bluuebunny/crossref_metadata_2025_split huggingface dataset:
How Much Cochlea Do You Need for Cochlear Implantation?
Authors: Plontke Stefan K. , Fröhlich Laura , Wagner Luise , Kösling Sabrina , Götze Gerrit , Siebolts Udo , Liebau Arne , Rahne Torsten 
Published: January 2020

Objective:
To assess the efficacy of cochlear implantation (CI) after surgical removal of sporadic intracochlear or intravestibulocochlear schwannomas.

Study Design:
Nonconcurrent cohort study.

Setting:
Monocentric study at a tertiary referral center.

Patients:
Patients with tumor resection and CI between 2011 and 2018 and a historic control group of CI patients matched by age, CI electrode type, and follow-up.

Interventions:
Partial or subtotal cochleoectomy for tumor removal and single-stage CI.

Outcome Measures:
Main outcome measure: word recognition score for monosyllables in quiet at 65 dB SPL.

Results:
Sixteen patients with tumor removal and CI (6 female, 10 male; mean age 55 ± 14 years) and 16 control patients (6 female, 10 male; mean age 55 ± 15 years) were identified. In the tumor group, surprisingly good word recognition scores were reached even after substantial structural defects in the cochlear capsule. While 12 months after cochlear implantation mean word recognition score for monosyllables in quiet was 58% (SD: 26) and 41% (SD: 26) in the control groups, it was 75% (SD: 19%) in the tumor group.

Conclusions:
In patients with intracochlear schwannomas, despite substantial structural damage to the cochlear capsule by partial or subtotal cochleoectomy, a tendency toward better performance with respect to word recognition with CI was observed as compared with other CI patients. The surprisingly good functional results despite substantial cochlear trauma may change clinical thinking with respect to cochlear implantation also beyond this special indication.
Manometric Esophageal Length to Height (MELH) Ratio Predicts Hiatal Hernia Recurrence
Authors: Lal Pooja , Tang Andrew , Sarvepalli Shashank , Raja Siva , Thota Prashanthi , Lopez Rocio , Murthy Sudish , Ray Monica , Gabbard Scott 
Published: January 2020

Introduction:
The shortened esophagus is poorly defined and is determined intraoperatively, as there exists no objective test to identify a shortened esophagus before surgical hiatal hernia repair. We devised a unique manometric esophageal length to height (MELH) ratio to define the presence of a shortened esophagus and examined the role of esophageal length in hiatal hernia recurrence.

Patients and Methods:
A retrospective review identified 254 patients with hiatal hernia who underwent preoperative esophageal manometry and either an open hernia repair with Collis gastroplasty and fundoplication (with Collis) or laparoscopic repair and fundoplication without Collis gastroplasty (without Collis) from 2005-2016. The MELH ratio was calculated by measuring the upper to lower esophageal sphincter distance divided by the patient’s height.

Results:
Of 245 patients, 157 underwent repair with Collis, while 97 underwent repair without Collis. The Collis group had a shorter manometric esophageal length (20.2 vs. 22.4 cm, P<0.001) and lower MELH (0.12 vs. 0.13, P<0.001). The Collis group had fewer hernia recurrences (18% vs. 55%, log-rank P<0.001) and fewer reoperations for recurrence (0% vs. 10%, log-rank P<0.001) at 5 years. A 33% decrease in risk of hernia recurrence was seen for every 0.01 U increment in MELH ratio (hazard ratio: 0.67; 95% confidence interval: 0.55-0.83, P<0.001) while repair without Collis (hazard ratio: 6.1; 95% confidence interval: 3.2-11.7, P<0.001) was associated with increased risk of hernia recurrence.

Conclusion:
MELH ratio is an objective predictor of a shortened esophagus preoperatively. Lower MELH is associated with increased risk of recurrence and the risk associated with shortened esophagus can be mitigated with an esophageal lengthening procedure such as Collis gastroplasty.
Adequacy of Prescription Drug Coverage in Long-term Care
Authors: Briesacher Becky , Oliveri-Mui Brianne , Chhabra Bhavika , Koethe Benjamin 
Published: January 2020

Research Objective:
Affordable access to medications is important to Medicare enrollees in long-term care (LTC), yet, it is unknown if prescription drug coverage is universal and adequate to meet their high medication needs.

