bluuebunny/crossref_metadata_2025_split huggingface dataset:
Diagnostic Performance of Hemophagocytic Lymphohistiocytosis Criteria and HScore in Critically Ill Patients With Severe Hemophagocytic Syndrome
Authors: Valade Sandrine , Monseau Grégoire , Mariotte Eric , Darmon Michael 
Published: April 2021

OBJECTIVES:
To assess whether critically ill hematologic patients without diagnosis of hemophagocytic lymphohistiocytosis may have features mimicking hemophagocytic lymphohistiocytosis according to both diagnostic scores.

DESIGN:
A retrospective case-control study.

SETTING:
Hemophagocytic syndrome diagnosis was standardized and based on a consensual diagnosis by at least two experts of a university hospital which is a reference center for hemophagocytic syndrome.

PATIENTS:
Cases (hemophagocytic syndrome+) consisted in a group of consecutive patients (n = 150) admitted in our ICU between 2007 and 2018. Control group (hemophagocytic syndrome–) consisted in patients included in a prospective multicenter cohort of hematologic patients in whom three independent experts ruled out the diagnosis of hemophagocytic syndrome (n = 1011).

MEASUREMENTS AND MAIN RESULTS:
Overall, 1,161 patients were included. Hospital mortality was 45.8% in hemophagocytic syndrome– patients (n = 66) and 38.8% in control patients (n = 392; p = 0.126). Median HScore was 235 (205–262) in hemophagocytic syndrome+ and 42 (18–62) in hemophagocytic syndrome– patients (p < 0.001); number of hemophagocytic lymphohistiocytosis criteria was 4 (4–5) vs 1 (0–1), respectively (p < 0.001). Diagnostic performances of both scores were excellent with area under receiver operating characteristic curve of 0.99 (95% CI, 0.99–0.99) and 0.99 (95% CI, 0.99–0.99) for hemophagocytic lymphohistiocytosis and HScore, respectively. After propensity score matching (n = 144 × 2), the median HScore was 234 (205–262) in hemophagocytic syndrome+ patients versus 49 (18–71) in hemophagocytic syndrome– patients (p < 0.001). Median number of hemophagocytic lymphohistiocytosis criteria was 4 (4–5) in hemophagocytic syndrome+ and 1 (0–1) in hemophagocytic syndrome– patients (p < 0.001). Area under receiver operating characteristic curve was then of 0.98 (95% CI, 0.96–0.99) for hemophagocytic lymphohistiocytosis criteria and 0.99 (95% CI, 0.99–1) for HScore.

CONCLUSIONS:
In ICU patients, several conditions share some similarities with hemophagocytic syndrome, explaining the poor predictive value of isolated biological markers such as ferritin level. Despite these potential confounding factors, our study suggests HScore and hemophagocytic lymphohistiocytosis criteria to be highly discriminant identifying hemophagocytic syndrome in critically ill patients.
Analysis of Genetic Alterations in Cutaneous Malignant Melanomas Unveils Unique Loco-Regional Variations and Novel Predictors of Metastatic Potential
Authors: Krishnamurthy Kritika , Urioste Sophia N. , Cusnir Mike , Schwartz Michael , Alghamdi Sarah , Sriganeshan Vathany , Poppiti Robert 
Published: April 2021

Abstract:
Cutaneous malignant melanoma is an aggressive cancer that contributes significantly to cancer-related mortality. Over the years, a deeper scrutiny of melanoma biology has led to identification of diverse evolutionary patterns involving various genetic pathways. This study attempts to further understand the genetic landscape of cutaneous malignant melanoma in terms of loco-regional variations and malignant potential. Thirty-five cases of cutaneous malignant melanoma were retrieved from the archives and were classified based on location of the primary tumor and presence or absence of metastatic disease. Next-generation sequencing data consisting of base substitutions, copy number variations, indels, and rearrangements in a total of 324 genes were analyzed for recurrent genetic alterations. Statistical analysis was performed using IBM SPSS26 software. Mutations in KDM gene family were found in 62.5% of the melanomas in the head and neck as compared with 10% in melanomas of the extremity and trunk (P = 0.03). Mutations in the RAS gene family were found in 70% of melanomas in the extremities as compared to 12.5% in melanomas of the head and neck (P = 0.003). BTK gene mutations were found exclusively in melanomas of the head and neck (P = 0.032). CREBBP mutations were seen in 50% of the nonmetastatic melanomas as compared with 3.57% of metastatic melanomas (P = 0.005). This study highlights the loco-regional variations in cutaneous malignant melanoma for genetic alterations involving the KDM, RAS, and BTK gene family. In addition, the CREBBP mutational status is identified as a potential prognostic marker for predicting metastatic potential in cutaneous malignant melanomas.
Effect of lumbar epidural blockade and propofol on mean arterial pressure, cardiac output and bispectral index
Authors: Sitsen Elske , Olofsen Erik , Dahan Albert , Vuyk Jaap 
Published: April 2021

