Geospatial and Socioeconomic Disparities Influencing the Management of Craniosynostosis.

BACKGROUND: Various social determinants of health have been described as predictors of clinical outcomes for the craniosynostosis population. However, literature lacks a granular depiction of socioeconomic factors that impact these outcomes, and little is known about the relationship between patients' proximity to the care center and management of the condition. METHODS/DESIGN: This study retrospectively evaluated patients with craniosynostosis who presented to a tertiary children's hospital between 2000 and 2019. Outcomes of interest included age at presentation for surgery, incidence of reoperation, and length of follow-up. Patient addresses were geocoded and plotted on two separate shapefiles containing block group information within San Diego County. The shapefiles included percent parental educational attainment (bachelor's degree or higher) and median household income from 2010. The year 2010 was chosen for the shapefiles because it is the median year of data collection for this study. Multivariate linear, logistic, and polynomial regression models were used to analyze the relationship between geospatial and socioeconomic predictors and clinical outcomes. RESULTS: There were 574 patients with craniosynostosis included in this study. The mean ± SD Haversine distance from the patient's home coordinates to the hospital coordinates was 107.2 ± 321.2 miles. After adjusting for the suture fused and insurance coverage, there was a significant positive correlation between distance to the hospital and age at index surgery (P = 0.018). There was no correlation between distance and incidence of reoperation (P = 0.266) or distance and duration of follow-up (P = 0.369). Using the same statistical adjustments, lower parental percent educational attainment and lower median household income correlated with older age at index surgery (P = 0.008 and P = 0.0066, respectively) but were not correlated with reoperation (P = 0.986 and P = 0.813, respectively) or duration of follow-up (P = 0.107 and P = 0.984, respectively). CONCLUSIONS: The results offer evidence that living a greater distance from the hospital and socioeconomic disparities including parental education and median household income may serve as barriers to prompt recognition of diagnosis and timely care in this population. However, the geospatial and socioeconomic factors studied do not seem to hinder incidence of reoperation or length of follow-up, suggesting that, once care has been initiated, longitudinal outcomes may be less impacted.

Geospatial and Socioeconomic Disparities Influencing the Management and Outcomes of Nonsyndromic Craniosynostosis: A Systematic Review.

Geospatial and socioeconomic health disparities are potential barriers to timely diagnosis and treatment of nonsyndromic craniosynostosis. This systematic review aims to assess published literature describing disparities in craniosynostosis care and to summarize the findings surrounding patient proximity to care centers and familial socioeconomic status as predictors of surgical management and outcomes. The data sources used include PubMed, MEDLINE, and Google Scholar. The Strengthening the Reporting of Observational Studies in Epidemiology checklist was used for appraisal of the quality of the studies included. Generally, the literature reviewed suggested that socioeconomic variables including race, insurance payor, and median zip code income quartile are predictors of suboptimal craniosynostosis surgical management outcomes including older age at time of surgery and more invasive surgical approach performed. The only geospatial data element assessed was the general region of the hospital where the patient was treated. The review highlighted various knowledge gaps within published literature describing health-related disparities in patients with craniosynostosis. There is a paucity of research assessing geospatial access to craniosynostosis care centers, suggesting that further research should be performed to evaluate this potential disparity. In addition, previous studies lack granularity when assessing socioeconomic factors and only one study accounted for suture fused, which is a potential confounding variable across the other published work. These considerations should be addressed in future studies addressing this topic. The limitations of this review include potential publication bias given that unpublished work was not included. An element of reviewer bias also exists considering only one reviewer screened the articles and extracted the data.

Perioperative Comparison Between Open Cranial Vault Remodeling and Distraction Osteogenesis for Unilateral Lambdoid Craniosynostosis.

There are multiple treatment options for unilateral lambdoid craniosynostosis (ULS) including open posterior cranial vault remodeling (OCVR) and distraction osteogenesis (DO). There is a paucity of data comparing these techniques in the treatment of ULS. This study compared the perioperative characteristics of these interventions for patients with ULS. An IRB-approved chart review was performed from January 1999 to November 2018 at a single institution. Inclusion criteria included the diagnosis of ULS, treatment with either OCVR or DO using a posterior rotational flap technique, and a minimum 1-year follow-up. Seventeen patients met the inclusion criteria (12 OCVR and 5 DO). Patients in each cohort were found to have a similar distribution in sex, age at the time of surgery, synostosis laterality, weight, and length of follow-up. There was no significant difference in mean estimated blood loss/kg, surgical time, or transfusion requirements between cohorts. Distraction osteogenesis patients had a longer mean hospital length of stay (3.4 +/- 0.6 d versus 2.0 +/- 0.6 d, P = 0.0004). All patients were admitted to the surgical ward postoperatively. In the OCVR cohort, complications included 1 dural tear, 1 surgical site infection, and 2 reoperations. In the DO cohort, 1 patient had a distraction site infection, treated with antibiotics. There was no significant difference in estimated blood loss, volume of blood transfusion, or surgical time between OCVR and DO. Patients who underwent OCVR had a higher incidence of postoperative complications and the need for reoperation. This data provides insight into the perioperative differences between OCVR and DO in patients with ULS.

