bluuebunny/crossref_metadata_2025_split huggingface dataset:
Clinical Characteristics Associated with the Prognosis of One-Stage Grafting for Flexor Digitorum Profundus Reconstruction in Zones I and II
Authors: Zhu Hongyi , Gao Yanchun , Chai Yimin , Han Pei 
Published: February 2019

Background:
The authors aimed to identify clinical characteristics related to the prognosis after one-stage grafting for flexor digitorum profundus reconstruction in zones I and II.

Methods:
A total of 401 patients who underwent one-stage flexor digitorum profundus reconstruction after injuries in zones I and II, between January 1, 2006, and June 1, 2016, were included for analysis. The authors recorded the following clinical characteristics: duration from injury to reconstruction, graft type and length, handling (preservation or removal) of flexor digitorum superficialis, tenorrhaphy technique, and duration of postoperative immobilization.

Results:
There was no significant difference in age, sex, duration between injury and reconstruction, graft type, and handling of flexor digitorum superficialis between subjects who underwent successful reconstruction and those who did not. Univariate and multivariate analyses revealed that end-to-end tenorrhaphy, immediate controlled motion, and immobilization for less than 2 weeks all independently were related to improved final outcomes. Grafting within zones I and II contributed to increased incidence of failure. In a subgroup having an injury-reconstruction duration of less than 2 weeks, the authors observed that grafting from zone III to zones I and II tended to result in better outcomes compared with grafting from zone III to the flexor digitorum profundus insertion. This, however, was not statistically significant (p = 0.11).

Conclusions:
The authors recommend end-to-end tenorrhaphy, reducing immobilization to less than 2 weeks, and avoiding grafting within zones I and II. In addition, further studies are still needed to clarify the optimal length of grafting.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, III.
Therapeutic Role of Fat Injection in the Treatment of Recalcitrant Migraine Headaches
Authors: Guyuron Bahman , Pourtaheri Navid 
Published: February 2019

Background:
This study was designed to assess the safety and efficacy of site-specific fat injection for the treatment of refractory migraine headaches following medical or surgical treatment.

Methods:
A prospective cohort study was performed on consecutive patients who had migraine headaches with persistent symptoms after surgical decompression and were given therapeutic fat injections from September of 2012 to January of 2015 with 12 months’ minimum follow-up. Clinical outcomes assessment included migraine frequency, intensity, duration, migraine headache index, and complications. A 50 percent or greater decrease in frequency, intensity, or duration was considered therapeutic success, whereas 10 percent or greater increase in migraine headache index was considered worsening of symptoms. Pairwise t tests were used to assess statistical significance (p < 0.05).

Results:
Twenty-nine patients met inclusion criteria. All were female, with a mean age of 49.0 years (range, 21.5 to 72.5 years), and mean follow-up was 29.4 months (range, 12.3 to 49.5 months). Twenty patients (69.0 percent) experienced successful improvement; 12 (41.4 percent) experienced complete resolution. Five patients (17.2 percent) experienced subtherapeutic improvement, and four (13.8 percent) experienced worsening of symptoms. Mean improvement per patient at their last follow-up was 5.1 (39.3 percent) fewer attacks per month (p = 0.035); 3.1 (42.0 percent) lower intensity on a scale of 1 to 10 (p = 0.001); 31.8 (74.4 percent) fewer hours of duration (p = 0.219); and 52.8 percent lower migraine headache index (p = 0.012). There were no complications for any patient.

Conclusions:
Migraine headache symptoms were successfully reduced in the majority of cases with fat injection. A comprehensive surgical treatment algorithm including this novel procedure is presented.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, IV.
Diversity in Plastic Surgery: Trends in Minority Representation among Applicants and Residents
Authors: Parmeshwar Nisha , Stuart Emelia R. , Reid Chris M. , Oviedo Parisa , Gosman Amanda A. 
Published: February 2019

Background:
Prior studies have shown a lack of diversity among plastic surgery trainees. The authors evaluate trends in minority representation among applicants to plastic surgery and the correlation with practicing residents, compared to other specialties.

