bluuebunny/crossref_metadata_2025_split huggingface dataset:
Putting Theory to Practice
Authors: Cramer Natan , Zuckerbraun Noel Spears , Puller Justin , Furtado Andre D. , Deb Arjamon , Dorfsman Michele L. , Siripong Nalyn , Christie Meghan , Tavarez Melissa M. 
Published: February 2021

Objective
We built 2 versions of an asynchronous pediatric orthopedic educational intervention for emergency medicine residents and sought to compare the two. We hypothesized that the version incorporating more instructional scaffolding in the form of a cognitive aid (CA) would optimize germane cognitive load for our target novice learners and result in higher test scores.

Methods
Learners were block randomized to either a “CA” or “non-CA” arm, each containing a random set of 18 modules. The CA arm incorporated an orthopedic fracture classification chart embedded within the diagnostic questions to guide the learner in forming a diagnosis. The non-CA arm was designed with more active learning as the classification chart was provided only after each diagnostic answer submission. For both arms, the final 6 modules completed per learner were scored. Learners also completed a perceived cognitive load assessment tool measured on a 10-point Likert scale.

Results
Learners in the non-CA arm had a mean total score on the testing modules of 33% correct compared with a mean total score of 44% correct for learners in the CA arm (mean difference, 11; 95% confidence interval, 4%–19%, P = 0.005). There was a trend for the CA arm to have lower perceived overall cognitive load scores; however, this did not reach statistical significance.

Conclusions
Emergency medicine residents performed better after completing the CA version of our educational intervention. Applying cognitive load theory to an educational intervention may increase its success among target learners.
Variables Associated With Shunt Failure in Children With Cerebrospinal Fluid Diverting Shunts
Authors: Burns Beech Stephen , Tanski Mary , Heilman James , Lin Amber , Ma Oscar John , Baird Lissa 
Published: February 2021

Pediatric patients with shunted hydrocephalus are frequently evaluated in the emergency department (ED) with concern for shunt failure. Because shunt failure is potentially life-threatening, accurate diagnosis is essential. However, neuroimaging imperfectly detects children in failure, with reported sensitivities of 53% to 92% for computed tomography and 51% to 59% for magnetic resonance imaging.

Objectives
We sought to identify clinical characteristics that would negatively predict shunt failure, thus potentially obviating the need for further diagnostic workup or extended periods of observation. We hypothesized that viral symptoms and a patient history of epilepsy or chronic headaches would be negative predictors of shunt failure.

Methods
Data were retrospectively collected for children 19 years or younger with a cerebrospinal fluid diverting shunt in their medical history or problem list who underwent neuroimaging during an ED visit from March 2008 to September 2016. Patients were defined as having shunt failure if they required surgical exploration for shunt revision within 7 days of the ED visit. Descriptive statistics were used for patient demographics, current symptoms, and historical features. We conducted a logistic regression analysis to determine which characteristics were associated with the odds of shunt failure and used binary recursive partitioning to determine if there were features or a combination of features that were able to accurately classify patients without shunt failure.

Results
There were 606 visits by 277 patients during this interval, 34% of whom were experiencing shunt failure. Variables found to be significantly predictive of shunt failure were revision within the prior 6 months, vomiting, personality changes, family opinion of shunt failure, and cranial nerve palsies. Viral symptoms and a history of epilepsy or chronic headaches were not predictive of shunt failure. Binary recursive partitioning identified family opinion and personality changes as predictive of shunt failure, with a sensitivity of 72.2% (95% confidence interval, 65.5%–78.2%) and specificity of 46.6% (95% confidence interval, 41.7%–51.7%).

Conclusions
Although certain clinical and historical features have modest predictive value in children with shunted hydrocephalus, these factors are insufficiently sensitive to exclude shunt failure, arguing for liberal neuroimaging and extended observation.
Unique Pattern of Intrahepatic T-cell Clonality in Biliary Atresia Livers Versus Intestinal Controls: A Pilot Study
Authors: Ogholikhan Sina , Schwarz Kathleen B. , Anders Robert 
Published: February 2021

Biliary atresia (BA) is a rare infantile cholangiopathy of unclear etiology proposed by some to be due to virus-induced autoreactive T-cell-mediated inflammation. The hallmark of T cell activity is clonal expansion of T lymphocytes expressing similar T-cell receptor (TCR) variable regions of the β-chain.