Study Design:
We assessed enrollment in prescription drug coverage, out-of-pocket (OOP) payments and medication use in a nationwide LTC database of prescription-level, resident-level, and facility-level data for the period 2011–2013. Inadequate drug coverage was defined as ≥50% medications paid for OOP. Risk-adjusted generalized estimation equations models were estimated to identify predictors of inadequate drug coverage and total prescription fills.

Population Studied:
A nationwide sample of 332,087 Medicare enrollees observed >100 days in LTC.

Principal Findings:
We found Medicare Part D was the main source of drug coverage (82.4%), followed by private insurance (8.5%), and Veterans Administration (0.2%). No drug coverage could be detected for 8.9% (n=29,378) who paid for all of their medications OOP or received only temporary drug payment assistance. Inadequate drug coverage was identified in another 2721 persons. LTC Medicare enrollees without drug coverage or who had private insurance received significantly fewer prescriptions than if they had been enrolled in Medicare Part D.

Conclusion:
A substantial proportion of Medicare enrollees in LTC have inadequate or no drug coverage and are receiving less medication than indicated by their health needs.

Policy Implications:
Medicare Part D is an important policy for ensuring affordable access to medications in LTC. However, expansions are needed to increase enrollment and decrease inadequate drug coverage.
A Quality Improvement Project Focused on Improving First Dose Antibiotic Timeliness for Pediatric Intensive Care Unit Patients with Severe Sepsis
Authors: Keul Ryan , Rodriguez Jordan , Coleman Ariel , Yadav Prerna 
Published: January 2020

Introduction:
Recommended time to start administration of first dose antibiotics for sepsis patients is 60 minutes from time 0. Institution-specific data revealed that only one-quarter of severe sepsis patients were meeting this goal when measured from the time of provider order entry. Reliance on a pneumatic tube system for first-dose antibiotic delivery was deemed largely responsible for this finding. This project aimed to increase the percentage of pediatric intensive care unit patients with severe sepsis receiving first dose antibiotics within 60 minutes of provider order entry to ≥50%.

Methods:
Baseline data were collected from May to June 2018 and resulted in the development of a new “antibiotic champion” process, which we piloted for 1 week in early August 2018. The primary outcome measure was the cumulative percentage of patients meeting the 60-minute goal as measured from provider order entry to start of antibiotic administration. A key secondary endpoint was the median time in minutes from provider order entry to antibiotic administration.

Results:
We included 14 patients in baseline data analysis and 16 patients in the pilot. The overall percentage of patients receiving antibiotics within 60 minutes of order entry increased from 29% to 75% (P-value: 0.026). The median time from provider order entry to antibiotic administration decreased by 36.5 minutes [baseline: 84.5 (range 58.8–117) versus pilot 48 (range 32–65), P-value: 0.0017].

Conclusion:
The antibiotic champion process significantly increased the total percentage of severe sepsis patients meeting the 60-minute goal and decreased the median time to first-dose antibiotic administration for pediatric intensive care unit patients.
An Evaluation of Safety and Patient Outcomes for Hand Surgery following Prior Breast Cancer Treatment: Establishing New Recommendations in Lymphedema
Authors: Paton Madeline , Kovar Alexandra , Iorio Matthew L. 
Published: January 2020

Background:
Injuries to the upper extremity lymphatic system from cancer may require measures to prevent secondary lymphedema. Guidelines were established relating to the use of tourniquet and elective hand and upper extremity surgery. However, reports in the setting of hand surgery have indicated that prior guidelines may not be protective to the patient.

Methods:
The study systematically reviewed the current literature evaluating elective hand surgery in breast cancer patients. The authors evaluated the risk of complications, including new or worsening lymphedema and infection.

Results:
One hundred ninety-eight abstracts were identified, and a bibliographic review was performed. Nine studies pertained to our subject, and four were included for final review. All studies included patients with prior breast cancer treatment involving breast surgery and axillary lymph node dissection. Pneumatic tourniquets were used during nearly all operations. Patients without presurgery ipsilateral lymphedema had a 2.7 percent incidence of developing new lymphedema and a 0.7 percent rate of postoperative infection. Patients with presurgery lymphedema had a 11.1 percent incidence of worsening lymphedema and a 16.7 percent rate of infection. However, all cases of new or exacerbated lymphedema resolved within 3 months. Tourniquet use was not found to increase rates of lymphedema.