Methods:
The Association of American Medical Colleges Electronic Residency Application Service provided applicant data for integrated, independent plastic surgery, and other select specialties from 2010 to 2016. Journal of the American Medical Association Graduate Medical Education annual reports and Association of American Medical Colleges graduate student questionnaires provided resident and medical student data. Binomial distribution analysis was used to assess differences in Black, Hispanic, and female proportions of applicants and residents. Best-fit trend lines were compared among groups and specialties.

Results:
Women have seen an increase in integrated and independent resident representation (+2.23 percent and +0.7 percent per year, respectively) over the past 7 years, despite a relative decrease in applicants. The proportion of female applicants and residents correlated yearly for all specialties (p > 0.05). Conversely, for all years and all specialties, the Black proportion of applicants was significantly higher than the resident representation of the same year (p < 0.05). Hispanic applicant and resident representation have seen a minimal change.

Conclusions:
Female representation among trainees has increased greatly, but there has been a decline in Black representation of integrated plastic surgery residents despite increases in medical school graduates and applicants. The data highlight a discrepancy between the population of applicants and residents suggesting that barriers starting from medical school may contribute to the lack of diversity in plastic surgery.
Stacked Profunda Artery Perforator Flap for Breast Reconstruction in Failed or Unavailable Deep Inferior Epigastric Perforator Flap
Authors: Haddock Nicholas T. , Cho Min-Jeong , Gassman Andrew , Teotia Sumeet S. 
Published: February 2019

Background:
Recently, the profunda artery perforator flap has become one of the popular flap choices for patients who desire autologous breast reconstruction but are not optimal candidates for deep inferior epigastric perforator (DIEP) flap surgery. These patients are not ideal patients for DIEP flap surgery because of having poor perforators, previous abdominal operations, low body mass index, or previously used/failed DIEP flap. In their institution, the authors have performed stacked profunda artery perforator flaps for these patients to provide full volumetric and aesthetic reconstruction.

Methods:
A retrospective review of 20 patients (40 flaps) who underwent stacked profunda artery perforator flap surgery from 2014 to 2018 was performed. Patient characteristics, demographics, and flap data were collected.

Results:
Forty flaps were used to reconstruct 20 breasts in 20 patients. The mean age of patients was 51.5 years (range, 38 to 74 years), the average body mass index was 27.3 kg/m2 (range, 21.0 to 34.4 kg/m2), and the mean flap weight was 398.5 g (range, 170 to 600 g). The majority of anastomoses were performed in internal mammary vessels (60 percent), followed by thoracodorsal (10 percent), serratus (10 percent), and side branch of profunda artery perforator vessels (20 percent). There were no flap losses, and two patients experienced donor-site wound dehiscence.

Conclusions:
Stacking profunda artery perforator flaps is an innovative yet technically challenging choice of flap for autologous breast reconstruction. It can provide an aesthetically pleasing result in the appropriately selected patient, and we recommend this technique in patients who are not optimal candidates for DIEP flap surgery because of previous flap failure or unavailable donor site.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, IV.
Achieving Aesthetic Results in the Umbilical Float Mini-Abdominoplasty: Patient Selection and Surgical Technique
Authors: Wan Dinah , Hubbard Bradley A. , Byrd H. Steve 
Published: February 2019

Background:
The umbilical float mini-abdominoplasty has been criticized for low final umbilicus position and umbilical distortion. The authors believe that in the properly selected patient and with proper technique, the umbilical float can achieve superior aesthetic results in a subset of patients.

Methods:
A retrospective review was performed of all umbilical floats performed by two surgeons (B.A.H. and H.S.B.) at the authors’ institution. Postoperative photographs were reviewed by 20 blinded evaluators.

Results:
Thirty-one female patients underwent umbilical float mini-abdominoplasty between 2010 and 2017. All patients had starting umbilicus position at or above the level of the iliac crest. The umbilicus was floated for a distance of 1 to 3.5 cm. Average umbilicus position was slightly above the midpoint between the xiphoid and pubis preoperatively, and slightly below the midpoint postoperatively. Final umbilicus was considered “too low” in five patients (18.5 percent), all of which were positioned at the level of the anterior superior iliac spine.

