Free Crushed Cartilage Filler Graft to Optimize Tip Aesthetics in Asian Rhinoplasty.

BACKGROUND: The thick skin and weak cartilages make tip rhinoplasty very challenging in Asian patients. Most require an open approach for structural grafting in order to achieve the desired projection and rotation. This need for substantial tip grafting may result in subtle imperfections that are only noticed as the incisions are closed. OBJECTIVES: This study describes the senior author's technique of free crushed cartilage filler graft to optimize nasal tip aesthetics in Asian rhinoplasty. The goal is to introduce this easy-to-use and effective technique to refine the final nasal tip aesthetic with immediate visual and tactile feedback. METHODS: This is a retrospective review of all patients with free crushed cartilage filler graft with at least 12 months of follow-up. Medical records were reviewed for patient demographics, intra-operative manoeuvres, and complications. Photographs were analysed to evaluate changes in nasal length, tip height, and nasolabial and columellar-labial angles as well as aesthetic complications. RESULTS: Sixty-six patients were included in this study, with an average follow-up of 16.3 months. Nasal length was 8.3% greater than pre-op (P < 0.01), and nasal tip height was 12.7% greater than pre-op (P < 0.01). Aesthetic analysis demonstrated that 6.1% of patients had an amorphous tip, 3.0% had an irregular or asymmetric tip, and 4.5% had visible tip grafts. 12.1% of patients expressed aesthetic dissatisfaction, but none was recommended for or pursued revision surgery. CONCLUSIONS: When used correctly, free crushed cartilage filler graft can improve the final tip aesthetic and help camouflage underlying prominences to give the patient a natural result. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Subject-level spinal osteoporotic fracture prediction combining deep learning vertebral outputs and limited demographic data.

Automated screening for vertebral fractures could improve outcomes. We achieved an AUC-ROC = 0.968 for the prediction of moderate to severe fracture using a GAM with age and three maximal vertebral body scores of fracture from a convolutional neural network. Maximal fracture scores resulted in a performant model for subject-level fracture prediction. Combining individual deep learning vertebral body fracture scores and demographic covariates for subject-level classification of osteoporotic fracture achieved excellent performance (AUC-ROC of 0.968) on a large dataset of radiographs with basic demographic data. PURPOSE: Osteoporotic vertebral fractures are common and morbid. Automated opportunistic screening for incidental vertebral fractures from radiographs, the highest volume imaging modality, could improve osteoporosis detection and management. We consider how to form patient-level fracture predictions and summarization to guide management, using our previously developed vertebral fracture classifier on segmented radiographs from a prospective cohort study of US men (MrOS). We compare the performance of logistic regression (LR) and generalized additive models (GAM) with combinations of individual vertebral scores and basic demographic covariates. METHODS: Subject-level LR and GAM models were created retrospectively using all fracture predictions or summary variables such as order statistics, adjacent vertebral interactions, and demographic covariates (age, race/ethnicity). The classifier outputs for 8663 vertebrae from 1176 thoracic and lumbar radiographs in 669 subjects were divided by subject to perform stratified fivefold cross-validation. Models were assessed using multiple metrics, including receiver operating characteristic (ROC) and precision-recall (PR) curves. RESULTS: The best model (AUC-ROC = 0.968) was a GAM using the top three maximum vertebral fracture scores and age. Using top-ranked scores only, rather than all vertebral scores, improved performance for both model classes. Adding age, but not ethnicity, to the GAMs improved performance slightly. CONCLUSION: Maximal vertebral fracture scores resulted in the highest-performing models. While combining multiple vertebral body predictions risks decreasing specificity, our results demonstrate that subject-level models maintain good predictive performance. Thresholding strategies can be used to control sensitivity and specificity as clinically appropriate.

Using an Ensemble of Segmentation Methods to Detect Vertebral Bodies on Radiographs.

