bluuebunny/crossref_metadata_2025_split huggingface dataset:
Cephalometric Analysis of the Craniofacial Morphology in Patients With Moebius Syndrome
Authors: Telich-Tarriba Jose E. , Amador-Lara Arianel , Quiroz-Barrios Julio , Cardenas-Mejia Alexander 
Published: February 2021

Background:
Patients with Moebius syndrome may present a wide range of associated orofacial malformations, however, their craniofacial morphology has not been established via controlled cephalometric studies.

Objective:
To present our institution's findings in the cephalometric evaluation in patients with Moebius syndrome.

Methods:
Retrospective, cross-sectional study that included patients with Moebius syndrome over 9 years of age who had lateral cephalometric radiographs. Cephalometric analysis measurements of Ricketts, Steiner, and McNamara were performed. Quantitative data are expressed as mean and standard deviation, and qualitative data are expressed in totals and percentages. Comparative statistics between classic and incomplete Moebius and between patients older and younger than 16 years of age were performed.

Results:
Twenty-four patients were included (54.2% females), mean age 17.46 ± 8.85 years. Fifteen patients (62.5%) had classic Moebius syndrome, and nine (37.5%) had incomplete Moebius. Sixty-six percent of the patients presented either micrognathia or retrognathia, 95% showed mandibular hypoplasia, and 75% had a skeletal class II. Maxillary height was increased resulting in a vertical growth pattern. Upper and lower incisors tended towards proclination, and upper and lower lips protruded over cephalometric markings, and a long upper lip was evidenced in 41% of the patients. No significant differences were noted when comparing classic and incomplete Moebius syndrome. Patients younger than 16 years of age had significantly larger sella–nasion–A point and sella–nasion–B point angles, and a higher proportion of skeletal class II cases.

Conclusions:
Patients with Moebius syndrome have a vertical maxillary growth, micro or retrognathia, developing a skeletal class II and lip protrusion.
Use of Dental Bisphenol A-Glycidyl Methacrylate Composite to Repair Refractory Cerebrospinal Fluid Leaks Associated With Large-Scale Anterior Skull Base Defects
Authors: Paul Djientcheu Vincent de , Fankem Casimir , Halalmeh Dia R. , Clement Ewo , Sandio Aubin , O Haman , Moisi Marc D. , Sosso Aurelien M. 
Published: February 2021

Abstract
Treatment of refractory cerebrospinal fluid (CSF) leaks, particularly those associated with large skull base defects, is challenging. A variety of synthetic biomaterial-based systems have been investigated in experimental models and/or humans for reconstructing cranial base defects. A widely used dental composite (bisphenol A-glycidyl methacrylate [bis-GMA]) has been shown to be effective for reconstruction of anterior skull base defects in animal models. Here, we report 4 patients who underwent reconstruction of large anterior skull base defects (1405.8 ± 511 mm2) secondary to tumor resection and traumatic injury using the dental bis-GMA resin-based composite. A vascularized pericranial flap with fibrin glue was initially performed in all patients with concurrent use of dental bis-GMA during the primary surgery in 2 patients, and later use (in a repeat surgery) in other 2 cases. In these latter 2, CSF rhinorrhea persisted after the initial surgery (in the absence of bis-GMA use) despite external CSF drainage with lumbar drain. Following treatment with bis-GMA, rigid structural support and watertight closure of the defect were successfully achieved. At the follow-up, CSF leak did not recur and none of the patients had any complications related to the surgery or the composite. The results obtained from this series are promising, and dental bis-GMA resin seems to provide an effective and feasible material for the treatment and prevention of CSF leaks related to large-scale anterior skull base defects. However, further studies with longer clinical follow-up and larger number of patients are required to prove the safety and efficacy of this matrix in the long run.
Firearm Violence, Access to Care, and Gentrification
Authors: Scantling Dane , Orji Whitney , Hatchimonji Justin , Kaufman Elinore , Holena Daniel 
Published: February 2021

Objective:
We aimed to determine whether gentrification predicts the movement of shooting victims over time and if this process has decreased access to care.

Background:
Trauma centers remain fixed in space, but the populations they serve do not. Nationally, gentrification has displaced disadvantaged communities most at risk for violent injury, potentially decreasing access to care. This process has not been studied, but an increase of only 1 mile from a trauma center increases shooting mortality up to 22%.