Objective:
To test our hypothesis that BA liver tissues would show clonal expansion of 1 or several TCRs.

Methods:
The complementarity-determining region 3 region of the β-chain of the TCR was characterized using next-generation sequencing of 7 BA liver samples (age 51 ± 14 days) and 9 intestinal control samples (age 38 ± 16 days). Following sequencing, clonality scores, various VDJ recombinations, total and productive templates, and complementarity-determining region 3 length were measured using the immunoSEQ Analyzer.

Results:
Next-generation sequencing revealed 1 common TCR rearrangement in 3 BA samples not found in controls. There was a highly diverse TCR population among BA liver and the control samples. The clonality scores ranged from 0.0004 to 0.0062 using a Shannon’s entropy score, with numbers close to 0 being highly diverse and numbers close to 1 being highly clonal. The most common TCR VDJ recombinations comprised 1.47–12.9% of the total population of TCR for the BA tissues and 1.05–10.3% for the control samples.

Conclusions:
Our results show a highly diverse TCR repertoire among all of our samples. However, predominant TCR clonality was not found in any sample. Further studies are required for any possible antigenic triggers responsible for the unique T-cell rearrangements observed in the BA samples.
Effects of Transcranial Direct Current Stimulation on Muscle Fatigue in Recreational Runners
Authors: Uehara Laura , Boari Coelho Daniel , Leal-Junior Ernesto Cesar Pinto , Vicente de Paiva Paulo Roberto , Batista Abrahão Fontes , Duarte Moreira Rafael Jardim , Faria Coura Maria Helena , Hideki Okano Alexandre , Ferrari Corrêa João Carlos , Corrêa Fernanda Ishida 
Published: February 2021

Objectives
The aim of this study is to evaluate the effects of transcranial direct current stimulation (tDCS) on central and peripheral fatigue in recreational runners.

Design
This is a clinical randomized, sham-controlled, triple-blind, crossover study. Twenty adult runners will be randomized on the first day of the intervention to receive active or sham tDCS before fatigue protocol. After 1 wk, the participants will receive the opposite therapy to the one that they received on the first day. The tDCS, 2 mA, will be applied for 20 mins over the motor cortex. The fatigue protocol will be performed after tDCS, in which the participant should perform concentric knee flexion/extension contractions until reaching three contractions at only 50% of maximum voluntary contraction. Central fatigue will be evaluated with the motor evoked potential of the quadriceps muscle; peripheral fatigue with the peak torque (N.m) using an isokinetic dynamometer; the electrical activity of the quadriceps muscle using surface electromyography (Hz); blood lactate level (mmol/L); and the subjective perception of effort (Borg scale). All evaluations will be repeated before and after the interventions.

Conclusion
This study will evaluate the effect of tDCS on fatigue in runners, possibly determining an application protocol for this population.
The Flexor Pollicis Longus Reflex
Authors: Gladitz Luisa Marilena , Schöttker-Königer Thomas , Sturm Christian , Gutenbrunner Christoph , Ranker Alexander 
Published: February 2021

Objective
The aim of this study was to investigate the interrater reliability and intrarater reliability of the flexor pollicis longus muscle stretch reflex (FPLR) and compare it with clinically established reflexes.

Design
A total of 71 healthy volunteers participated. The FPLR, biceps reflex, brachioradialis reflex, and patellar tendon reflex of each participant were tested bilaterally and rated by eight examiners (four experienced, four inexperienced). For intrarater reliability evaluation, five examiners rated the reflexes of four volunteers at four different points in time.