BACKGROUND AND PURPOSE: Vertebral compression fractures may indicate osteoporosis but are underdiagnosed and underreported by radiologists. We have developed an ensemble of vertebral body (VB) segmentation models for lateral radiographs as a critical component of an automated, opportunistic screening tool. Our goal is to detect the approximate location of thoracic and lumbar VBs, including fractured vertebra, on lateral radiographs. MATERIALS AND METHODS: The Osteoporotic Fractures in Men Study (MrOS) data set includes spine radiographs of 5994 men aged ≥65 years from 6 clinical centers. Two segmentation models, U-Net and Mask-RCNN (Region-based Convolutional Neural Network), were independently trained on the MrOS data set retrospectively, and an ensemble was created by combining them. Primary performance metrics for VB detection success included precision, recall, and F1 score for object detection on a held-out test set. Intersection over union (IoU) and Dice coefficient were also calculated as secondary metrics of performance for the test set. A separate external data set from a quaternary health care enterprise was acquired to test generalizability, comprising diagnostic clinical radiographs from men and women aged ≥65 years. RESULTS: The trained models achieved F1 score of U-Net = 83.42%, Mask-RCNN = 86.30%, and ensemble = 88.34% in detecting all VBs, and F1 score of U-Net = 87.88%, Mask-RCNN = 92.31%, and ensemble = 97.14% in detecting severely fractured vertebrae. The trained models achieved an average IoU per VB of 0.759 for U-Net and 0.709 for Mask-RCNN. The trained models achieved F1 score of U-Net = 81.11%, Mask-RCNN = 79.24%, and ensemble = 87.72% in detecting all VBs in the external data set. CONCLUSIONS: An ensemble model combining predictions from U-Net and Mask-RCNN resulted in the best performance in detecting VBs on lateral radiographs and generalized well to an external data set. This model could be a key component of a pipeline to detect fractures on all vertebrae in a radiograph in an automated, opportunistic screening tool under development.

Variant Coronary Arterial Collateral Ring.

A 74-year-old man presented with symptoms and noninvasive diagnostic studies suggestive of myocardial infarction. Coronary angiography revealed total occlusion of the distal right coronary artery with a unique accessory coronary ring that provided retrograde collateral flow to the left ventricle, demonstrating the importance of considering non-native vessels when identifying target lesions.

The robotic-assisted free jejunal flap for neovaginal canal creation in gender-affirming vaginoplasties.

INTRODUCTION: One of the biggest challenges with gender-affirming vaginoplasty was the creation of a long-lasting, durable, patent, and self-lubricating neovaginal canal that allowed for spontaneous, pain-free sexual intercourse. The jejunum was a durable, physiologic, and intestinal option to create the neovaginal canal that minimizes the adverse effects of skin graft, peritoneal, and colonic vaginoplasties. Free jejunal vaginoplasties had been performed in cis females for congenital genitourinary anomalies like Mullerian agenesis or after gynecologic-oncologic surgery but had yet to be reported for gender-affirming vaginoplasties. The purpose of this report was to present a technique for a physiologic, intestinal, gender-affirming vaginoplasty without the disadvantages of colonic vaginoplasties. PATIENTS AND METHODS: This report presented six patients, all natal males who identified as female, undergoing robotic-assisted free jejunal flap gender-affirming vaginoplasty. Mean age was 35.8 years (range: 21-66). Mean body mass index was 33.2 kg/m2 (range: 28.0-41.0). The proximal aspect of the neovaginal canal was created intra-abdominally by elevating peritoneal flaps from the posterior bladder wall to be reflected downward into the external neovaginal canal. The jejunal flap was harvested. The greater saphenous vein was harvested to create an arteriovenous loop between the flap vessels and the recipient femoral artery in an end-to-side fashion and a branch of the femoral vein. The jejunal flap was passed intra-abdominally through the groin incision and then trans-peritoneally into the neovaginal canal. The jejunal segment was inset to the proximal peritoneal flaps and the distal inverted penoscrotal skin of the neovaginal introitus. RESULTS: Mean length of the harvest jejunal segment was 19.2 cm (range: 15-20). Mean time to ambulation, foley removal, and first vaginal dilation were 3.3 (range: 3-4), 4.0 (range: 3-5), and 4.5 days (range: 4-6), respectively. By a mean follow-up duration of 8.0 months (range: 1-14), mean vaginal depth and diameter were 7.0 and 1.3 cm (range: 1.0-1.5), respectively. Two (33.3%) patients experienced postoperative complications, including groin hematoma (n = 1, 16.7%) and reoperation for correction of dehiscence of the jejunal flap to the vaginal introitus (n = 1, 16.7%). CONCLUSION: Gender-affirming surgeons should consider a free vascularized segment of jejunum as an option to line the neovaginal canal in the correct patients.