Methods:
We performed a cross-sectional study utilizing Philadelphia Police Department (PPD) and Pennsylvania trauma systems outcome (PTOS) data 2006–2018. Shootings were mapped and grouped into census tracts. They were then cross-mapped with gentrification data and hospital location. PPD and PTOS shooting data were compared to ensure patients requiring trauma care were captured. Census tracts with ≥500 residents with income and median home values in the bottom 40th percentile of the metropolitan area were eligible to gentrify. Tracts were gentrified if residents ≥25 with a bachelor's degree increased and home price increased to the top third in the metropolitan area. Change in distribution of shootings and its relation to gentrification was our primary outcome while proximity of shootings to a trauma center was our secondary outcome.

Results:
Thirty-two percent (123/379) of eligible tracts gentrified and 31,165 shootings were captured in the PPD database. 9090 (29.2%) patients meeting trauma criteria were captured in PTOS with an increasing proportion over time. The proportion of shootings within gentrifying tracts significantly dropped 2006–2018 (40%–35%, P < 0.001) and increased in non-gentrifying tracts (52%–57%, P < 0.001). In evaluation of shooting densities, a predictable redistribution occurred 2006–2018 with incident density decreasing in gentrified areas and increasing in non-gentrified areas. Shootings within 1 mile of a trauma center increased overall, but proportional access decreased in gentrified areas.

Conclusions:
Shootings in Philadelphia predictably moved out of gentrified areas and concentrated in non-gentrified ones. In this case study of a national crisis, the pattern of change paradoxically resulted in an increased clustering of shootings around trauma centers in non-gentrified areas. Repetition of this work in other cities can guide future resource allocation and be used to improve access to trauma care.
Comprehensive Characterization of the General Surgery Residency Learning Environment and the Association With Resident Burnout
Authors: Ellis Ryan J. , Nicolas Joseph D. , Cheung Elaine , Zhang Lindsey , Ma Meixi , Turner Patricia , Nussbaum Michael S. , Are Chandrakanth , Smink Douglas S. , Etkin Caryn , Bilimoria Karl Y. , Hu Yue-Yung 
Published: February 2021

Objectives:
To characterize the learning environment (ie, workload, program efficiency, social support, organizational culture, meaning in work, and mistreatment) and evaluate associations with burnout in general surgery residents.

Background Summary Data:
Burnout remains high among general surgery residents and has been linked to workplace exposures such as workload, discrimination, abuse, and harassment. Associations between other measures of the learning environment are poorly understood.

Methods:
Following the 2019 American Board of Surgery In-Training Examination, a cross-sectional survey was administered to all US general surgery residents. The learning environment was characterized using an adapted Areas of Worklife survey instrument, and burnout was measured using an abbreviated Maslach Burnout Inventory. Associations between burnout and measures of the learning environment were assessed using multivariable logistic regression.

Results:
Analysis included 5277 general surgery residents at 301 programs (85.6% response rate). Residents reported dissatisfaction with workload (n = 784, 14.9%), program efficiency and resources (n = 1392, 26.4%), social support and community (n = 1250, 23.7%), organizational culture and values (n = 853, 16.2%), meaning in work (n = 1253, 23.7%), and workplace mistreatment (n = 2661, 50.4%). The overall burnout rate was 43.0%, and residents were more likely to report burnout if they also identified problems with residency workload [adjusted odds ratio (aOR) 1.60, 95% confidence interval (CI) 1.31–1.94], efficiency (aOR 1.74; 95% CI 1.49–2.03), social support (aOR 1.37, 95% CI 1.15–1.64), organizational culture (aOR 1.64; 95% CI 1.39–1.93), meaning in work (aOR 1.87; 95% CI 1.56–2.25), or experienced workplace mistreatment (aOR 2.49; 95% CI 2.13–2.90). Substantial program-level variation was observed for all measures of the learning environment.