Conclusions:
Based on the available evidence, there is no increased risk of complications for elective hand surgery in patients with prior breast cancer treatment. Breast cancer patients with preexisting ipsilateral lymphedema carry slightly increased risk of postoperative infection and worsening lymphedema. It is the authors’ opinion and recommendation that elective hand surgery with a tourniquet is not a contradiction in patients who have received previous breast cancer treatments.
Impact of Physician Payments on Microvascular Breast Reconstruction: An All-Payer Claim Database Analysis
Authors: Panchal Hina , Shamsunder Meghana G. , Sheinin Avraham , Sheckter Clifford C. , Berlin Nicholas L. , Nelson Jonas A. , Allen Robert , Rubin David , Kozlow Jeffrey H. , Matros Evan 
Published: January 2020

Background:
Rates of autologous breast reconstruction are stagnant compared with prosthetic techniques. Insufficient physician payment for microsurgical autologous breast reconstruction is one possible explanation. The payment difference between governmental and commercial payers creates a natural experiment to evaluate its impact on method of reconstruction. This study assessed the influence of physician payment differences for microsurgical autologous breast reconstruction and implants by insurance type on the likelihood of undergoing microsurgical reconstruction.

Methods:
The Massachusetts All-Payer Claims Database was queried for women undergoing immediate autologous or implant breast reconstruction from 2010 to 2014. Univariate analyses compared demographic and clinical characteristics between different reconstructive approaches. Logistic regression explored the relative impact of insurance type and physician payments on breast reconstruction modality.

Results:
Of the women in this study, 82.7 percent had commercial and 17.3 percent had governmental insurance. Implants were performed in 80 percent of women, whereas 20 percent underwent microsurgical autologous reconstruction. Women with Medicaid versus commercial insurance were less likely to undergo microsurgical reconstruction (16.4 percent versus 20.3 percent; p = 0.063). Commercial insurance, older age, and obesity independently increased the odds of microsurgical reconstruction (p < 0.01). When comparing median physician payments, governmental payers reimbursed 78 percent and 63 percent less than commercial payers for microsurgical reconstruction ($1831 versus $8435) and implants ($1249 versus $3359, respectively). Stratified analysis demonstrated that as physician payment increased, the likelihood of undergoing microsurgical reconstruction increased, independent of insurance type (p < 0.001).

Conclusions:
Women with governmental insurance had lower odds of undergoing microsurgical autologous breast reconstruction compared with commercial payers. Regardless of payer, greater reimbursement for microsurgical reconstruction increased the likelihood of microsurgical reconstruction. Current microsurgical autologous breast reconstruction reimbursements may not be commensurate with physician effort when compared to prosthetic techniques.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Risk, II.
Can You Trust What You Watch? An Assessment of the Quality of Information in Aesthetic Surgery Videos on YouTube
Authors: Gray Megan C. , Gemmiti Amanda , Ata Ashar , Jun Brandon , Johnson Philip K. , Ricci Joseph A. , Patel Ashit 
Published: January 2020

Background:
Videos on YouTube can be posted without regulation or content oversight. Unfortunately, many patients use YouTube as a resource on aesthetic surgery, leading to misinformation. Currently, there are no objective assessments of the quality of information on YouTube about aesthetic surgery.

Methods:
YouTube was queried for videos about the 12 most common aesthetic surgical procedures, identified from the 2015 American Society of Plastic Surgeons procedural statistics between May and June of 2016. The top 25 results for each search term were scored using the modified Ensuring Quality Information for Patients criteria based on video structure, content, and author identification. Average Ensuring Quality Information for Patients score, view count, and video duration were compared between authorship groups.

Results:
A total of 523 videos were graded after excluding duplicates. The mean modified Ensuring Quality Information for Patients score for all videos was 13.1 (SE, 0.18) of a possible 27. The videos under the search “nose reshaping” had the lowest mean score of 10.24 (SE, 0.74), whereas “breast augmentation” had the highest score of 15.96 (SE, 0.65). Physician authorship accounted for 59 percent of included videos and had a higher mean Ensuring Quality Information for Patients score than those by patients. Only three of the 21 search terms had a mean modified Ensuring Quality Information for Patients score meeting criteria for high-quality videos.