Prognostic Significance of Immune Cell Infiltration in Muscle-invasive Bladder Cancer Treated with Definitive Chemoradiation: A Secondary Analysis of RTOG 0524 and RTOG 0712.

Chemoradiation therapy (CRT) is a treatment for muscle-invasive bladder cancer (MIBC). Using a novel transcriptomic profiling panel, we validated prognostic immune biomarkers to CRT using 70 pretreatment tumor samples from prospective trials of MIBC (NRG/RTOG 0524 and 0712). Disease-free survival (DFS) and overall survival (OS) were estimated via the Kaplan-Meier method and stratified by genes correlated with immune cell activation. Cox proportional-hazards models were used to assess group differences. Clustering of gene expression profiles revealed that the cluster with high immune cell content was associated with longer DFS (hazard ratio [HR] 0.53, 95% confidence interval [CI] 0.26-1.10; p = 0.071) and OS (HR 0.48, 95% CI 0.24-0.97; p = 0.040) than the cluster with low immune cell content. Higher expression of T-cell infiltration genes (CD8A and ICOS) was associated with longer DFS (HR 0.40, 95% CI 0.21-0.75; p = 0.005) and OS (HR 0.49, 95% CI 0.25-0.94; p = 0.033). Higher IDO1 expression (IFNγ signature) was also associated with longer DFS (HR 0.44, 95% CI 0.24-0.88; p = 0.021) and OS (HR 0.49, 95% CI 0.24-0.99; p = 0.048). These findings should be validated in prospective CRT trials that include biomarkers, particularly for trials incorporating immunotherapy for MIBC. PATIENT SUMMARY: We analyzed patient samples from two clinical trials (NRG/RTOG 0524 and 0712) of chemoradiation for muscle-invasive bladder cancer using a novel method to assess immune cells in the tumor microenvironment. Higher expression of genes associated with immune activation and high overall immune-cell content were associated with better disease-free survival and overall survival for patients treated with chemoradiation.

A Case of Klippel-Trenaunay Syndrome Complicated by Group A Streptococcemia and Multiple Organ Failure.

Klippel-Trenaunay syndrome (KTS) is a rare congenital disorder defined as a triad of capillary malformation, venous malformation, and hypertrophy of soft tissue and bones, with or without lymphatic malformation. We report a case of a KTS patient with a hospital course complicated by Group A Streptococcus bacteremia and multiple organ failure. The 39-year-old female with KTS presented to the emergency department with a fever, tachycardia, hypotension, and profuse diarrhea for one week. Blood cultures grew Group A Streptococcus necessitating a multi-antibiotic regimen and intravenous immunoglobulins (IVIG). Secondary to septic shock, the patient's renal function continuously declined requiring eight rounds of hemodialysis. She was electively intubated due to worsening acute hypoxic respiratory failure. Chest X-rays demonstrated consolidation, pneumonitis, pleural embolism, and effusions. The patient also required eight units of packed RBC throughout her hospitalization. An underlying autoimmune etiology was suspected due to multiorgan involvement and abnormal blood smears, which was confirmed by an autoimmune panel. The patient ultimately was stabilized and was optimized for discharge. This case demonstrates the importance of a multidisciplinary approach in managing patients with KTS due to their associated lymphatic abnormalities that predispose them to severe infections.

Alternate Electrode Placements to Facilitate Frontal Electroencephalography Monitoring in Anesthetized and Critically Ill Patients.

