bluuebunny/crossref_metadata_2025_split huggingface dataset:
Early Discontinuation of Breast Free Flap Monitoring: A Strategy Driven by National Data
Authors: Baltodano Pablo A. , Schalet Grant , Rezak Kristen , Aliu Oluseyi , Weinberg Maxene , Ata Ashar , Agag Richard L. , Patel Ashit , Ricci Joseph A. 
Published: August 2020

Background:
Multiple single-institution studies have revealed that breast free flap compromise usually occurs within the first 48 postoperative hours. However, national studies analyzing the rates and timing of breast free flap compromise are lacking. This study aimed to fill this gap in knowledge to better guide postoperative monitoring.

Methods:
All women undergoing breast free flap reconstruction from the American College of Surgeons National Surgical Quality Improvement Program 2012 to 2016 database were analyzed to determine the rates and timing of free flap take-back. Take-backs were stratified by postoperative day through the first month. Multivariable modified Poisson regression analysis was used to determine the independent predictors of free flap take-back.

Results:
A total of 6792 breast free flap patients were analyzed. Multivariable analysis revealed that body mass index of 40 kg/m2 or higher, hypertension, American Society of Anesthesiologists class of 3 or higher, steroid use, and smoking were independent predictors of take-back (p < 0.05). Take-back occurred at the highest rate during postoperative day 1, dropped significantly by postoperative day 2 (p < 0.001), and remained consistently low after postoperative day 2 (<0.6 percent daily). The identified risk factors significantly increased the likelihood of take-back on postoperative day 1 (p < 0.05), with a trend noted on postoperative day 2 (p = 0.06). Fewer than 0.4 percent of patients (n = 27) underwent take-back on postoperative day 2 without having risk factors.

Conclusions:
This is the first national study specifically analyzing rates, timing, and independent predictors of breast free flap take-back. The data support discontinuing breast free flap monitoring by the end of postoperative day 1 for patients without risk factors, given the very low rate of take-back for such patients during postoperative day 2 (≤0.4 percent).

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Risk, III.
Comparison of Telfa Rolling and a Closed Washing System for Autologous Fat Processing Techniques in Postmastectomy Breast Reconstruction
Authors: Valmadrid Al C. , Kaoutzanis Christodoulos , Wormer Blair A. , Farinas Angel F. , Wang Li , Al Kassis Salam , Perdikis Galen , Braun Stephane A. , Higdon Kent K. 
Published: August 2020

Background:
The purpose of this study was to compare the commonly used fat grafting techniques—Telfa rolling and a closed washing system—in breast reconstruction patients.

Methods:
Consecutive patients undergoing fat grafting were retrospectively reviewed and grouped by technique. Patients with less than 180 days of follow-up were excluded. Demographics, operative details, and complications were compared using univariate analysis with significance set at p < 0.05.

Results:
Between January of 2013 and September of 2017, 186 women underwent a total of 319 fat grafting procedures. There was no difference in demographics, number of procedures performed, volume of fat grafted, and number of days after reconstruction that fat grafting was performed between groups (p > 0.05). Telfa rolling patients had longer operative times for second fat grafting procedures (implant exchange often completed prior) [100.0 minutes (range, 60.0 to 150.0 minutes) versus 79.0 minutes (range, 64.0 to 94.0 minutes); p = 0.03]. Telfa rolling breasts had more palpable masses requiring imaging (26.0 percent versus 14.4 percent; p = 0.01) and an increased incidence of fat necrosis (20.6 percent versus 8.0 percent; p < 0.01). The closed washing system was found to be an independent predictor of decreased rates of imaging-confirmed fat necrosis (OR, 0.29; p = 0.048). There was no difference in fat necrosis excision or cancer recurrence between the groups.

Conclusion:
The closed washing system was independently associated with decreased rates of imaging-confirmed fat necrosis compared to Telfa rolling without an increase in other complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, III.
Closed Metacarpal Neck Fractures: A Review of Resource Use in Operative and Nonoperative Management
Authors: Hooper Rachel C. , Chen Jung-Sheng , Kuo Chang-Fu , Chung Kevin C. 
Published: August 2020

Background:
Closed metacarpal neck fractures are extremely common. The authors investigated resource use among those managed operatively versus nonoperatively. They hypothesized that considerable use of services and costs are incurred with nonoperative management.