Conclusions:
Optimal candidates for the umbilical float mini-abdominoplasty are postpartum women with normal body mass index, mild to moderate infraumbilical skin excess, and minimal to mild supraumbilical excess. Starting umbilicus position should be at or above the level of iliac crests, or slightly above the mid torso. Final umbilicus position should remain above the anterior superior iliac spine. The umbilical base is reattached with multiple sutures to prevent distortion. At least 10 cm of hairless lower abdominal skin should be maintained between the final scar and navel to prevent a low-appearing umbilicus.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, IV.
Reappraisal of Perforasomes of the Superficial Femoral, Descending Genicular, and Saphenous Arteries and Clinical Applications to Locoregional Reconstruction
Authors: Mohan Anita T. , Zhu Lin , Morsy Mohamed , Sur Yoo Joon , Michalak Gregory J. , Lachman Nirusha , Mardini Samir , Saint-Cyr Michel 
Published: February 2019

Background:
The superficial femoral artery and medial thigh region has been an underused donor site for perforator flaps. This study evaluated perforasomes of the superficial femoral artery and its principal branches to review the clinical applications for locoregional reconstruction.

Methods:
Twenty-six fresh cadaveric lower extremities were dissected. Perforator size and anatomical course from the superficial femoral artery, descending genicular artery, and saphenous artery branch were documented. Perforators were selectively injected with iodinated contrast to assess vascular territories using computed tomography. A retrospective chart review was conducted on consecutive patients (2014 to 2015).

Results:
One hundred thirty perforators were mapped in the medial thigh region. Eleven extended medial thigh perforator flaps and 15 hemicircumferential flaps were harvested. The mean distance from the joint line was 16.7 ± 7.3 cm. Perforators arose from the superficial femoral artery (62 percent), saphenous artery branch (23 percent), and descending genicular artery (15 percent). Superficial femoral artery perforators were located around the mid and proximal thigh region (p < 0.001). The median perforasome surface area was 244 cm2, representing 36 percent in hemithigh flaps with preferential filling in the anteromedial region. Proximal perforasomes were the smallest. Perforasome areas based on vessel origin were comparable; however, saphenous artery perforators had a broader perforasome compared with descending genicular (p = 0.01) and superficial femoral artery perforators (p = 0.04). Six clinical case examples were presented for knee, thigh, and lower leg reconstruction.

Conclusions:
The superficial femoral artery or its branches can provide nontraditional reconstructive perforator flap options in regional reconstruction. They can be simple to harvest using a free-style approach, do not require preoperative imaging, offer a one-stage reconstructive method with low morbidity, and obviate the need for microsurgery or muscle flaps.
Current Risk Estimate of Breast Implant–Associated Anaplastic Large Cell Lymphoma in Textured Breast Implants
Authors: Collett David J. , Rakhorst Hinne , Lennox Peter , Magnusson Mark , Cooter Rodney , Deva Anand K. 
Published: February 2019

Background:
With breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) now accepted as a unique (iatrogenic) subtype of ALCL directly associated with textured breast implants, we are now at a point where a sound epidemiologic profile and risk estimate are required. The aim of this article is to provide a comprehensive and up-to-date global review of the available epidemiologic data and literature relating to the incidence, risk, and prevalence of BIA-ALCL.

Methods:
All current literature relating to the epidemiology of BIA-ALCL was reviewed. Barriers relating to sound epidemiologic study were identified, and trends relating to geographical distribution, prevalence of breast implants, and implant characteristics were analyzed.

Results:
Significant barriers exist to the accurate estimate of both the number of women with implants (denominator) and the number of cases of BIA-ALCL (numerator), including poor registries, underreporting, lack of awareness, cosmetic tourism, and fear of litigation. The incidence and risk of BIA-ALCL have increased dramatically from initial reports of 1 per million to current estimates of 1/2,832, and is largely dependant on the “population” (implant type and characteristics) examined and increased awareness of the disease.