Results
Analysis of the interrater reliability with Gwet’s AC1 demonstrated almost perfect agreement for FPLR (Gwet’s AC1 = 0.90), biceps reflex (Gwet’s AC1 = 0.90), and patellar tendon reflex (Gwet’s AC1 = 0.95) when using binary data (reflex present vs. absent). Only fair agreement was found for the brachioradialis reflex (Gwet’s AC1 = 0.56). Experienced raters had a higher agreement than inexperienced raters did when rating the biceps reflex and the patellar tendon reflex. The intrarater reliability was almost perfect for the patellar tendon reflex (Gwet’s AC1 = 0.94), followed by the FPLR (Gwet’s AC1 = 0.83) with substantial agreement and the biceps reflex (Gwet’s AC1 = 0.57) with moderate agreement.

Conclusion
The FPLR is a reliable diagnostic neuromuscular test and may therefore be useful in the clinical examination for C8/T1 nerve root lesions or pathologies of the interosseous anterior nerve.

To Claim CME Credits
Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME

CME Objectives
Upon completion of this article, the reader should be able to: (1) Elicit the flexor pollicis longus muscle stretch reflex; (2) Discuss the disadvantage of kappa statistics in assessing the interrater reliability when the prevalence of the studied trait is very high or very low; and (3) Name the spinal nerves involved in the innervation of the flexor pollicis longus muscle.

Level
Advanced

Accreditation
The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
BREAST-Q Outcomes before and after Bilateral Reduction Mammaplasty
Authors: Wampler Ariel T. , Powelson Ian A. , Homa Karen , Freed Gary L. 
Published: February 2021

Background:
The BREAST-Q is the only questionnaire specific to bilateral breast reduction that was developed according to federal and international standards. Many payors mandate minimum resection weights for preapproval, despite lacking supportive evidence for this practice. This study aimed to assess changes in BREAST-Q scores after bilateral breast reduction, and determine whether compliance with Schnur requirements impacts improvement in patient-reported outcomes.

Methods:
Patients presenting for bilateral breast reduction from 2011 to 2017 were asked to complete the BREAST-Q preoperatively and postoperatively. Multivariate regression analysis was performed to isolate factors associated with favorable outcomes.

Results:
Complete data were available for 238 patients. Mean time to postoperative BREAST-Q was 213 days. Complications occurred in 31 patients (13.0 percent). Mean preoperative BREAST-Q scores were below normative values (p < 0.001), and mean postoperative scores were above normative values (p < 0.001 for Satisfaction with Breasts, Psychosocial Well-being, and Sexual Well-being; and p = 0.05 for Physical Well-being). Postoperative Physical Well-being scores were similar to normative values for resections less than Schnur (p = 0.32), but below norms for resections greater than Schnur (p < 0.0001). On multivariate regression (n = 230), complication and surgeon experience were the only independent predictors of lesser improvement on the Satisfaction with Breasts subscale.

Conclusions:
This study is the largest to include both preoperative and postoperative bilateral breast reduction BREAST-Q scores, and to compare multiple subscales to normative data. Scores overwhelmingly increased, regardless of age or Schnur compliance. Complications negatively impacted degree of BREAST-Q improvement. Interestingly, postoperative Physical Well-being was slightly higher in women with non–Schnur-compliant resections. Bilateral breast reduction substantially improves patient welfare, and our data question the validity of insurer-mandated minimum resections.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, III.
Lipofilling after Laser-Assisted Treatment for Facial Filler Complication: Volumetric and Regenerative Effect
Authors: De Santis Giorgio , Pinelli Massimo , Benanti Elisa , Baccarani Alessio , Starnoni Marta 
Published: February 2021

Background:
Nonresorbable substances are still injected to enhance soft-tissue volumes and fill subcutaneous defects. The minimally invasive intralesional laser treatment can remove foreign substances and the inflammatory reaction, eventually leaving depression and scar tissue in the treated area. Fat grafting can restore volume loss and improve scar tissue.

Methods:
From March of 2010 to February of 2017, 33 patients were studied. All of them had suffered from inflammatory reactions to permanent facial fillers and had been treated with the 808-nm diode laser at the authors’ institution. The evacuation of material had left facial asymmetry and visible depression. To restore facial aesthetic units, fat grafting was performed. The minimum follow-up was 6 months.