Conclusions:
Resident burnout is independently associated with multiple aspects of the learning environment, including workload, social support, meaning in work, and mistreatment. Efforts to help programs identify and address weaknesses in a targeted fashion may improve trainee burnout.
Association of a Statewide Surgical Coaching Program With Clinical Outcomes and Surgeon Perceptions
Authors: Greenberg Caprice C. , Byrnes Mary E. , Engler Tedi A. , Quamme Sudha Pavuluri R. , Thumma Jyothi R. , Dimick Justin B. 
Published: February 2021

Objective:
To assess risk-adjusted outcomes and participant perceptions following a statewide coaching program for bariatric surgeons.

Summary of Background Data:
Coaching has emerged as a new approach for improving individual surgeon performance, but lacks evidence linking to clinical outcomes.

Methods:
This program took place between October 2015 and February 2018 in the Michigan Bariatric Surgery Collaborative. Surgeons were categorized as coach, participant, or nonparticipant for an interrupted time series analysis. Multilevel logistic regression models included patient characteristics, time trends, and number of sessions. Risk-adjusted overall and surgical complication rates are reported, as are within-group relative risk ratios and 95% confidence intervals. We also compared operative times and report risk differences and 95% confidence intervals. Iterative thematic analysis of semi-structured interviews examined participant and coach perceptions of the program.

Results:
The coaching program was viewed favorably by most surgeons and many participants described numerous technical and nontechnical practice changes. The program was not associated with significant change in risk-adjusted complications with relative risks for coaches, participants, and nonparticipants of 0.99 (0.62–1.37), 0.91 (0.64–1.17), and 1.15 (0.83–1.47), respectively. Operative times did improve for participants, but not coaches or nonparticipants, with risk differences of –14.0 (–22.3, –5.7), –1.0 (–4.5, 2.4), and –2.6 (–6.9, 1.7). Future coaching programmatic design should consider dose-complexity matching, hierarchical leveling, and optimizing video review.

Conclusions:
This statewide surgical coaching program was perceived as valuable and surgeons reported numerous practice changes. Operative times improved, but there was no significant improvement in risk-adjusted outcomes.
Transanal Endoscopic Microsurgery: An Alternative Perineal Approach to Treat Rectal Prolapse: A Video Vignette
Authors: Pallisera-Lloveras Anna , Arruabarrena-Oyarbide Arantxa , Mora-López Laura , Serra-Pla Sheila , Serracant-Barrera Anna , García-Nalda Albert , Navarro-Soto Salvador , Serra-Aracil Xavier 
Published: February 2021

Purpose:
Laparoscopic ventral rectopexy is the most favored surgical treatment for rectal prolapse. Perineal approaches are recommended for frail patients and those with major comorbidities, and in young men to avoid genitourinary disorders. There are very few descriptions in the literature of transanal endoscopic surgery to treat complete rectal prolapse. The aim of this article is to describe our experience with this technique.

Patients and Methods:
Patients undergoing transanal endoscopic surgery for rectal prolapse repair between 2010 and 2019 were recruited for the study. Preoperative, surgical, and postoperative variables were recorded. Surgical technique, 30-day morbidity and follow-up are described.

Results:
Five patients have been included. The postoperative period was uneventful and all patients were discharged in 48 hours without complications. All showed improved symptoms at 1-year control, and none presented recurrence in a mean follow-up period of 6 years.

Conclusions:
The transanal endoscopic procedure allows improved endoscopic vision, and the reconstruction is performed transpelvically by fixing the anastomosis suture to the pelvic wall to prevent recurrence. Therefore, we think it is a valid alternative to other perineal procedures in patients in whom abdominal surgery is contraindicated.
Causes and Countermeasures of Difficult Selective Biliary Cannulation: A Large Sample Size Retrospective Study
Authors: Liu Yang , Liu Wei , Hong Junbo , Li Guohua , Chen Youxiang , Xie Yong , Zhou Xiaojiang 
Published: February 2021

Objective:
Selective biliary cannulation is a difficult part of endoscopic retrograde cholangiopancreatography (ERCP). Therefore, endoscopists have focused on how to improve the cannulation success rate and reduce the postoperative complication rate. This study aims to provide practical advice on safe operation for endoscopists.

Materials and Methods:
Data from the ERCP database of our medical center from January 2008 to December 2017 were retrospectively reviewed. All patients underwent ERCP for the first time. Data pertaining to diseases, anatomic factors, difficult cannulation rates, cannulation success rates, and postoperative complication rates for various assistive cannulation techniques were analyzed by using the Pearson χ2 tests and Fisher exact tests.