BACKGROUND: Frontal electroencephalography (EEG) monitoring can be useful in guiding the titration of anesthetics, but it is not always feasible to place electrodes in the standard configuration in some circumstances, including during neurosurgery. This study compares 5 alternate configurations of the Masimo Sedline Sensor. METHODS: Ten stably sedated patients in the intensive care unit were recruited. Frontal EEG was monitored in the standard configuration (bifrontal upright) and 5 alternate configurations: bifrontal inverse, infraorbital, lateral upright, lateral inverse, and semilateral. Average power spectral densities (PSDs) with 95% CIs in the alternate configurations were compared to PSDs in the standard configuration. Two-one-sided-testing with Wilcoxon signed-rank tests assessed equivalence in the spectral edge frequency (SEF-95), EEG power, and relative delta (0.5 to 3.5 Hz), alpha (8 to 12 Hz), and beta (20 to 30 Hz) power between each alternate and standard configurations. RESULTS: After the removal of unanalyzable tracings, 7 patients were included for analysis in the infraorbital configuration and 9 in all other configurations. In the lateral upright and lateral inverse configurations, PSDs significantly differed from the standard configuration within the 15 to 20 Hz band. The greatest decrease in EEG power was in the lateral inverse configuration (median: -97 dB; IQR: -130, -62 dB). The largest change in frequency distribution of EEG power was in the infraorbital configuration; median SEF-95 change of -1.4 Hz (IQR: -2.8, 0.7 Hz), median relative delta power change of +7.3% (IQR: 1.4%, 7.9%), and median relative alpha power change of -0.6% (IQR: -5.7%, 0.0%). CONCLUSIONS: These 5 alternate Sedline electrode configurations are suitable options for monitoring frontal EEG when the standard configuration is not possible.

Long-term Outcomes of Chemoradiation for Muscle-invasive Bladder Cancer in Noncystectomy Candidates. Final Results of NRG Oncology RTOG 0524-A Phase 1/2 Trial of Paclitaxel + Trastuzumab with Daily Radiation or Paclitaxel Alone with Daily Irradiation.

BACKGROUND: Chemo-radiation is a well-established alternative to radical cystectomy in patients with muscle-invasive bladder cancer. Many patients due to age or medical comorbidity are unfit for either radical cystectomy, or standard cisplatin- or 5-fluorouracil-based chemoradiation, and do not receive appropriate treatment with curative intent. We treated patients with a less aggressive protocol employing seven weekly doses of paclitaxel and daily irradiation. In those whose tumors showed overexpression of her2/neu, seven weekly doses of trastuzumab were also administered. OBJECTIVE: To report the long-term survival outcomes and toxicity results of the of NRG Oncology RTOG 0524 study. DESIGN, SETTING, AND PARTICIPANTS: Seventy patients were enrolled and 65 (median age: 76 yr) were deemed eligible. Patients were assigned to daily radiation and weekly paclitaxel + trastuzumab (group 1, 20 patients) or to daily radiation plus weekly paclitaxel (group 2, 45 patients) based on tumor her2/neu overexpression. Radiation was delivered in 1.8 Gy fractions to a total dose of 64.8 Gy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary endpoint was unresolved treatment-related toxicity. The secondary endpoints were complete response rate, protocol completion rate, and disease-free and overall survival. RESULTS AND LIMITATIONS: Protocol therapy was completed by 60% (group 1) and 76% (group 2); complete response rates at 12 wk were 62% in each group. Acute treatment-related adverse events (AEs) of grade ≥3 were observed in 80% in group 1 and 58% in group 2. There was one treatment-related grade 5 AE in group 1. Unresolved acute treatment-related toxicity was 35% in group 1 and 31% in group 2. The median follow-up was 2.3 yr in all patients and 7.2 yr in surviving patients. Overall survival at 5 yr was 25.0% in group 1 and 37.8% in group 2 (33.8% overall). At 5 yr, disease-free survival was 15.0% in group 1 and 31.1% in group 2. CONCLUSIONS: In a cohort of patients with muscle-invasive bladder cancer who are not candidates for cystectomy or cisplatin chemotherapy, chemoradiation therapy offers a treatment with a significant response rate and 34% 5-yr overall survival. While there were many AEs in this medically fragile group, there were few grade 4 events and one grade 5 event attributable to therapy. PATIENT SUMMARY: Patients with invasive bladder cancer who cannot tolerate surgery were treated with radiation and systemic therapy without surgically removing their bladders. Most patients tolerated the treatment, were able to keep their bladders, and showed a significant treatment response rate.

Primary Targeted Muscle Reinnervation in Above-Knee Amputations in Patients with Unsalvageable Limbs from Limb-Threatening Ischemia or Infection.