Results:
Volume restoration was recognized (according to the Global Aesthetic Improvement Scale) as significantly improved in 22 patients, moderately improved in eight patients, and slightly improved in three patients. Improvement in atrophic and scarred tissues (with an apparent thickening of the skin or even elimination of scars) was also assessed with the following results: 25 patients were very much improved and eight were moderately improved.

Conclusions:
This is the first study on filler-induced complications of the face treated by intralesional laser treatment followed by lipofilling. A systematic approach to volume restoration is proposed to patients who had filler removal of the face. There was a high degree of patient satisfaction with this technique.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, IV.
Time-Driven, Activity-Based Costing of Presurgical Infant Orthopedics: A Critical Component of Establishing Value of Latham Appliance and Nasoalveolar Molding
Authors: Ganske Ingrid M. , Sanchez Karl , Le Elliot , Langa Olivia C. , Sharif-Askary Banafsheh , Ross Elizabeth , Santiago Pedro , Meara John G. , Padwa Bonnie L. , Allori Alexander C. 
Published: February 2021

Background:
Value-based health-care reform requires assessment of outcomes and costs of medical interventions. In cleft care, presurgical infant orthopedics is still being evaluated for clinical benefits and risks; however, the cost of these procedures has been largely ignored. This study uses robust accounting methods to quantify the cost of providing two types of presurgical infant orthopedics: Latham appliance treatment and nasoalveolar molding.

Methods:
This is a prospective study of patients with nonsyndromic cleft lip and/or palate who underwent treatment with presurgical infant orthopedics from 2017 to 2019 at two academic centers. Costs were measured using time-driven activity-based costing. Personnel costs, facility costs (operating room, clinic, and inpatient ward), and equipment costs were included. Travel expenses were incorporated as an estimate of direct costs borne by the family, but indirect costs (e.g., time off from work) were not considered.

Results:
Twenty-three patients were treated with Latham appliance treatment and 14 were treated with nasoalveolar molding. For Latham appliance treatment, average total cost was $7553 per patient ($1041 for personnel, $637 for equipment, $4871 for facility, and $1004 for travel over 6.5 visits). Unilateral and bilateral costs were $6891 and $8860, respectively. For nasoalveolar molding, average cost totaled $2541 ($364 for personnel, $151 for equipment, $300 for facility, and $1726 for travel over 13 visits); $2120 for unilateral and $3048 for bilateral treatment.

Conclusions:
The major difference in cost is attributable to operative placement of the Latham device. Travel cost for nasoalveolar molding is often higher because of frequent clinical encounters required. Future investigation should focus on whether outcomes achieved by presurgical infant orthopedics justify the $2100 to $8900 expenditure for these adjunctive procedures.
A Safer Way to Harvest a Superthin Perforator Flap
Authors: Innocenti Marco , Calabrese Sara , Tanini Sara , Malzone Gerardo , Innocenti Alessandro 
Published: February 2021

Summary:
The updated knowledge of perforasome anatomy and the evolution of microsurgical techniques have enabled surgeons to safely harvest a thin flap. Recently, the anterolateral thigh perforator flap, the current workhorse in soft-tissue reconstruction, has started to be designed and harvested on the superficial fascia, which divides the deep from the superficial fat. This allows elevation of a very thin flap tailored to the defect. Faithful to the ultrathin concept, in an attempt to make flap dissection simpler and safer, the authors describe a revisited harvesting technique of superthin anterolateral thigh perforator flap. This study presents the outlined technique performed in 16 patients with complex soft-tissue defects after trauma or tumor ablation. All of them underwent primary reconstruction using superthin anterolateral thigh perforator free flaps by superficial fascia elevation harvested according to the described surgical procedure. Complications and functional outcomes were assessed. The authors’ series of anterolateral thigh perforator superthin flaps demonstrated an overall 100 percent survival rate. Of 16 anterolateral thigh perforators, 12 (75 percent) had no complications and four (25 percent) had minor complications. No major complications such as total flap loss requiring additional salvage surgery were reported. In no case was secondary debulking performed. The superthin anterolateral thigh perforator flap harvested with the described approach was used successfully in microsurgical reconstruction, providing an excellent outer skin cover tailored to the defect. The dissection procedure was safe, quick, simple, and free of major complications. With minimal donor- and recipient-site morbidity, it provided great aesthetic results, avoiding secondary operations.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, IV.
Are You Ready to Negotiate Your First Employment Contract? Experience of More Than 700 Plastic Surgeons
Authors: Hollier Larry H. , Davis Matthew J. , Abu-Ghname Amjed , Patel Nirav B. , Pacitti Steven , Reece Edward M. 
Published: February 2021