Methods:
The authors used the 2009 to 2017 Truven Marketscan Research Database to identify patients with closed metacarpal neck fractures and divided them into operative and nonoperative groups. They examined resource use, including imaging, clinic visits, surgery, and occupational therapy sessions, and performed a chi-square analysis of patient demographic data and resources used.

Results:
Of 125,610 patients identified, 46,845 met inclusion criteria: nonoperative, n = 45,067 (96.2 percent); and operative, n = 1778 (3.8 percent). The operative group comprised percutaneous fixation (62 percent) and open reduction and internal fixation (38 percent) patients. Nonoperative patients had the greatest mean number of clinic visits, with 1.7 per patient, compared to 1.2 for both percutaneous fixation and open reduction and internal fixation patients (p < 0.001). For nonoperative patients, one to two radiographs (beyond the index radiograph) were obtained, and they had 2.9 occupational therapy sessions; in the operative group, two to three radiographs were obtained, and they had three to four occupational therapy sessions (p < 0.001). Mean total costs were $2406 per patient for percutaneous fixation, $3092 per patient for open reduction and internal fixation, $546 per patient for closed reduction, and $261 per patient for no intervention.

Conclusions:
Nonoperative management of closed metacarpal neck fracture has lower costs without the associated operating room, surgeon, and service fees; however, patient care remains resource intensive with the use of imaging, clinic visits, and occupational therapy. Shifts in the authors’ treatment paradigm, including judicious use of services, will result in significant health care savings.
Reverse End-to-Side Anterior Interosseous Nerve–to–Ulnar Motor Transfer for Severe Ulnar Neuropathy
Authors: Doherty Christopher D. , Miller Thomas A. , Larocerie-Salgado Juliana , Byers Brett A. , Ross Douglas C. 
Published: August 2020

Background:
Reverse end-to-side anterior interosseous nerve transfer has been reported to enhance treatment of severe, proximal ulnar neuropathy. The authors report on patients with severe neuropathy treated with ulnar nerve transposition and distal reverse end-to-side anterior interosseous nerve transfer.

Methods:
Thirty patients with severe ulnar neuropathy at the elbow were reviewed. Clinical parameters included preoperative and postoperative Medical Research Council muscle strength, clawing, and degree of wasting. Electrodiagnostic data included compound motor action potential and sensory nerve action potential amplitudes. Summary statistics were used for demographic and clinical data. The t test and Wilcoxon signed rank test were used where appropriate.

Results:
Average follow-up was 18.6 months. Preoperatively, 20 patients had Medical Research Council less than or equal to grade 1 in hand intrinsics, small finger sensory nerve action potentials were absent in all patients except for three, and average compound motor action potentials were severely reduced (absent in nearly 40 percent) confirming severity. All groups had a statistically significant increase in strength. More than three-quarters of patients noted partial or complete resolution of clawing and intrinsic muscle wasting. Seventy-three percent of patients regained Medical Research Council greater than or equal to grade 3 and 47 percent achieved Medical Research Council greater than or equal to grade 4. Mean time to observation of nascent units was 8.5 months, and 77 percent of patients demonstrated an augmentation of motor unit numbers with forearm pronation on needle electromyography

Conclusion:
Proximal subcutaneous ulnar nerve transposition when combined with reverse end-to-side anterior interosseous nerve–to–ulnar nerve transfer demonstrates significant clinical and electrodiagnostic improvement of intrinsic muscle function.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, IV.
Psychometric Findings for the SCAR-Q Patient-Reported Outcome Measure Based on 731 Children and Adults with Surgical, Traumatic, and Burn Scars from Four Countries
Authors: Ziolkowski Natalia I. , Pusic Andrea L. , Fish Joel S. , Mundy Lily R. , Wong She Richard , Forrest Christopher R. , Hollenbeck Scott , Arriagada Cristian , Calcagno Manual , Greenhalgh David , Klassen Anne F. 
Published: August 2020

Background:
Each year, millions of individuals develop scars secondary to surgery, trauma, and/or burns. Scar-specific patient-reported outcome measures to evaluate outcomes are needed. To address the gap in available measures, the SCAR-Q was developed following international guidelines for patient-reported outcome measure development. This study field tested the SCAR-Q and examined its psychometric properties.