BACKGROUND
It is generally accepted that a neuraxial blockade strengthens the sedative effects of propofol. Deafferentation caused by neuraxial blockade is thought to play a key role.

OBJECTIVES
The objective is to determine whether epidural blockade affects the bispectral index (BIS) of propofol and two other pharmacodynamic endpoints, mean arterial pressure (MAP) and cardiac output (CO).

DESIGN
Randomised, placebo-controlled study.

SETTING
University hospital.

PATIENTS
Patients scheduled for surgery needing epidural analgesia.

INTERVENTION
28 ASA one or two patients received 0, 50, 100 or 150 mg of epidural ropivacaine. After stabilisation of the epidural blockade, propofol was given by target-controlled infusion. The propofol plasma target concentrations were increased at 6-min intervals from 0 to 1, 2.5, 4 and 6 μg ml−1. The study was performed before surgery.

MAIN OUTCOME MEASURES
Three endpoints, BIS, mean arterial blood pressure and CO were measured from baseline (prior to the administration of epidural ropivacaine) until 2 h after the start of propofol infusion. The propofol concentration–effect data were analysed to determine the interaction between epidural blockade and propofol sedation.

RESULTS
In the absence of propofol, the increase in number of epidural blocked segments from 0 to 15.5 (range 6 to 21) reduced the MAP by 30%, without affecting BIS or CO. In the absence of epidural blockade, the increase in propofol concentration to 6 μg ml−1 reduced BIS, MAP and CO. When combined, epidural anaesthesia and intravenous propofol exhibited no pharmacodynamic interaction on any of the three endpoints. In addition, epidural blockade did not affect the propofol effect-site equilibration half-life for its haemodynamic effects (11.5 ± 0.5 min) or for its effects on the BIS (4.6 ± 0.4 min).

CONCLUSION
Epidural blockade reduces the propofol requirements for sedative end points. This is not the result of a pharmacodynamic interaction.

TRIAL REGISTRATION
Dutch trial register CCMO, Central Committee on Research Involving Human Subjects, trial number NL 32295.058.10.
Keystone Flap Reconstruction after Resection of a Large Paraspinal Venous Malformation in an Infant
Authors: Parus Anamaria , Waler Alexandria , Westmoreland Tamarah , Johnson Craig , Kellogg Brian 
Published: April 2021

Summary:
The keystone flap is well known to plastic surgeons and is frequently utilized for its ease of implementation, limited donor site morbidity, and favorable aesthetic outcomes. Although keystone flaps have been described in reconstruction of myelomeningocele defects, there have been no reports of their application to infants with large vascular malformations. This case illustrates the utilization of a keystone flap in reconstruction of a large posterior trunk defect that resulted from excision of a massive venous malformation in an 8-week-old infant with blue rubber bleb nevus syndrome. The patient’s consumptive coagulopathy resolved in the early postoperative period, and long-term follow-up demonstrated a favorable aesthetic outcome. This case reiterates the power and versatility of the keystone flap technique through its novel application to an infant with a life-threatening venous malformation on the posterior trunk.
Untethered and HIPAA-compliant Interactive Livestreaming of Surgery to Residents and Medical Students
Authors: Yuen James C. , Gonzalez Santiago R. , Osborn Tamara , Abu-Rmaileh Muhammad 
Published: April 2021