Conclusions:
Although many barriers stand in the way of calculating accurate estimates of the incidence and risk of developing BIA-ALCL, steady progress, international registries, and collegiality between research teams are for the first time allowing early estimates. Most striking is the exponential rise in incidence over the last decade, which can largely be explained by the increasingly specific implant subtypes examined—driven by our understanding of the pathologic mechanism of the disease. High-textured high-surface area implants (grade 4 surface) carry the highest risk of BIA-ALCL (1/2,832).
Breast Reconstruction Following Breast Implant–Associated Anaplastic Large Cell Lymphoma
Authors: Lamaris Gregory A. , Butler Charles E. , Deva Anand K. , Miranda Roberto N. , Hunt Kelly K. , Connell Tony , Lipa Joan E. , Clemens Mark W. 
Published: February 2019

Background:
Standard of care treatment of breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) involves surgical resection with implant removal and complete capsulectomy. We report a case series of BIA-ALCL reconstruction with proposals for timing and technique selection.

Methods:
We retrospectively reviewed and prospectively enrolled all BIA-ALCL patients at 2 tertiary care centers and 1 private plastic surgery practice from 1998 to 2017. Demographics, treatment, reconstruction, pathology staging, patient satisfaction, and oncologic outcomes were reviewed.

Results:
We treated 66 consecutive BIA-ALCL patients and 18 (27%) received reconstruction. Seven patients (39%) received immediate reconstruction, and 11 (61%) received delayed reconstruction. Disease stage at presentation was IA (T1N0M0 disease confined to effusion or a layer on luminal side of capsule with no lymph node involvement and no distant spread) in 56%, IB in 17%, IC (T3N0M0 cell aggregates or sheets infiltrating the capsule, no lymph node involvement and no distant spread) in 6%, IIA (T4N0M0 lymphoma infiltrating beyond the capsule, no lymph node involvement and no distant spread) in 11%, and III in 11%. Types of reconstruction included smooth implants (72%), immediate mastopexy (11%), autologous flaps (11%), and fat grafting (6%). Outcomes included no surgical complications, but 1 patient progressed to widespread bone metastasis (6%); ultimately, all patients achieved complete remission. Ninety-four percent were satisfied/highly satisfied with reconstructions, whereas 6% were highly unsatisfied with immediate smooth implants.

Conclusions:
Breast reconstruction following BIA-ALCL management can be performed with acceptable complications if complete surgical ablation is possible. Immediate reconstruction is reserved for disease confined to capsule on preoperative positive emission tomography/computed tomography scan. Genetic predisposition and bilateral cases suggest that BIA-ALCL patients should not receive textured implants. Autologous options are preferable for implant adverse BIA-ALCL patients. Patients with extensive disease at presentation should be considered for 6- to 12-month delayed reconstruction with interval positive emission tomography/computed tomography evaluation.
Kinematic Analysis of the Distal Radioulnar Joint in Asymptomatic Wrists Using 4-Dimensional Computed Tomography–Motion Pattern and Interreader Reliability
Authors: Shakoor Delaram , Hafezi-Nejad Nima , Haj-Mirzaian Arya , Shores Jaimie T. , Lifchez Scott D. , Morelli John N. , Thakur Uma , Demehri Shadpour 
Published: February 2019

Purpose
The aim of this study was to determine the normal measurement values and interobserver performance of the distal radioulnar joint during wrist pronation-supination using 4-dimensional computed tomography (CT).

Methods
Four-dimensional CT examinations were performed on the asymptomatic contralateral wrists of 10 patients with unilateral chronic wrist pain. Measurements were conducted using the modified radioulnar (mRU) line and epicenter (Epi) methods. Volar subluxation of the ulnar head was demonstrated with negative values. Wilcoxon rank sum test was used to determine the measurement changes. Interobserver agreements were assessed using interclass correlation coefficients.

Results
In pronation, mRU line measurements (median, 0.09; interquartile range, 0–0.15) were significantly larger than in supination (median, −0.1; interquartile range, −0.18 to 0; P = 0.008).The Epi measurements were not significantly different in pronation (median, 0.03; interquartile range, 0.01–0.07) and supination (median, 0.06; interquartile range, 0.01–0.1; P = 0.799). There was an excellent inter-observer agreement between the two readers using mRU and Epi methods in pronation (0.982, 0.898), midpoint (0.994, 0.827) and supination (0.989, 0.972) positions, respectively.