Background:
Plastic surgeons have been shown to be unprepared to negotiate their first employment contracts. Previous survey studies have attempted to assess plastic surgeons’ first employment contracts to outline common pitfalls in contract negotiation. With this study, the authors aim to expand these previous studies and help plastic surgeons become prepared to negotiate their employment contracts.

Methods:
A seven-question, cross-sectional survey was sent to attending-level surgeon members of the California Society of Plastic Surgeons, the American Society of Plastic Surgeons, the Texas Society of Plastic Surgeons, and the American Cleft Palate-Craniofacial Association. Questions investigated plastic surgeons’ first contracts. Correlations were determined using a two-sample Wilcoxon rank sum test in an attempt to link these questions with overall satisfaction.

Results:
From the 3908 distributed surveys, 782 (20 percent) responses were collected, and 744 were included for analysis. The majority of respondents were found to join a group-centered, private practice following residency. Surprisingly, 69 percent of surgeons did not use attorney assistance when negotiating their contract. Although greater than 70 percent of respondents reported a salary of $200,000 or less, satisfaction with one’s contract was most strongly correlated with a salary of greater than $300,000 (p < 0.0001). However, only 12 percent of respondent surgeons were able to secure such a salary.

Conclusions:
This study examined the largest, most diverse plastic surgeon cohort to date regarding surgeons’ first employment contract. Although the authors’ findings indicate that certain factors should be prioritized when approaching a first employment contract, they ultimately recommend that all surgeons take into account their personal priorities and attempt to proactively define their terms of employment before signing a contract.
Optimizing Throughput in Clinical Practice: Lean Management and Efficient Care in Plastic and Reconstructive Surgery
Authors: Bekeny Jenna C. , Fan Kenneth L. , Malphrus Elizabeth , Klein Doron , Song David H. 
Published: February 2021

Background:
As the cost of health care continues to rise, the role of medical providers has evolved to include the duties of an operations manager. Two theories of operations management can be readily applied to health care—lean management, the process of identifying and eliminating waste; and Little’s law, the idea that throughput is maximized by changing the capacity to host patients or the time they spend in the system. Equipped with theories of operations management, providers are better able to identify and address flow limitations in their own practices.

Methods:
Operations flow data were collected from three areas of care—clinic, surgical booking, and the operating room—for one provider. Variables of interest included visit or procedure characteristics and operations flow characteristics, such as different time points involved in the sector of care.

Results:
Clinic data were collected from 48 patients. Variables with a significant relationship to total clinic visit time included afternoon appointments (p = 0.0080) and visit type (p = 0.0114). Surgical booking data were collected for 127 patients. Shorter estimated procedure length (p = 0.0211) decreased time to surgery. Operating room data were collected for 65 cases. Variables with a significant relationship to total operating room time were patient age (p = 0.0325), Charlson Comorbidity Index (p = 0.0039), flap type (p = 0.0153), and number of flaps (p < 0.0001).

Conclusions:
This brief single-provider study provides examples of how to apply operations management theories to each point of care within one’s own practice. Although longitudinal data following patients through each point of care are the next step in operations flow analysis, this work lays the foundation for evaluation at each time point with the goal of developing practical strategies to improve throughput in one’s practice.