To Operate or Not to Operate? Reconstructive Surgical Burden and Quality of Life of Pediatric Patients with Facial Differences.

OBJECTIVE: The Craniofacial Condition Quality of Life Scale (CFC-QoL) was used to evaluate the relationship between surgical burden and quality of life (QoL). DESIGN: Patient-parent dyads completed the CFC-QoL which queries the following QoL domains: Bullying, Peer Problems, Psychological Impact, Family Support, Appearance Satisfaction, and Desire for Appearance Change. Stepwise multivariate linear regressions were performed for each QoL domain. SETTING: Urban tertiary care center. PATIENTS, PARTICIPANTS: Pediatric patients with facial differences, and their parents. INTERVENTION: Survey study. MAIN OUTCOME MEASURE(S): Demographic, diagnostic, and surgical characteristics were collected. Surgical burden was calculated as the standard deviation from the mean number of surgeries per diagnostic cohort. RESULT: Patients (N = 168) were majority female (57.1%) and Hispanic (64.3%). Diagnoses were cleft lip and/or palate (CLP,n = 99) or other craniofacial conditions (CFC,n = 69). Average patient age was 2.3 ± 5.6 years at first reconstructive surgery and 12.3 ± 3.4 years at study enrollment. Patients received an average of 4.3 ± 4.1 reconstructive surgeries.Worse Bullying was associated with higher surgical burden. Worse Peer Problems was associated with higher surgical burden, but only for children with non-CLP CFCs. Worse Family Support was associated with CFC diagnosis, female sex, and higher surgical burden. Worse Psychological Impact was associated with higher surgical burden. Worse Appearance Satisfaction was associated with younger age and with lower surgical burden. Greater Desire for Appearance Change was associated with older age, higher surgical burden, CLP diagnosis, female sex, and non-Hispanic ethnicity. Socioeconomic status did not predict QoL per patient self- or parent-proxy report. CONCLUSIONS: Higher surgical burden was associated with worse QoL outcomes in multiple domains.

Delayed Presentation of Sagittal Suture Craniosynostosis.

BACKGROUND: Sagittal craniosynostosis typically presents as dolichocephaly or less frequently as clinocephaly, a "saddle-shaped" phenotype. This project aimed to characterize clinically relevant differences between sagittal synostosis phenotypes and examine the etiology of the delay in presentation. METHODS: An institutional review board-approved retrospective review was performed from January 1999 to November 2018 at a single institution. Analyses examined correlations between subphenotype, time of presentation, minor suture fusion, developmental delay, and operative technique. RESULTS: One hundred sixty patients diagnosed with single-suture sagittal craniosynostosis were identified. A total of 30.6% had a saddle phenotype (n = 49) and 69.4% had dolichocephaly (n = 111). Patients with the saddle phenotype were more likely to present with a developmental delay and to have at least 1 minor suture fused than patients with dolichocephaly were. Patients with the saddle phenotype presented for surgery at an older age and were more likely to undergo open cranial vault repair, with increased blood loss, higher transfusion volume, and longer time. CONCLUSIONS: This study highlights clinical differences in sagittal craniosynostosis phenotypes and shows that developmental delay is an initial presentation of the saddle phenotype. The saddle phenotype also correlated with fusion of the minor squamous and sphenoid sutures. The link between developmental delay and minor suture fusion was notable and should be explored with a larger sample size. Patients with saddle synostosis present for surgery at an older age than patients with dolichocephaly and therefore are more likely to receive open cranial vault repair, with a taxing intraoperative experience characterized by increased blood loss, increased transfusions, and longer operation time.

Management of Plastic Surgery Complications at a Tertiary Medical Center after Aesthetic Procedures.

