bluuebunny/crossref_metadata_2025_split huggingface dataset:
A Quality Improvement Project to Reduce Postcesarean Opioid Consumption
Authors: Kahn Kristien Marie , Demarco Kathleen , Pavsic Joy , Sangillo Julie 
Published: May 2021

Abstract

Background:
The opioid epidemic is a public health emergency in the United States, stemming in part from widespread misuse and overprescribing of opioids following surgery. Approximately 1 in 300 women with no prior exposure to opioids develops an opioid use disorder following cesarean birth. Effective management of postcesarean pain requires individualized treatment and a balance of the woman's goals for optimal recovery and ability to safely care for her newborn. The American College of Obstetricians and Gynecologists recommends a multimodal approach to pain management after cesarean birth.

Methods:
In April 2019, a multidisciplinary team was formed at New York University Langone Health to study opioid use postcesarean. The team used the Plan, Do, Study, Act process model for continuous quality improvement to launch a postcesarean pathway called “Your Plan After Cesarean,” a standardized visual tool with quantifiable milestones. It facilitates integration of women's preferences in their postcesarean care, and emphasizes providers' routine use of nonpharmacological interventions to manage pain.

Results:
During the pilot period of the project, postcesarean high consumption of 55 to 120 mg of opioids was reduced from 25% to 8%. By January 2020, 75% of women postoperative cesarean took little-to-no opioids during their hospital stay. By February 2021, the total number of opioids consumed by women after cesarean birth in-hospital was reduced by 79%. Satisfaction among women with pain management after cesarean continued to be high.

Clinical Implications:
Reduction in postcesarean opioid administration and the number of opioids prescribed at hospital discharge can be accomplished without having a negative effect on women's perceptions of post-op pain relief. These changes can potentially be a factor in helping to avoid an opioid-naive woman who has a cesarean birth from developing an opioid use disorder.
The Navajo Nation Healthy Diné Nation Act: A Description of Community Wellness Projects Funded by a 2% Tax on Minimal-to-No-Nutritious-Value Foods
Authors: Yazzie Del , Tallis Kristen , Curley Caleigh , Sanderson Priscilla R. , Eddie Regina , Shin Sonya , Behrens Timothy K. , George Carmen , Antone-Nez Ramona , Jumbo-Rintila Shirleen , Begay Gloria Ann , de Heer Hendrik “Dirk” 
Published: May 2021

Context:
To promote the health of the Navajo people, the Navajo Nation passed the Healthy Diné Nation Act (HDNA) in 2014. The HDNA included a 2% tax on “minimal-to-no-nutritional-value” foods and waived 5% sales tax on healthy foods, the first such policy in the United States and any sovereign Tribal nation. Uniquely aligned with Tribal government structures, revenue was directly allocated to 110 small local government entities (Chapters) for self-determined wellness projects.

Objective:
To characterize HDNA-funded wellness projects, test for variation in project type, and funding amount over time by region and community size.

Design:
Longitudinal study assessing funded wellness projects from tax inception through 2019.

Setting:
The Navajo Nation.

Participants:
One hundred ten Navajo Nation Chapters receiving funding for self-determined wellness projects.

Outcome Measures:
The categories and specific types of wellness projects and funding over 4 years by region and community size.

Results:
Of revenue collected in 2015-2018, more than 99.1% was disbursed through 2019 ($4.6 million, $13 385 annually per community) across 1315 wellness projects (12 per community). The built recreational environment category received 38.6% of funds, equipment/supplies 16.5%, instruction 15.7%, food and water initiatives 14.0%, and social events 10.2%. Most common specific projects were walking trails ($648 470), exercise equipment ($585 675), food for events ($288 879), playgrounds ($287 471), and greenhouses ($275 554). Only the proportion allocated to instruction changed significantly over time (increased 2% annually, P = .02). Smaller communities (population <1000) allocated significantly higher proportions to traditional, agricultural, and intergenerational projects and less to the built environment.