Results:
The difficult cannulation rate was 8.1%. The main influencing factors were benign and malignant biliary stricture, duodenal papillae or ampullary tumors, thick and long duodenal papillae, peridiverticular papillae, ectopic papillae, edematous papillae, ulcerative papillae, anomalous pancreaticobiliary junction, and Billroth II gastrectomy. The postoperative complication rates and overall cannulation success rates of 7 assistive techniques were not statistically different (P>0.05), but the overall complication rates were statistically different (P<0.05). Needle-knife precut sphincterotomy had the highest rate of complications.

Conclusions:
Benign and malignant biliary stricture, duodenal papillae or ampullary tumors, thick and long duodenal papillae, peridiverticular papillae, ectopic papillae, edematous papillae, ulcerative papillae, anomalous pancreaticobiliary junction, and Billroth II gastrectomy were the main factors of difficult selective biliary cannulation. The overall incidence of needle-knife precut sphincterotomy complications was higher than that of other techniques, but various assistive techniques were safe and effective in our single center.
Rib-oriented Thoracoscopic Sympathetic Surgery for Hyperhidrosis: Prospective Long-term Results and Quality of Life
Authors: Nachira Dania , Meacci Elisa , Congedo Maria T. , Petracca-Ciavarella Leonardo , Zanfrini Edoardo , Iaffaldano Amedeo , Vita Maria L. , Chiappetta Marco , Griffo Raffaella , Lococo Filippo , Margaritora Stefano 
Published: February 2021

Background:
The optimal thoracoscopic sympathetic surgery for primary palmar and/or axillary hyperhidrosis (PPAH) is still unclear because of lack of uniform technique and qualitative/quantitative scales for definition of results. The aims of this study were to compare long-term outcomes based on the surgical technique and the level of sympathetic trunk interruption by clipping and to assess postoperative compensatory sweating (CS), patients’ satisfaction, and quality of life (QoL).

Materials and Methods:
Between September 2009 and April 2016, 94 patients who underwent 2-stage bilateral thoracoscopic rib-oriented (R) sympathetic clipping were prospectively followed up through the administration of standardized preoperative and postoperative questionnaires.
Thirty-four (36.2%) patients underwent single-port transaxillary access instead of the standard two 5-mm incisions. The level of sympathetic clipping for PPAH was R3+4(top and bottom); in patients who complained associated facial or plantar hyperhidrosis R2-bottom and R5-top were clipped, respectively. Seventy-five patients completed bilateral surgery.

Results:
There were no significant differences between single-port and biportal video-assisted thoracoscopic surgery in terms of operative times and postoperative results. At a mean follow-up of 72 (SD: 26) months, CS was reported in 42 (56%) patients, severe only in 6 (8%). It was higher in the case of R2-bottom clipping (P=0.03). Thirty-one of 60 (51.6%) patients who had a plantar hyperhidrosis declared an improvement of feet sweating after surgery. Postoperative satisfaction was excellent (86.11% on a 0 to 100 scale) and 95.4% of patients declared an improvement in QoL, which was statistically significant in all evaluated parameters. These results were not related to the level of clipping.

Conclusion:
Thoracoscopic R3 to R4 clipping appears to be a safe and effective treatment for PPAH. Although postoperative CS was common and higher after R2-bottom clipping, this did not seem to affect patients’ satisfaction and improvement in QoL.
Rates of Pessary Self-Care and the Characteristics of Patients Who Perform it
Authors: Holubyeva Anastasiya , Rimpel Katherinne , Blakey-Cheung Sophia , Finamore Peter S. , O’Shaughnessy Danielle L. 
Published: February 2021

Objective
The aims of this study were to determine the percentage of patients who opt to undergo pessary self-care versus those who return to the office for care and to identify any differences in the characteristics between the 2 groups.

Methods
This study is a retrospective chart review conducted at a tertiary care center. Demographic data; details regarding pessary use; body weight; pelvic organ prolapse stage; and medical, surgical, and obstetrical histories were evaluated. Variables were compared between groups of patients using the t test, Wilcoxon rank sum test, χ2 test, and Fisher exact test.