Summary:
Traditional livestreaming of surgery to an audience requires stationary video broadcasting infrastructure, with viewers congregating in front of a screen, while audiovisual technicians provide support in the background. In recent years, livestreaming technologies from cameras to teleconference platforms have advanced dramatically, even to allow for compliance with the Health Insurance Portability and Accountability Act of 1996 with web-based encryption. The objective of this article is to show that livestreaming surgery in medical education is possible using portable devices, with the resident and medical students as audience at home interacting on their computer or smart devices. The surgeon utilizes a head-mounted camera transmitting video feed using a wireless transmitter broadcasting to a laptop computer, which is hosting a Health Insurance Portability and Accountability Act–compliant version of Zoom. The entire setup is portable, and the surgeon is tethered neither to a cord nor to the institution’s audiovisual enterprise. This prototype setup allows the surgeon to broadcast live surgery interactively at any time and from any operating room with remote medical students and surgical residents. We posit that our medical education industry would need to condense the devices into a turnkey livestreaming camera system with optimized frames per second reception.
Muscle-sparing Latissimus Dorsi: A Safe Option for Postmastectomy Reconstruction in Extremely Obese Patients
Authors: Schwartz Jean-Claude D. 
Published: April 2021

Background:
Postmastectomy reconstruction in obese patients has a significant risk of complications and poor outcomes after implant-based and autologous methods. Here we present 22 consecutive patients with Class III obesity [body mass index (BMI) > 40 kg/m2] who underwent reconstruction with a muscle-sparing latissimus dorsi (MSLD) flap.

Methods:
A chart review of a single surgeon experience with 22 consecutive patients with Class III obesity who underwent postmastectomy reconstruction with an MSLD flap was performed. Demographics, operative details, outcomes, and complications were evaluated.

Results:
Twenty-two patients underwent 29 mastectomy and MSLD reconstructions. There were no flap failures. The average BMI was 47.2 kg/m2, including 12 patients with BMI > 50 kg/m2. Seven breasts demonstrated partial nipple and or mastectomy flap necrosis. There was 1 (3.4%) donor site dehiscence that healed with outpatient wound care and 1 (3.4%) seroma that required multiple aspirations in the office. The average operative times were 178 and 420 minutes for unilateral and bilateral mastectomy and immediate reconstructions, respectively. The average hospital length of stay was 0.56 and 1.3 days for unilateral and bilateral surgeries, respectively.

Conclusions:
These results demonstrate the utility of the MSLD flap in reconstructing the very obese. Operative times and lengths of stay compare favorably with conventional latissimus dorsi flap and abdominal-based microvascular free tissue transfer reconstructions. While our complication rates were higher than historically seen for patients with normal BMIs, there were no instances of flap failure, making this a viable reconstructive option for these very high-risk patients.
Noncontrast Magnetic Resonance Imaging of Perforators for Preoperative Evaluation of Anterolateral Thigh Flaps
Authors: Chen Frank R. , Kerluku Jona , Mintz Douglas , Burge Alissa J. , Chen Aaron Z. , MacMahon Aoife , Osei Daniel A. , Fufa Duretti T. 
Published: April 2021

Background:
The anterolateral thigh (ALT) flap is a commonly utilized perforator-based flap in reconstructive surgery. Although previous studies have used various angiographic techniques to preoperatively image ALT perforators, none have investigated the efficacy of noncontrast magnetic resonance imaging (MRI). Our study investigates the efficacy of our institutional fat suppression noncontrast MRI sequence to characterize the number, location, and course of dominant skin perforators in the ALT for preoperative planning.

Methods:
We queried our institutional database for 100 noncontrast thigh MRIs from July 2013 to July 2018 that included an axial fat suppression sequence with visualization from the lesser trochanter to the distal musculotendinous junction of the rectus femoris. Perforator course, size, and location relative to bony landmarks were determined.

Results:
Of the 100 examinations, 70 included bilateral thighs for a total of 170 thighs for perforator analysis. An estimated 277 perforators were identified, of which 101 were septocutaneous (36.5%) and 176 were musculocutaneous (63.5%). An average of 1.63 perforators were visualized in each thigh (min, 1; max, 4). The average perforator diameter at exit from the anterior thigh compartment fascia was 2.5 mm (SD, 0.5). Perforator exit location along the anterior superior iliac spine- or lesser trochanter-patella line could be determined for n = 57 perforators and mapped into 3 predictable clusters.