Conclusions:
Through 2019, more than 99% of HDNA revenue was successfully disbursed to 110 rural, Tribal communities. Communities chose projects related to promoting the built recreational environment, agriculture, and fitness/nutrition education, with smaller communities emphasizing cultural and intergenerational projects. These findings can inform other indigenous nations considering similar policies and funding distributions.
Gender Inequity in the Public Health Workforce
Authors: Yassine Brianne Bostian , Rojewski Jay W. , Ransom Montrece McNeill 
Published: May 2021

Context:
Public health is a gendered field. Although a majority of the public health workforce, women encounter an imbalance of power and experience disparate opportunities within the profession.

Analysis:
This article offers a multidimensional critique of gender inequity within the public health workforce through an examination of the literature.

Results:
There are three existing disparities between men and women in public health: unequal representation in leadership positions; persistence of wage discrimination; and disparities in scholarly publication and citations. Disparities are often more pronounced among women with intersectional identities (eg, race/ethnicity or other identities).

Discussion:
Gender inequity is structural, and solutions must address micro-, interactional, and macro-levels. The changing workforce and practitioners' skills in addressing upstream issues provide the opportunity to address this issue.
The Impact of Covid-19 State Closure Orders on Consumer Spending, Employment, and Business Revenue
Authors: Dunphy Christopher , Miller Gabrielle F. , Rice Ketra , Vo Linda , Sunshine Gregory , McCord Russell , Howard-Williams Mara , Coronado Fátima 
Published: May 2021

Context:
In response to the COVID-19 pandemic, states across the United States implemented various strategies to mitigate transmission of SARS-CoV-2 (the virus that causes COVID-19).

Objective:
To examine the effect of COVID-19–related state closures on consumer spending, business revenue, and employment, while controlling for changes in COVID-19 incidence and death.

Design:
The analysis estimated a difference-in-difference model, utilizing temporal and geographic variation in state closure orders to analyze their impact on the economy, while controlling for COVID-19 incidence and death.

Participants:
State-level data on economic outcomes from the Opportunity Insights data tracker and COVID-19 cases and death data from usafacts.org.

Interventions:
The mitigation strategy analyzed within this study was COVID-19–related state closure orders. Data on these orders were obtained from state government Web sites containing executive or administrative orders.

Main Outcome Measures:
Outcomes include state-level estimates of consumer spending, business revenue, and employment levels.

Results:
Analyses showed that although state closures led to a decrease in consumer spending, business revenue, and employment, they accounted for only a small portion of the observed decreases in these outcomes over the first wave of COVID-19.

Conclusions:
The impact of COVID-19 on economic activity likely reflects a combination of factors, in addition to state closures, such as individuals' perceptions of risk related to COVID-19 incidence, which may play significant roles in impacting economic activity.
Improving Care for Childhood Obesity: A Quality Improvement Initiative
Authors: Satti Komal F. , Tanski Susanne E. , Jiang Yike , McClure Auden 
Published: May 2021

Introduction:
Obesity affected 13.7 million children in the United States in 2015. The American Academy of Pediatrics (AAP) offers an evidence-based approach to obesity management, but adherence to recommendations is suboptimal. Our objective was to improve provider adherence to the AAP recommendations for care of patients with obesity by making systematic changes in our practice for patients of ages > 2 and younger than 19 years with a BMI > 95th percentile.

Methods:
We performed a retrospective chart review of 417 qualifying encounters to assess adherence in the six months preceding the initiative. We measured adherence as a proportion of eligible patients who had (1) obesity on the problem list; (2) laboratory work offered; (3) counseling provided; (4) early follow-up recommended; (5) referral to a weight management program. In 2018, a multidisciplinary QI team conducted plan-do-study-act cycles to educate providers on the AAP recommendations and improve obesity-related care systems. The initiative lasted 18 months.

Results:
During the initiative, we tracked 885 patient encounters via chart review. We witnessed continued improvement in 4 out of 5 measures. For early follow-up offered, we saw improvement after PDSA 1, followed by a decline after PDSA 3. Providers ordered laboratory tests in only 13% of encounters for eligible children ages younger than 6 years versus 45% for ages older than 6 years, an age-dependent disparity that persisted despite the QI initiative.