Methods:
Patients aged 8 years and older with a surgical, traumatic, and/or burn scar anywhere on their face or body were recruited between March of 2017 and April of 2018 at seven hospitals in four countries. Participants answered demographic and scar questions, the Fitzpatrick Skin Typing Questionnaire, the Patient and Observer Scar Assessment Scale (POSAS), and the SCAR-Q. Rasch measurement theory was used for the psychometric analysis. Cronbach’s alpha, test-retest reliability, and concurrent validity were also examined.

Results:
Consent was obtained from 773 patients, and 731 completed the study. Participants were aged 8 to 88 years, and 354 had surgical, 184 had burn, and 199 had traumatic scars. Analysis led to refinement of the SCAR-Q Appearance, Symptoms, and Psychosocial Impact scales. Reliability was high, with person separation index values of 0.91, 0.81, and 0.79; Cronbach alpha values of 0.96, 0.91, and 0.95; and intraclass correlation coefficient values of 0.92, 0.94, and 0.88, respectively. As predicted, correlations between POSAS scores and the Appearance and Symptom scales were higher than those between POSAS and Psychosocial Impact scale scores.

Conclusions:
With increasing scar revisions, a scar-specific patient-reported outcome measure is needed to measure outcomes that matter to patients from their perspective. The SCAR-Q represents a rigorously developed, internationally applicable patient-reported outcome measure that can be used to evaluate scars in research, clinical care, and quality improvement initiatives.
Stability of Long-Term Outcomes in Implant-Based Breast Reconstruction: An Evaluation of 12-Year Surgeon- and Patient-Reported Outcomes in 3489 Nonirradiated and Irradiated Implants
Authors: Seth Akhil K. , Cordeiro Peter G. 
Published: August 2020

Background:
Outcomes following prosthetic breast reconstruction have been well studied. However, the majority of studies are limited by short-term follow-up and a lack of aesthetic and patient-reported outcomes. This study objectively examines long-term surgeon- and patient-reported outcomes following two-stage prosthetic breast reconstruction.

Methods:
Consecutive patients undergoing two-stage prosthetic breast reconstruction from 1994 to 2016 performed by the senior author (P.G.C.), with at least 1-year follow-up after implant exchange, were reviewed retrospectively. Long-term surgeon-reported outcomes, including aesthetic and capsular contracture scores, and patient-reported outcomes using the BREAST-Q, were recorded at each outpatient visit and analyzed over the 12-year follow-up period.

Results:
Retrospective review revealed 2284 patients, or 3489 breasts, that fit the inclusion criteria. Aesthetic scores and capsular contracture rates remained stable over the entire follow-up period. Subset analysis demonstrated that bilateral and nonirradiated reconstructions consistently had the highest aesthetic scores, whereas unilateral irradiated breasts had the lowest. Irradiated breasts consistently had high rates of capsular contracture, although the extent of contracture improved over time in all patients. Patient-reported BREAST-Q scores showed either stability or improvement over time in all patients. Irradiated and nonirradiated patients demonstrated comparable long-term satisfaction with outcomes despite significant differences in satisfaction with their breasts.

Conclusions:
The authors’ study, the largest of its kind, demonstrates that prosthetic breast reconstruction outcomes do not deteriorate over time. This stability is apparent in both long-term surgeon- and patient-reported outcomes data measured in the same patients. These results contradict the surgical dogma surrounding prosthetic breast reconstruction and therefore should be given significant consideration when counseling patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, IV.
Breast Reduction: Surgical Techniques with an Emphasis on Evidence-Based Practice and Outcomes
Authors: Colohan Shannon M. , Massenburg Benjamin B. , Gougoutas Alexander J. 
Published: August 2020

Learning Objectives:
After studying this article, the participant should be able to: 1. Understand the relevant anatomy involved in breast reduction. 2. Understand the different breast reduction techniques and their indications. 3. Appreciate the outcomes of these techniques as they pertain to clinical outcomes.