Conclusions
Using 4-dimensional CT examination, distal radioulnar joint kinematics in asymptomatic wrists demonstrate excellent interobserver agreements with increased volar ulnar subluxation with supination as detected using mRU, but not the Epi method.
Spectral Computed Tomography Imaging in the Differential Diagnosis of Lung Cancer and Inflammatory Myofibroblastic Tumor
Authors: Yu Yixing , Wang Ximing , Shi Cen , Hu Su , Zhu Hui , Hu Chunhong 
Published: February 2019

Objective
The aim of this study was to explore the value of spectral computed tomography (CT) imaging in differentiating lung cancer from inflammatory myofibroblastic tumor (IMT).

Methods
One hundred twelve patients with 96 lung cancers and 16 IMTs underwent spectral CT during arterial phase (AP) and venous phase (VP). The normalized iodine concentration in AP (NICAP) and VP (NICVP), slope of spectral Hounsfield unit curve in AP (λAP) and VP (λVP), and normalized iodine concentration difference between AP and VP (ICD) were calculated. The 2-sample t test compared quantitative parameters. Two readers qualitatively assessed lesion types according to imaging features. Receiver operating characteristic curves were generated to calculate sensitivity and specificity. Sensitivity and specificity of the qualitative and quantitative studies were compared.

Results
The patients with IMT had significantly higher NICAP, NICVP, λAP, λVP, and ICD than did the patients with lung cancer (P < 0.05). The threshold NICVP of 0.425 would yield the highest sensitivity and specificity of 92.7% and 81.3%, respectively, for differentiating lung cancer from IMT. The logistic regression model produced from combining quantitative parameters NICAP, NICVP, λAP, and λVP provided a sensitivity and specificity of 100% and 81.3%, respectively, for differentiating lung cancer from IMT.

Conclusions
Spectral CT imaging with the quantitative analysis may help to increase the accuracy of differentiating lung cancer from IMT.
A Simple Low-Cost Method to Integrate Telehealth Interprofessional Team Members During In Situ Simulation
Authors: Bond William F. , Barker Lisa T. , Cooley Kimberly L. , Svendsen Jessica D. , Tillis William P. , Vincent Andrew L. , Vozenilek John A. , Powell Emilie S. 
Published: February 2019

Introduction
With the growth of telehealth, simulation personnel will be called upon to support training that integrates these new technologies and processes. We sought to integrate remote telehealth electronic intensive care unit (eICU) personnel into in situ simulations with rural emergency department (ED) care teams. We describe how we overcame technical challenges of creating shared awareness of the patient's condition and the care team's progress among those executing the simulation, the care team, and the eICU.

Methods
The objective of the simulations was to introduce telehealth technology and new processes of engaging the eICU via telehealth during sepsis care in 2 rural EDs. Scenario development included experts in sepsis, telehealth, and emergency medicine. We describe the operational systems challenges, alternatives considered, and solutions used. Participants completed surveys on self-confidence presimulation/postsimulation in using telehealth and in managing patients with sepsis (1–10 Likert scale, with 10 “completely confident”). Pre-post responses were compared by two-tailed paired t test.

Results
We successfully engaged the staff of two EDs: 42 nurses, 9 physicians or advanced practice providers, and 9 technicians (N = 60). We used a shared in situ simulation clinical actions observational checklist, created within an off-the-shelf survey software program, completed during the simulations by an on-site observer, and shared with the eICU team via teleconferencing software, to message and cue eICU nurse engagement. The eICU nurse also participated in debriefing via the telehealth video system with successful simulation engagement. These solutions avoided interfering with real ED or eICU operations. The postsimulation mean ± SD ratings of confidence using telehealth increased from 5.3 ± 2.9 to 8.9 ± 1.1 (Δ3.5, P < 0.05) and in managing patients with sepsis increased from 7.1 ± 2.5 to 8.9 ± 1.1 (Δ1.8, P < 0.05).

Conclusions
We created shared awareness between remote eICU personnel and in situ simulations in rural EDs via a low-cost method using survey software combined with teleconferencing methods.