Conclusion:
Our pediatric practice sustained improvement in adherence to AAP recommendations. There is a need to assess the reasons behind the care disparity based on patient ages.
A Quality Improvement Initiative to Reduce Blood Culture Contamination in the Neonatal Unit
Authors: Allen Elizabeth , Cavallaro Angela , Keir Amy K. 
Published: May 2021

Introduction:
Peripheral blood culture contamination (BCC) can lead to an initiation of unnecessary antimicrobial treatment, further laboratory tests, increased length of stay, and increased costs. This study describes a 12-month quality improvement (QI) program to reduce the BCC rate in a neonatal unit by 50%.

Methods:
The QI team focused on standardizing processes to align with best practices using process mapping and cause and effect diagrams. Plan-Do-Study-Act (PDSA) 1: inoculation of blood culture bottles with the introduction of transfer device; PDSA 2: preparation of the skin for peripheral intravenous cannula insertion; PDSA 3: aseptic technique education package; and PDSA 4: optimizing blood volume of blood collected for culture. The team used statistical process control methodology to detect special cause variation.

Results:
Compliance with the standard processes as part of PSDA 1 improved from a mean level of 50% to 100% and for PDSA 2 improved from a mean level of 50% to 95%. After implementation of PDSA 3, scores on a relevant knowledge test increased from a mean of 39% (pretraining test; n = 10) to 92% (posttraining test; n = 10) (P < 0.001). Postimplementation of the processes for PDSA 4, a minimum of 1 mL was collected in 94% of blood culture collection events (n = 450) (mean 1.1 mL; range 0.5–3.5 mL). Special cause variation occurred after the implementation of the PDSA cycles. During the baseline period, the BCC rate was 2.0% and decreased to 1.0% postinterventions implementation.

Conclusions:
Interventions focused on standardizing practices around collection of blood cultures in neonates were associated with fewer contaminants.
This study is reported according to the SQUIRE 2.0 guidelines.
Definition of a Risk Zone for the Axillary Nerve Based on Superficial Landmarks
Authors: Schwarz Angelika M. , Weiglein Andreas H. , Schwarz Ulrike M. , Gänsslen Axel , Krassnig Renate , Grechenig Peter , Maier Marco J. , Hohenberger Gloria M. 
Published: May 2021

Background:
The aim of this study was to investigate the axillary nerve’s location along superficial anatomical landmarks, and to define a convenient risk zone.

Methods:
A total of 123 upper extremities were evaluated. After dissection of the axillary nerve, the vertical distance between the upper border of the anterolateral edge of the acromion and the proximal border of the nerve was measured. Furthermore, the interval between the proximal border and the distal border of the axillary nerve’s branches was evaluated. The interval between the distal border of the branches and the most distal part of the lateral humeral epicondyle was measured. The distance between the anterolateral edge of the acromion and the lateral humeral epicondyle was evaluated. Measurements were expressed as proportions with respect to the distance between the acromion and the lateral humeral epicondyle.

Results:
The distance between the acromion and the proximal border of the axillary nerve’s branches was at a height of 10 percent of the distance between the acromion and the lateral humeral epicondyle, starting from the acromion (90 percent when starting from the lateral humeral epicondyle). The interval between the proximal and distal margins of the axillary nerve’s branches was between 10 percent and 30 to 35 percent of this interval, starting from the acromion (65 to 70 percent when starting from the lateral humeral epicondyle).

Conclusions:
The authors were able to locate the branches of the axillary nerve at an interval between 10 and 35 percent of the distance between the acromion and the lateral humeral epicondyle, starting from the acromion. This makes the proximal third of this distance an easily applicable risk zone during shoulder surgery.
Fifteen-Year Review of the American Board of Plastic Surgery Maintenance of Certification Tracer Data: Clinical Practice Patterns and Evidence-Based Medicine in Zygomatico-Orbital Fractures
Authors: Kearney Aaron M. , Shah Nikhil , Zins James , Gosain Arun K. 
Published: May 2021

Background:
From 2005 to 2020, the American Board of Plastic Surgery collected data on 20 common plastic surgery operations as part of the Maintenance of Certification process. These data allow the authors to examine national trends in zygomatico-orbital fracture repair over a 15-year period.