Summary:
This continuing medical education article is designed to refresh one’s knowledge on breast reduction while placing emphasis on clinical outcomes. It reviews the relevant anatomy, techniques, and published literature on outcomes, including those that are patient-reported. Photographic representations of most techniques are shown, in addition to supplemental digital video content, to demonstrate each technique. This is designed to be an overview, and the reader should appreciate that no one technique is “right,” and the technique used should be selected with patient factors and desired outcomes in mind.
Long-Acting Injectable Cabotegravir + Rilpivirine for HIV Maintenance Therapy: Week 48 Pooled Analysis of Phase 3 ATLAS and FLAIR Trials
Authors: Rizzardini Giuliano , Overton Edgar T. , Orkin Chloe , Swindells Susan , Arasteh Keikawus , Górgolas Hernández-Mora Miguel , Pokrovsky Vadim , Girard Pierre-Marie , Oka Shinichi , Andrade-Villanueva Jaime F. , Richmond Gary J. , Baumgarten Axel , Masiá Mar , Latiff Gulam , Griffith Sandy , Harrington Conn M. , Hudson Krischan J. , St. Clair Marty , Talarico Christine L. , Patel Parul , Cutrell Amy , Van Eygen Veerle , D'Amico Ronald , Mrus Joseph M. , Wu Sterling , Ford Susan L. , Chow Ken , Roberts Jeremy , Wills Angela , Walters Nicola , Vanveggel Simon , Van Solingen-Ristea Rodica , Crauwels Herta , Smith Kimberly Y. , Spreen William R. , Margolis David A. 
Published: August 2020

Background:
Long-acting (LA) injectable regimens are a potential therapeutic option in people living with HIV-1.

Setting:
ATLAS (NCT02951052) and FLAIR (NCT02938520) were 2 randomized, open-label, multicenter, multinational phase 3 studies.

Methods:
Adult participants with virologic suppression (plasma HIV-1 RNA <50 copies/mL) were randomized (1:1) to continue with their current antiretroviral regimen (CAR) or switch to the long-acting (LA) regimen of cabotegravir (CAB) and rilpivirine (RPV). In the LA arm, participants initially received oral CAB + RPV once-daily for 4 weeks to assess individual safety and tolerability, before starting monthly injectable therapy. The primary endpoint of this combined analysis was antiviral efficacy at week 48 (FDA Snapshot algorithm: noninferiority margin of 4% for HIV-1 RNA ≥50 copies/mL). Safety, tolerability, and confirmed virologic failure (2 consecutive plasma HIV-1 RNA ≥200 copies/mL) were secondary endpoints.

Results:
The pooled intention-to-treat exposed population included 591 participants in each arm [28% women (sex at birth), 19% aged ≥50 years]. Noninferiority criteria at week 48 were met for the primary (HIV-1 RNA ≥50 copies/mL) and key secondary (HIV-1 RNA <50 copies/mL) efficacy endpoints. Seven individuals in each arm (1.2%) developed confirmed virologic failure; 6/7 (LA) and 3/7 (CAR) had resistance-associated mutations. Most LA recipients (83%) experienced injection site reactions, which decreased in incidence over time. Injection site reactions led to the withdrawal of 6 (1%) participants. The serious adverse event rate was 4% in each arm.

Conclusion:
This combined analysis demonstrates monthly injections of CAB + RPV LA were noninferior to daily oral CAR for maintaining HIV-1 suppression.
Endometrial Cancer, the Current International Federation of Gynecology and Obstetrics Staging System, and the Role of Imaging
Authors: Saleh Mohammed , Virarkar Mayur , Bhosale Priya , El Sherif Sherif , Javadi Sanaz , Faria Silvana C. 
Published: August 2020

Abstract
Imaging plays a crucial role in the diagnosis, staging, and follow-up of endometrial cancer. Endometrial cancer is staged surgically using the International Federation of Gynecology and Obstetrics (FIGO) staging system. Preoperative imaging can complement surgical staging but is not yet considered a required component in the current FIGO staging system. Preoperative imaging can help identify some tumor characteristics and tumor spread, both locally and distally. More accurate assessment of endometrial cancers optimizes management and treatment plan, including degree of surgical intervention. In this article, we review the epidemiology, FIGO staging system, and the importance of imaging in the staging of endometrial cancer.
Association Between Incomplete Partition Type III and Abnormal Hypothalamic Morphology: Further Imaging Evidence
Authors: Oztunali Cigdem , Saylisoy Suzan , Toprak Ugur , Incesulu Armagan 
Published: August 2020

Purpose
Incomplete partition III (IP-III), characterized by congenital mixed or sensorineural hearing loss, is a rare genetic disease transmitted through X-linked mode of inheritance. Inner ear findings of IP-III have been well described and allow an immediate diagnosis to be made. Recently, an association between IP-III and distinct hypothalamic malformations has been reported in some of the patients with IP-III. The purpose of this study was to investigate the morphologic abnormalities of the hypothalamus in IP-III.