Conclusions:
The information contained in aesthetic surgery videos on YouTube is low quality. Patients should be aware that the information has the potential to be inaccurate. Plastic surgeons should be encouraged to develop high-quality videos to educate patients.
Recent Advances in Implant-Based Breast Reconstruction
Authors: Colwell Amy S. , Taylor Erin M. 
Published: January 2020

Learning Objectives:
After reading this article, the participant should be able to: 1. Understand the indications for implant-based breast reconstruction and the indications for nipple preservation compared to skin-sparing or skin-reducing patterns. 2. Understand the indications for direct-to-implant breast reconstruction versus tissue expander/implant breast reconstruction and the advantages and disadvantages of total, partial, or no muscle coverage. 3. Understand the role of acellular dermal matrix or mesh in reconstruction. 4. Learn the advantages and disadvantages of different types and styles of implants and develop a postoperative plan for care and pain management.

Summary:
Breast reconstruction with implants has seen a decade of advances leading to more natural breast reconstructions and lower rates of complications.
Challenging Traditional Thinking: Early Free Tissue Transfer for Active Hemifacial Atrophy in Children
Authors: Israel Jacqueline S. , Chen Jenny T. , Farmer Rebecca L. , Siebert John W. 
Published: January 2020

Background:
Hemifacial atrophy (Parry-Romberg syndrome) is an enigmatic craniofacial disorder characterized by progressive facial atrophy. Early age at onset is associated with significant skeletal involvement and jaw abnormalities. Standard reconstructive dogma dictates that the disease should “burn out,” with at least 2 years of no disease progression, before pursuing reconstructive intervention. The purpose of this article is to present the senior author’s (J.W.S.) experience treating preadolescent children with free soft-tissue transfer for reconstruction of progressing hemifacial atrophy, and to review surgical techniques in this patient population.

Methods:
Pediatric free tissue transfer cases performed by the senior author were reviewed. Free tissue transfer using a circumflex scapular adipofasciocutaneous flap was performed to treat deformities arising from hemifacial atrophy.

Results:
Thirty-six patients aged 3 to 6 years underwent free tissue transfer in the presence of progressing, active disease. Follow-up ranged from 7 months to 25 years. There were no cases of flap loss. In all patients, the disease process seemed to be altered, with no symptoms recurring to date.

Conclusions:
The authors believe that early microsurgical correction of hemifacial atrophy in children as young as 3 years is reliable and effective. The authors theorize that the interposition of vascularized, healthy tissue may alter or even halt the progression of disease, and may also prevent the skeletal hypoplasia classically seen in older patients. Further study incorporating autologous fat grafting as a control procedure may provide additional insight into this challenging disease process.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, IV.
Spare Roof Technique: A New Technique for Hump Removal—The Step-by-Step Guide
Authors: Gonçalves Ferreira Miguel , Santos Mariline , Rosa Francisco , Sousa Cecília A. , Santos Jorge , Dourado Nuno , Amarante José 
Published: January 2020

Summary:
Humpectomy is one of the most common steps in reduction rhinoplasty among Caucasian patients. The most widespread procedures to address hump removal are both the “en bloc humpectomy” (with reconstruction of the middle third with spreader grafts) and the “split hump technique” (with confection of spreader flaps). The spare roof technique, for rhinoplasty reduction, has been developed over the past 4 years. In this technique, the upper lateral cartilages are completely preserved—even the hidden part under the caudal aspect of the nasal bones. It consists of five main steps: step 1, the upper lateral cartilages are released from the dorsal aspect of the nasal septum; step 2, a 1-mm strip of the dorsal septum is taken in each movement as required; step 3, ostectomy of the caudal aspect of nasal bones, keeping the upper lateral cartilages intact and releasing the “lateral” (left and right) pyriform aperture ligament; step 4, classic medial and lateral osteotomies (closing the open bony roof); and step 5, suturing the upper lateral cartilages to the dorsal septum and thus avoiding the natural spring effect. The outcomes of the first 100 patients have been validated by a prospective, interventional, and longitudinal study performed on patients undergoing primary rhinoplasty by means of the spare roof technique. This study confirms that the spare roof technique significantly improved patient quality of life regarding nose function and appearance. It is a reliable technique that can help deliver consistently good results in Caucasian and Mediterranean patients with a dorsal hump seeking rhinoplasty.
Regional Patterns of Fluid and Fat Accumulation in Patients with Lower Extremity Lymphedema Using Magnetic Resonance Angiography
Authors: Dayan Joseph H. , Wiser Itay , Verma Richa , Shen Jody , Talati Nishi , Goldman Debra , Mehrara Babak J. , Smith Mark L. , Dayan, M.D. Erez , Coriddi, M.D. Michelle , Kagan Alexander 
Published: January 2020

Background:
Fat accumulation is frequently observed in patients with lymphedema but is not accounted for in existing staging systems. In addition, the specific regional patterns of fat and fluid accumulation remain unknown and might affect outcomes following medical or surgical intervention. The purpose of this study was to evaluate fluid and fat distribution in patients with lower extremity lymphedema using magnetic resonance angiography.