Background: The aesthetic plastic surgery industry has seen tremendous growth, with Americans spending an estimated 20 billion dollars on procedures in 2020. However, the effect of complications from these procedures on the healthcare system is poorly understood. This study aims to create awareness regarding aesthetic procedure complications through the scope of plastic surgeons at a tertiary medical facility. Methods: A retrospective chart review was performed on patients who received care at a single academic tertiary referral center over 5 years for complications from a cash-paid aesthetic procedure at an outside facility. Physician and hospital billing data were analyzed for relevant encounters. Results: Patients in this study (n = 40) presented to the emergency department most frequently with complications secondary to abdominoplasty (35%), breast augmentation (27.5%), and injectable fillers (17.5%). The most common complications were infection (32.5%) and wound dehiscence (22.5%). Of those evaluated, 50% required inpatient admission. Additionally, 42.5% required surgical intervention. The distribution of payors included Medicaid (55%), commercial insurance (30%), and Medicare (7.5%), and 7.5% were uninsured. For physician billing, the total gross collection ratio was 21.3%, whereas the hospital billing total gross collection ratio was 25.16%. Conclusions: Larger referral hospitals are well-suited to support the aesthetic community with complication management; however, the care required to serve this population is resource-intensive. These data advocate for thorough closed-loop patient-surgeon communication regarding risk-benefit analysis and detailed courses of action should complications arise. Likewise, stronger communication between ambulatory surgical centers and tertiary referral centers may also help minimize complications and subsequent healthcare needs.

Non-Healing Perianal Fistulas: A Clinical Model of Tissue Senescence Impairing Both Tissue Fibrosis and Regenerative Potential.

Senescent cells and fibrosis are important components that impact the regenerative capacity of skin, particularly when considering chronic non-healing wounds. Anoderm and perianal fistulas in the setting of Crohn's disease are clinically pathophysiological extremes with consequently different healing processes which impact treatment modalities. This study describes the implications of potential senescence reversing techniques including autologous fat grafting and pharmacologic and immunomodulating agents. Given these findings, the authors propose a future direction of study involving exosomes loaded with senolytics as a method for potentially improving chronic wound healing. In conclusion, this manuscript explores the diversity of skin healing and healing outcomes which supports the future investigation of senotherapeutic agents promoting regenerative processes for non-healing wounds.

A Retrospective Review of Arthroscopic Shaver Utilization in Adolescent Gynecomastia.

Background: This study compares the arthroscopic shaver and liposuction with other established methods for treatment of adolescent gynecomastia. Methods: Surgical management was via four operative techniques: open excision, open excision/liposuction, arthroscopic shaver/liposuction, or open excision and free nipple graft. Data were collected and compared using independent t tests, linear regression models, and one-way analysis of variance. Results: Patients were stratified by Rohrich grades I -II (low) (N = 47) or III -IV (high) (N = 13). The groups were similar in age (P = 0.662) with lower BMI in the low-grade group (x̄ = 25.36 ± 2.1) vs. high-grade group (x̄ = 27.62 ± 4.0; P < 0.001). The low-grade group showed no significant difference in operative time across surgical techniques with decreased mean operative time in the high-grade group using the arthroscopic shaver technique (x̄ = 55.8 ± 7.56) compared with open excision (x̄ = 70.83 ± 11.02, P = 0.04), open excision plus liposuction (x̄ = 89.5 ± 24.93, P = 24.93), and open excision plus free nipple graft (x̄ = 81.67 ± 19.11, P = 0.05). There was no significant difference in complication (P = 0.84) or reoperation (P = 0.68) rates across surgical techniques regardless of grade. Conclusions: These findings suggest that the arthroscopic shaver is safe and effective for treatment of both low- and high-grade gynecomastia in adolescents. The results yielded a similar incidence of complications and reoperation across surgical techniques, and the arthroscopic shaver approach demonstrated a shorter operative time compared with other techniques for high-grade gynecomastia.

Virtual Subinternships in the COVID Era: Lessons Learned from Three Institutional Experiences.

After the cessation of all in-person visiting rotations during the coronavirus 2019 pandemic, many programs developed virtual rotations as an alternative for the recruitment and education of prospective applicants. In this study, we developed a consortium of three institutions each with a unique virtual subinternship and prospectively surveyed participating students in order to reflect and improve upon future rotations. All students participating in virtual subinternships at three institutions were administered the same pre subinternship and post subinternship electronic surveys. Subinternship curricula were developed independently at each respective institution. Fifty-two students completed both surveys, for an overall response rate of 77.6%. Students' primary objectives were to evaluate their fit with the program (94.2%), interact with residents (94.2%), gain faculty mentorship (88.5%), and improve didactic knowledge (82.7%). Postrotation surveys revealed that over 73% of students reported having met all of these objectives over the course of the rotation. On average, students ranked programs 5% higher overall after the rotation (P = 0.024). Postrotation results showed that the majority (71.2%) of students perceived the virtual subinternship as slightly less valuable than in-person subinternships but that all students would participate in a virtual subinternship again. Student objectives can be successfully met using the virtual format for subinternships. The virtual format is also effective in enhancing the overall perception of a program and its residents. Although students still prefer in-person subinternships, our results suggest that virtual rotations are more accessible and very capable of meeting student goals.