Results
The rate of patients choosing to perform pessary self-care was 31%. The patients in the self-care group were significantly younger (65.0 vs 75.0 years, P < 0.001). Those who were performing self-care were more likely to be premenopausal (6.9% vs 1.5%, P = 0.003), have a lower stage of pelvic organ prolapse (61.3% vs 42.1%, P < 0.001), and more likely to be sexually active (40.5% vs 9.6%, P < 0.001). Those not performing self-care had higher rates of vaginal bleeding (26.0% vs 16.4%, P = 0.012) and erosion (23.5% vs 9.9%, P < 0.001). Self-care patients predominantly used the ring with support pessary, whereas those in the non–self-care group were mostly using the Gellhorn.

Conclusions
Only one third of patients who use a pessary chose to perform self-care. Patients who use self-care are younger, premenopausal, sexually active, and have lower degrees of prolapse. These data can help educate patients on the characteristics more often seen in those choosing self-care. This study highlights the importance of further exploring pessary care preferences and using this information for counseling.
National estimates of intestinal ostomy creation and reversal for trauma
Authors: Hashmi Zain G. , Dalton Michael K. , Sheikh Saulat S. , McCarty Justin C. , Salim Ali , Haider Adil H. 
Published: February 2021

BACKGROUND
Intestinal ostomy creation after trauma is selectively indicated for destructive colon and rectal injuries. However, the nationwide rates of creation of ostomies for trauma and their reversal are not known. The objective of this study was to ascertain national estimates of trauma ostomy creation and reversal.

METHODS
Weighted analysis of Healthcare Cost and Utilization Project Nationwide Readmissions Database 2014 to 2015 was performed. Adult trauma patients (≥16 years) with a hollow viscus injury were included. Patients with preexisting ostomies and permanent ostomies and those who died within 48 hours of admission were excluded. Rates of ostomy creation and same admission ostomy reversal were calculated. Rates of postdischarge ostomy reversal were calculated using the Kaplan-Meier estimator. Multivariable Cox proportional hazards model was used to determine factors associated with postdischarge trauma ostomy reversal.

RESULTS
A total of 22,542 patients sustained a hollow viscus injury resulting in the creation of 2,145 ostomies (9.6%). The rate of same-admission ostomy reversal was 0.7% (n = 16). At 1, 3, 6, and 9 months, the cumulative stoma reversal rates were 0%, 7.6%, 31.0%, and 43.1%, respectively. The mean ± SD time from ostomy creation to reversal was 123 ± 6.7 days for those undergoing reversal. Injury Severity Score greater than 9 was significantly associated with ostomy nonreversal after discharge (hazard ratio, 0.41; 95% confidence interval, 0.26–0.66). Age, sex, insurance status, penetrating injury, Charlson Comorbidity Index, and hospital teaching status were not significantly associated with ostomy reversal.

CONCLUSION
The nationwide rate of ostomy creation after trauma is nearly 10%. At 6 months postinjury, only one third of patients had undergone ostomy reversal. Future study is needed to understand patient and provider-level factors associated with trauma ostomy reversal.

LEVEL OF EVIDENCE
Epidemiology, level III.
When to stay out of the abdomen: Extending extraperitoneal approaches to complex ventral and incisional hernias—A video-based guide to the technique
Authors: Pakula Andrea , Martin Matthew 
Published: February 2021

BACKGROUND
Ventral and incisional hernias are common surgical pathologies managed by acute care surgeons and also an area of exploration in repair options and approaches. Several new minimally invasive techniques have been developed to better tailor the repair to the individual patient and minimize the risk of intra-abdominal complications, particularly in patients with significant adhesions from prior surgery or trauma. The extended totally extraperitoneal approach to incisional ventral hernias allows the repair of complex hernias while entirely avoiding entry into the peritoneal cavity.

METHODS
We present video clips demonstrating key steps to minimally invasive extended totally extraperitoneal Rives-Stoppa and transversus abdominis release procedures to complex incisional and ventral hernias.

CONCLUSION
The application of robotic-assisted laparoscopic surgery has enabled surgeons to expand the use of minimally invasive techniques for a variety of operations. Hernia repair in particular has seen the most rapid growth because of the enhanced ability to suture on the anterior abdominal wall. This video illustrates the key technical points to performing a safe and effective repair without the need for intraperitoneal access.