectively collected from January 1, 2015, until initiation of the quality improvement project (May 1, 2017), tracked over the 6-month quality improvement study period, and the subsequent 14 months. Metrics included morphine equivalents of opioids received during admission, administration of intraoperative nerve blocks, adherence to revised electronic medical record order sets, length of stay, and pain scores.

Results:
The final sample included 624 patients. Before implementation (n =354), children received an average of 0.30 mg/kg of morphine equivalents postoperatively. After implementation (n = 270), children received an average of 0.14 mg/kg of morphine equivalents postoperatively (p < 0.001) without increased length of stay (28.3 versus 28.7 hours; p = 0.719) or pain at less than 6 hours (1.78 versus 1.74; p = 0.626) or more than 6 hours postoperatively (1.50 versus 1.49; p = 0.924).

Conclusions:
Perioperative opioid administration after cleft repair can be reduced in a relatively short period by identifying key drivers and addressing perioperative education, standardization of intraoperative pain control, and postoperative prioritization of nonopioid medications and nonpharmacologic pain control. The authors’ quality improvement framework has promise for adaptation in future efforts to reduce opioid use in other surgical patient populations.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, III.
Migraine Surgery at the Frontal Trigger Site: An Analysis of Intraoperative Anatomy
Authors: Ortiz Ricardo , Gfrerer Lisa , Hansdorfer Marek A. , Nealon Kassandra P. , Lans Jonathan , Austen William G. 
Published: January 2020

Background:
The development of migraine headaches may involve the entrapment of peripheral craniofacial nerves at specific sites. Cadaveric studies in the general population have confirmed potential compression points of the supraorbital and supratrochlear nerves at the frontal trigger site. The authors’ aim was to describe the intraoperative anatomy of the supraorbital and supratrochlear nerves at the level of the supraorbital bony rim in patients undergoing frontal migraine surgery and to investigate associated pain.

Methods: Patients
scheduled for frontal-site surgery were enrolled prospectively. The senior author (W.G.A.) evaluated intraoperative anatomy and recorded variables using a detailed form and operative report. The resulting data were analyzed.

Results:
One hundred eighteen sites among 61 patients were included. The supraorbital nerve traversed a notch in 49 percent, a foramen in 41 percent, a notch plus a foramen in 9.3 percent, and neither a notch nor a foramen in one site. The senior author noted macroscopic nerve compression at 74 percent of sites. Reasons included a tight foramen in 24 percent, a notch with a tight band in 34 percent, and supraorbital and supratrochlear nerves emerging by means of the same notch in 7.6 percent or by means of the same foramen in 4.2 percent. Preoperative pain at a site was significantly associated with nerve compression by a foramen.

Conclusions:
The intraoperative anatomy and cause of nerve compression at the frontal trigger site vary greatly among patients. The authors report a supraorbital nerve foramen prevalence of 50.3 percent, which is greater than in previous cadaver studies of the general population. Lastly, the presence of pain at a specific site is associated with macroscopic nerve compression.
Staged Abbe-Rhinoplasty Technique to Correct Bilateral Cleft Deformity
Authors: Veeramani Anamika , Wilson Alexander T. , Sawh-Martinez Rajendra , Steinbacher Derek M. 
Published: January 2020

Summary:
The mature bilateral cleft nasolabial deformity exhibits prolabial and vermilion deficiency, a broad depressed nasal tip, and short columella.
1
Many strategies attempt to correct these stigmata, with varying degrees of success. The purpose of this communication is to describe a novel sequenced approach, staging an Abbe flap and rhinoplasty, with morphometric analysis of results.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, IV.
Review of Insurance Coverage for Abdominal Contouring Procedures in the Postbariatric Population
Authors: Ngaage Ledibabari M. , Elegbede Adekunle , Pace Lauren , Rosen Carly , Tannouri Sami , Rada Erin M. , Kligman Mark D. , Rasko Yvonne M. 
Published: January 2020

Background:
Following bariatric surgery, patients develop problems related to lax abdominal skin that may be addressed by contouring procedures. Third-party insurers have subjective requirements for coverage of these procedures that can limit patient access. The authors sought to determine how well third-party payers cover abdominal contouring procedures in this population.

Methods:
The authors conducted a cross-sectional analysis of insurance policies for coverage of panniculectomy, lower back excision, and circumferential lipectomy. Abdominoplasty was evaluated as an alternative to panniculectomy. Insurance companies were selected based on their market share and state enrolment. A list of medical necessity criteria was abstracted from the policies that offered coverage.

Results:
Of the 55 companies evaluated, 98 percent had a policy that covered panniculectomy versus 36 percent who would cover lower back excision (p < 0.0001), and one-third provided coverage for circumferential lipectomy. Of the insurers who covered panniculectomy, only 30 percent would also cover abdominoplasty. Documentation of secondary skin conditions was the most prevalent criterion in panniculectomy policies (100 percent), whereas impaired function and secondary skin conditions were most common for coverage of lower back excision (73 percent and 73 percent, respectively). Frequency of criteria for panniculectomy versus lower back excision differed most notably for (1) secondary skin conditions (100 percent versus 73 percent; p = 0.0030), (2) weight loss (45 percent versus 7 percent; p = 0.0106), and (3) duration of weight stability (82 percent versus 53 percent; p = 0.0415).

Conclusions:
For the postbariatric population, panniculectomy was covered more often and had more standardized criteria than lower back excision or circumferential lipectomy. However, all have vast intracompany and interpolicy variations in coverage criteria that may reduce access to procedures, even among patients with established indications.
The Robotic DIEP Flap
Authors: Selber Jesse C. 
Published: January 2020

Summary:
The history of autologous breast reconstruction has been characterized by the desire for progressively increasing reliability with decreasing donor-site morbidity. The robotic deep inferior epigastric artery perforator flap permits the longest possible pedicle harvest through the smallest possible fascial incision and, for this reason, may be the next stage in the evolution of minimally invasive, autologous breast reconstruction.