Methods:
Magnetic resonance angiographic examinations of patients with lower extremity lymphedema were reviewed. Fluid-fat grade and location were assessed by three observers. Three-point scales were developed to grade fluid (0 = no fluid, 1 = reticular pattern of fluid, and 2 = continuous stripe of subcutaneous fluid) and fat (0 = normal, 1 = subcutaneous thickness less than twice that of the unaffected side, and 2 = subcutaneous thickness greater than twice that of the unaffected side) accumulation.

Results:
In total, 76 magnetic resonance angiographic examinations were evaluated. Using the proposed grading system, there was good interobserver agreement for fat and fluid accumulation location (91.5 percent; κ = 0.9), fluid accumulation grade (95.7 percent; κ = 0.95), and fat accumulation grade (87.2 percent; κ = 0.86). Patients with International Society of Lymphology stage 2 lymphedema had a wide range of fluid and fat grades (normal to severe). The most common location of fluid accumulation was the lateral lower leg, whereas the most common location of fat accumulation was the medial and lateral lower leg.

Conclusion:
The proposed magnetic resonance angiographic grading system may help stratify patients with International Society of Lymphology stage 2 lymphedema on the basis of tissue composition.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Diagnostic, IV.
Concomitant Imbalances of Systemic and Mucosal Immunity Increase HIV Acquisition Risk
Authors: Morrison Charles S. , Chen Pai-Lien , Yamamoto Hidemi , Gao Xiaoming , Chipato Tsungai , Anderson Sharon , Barbieri Robert , Salata Robert , Doncel Gustavo F. , Fichorova Raina N. 
Published: January 2020

Background:
We previously reported association of increased cervical RANTES and decreased secretory leukocyte protease inhibitor (SLPI) with higher risk of HIV acquisition in reproductive-age women. We now examine the interaction of concomitantly altered systemic and cervical immunity on such risk.

Methods:
We measured immune biomarkers in 4390 cervical and 2390 paired serum specimens at quarterly visits in 218 HIV seroconverters and 784 seronegative women. We assessed proinflammatory (IL-1β, IL-6, IL-8, MIP-3α, and RANTES), anti-inflammatory (IL-1RA and SLPI), vascular activation (vascular endothelial growth factor and Intercellular Adhesion Molecule-1) and defensin (BD2) cervical biomarkers and systemic (peripheral blood) C reactive protein (CRP), IL-6, IL-7, and sCD14 as indicators of immune dysregulation. Biomarker levels were Box–Cox transformed and odds ratios for HIV acquisition calculated based on top quartile or higher/lower than median levels for all HIV-negative visits.

Results:
Subsequent HIV acquisition was associated with 5 of 14 individual biomarkers: low systemic CRP [odds ratio (OR) = 1.49, 1.21–1.83] and IL-6 (OR = 1.23, 1.00–1.51), high cervical BD-2 (OR = 1.33, 1.11–1.58) and RANTES (OR = 1.20, 1.01–1.43), and low cervical IL-1RA (OR = 0.65, 0.48–0.86). Low systemic CRP concomitant with altered cervical immunity, especially high BD2, conveyed highest HIV risk (1.63, 1.29–2.05). Additional markers of increased risk emerged when low systemic CRP coincided with: low systemic IL-6 and IL-7 (OR = 1.53, 1.18–1.97); high cervical IL-8 and MIP-3α (OR = 1.40, 1.07–1.83); high cervical IL-1β and IL-6 (OR = 1.43, 1.09–1.86); or low cervical SLPI (OR = 1.36, 1.08–1.71).

Conclusions:
Changes in both peripheral and mucosal immunity may precede and predispose women to HIV infection. Suppressed systemic immunity (ie, low CRP) alone or in combination with imbalanced cervical innate immunity (high proinflammatory and low anti-inflammatory mediators) indicated increased vulnerability to infection. Understanding these combined effects on HIV susceptibility is essential to preventing new infections.