BACKGROUND: Amputees frequently suffer from chronic pain in both their residual limbs (RLP) and phantom limbs (PLP) following their amputation. Targeted muscle reinnervation (TMR) is a nerve transfer technique that has been demonstrated to improve pain secondarily and at time of amputation. The goal of this study is to report on the efficacy of primary TMR at time of above-knee level amputations in the setting of limb-threatening ischemia or infection. METHODS: This is a retrospective review of a single-surgeon experience with TMR in patients undergoing through- or above-knee level amputations from January 2018 to June 2021. Patient charts were reviewed for the comorbidities in the Charlson Comorbidity Index. Postoperative notes were assayed for presence and absence of RLP and PLP, overall pain severity, chronic narcotic use, ambulatory status, and complications. A control group of patients undergoing lower limb amputation who did not receive TMR from January 2014 to December 2017 was used for comparison. RESULTS: Forty-one patients with through- or above-knee level amputations and primary TMR were included in this study. The tibial and common peroneal nerves were transferred in all cases to motor branches to the gastrocnemius, semimembranosus, semitendinosus, and biceps femoris. Fifty-eight patients with through- or above-knee level amputations without TMR were included for comparison. The TMR group had significantly less overall pain (41.5 vs. 67.2%, p = 0.01), RLP (26.8 vs. 44.8%, p = 0.04), and PLP (19.5 vs. 43.1%, p = 0.02). There were no significant differences in complication rates. CONCLUSION: TMR can safely and effectively be performed at time of a through- and above-knee level amputation and improves pain outcomes.

Generalizability of Deep Learning Classification of Spinal Osteoporotic Compression Fractures on Radiographs Using an Adaptation of the Modified-2 Algorithm-Based Qualitative Criteria.

RATIONALE AND OBJECTIVES: Spinal osteoporotic compression fractures (OCFs) can be an early biomarker for osteoporosis but are often subtle, incidental, and underreported. To ensure early diagnosis and treatment of osteoporosis, we aimed to build a deep learning vertebral body classifier for OCFs as a critical component of our future automated opportunistic screening tool. MATERIALS AND METHODS: We retrospectively assembled a local dataset, including 1790 subjects and 15,050 vertebral bodies (thoracic and lumbar). Each vertebral body was annotated using an adaption of the modified-2 algorithm-based qualitative criteria. The Osteoporotic Fractures in Men (MrOS) Study dataset provided thoracic and lumbar spine radiographs of 5994 men from six clinical centers. Using both datasets, five deep learning algorithms were trained to classify each individual vertebral body of the spine radiographs. Classification performance was compared for these models using multiple metrics, including the area under the receiver operating characteristic curve (AUC-ROC), sensitivity, specificity, and positive predictive value (PPV). RESULTS: Our best model, built with ensemble averaging, achieved an AUC-ROC of 0.948 and 0.936 on the local dataset's test set and the MrOS dataset's test set, respectively. After setting the cutoff threshold to prioritize PPV, this model achieved a sensitivity of 54.5% and 47.8%, a specificity of 99.7% and 99.6%, and a PPV of 89.8% and 94.8%. CONCLUSION: Our model achieved an AUC-ROC>0.90 on both datasets. This testing shows some generalizability to real-world clinical datasets and a suitable performance for a future opportunistic osteoporosis screening tool.

Health-related quality of life and pain outcomes with [177Lu]Lu-PSMA-617 plus standard of care versus standard of care in patients with metastatic castration-resistant prostate cancer (VISION): a multicentre, open-label, randomised, phase 3 trial.