Methods:
Tracer data for zygomatico-orbital fracture repair were reviewed in cohorts from 2005 to 2013 and 2014 to 2020. Results were categorized based on their presence in evidence-based medicine articles published during this period. Differences between years were assessed using the t test or chi-square test as appropriate.

Results:
Four hundred thirty patients were included as of March of 2020. Average age was 37 years (range, 6 to 85 years), and 76 percent were male. Operations took place on average 10 days from injury. There were significant decreases in the use of subciliary (31.9 percent versus 10.0 percent; p < 0.001), gingival buccal (84.3 percent versus 56.4 percent; p < 0.001), and lateral brow (45.2 percent versus 22.3 percent; p < 0.001) incisions, with an increase in lower lid external incisions (15.2 percent versus 30.9 percent; p < 0.001); 2.7 percent of patients had a complication requiring readmission and 4.5 percent required reoperation. The incidence of postoperative diplopia was 7.7 percent, and the infection rate was 1.7 percent.

Conclusions:
This article reviews the American Board of Plastic Surgery tracer data for zygomatico-orbital fracture repair. The Maintenance of Certification tracer data provide a national database with longer follow-up and more specific information than comparable databases. Analysis of these data over time enables the authors to describe practice trends and gives surgeons the opportunity to compare their outcomes to national norms.
Distal Arterialized Venous Supercharging Improves Perfusion and Survival in an Extended Dorsal Three-Perforasome Perforator Flap Rat Model
Authors: Wu Hongqiang , Zhang Chenxi , Chen Zhengtai , Lou Junsheng , Ding Jian , Wang Long , Xie Chenglong , Gao Weiyang , Lin Damu 
Published: May 2021

Background:
Perforator flaps are commonly applied for a variety of skin defects. Many strategies (e.g., hyperbaric oxygen and preconditioning) have been investigated to improve flap survival, but a postoperative 2.03 to 18.2 percent flap necrosis frequency remains a major complication. The authors hypothesized that a distal arterialized venous supercharged (DAVS) flap procedure might improve perfusion and survival in an extended three-perforasome perforator flap rat model and rescue flap ischemia intraoperatively.

Methods:
One hundred twenty male Sprague-Dawley rats (200 to 300 g) were divided into the thoracodorsal artery (TDA) flap group and the DAVS flap group (n = 60 per group). An approximately 11 × 2.5-cm2 flap based on the TDA perforasome was designed in the TDA flap. A DAVS flap was designed based on the TDA flap and supercharged by anastomosing the rat caudal artery with the deep circumflex iliac vein. At postoperative times 1, 3, 6, and 12 hours and 1, 3, 5, and 7 days, perfusion and angiography were compared. On day 7, flap viability and angiogenesis were assessed using histology and Western blotting.

Results:
The DAVS flap showed a higher survival rate compared with the TDA flap (100 percent versus 81.93 ± 5.38 percent; p < 0.001). All blood flow ratios of deep circumflex iliac artery to TDA perforasome and of choke zone II to choke zone I were higher in the DAVS flap (all p < 0.05). Angiography qualitatively revealed that choke vessels in choke zone II dilated earlier and extensively in the DAVS flap group. CD34+ vessels (68.66 ± 12.53/mm2 versus 36.82 ± 8.99/mm2; p < 0.001) and vascular endothelial growth factor protein level (0.22 ± 0.03 versus 0.11 ± 0.03; p < 0.001) were significantly increased in the DAVS flap group.

Conclusions:
The DAVS procedure improves three-perforasome perforator flap survival and can be used for rescuing flap ischemia intraoperatively. Further study is needed before possible clinical adoption for reconstructive operations.
Adjunctive Procedures and Informed Consent with Breast Implant Explantation
Authors: Manahan Michele A. 
Published: May 2021

Background:
The use of injectable or implantable materials or devices in the breast for augmentation or reconstruction has a history of innovation and controversy. Staying current in the field of breast implant management today means understanding not just the published literature but also its absence. Cutting edge breast implant treatment also means awareness of patient and media-driven interests and requests.

Methods:
Adjuvant treatments to optimize physical and psychological well-being with breast implant explantation, without replacement, will be addressed through literature review and analysis.