Conclusions:
At least 1 perforator was found in each of 170 thighs imaged. Perforator course, size, and location measured with noncontrast MRI are consistent with prior literature. Noncontrast MRI is a low-morbidity imaging modality that may serve as an effective tool in preoperative planning of the ALT flap.
Comparing the Clinical and Cost-Effectiveness of Abdominal-based Autogenous Tissue and Tissue-Expander Implant: A Feasibility Study
Authors: Thoma Achilles , Avram Ronen , Dal Cin Arianna , Murphy Jessica , Duku Eric , Xie Feng 
Published: April 2021

Background:
To determine the superiority of autologous abdominal tissue (AAT) or tissue-expander implant (TE/I) reconstruction, a robust comparative cohort study is required. This study sought to determine the feasibility of a future large pragmatic cohort study comparing clinical and cost-effectiveness of AAT and TE/I at 12 months postoperative.

Methods:
Potential participants were screened during consultation with their surgeon. Three health-related quality-of-life scales, the Health Utility Index Mark 3, the 12-Item Short Form Health Survey, and the BREAST-Q were used preoperatively, 1, 6, and 12 months postoperatively. Direct medical costs and postoperative patient/caregiver productivity loss were collected using patient diaries. Feasibility was assessed through patient recruitment rates and compliance of patients and study staff to complete required study documentation.

Results:
Sixty-three patients consented to participate, 44 completed baseline questionnaires; the feasibility objective of recruiting 80% of eligible patients was not met. A 90% completion rate for patient questionnaires was seen at 1-month follow-up and decreased up to 12 months. Quality-adjusted life years were calculated at 0.77 and 0.89 for the AAT and TE/I group, respectively. Case report form completion by study staff and patient diary completion was moderate and low, respectively. Collaborating with hospital case-costing specialists to identify direct medical costs was reliable and efficient.

Conclusions:
A future large-scale study is feasible. However, due to a diminishing rate of questionnaire completion, almost twice as many patients need to be recruited than expected to have adequate power. Cost data collection from hospital sources was reliable. Case report forms need to be tailored more toward a busy hospital setting.
Ethnic and Gender Diversity Comparison between Surgical Patients and Caring Surgeons
Authors: Noel Olivier F. , Berg Arthur , Onyango Nelson , Mackay Donald R. 
Published: April 2021

Background:
Diversity within the medical workforce remains a topic of discussion in academia, particularly when it comes to the underrepresentation of certain ethnic groups and gender in the surgical specialties. In this article, we look at how the gender and ethnicity of surgeons at a large academic institution in a rural setting compare with those of the population it serves.

Methods:
We looked at demographic data from 2008 to 2018 and compared population trends among surgeons and patients.

Results:
We found that while whites represent the large majority in both the surgeon and patient populations, absolute number and percentage of whites in the patient population seem to be trending downward from 2008 to 2018, but trending upward among surgeons (attendings and residents). In addition, we found that while Asians make up only 1% of the patient population, they represent the second largest group (17%) among surgeons, with more than twice the proportion percentage of the second largest group within the patient population, composed of Hispanics (6%). Finally, we found a significant gender difference between the 2 populations with almost two-thirds of the surgeons being men, compared with the nearly even split of men and women within the patient population.

Conclusions:
Ultimately, understanding how gender and ethnic diversity in the surgical workforce compares with that of the patient population being served may aid in designing training programs to address cultural competency and awareness as well as in impacting administrative decisions and hiring.
Double Spiral Dupuytren’s Disease: Case of Ulnar and Radial Spiral Cords in Shared Digit
Authors: Kator Jamie , Gopinath Rohan , Miller Nathan , Pensy Raymond 
Published: April 2021

Summary:
Dupuytren’s disease is a benign fibroproliferative disorder resulting in progressive contraction of palmar and digital fascia. Diseased fascia of the hand condenses into tensile cords, manifesting in various anatomical combinations. The spiral cord variant is especially troublesome, as the cord travels under the digital neurovascular bundle and places it at risk during surgical resection. In severe cases, limited fasciectomy is required to release contracture and restore finger extension. Here, we present the case of a 79-year-old right-handed man with a history of severe Dupuytren’s disease of both hands, who was found to have ulnar and radial spiral cords in his right ring finger. Diseased tissue was removed en bloc, restoring extension and function. To our knowledge, this is the first case of a digit with two spiral cords affecting both neurovascular bundles. It is important to be aware of the anatomical variations possible in Dupuytren’s disease to avoid iatrogenic injury.
Daily Quality-of-life Impact of Scars: An Interview-based Foundational Study of Patient-reported Themes
Authors: Hsieh Ji-Cheng , Maisel-Campbell Amanda L. , Joshi Chitang J. , Zielinski Eric , Galiano Robert D. 
Published: April 2021

Background:
Scars negatively impact mental health. Prior patient interview studies on cutaneous scars have elicited opinions pertaining to psychosocial effects, appearance, and symptoms. There remains a need for patient-reported opinions in broader contexts, including career and sexual well-being, to better understand patients’ experiences with their cutaneous scars.