BACKGROUND: In VISION, the prostate-specific membrane antigen (PSMA)-targeted radioligand therapy lutetium-177 [177Lu]Lu-PSMA-617 (vipivotide tetraxetan) improved radiographic progression-free survival and overall survival when added to protocol-permitted standard of care in patients with metastatic castration-resistant prostate cancer. Here, we report additional health-related quality of life (HRQOL), pain, and symptomatic skeletal event results. METHODS: This multicentre, open-label, randomised, phase 3 trial was conducted at 84 cancer centres in nine countries in North America and Europe. Eligible patients were aged 18 years or older; had progressive PSMA-positive metastatic castration-resistant prostate cancer; an Eastern Cooperative Oncology Group (ECOG) performance status score of 0-2; and had previously received of at least one androgen receptor pathway inhibitor and one or two taxane-containing regimens. Patients were randomly assigned (2:1) to receive either [177Lu]Lu-PSMA-617 plus protocol-permitted standard of care ([177Lu]Lu-PSMA-617 group) or standard of care alone (control group) using permuted blocks. Randomisation was stratified by baseline lactate dehydrogenase concentration, liver metastases, ECOG performance status, and androgen receptor pathway inhibitor inclusion in standard of care. Patients in the [177Lu]Lu-PSMA-617 group received intravenous infusions of 7·4 gigabecquerel (GBq; 200 millicurie [mCi]) [177Lu]Lu-PSMA-617 every 6 weeks for four cycles plus two optional additional cycles. Standard of care included approved hormonal treatments, bisphosphonates, and radiotherapy. The alternate primary endpoints were radiographic progression-free survival and overall survival, which have been reported. Here we report the key secondary endpoint of time to first symptomatic skeletal event, and other secondary endpoints of HRQOL assessed with the Functional Assessment of Cancer Therapy-Prostate (FACT-P) and EQ-5D-5L, and pain assessed with the Brief Pain Inventory-Short Form (BPI-SF). Patient-reported outcomes and symptomatic skeletal events were analysed in all patients who were randomly assigned after implementation of measures designed to reduce the dropout rate in the control group (on or after March 5, 2019), and safety was analysed according to treatment received in all patients who received at least one dose of treatment. This trial is registered with ClinicalTrials.gov, NCT03511664, and is active but not recruiting. FINDINGS: Between June 4, 2018, and Oct 23, 2019, 831 patients were enrolled, of whom 581 were randomly assigned to the [177Lu]Lu-PSMA-617 group (n=385) or control group (n=196) on or after March 5, 2019, and were included in analyses of HRQOL, pain, and time to first symptomatic skeletal event. The median age of patients was 71 years (IQR 65-75) in the [177Lu]Lu-PSMA-617 group and 72·0 years (66-76) in the control group. Median time to first symptomatic skeletal event or death was 11·5 months (95% CI 10·3-13·2) in the [177Lu]Lu-PSMA-617 group and 6·8 months (5·2-8·5) in the control group (hazard ratio [HR] 0·50, 95% CI 0·40-0·62). Time to worsening was delayed in the [177Lu]Lu-PSMA-617 group versus the control group for FACT-P score (HR 0·54, 0·45-0·66) and subdomains, BPI-SF pain intensity score (0·52, 0·42-0·63), and EQ-5D-5L utility score (0·65, 0·54-0·78). Grade 3 or 4 haematological adverse events included decreased haemoglobin (80 [15%] of 529 assessable patients who received [177Lu]Lu-PSMA-617 plus standard of care vs 13 [6%] of 205 who received standard of care only), lymphocyte concentrations (269 [51%] vs 39 [19%]), and platelet counts (49 [9%] vs five [2%]). Treatment-related adverse events leading to death occurred in five (1%) patients who received [177Lu]Lu-PSMA-617 plus standard of care (pancytopenia [n=2], bone marrow failure [n=1], subdural haematoma [n=1], and intracranial haemorrhage [n=1]) and no patients who received standard of care only. INTERPRETATION: [177Lu]Lu-PSMA-617 plus standard of care delayed time to worsening in HRQOL and time to skeletal events compared with standard of care alone. These findings support the use of [177Lu]Lu-PSMA-617 in patients with metastatic castration-resistant prostate cancer who received previous androgen receptor pathway inhibitor and taxane treatment. FUNDING: Advanced Accelerator Applications (Novartis).

Below-the-knee Amputation with Targeted Muscle Reinnervation: Operative Technique and Technical Pearls.