Results:
The body of literature demonstrates evidence of variable, and sometimes contradictory, methods to address adjunctive management of systemic concerns, the capsule, soft tissue of the native breast/chest, and treatment timing related to explantation. Few approaches are supported by very strong evidence. Many treatment methodologies are defensible. Any current attempts at optimizing management in patients undergoing explantation will be somewhat impaired by the ongoing nebulousness of related issues, such as breast implant illness. It seems clear, therefore, that plastic surgeons must fulfill their duty as caregivers to provide explantation surgery, either to attempt to improve physical health, mental well-being, or simply to respect patients’ wishes. A well-informed surgeon will likely employ a variety of approaches, adapted to the unique patient presentations at hand.

Conclusion:
It is expected that consultations, incisions, tissue rearrangements, surgical timing, and treatment indications will continue to vary as scientific investigation strives to understand and to optimize treatment of patients experiencing difficulty with breast implants.
Management of Symptomatic Patients with Textured Implants
Authors: Asaad Malke , Offodile Anaeze C. , Santanelli Di Pompeo Fabio , Bevers Therese B. , Stelly Sharon , Carew Lori A. , Barnea Yoav , Miranda Roberto N. , Butler Charles E. , Clemens Mark W. 
Published: May 2021

Summary:
Proper management of symptomatic textured implant patients is critical to identify and treat associated oncologic disease. Textured surface breast implants were first introduced more than 50 years ago in an effort to decrease high rates of capsular contracture and implant malposition observed with first-generation smooth surface breast implants. Textured implants were dominant over smooth devices in the United States in the late 1990s, but they fell out of favor for newer-generation smooth implants, while texture remained the dominant selling implants worldwide until recently. A class I device recall by the US Food and Drug Administration in 2019 precipitated a removal of the highest selling implant worldwide, Allergan Biocell, due to a disproportionately increased risk of breast implant–associated anaplastic large cell lymphoma (BIA-ALCL). Operative strategies, such as bacterial control at the time of textured implant insertion, have not been credibly shown to affect or prevent the future development of BIA-ALCL. BIA-ALCL patients require complete surgical excision of their disease, whereas textured implant patients who are otherwise asymptomatic do not require surgical removal. For suspicious cases, diagnostic testing with CD30 immunohistochemistry should be performed before any surgical intervention. Capsules are evaluated with 12 strategic regional biopsies in a standardized approach. If surgeons are revising or exchanging textured implants, they may reasonably consider a total capsulectomy, though this is not advocated by the Food and Drug Administration or national societies, and has not been shown to mitigate future risk of BIA-ALCL. The purpose of this article is to review data on and outcomes for textured surface implants, disease-associated risk, and the management strategy for revisionary surgery and device surveillance.
What’s in a Name? Implicit Bias Affects Patient Perception of Surgeon Skill
Authors: Bhat Deepa , Kollu Tejas , Ricci Joseph A. , Patel Ashit 
Published: May 2021

Background:
Implicit bias is the unconscious associations and beliefs held toward specific demographic groups. Instagram is commonly used by plastic surgeons to market their practice. This study investigates whether a surgeon’s name on a social media platform influences perception of their competence and their likelihood of gaining a new patient.

Methods:
A mock Instagram post was created using before-and-after photographs of a breast augmentation patient. Eight different ethnicities were selected, and common female and male names were selected based on U.S. Census data for each ethnicity. Surveys using the Instagram post were distributed asking responders to evaluate the competency of the surgeon and how likely they are to become a patient of that plastic surgeon. The surgeon’s name was the only variable in the survey.

Results:
A total of 2965 survey responses were analyzed. The majority of responders were Caucasian (57 percent); 55 percent were men and 45 percent were women. Overall, competence and recruitment likelihood scores between surgeons of different ethnicities were not significantly different. Caucasian and Latinx responders both assigned higher competence and recruitment likelihood scores to their own respective ethnicities.

Conclusions:
Implicit bias plays a role in whether or not a patient is likely to seek care from a surgeon with an ethnically identifiable name. The two most common cosmetic surgery demographic groups, Caucasians and Latinxs, were also the only two ethnic groups to display in-group favoritism. Public education should be directed toward surgeon qualifications and experience in an effort to reduce implicit bias on patient decision-making.