Materials and Methods
Magnetic resonance imaging studies of 8 subjects, including 1 set of brothers, who were diagnosed with IP-III based on their clinical and inner ear imaging findings, were analyzed.

Results
Of the 8 subjects, 7 demonstrated some degree of morphologic abnormality of the hypothalamus. Of these, 2 showed asymmetrical thickening, 1 showed symmetrical thickening, and 4 showed mass-like enlargement of the hypothalamus. Six of 7 subjects with hypothalamic abnormalities showed asymmetry in caudal extension of the abnormalities, which was more discernible on coronal oblique T2-weighted images. Clinically, none of the subjects had endocrinologic or neurologic symptoms.

Conclusions
This retrospective analysis presents further magnetic resonance imaging evidence on the association between the rare IP-III malformations and the presence of hypothalamic morphologic abnormalities.
Computed Tomography Angiography–Based Pulmonary Artery Volumetry as a Diagnostic Tool for Pulmonary Hypertension
Authors: Cassady Steven James , Mills-Robertson Kweku , Deepak Janaki , Hossain Rydhwana 
Published: August 2020

Objectives
We evaluated use of three-dimensional pulmonary artery volumes derived from computed tomography pulmonary angiography (CTPA) in a group with pulmonary hypertension (PH) compared with healthy controls as a tool for the diagnosis of PH.

Methods
Retrospective analysis was performed of 40 CTPA scans obtained within 90 days of right heart catheterization demonstrating PH. The CTPA scans of 40 age- and sex-matched patients without cardiopulmonary disease were used as comparison. Diameters and volumes of the pulmonary arteries were compared.

Results
Adjusted total volume of the main, right, and left proximal pulmonary arteries (PAvol) demonstrated area under the curve of 0.918 (95% confidence interval, 0.860–0.975) for detection of PH, comparable to main pulmonary artery diameter measurement. Area under the curve values for PAvol were higher in subgroups divided by sex and PH severity.

Conclusions
Volumetric analysis of the proximal pulmonary arteries using CTPA is a promising diagnostic tool for PH in a real-world cohort.
Prevention and Treatment of Posttraumatic Lymphedema by Soft Tissue Reconstruction With Lymphatic Vessels Free Flap
Authors: Pereira Nicolás , Cambara Álvaro , Kufeke Matías , Roa Ricardo 
Published: August 2020

Background
Extremities soft tissue damage may increase the risk of presenting posttraumatic lymphedema. This type of lymphedema is often ignored in trauma and reconstructive literature. We propose a microsurgical soft tissue reconstruction approach to prevent and/or treat posttraumatic lymphedema.

Patients and Methods
This is a multicentric retrospective observational study. Primary and secondary end points were to prevent and/or treat posttraumatic lymphedema and to achieve a stable soft tissue coverage, respectively. Patients with posttraumatic lymphedema and functional lymphatic channels in the indocyanine green lymphography, and patients with acute soft tissue trauma with lymphatic damage without lymphedema, either to treat and prevent lymphedema, respectively, were included as candidates for soft tissue reconstruction using a superficial circumflex iliac artery perforator lymphatic vessels free flap (SCIP-LV). Patients with no pitting edema, fibrosis, or nonfunctional lymphatics channels were excluded. The inguinal lymphatic anatomy was studied with indocyanine green lymphography for designing and in-setting the flap.

Results
Eleven patients underwent to microsurgical reconstruction with SCIP-LV free flap; minimum follow-up was 12 months. There were no flap failures. In the posttraumatic lymphedema group, the mean reduction of excess volume was 63.01%. Quality of life improved 51.85%. No patients in the acute trauma group developed lymphedema after the preventive microsurgical approach.

Conclusions
Soft tissue reconstruction with SCIP-LV free flap is an effective approach to prevent and treat posttraumatic lymphedema.