Methods:
In this qualitative study, patients with cutaneous scars participated in semi-structured interviews. Transcripts were analyzed using a constant comparative approach using the data software QDAMiner, to generate a thematic framework encompassing patients’ experience with cutaneous scars.

Results:
In total, 37 patients aged 25–79 years (mean 45, SD 17.9) were interviewed. Patients presented with keloid (2/37, 5%), hypertrophic (5/37, 14%), atrophic (4/37, 11%), and linear surgical (18/37, 49%) scars. Opinions fell under 8 overarching themes. Patients spoke commonly about psychological and social well-being (references to the frequency of thinking about a scar and talking about scars with others were mentioned 56 times by 26 patients and 103 times by 29 patients, respectively, for example). Discussions of sexual well-being and career were elicited but rarer (references to feeling uncomfortable when naked and negative impacts on professional networking were mentioned 17 times by 7 patients and 5 times by 3 patients, respectively, for example).

Conclusions:
The relationship between determinants of patients’ opinions of their scars and their impact on quality-of-life is complex. These results expand upon the existing knowledge of the effects scars have on quality-of-life and can contribute to the development and validation of future scar outcome measures.
“Trap Door” Orbital Floor Fractures in Adults: Are They Different from Pediatric Fractures?
Authors: Al-Qattan Mohammad M. , Al-Qattan Yousef M. 
Published: April 2021

Background:“Trap door” orbital floor fractures are usually seen in children. In the linear fracture type, a break occurs in the bones of the orbital floor that permits orbital tissue to prolapse into the fracture site during fracture formation. The bony fragments of the fracture then return to their original position, entrapping the prolapsed orbital tissue. In the hinged fracture type, the fractured part of the floor is minimally displaced into the maxillary sinus and acts as the hinge of a “swinging door” entrapping the orbital tissue.Methods:We report on a series of 10 adult patients with hinged orbital floor fractures.Results:The mean patient age was 35 years. Seven patients had a pure orbital floor fracture and the remaining 3 patients had fractures of both the orbital floor and the inferior orbital rim. All 10 patients had diplopia in the upgaze. None of the patients had signs of the oculocardiac reflex. None of the CT scans showed a “tear-drop” sign. However, the sagittal CT scans showed evidence of entrapment of the inferior rectus. All patients had a small area of a slightly depressed orbital floor at the site of entrapment, without a bony defect. All patients underwent surgery through an infraorbital incision and a titanium mesh was used in all patients. There were no postoperative complications. All patients regained full range of motion of the globe.Conclusion:This is the first series in the literature that reports on the characteristics and outcome of trap door orbital floor fractures in adults.
“Corneal Plication” for the Management of Progressive Corneal Graft Protrusion in Patients With Keratoconus: a New Technique
Authors: Petrelli Myrsini , Savopol Hélène , Blavakis Emmanouil , Petrou Petros , Droutsas Konstantinos , Kymionis George D. 
Published: April 2021

Purpose:
The purpose of this study was to present a new surgical technique, namely corneal plication, for the management of high astigmatism and progressive corneal graft protrusion after penetrating keratoplasty (PKP) for keratoconus.

Methods:
New surgical approach description.

Results:
A 61-year-old woman with a history of bilateral keratoconus was referred to our institute for the management of progressive corneal graft protrusion in her left eye 25 years after PKP. On presentation, the uncorrected distance visual acuity in the involved eye was counting fingers, whereas slit-lamp examination revealed a clear graft with a crescentic area of thinning in the inferior host cornea, extending from 4 to 9 o'clock that resulted in significant graft protrusion and astigmatism. We proceeded with a novel surgical approach that included “folding” and suturing the thinned, diseased corneal tissue and thus creating a form of corneal plication. No intraoperative or postoperative complications were observed, and uncorrected distance visual acuity was 0.32 6 months after the operation.

Conclusions:
Corneal graft plication may represent a realistic alternative to more invasive procedures, currently used for the management of this long-term post-PKP complication in patients with keratoconus because it is a nonperforating technique that seems to provide satisfactory anatomical and visual outcomes without the need for any tissue excision or regrafting.