Postamputation pain from symptomatic neuromas and/or phantom limb pain can have a significant detrimental impact on patients' quality of life following a major lower extremity amputation. Various methods of physiologic nerve stabilization, such as targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface, have been proposed as the best current techniques to prevent that pathologic neuropathic pain. Methods: This article details our institution's technique that has been performed safely and effectively on over 100 patients. Our approach and rationale for each of the major nerves of the lower extremity are presented. Results: In contrast to other described techniques for TMR for below-the-knee amputations, this current protocol does not involve performing transfers on all five major nerves, as one must balance rates of symptomatic neuroma formation and nerve-specific phantom limb pain with needed operative time and surgical morbidity from removing proximal sensory function and denervation of the donor motor nerve branches. This technique also differs significantly from others by performing a transposition of the superficial peroneal nerve to place the neurorrhaphy away from the weight-bearing stump. Conclusion: This article details our institution's approach to physiologic nerve stabilization via TMR at time of below-the-knee amputation.

Selecting a chest masculinization plastic surgeon: a survey of transgender patients.

Background: Chest masculinization is a commonly performed gender-affirming procedure in transmasculine and non-binary patients and has increased in prevalence in recent years despite continued barriers to surgical care. With the expansion of insurance coverage and trained surgeons, patients at times have the opportunity to be selective in choosing their gender-affirming surgeon. This study aimed to investigate factors that transmasculine individuals consider important when selecting their chest masculinization plastic surgeon. Methods: All patients who underwent chest masculinization with a single surgeon between January 2018 and December 2021 were surveyed via an online questionnaire to rate 21 factors associated with surgeon selection. Multiple-choice questions and free text space were included to further clarify patient preferences. Results were analyzed to rate factors in order of importance. Results: One hundred three individuals completed the survey, generating a response rate of 49.5%. Average patient age at time of surgery was 27.0 years, and 2.0% of patients had prior gender affirmation surgery (GAS). The top five most important factors were surgeon specialization in GAS, insurance coverage, board certification, number of times surgeon has performed procedure, and availability of Before and After photographs. The five least important factors were age of surgeon, medical publications, availability of YouTube videos, location of training, and surgeon presence on social media. Conclusions: Transmasculine patients employ distinct criteria when selecting a chest masculinization gender-affirming plastic surgeon. An improved understanding of these factors informs providers of ways to enhance patient access to information and gender-affirming care.Level of evidence: Not gradable.

Perioperative misgendering experiences in patients undergoing gender-affirming surgery: a call for a gender-inclusive healthcare environment.

Background: Transgender individuals have long experienced discrimination and exclusion from medicine. Misgendering occurs when an individual is referred to using a gender or address incongruent with their identity. We evaluated the incidence of misgendering throughout the perioperative experience for patients undergoing gender-affirming surgery (GAS). Methods: Patients diagnosed with gender dysphoria who previously received GAS by the senior author were contacted to complete an IRB-approved survey to evaluate instances of misgendering while in the hospital for GAS. Study results were summarized using descriptive statistics. Results: Of 471 patients contacted, 182 completed the survey (38.6%). The most cited gender identity was transfemale (28.0%). Most patients reported respect for their gender identity (60.4%) and name (76.8%) during their perioperative experience. Twenty-two percent cited triggering experiences, and 15.4% reported interactions with healthcare employees causing them to reach out to a support system. Misgendering most commonly included incorrect use of patients' preferred names and/or pronouns (n = 50, 86.2%), most commonly at surgical check-in (n = 10, 45.5%). Recommendations to improve feelings of gender congruence during patients' stay included updated names and gender identities in electronic medical records (80.8%), and names and pronouns listed on curtains and doors (52.3%) and name tags (51.5%). Conclusions: Until now, the exact incidence of misgendering among patients seeking GAS have not been well established. Despite high levels of satisfaction, a large proportion still reported serious instances of misgendering. Improvements must be made to the perioperative experience to reduce misgendering and provide support and comfort during the sensitive period surrounding patients' gender transition.Level of evidence: Not gradable. Supplementary Information: The online version contains supplementary material available at 10.1007/s00238-022-02040-2.

Frontal Electroencephalography Findings in Critically Ill COVID-19 Patients.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) negatively impacts the central nervous system, and studies using a full montage of electroencephalogram (EEG) electrodes have reported nonspecific EEG patterns associated with coronavirus disease 2019 (COVID-19) infection. The use of this technology is resource-intensive and limited in its implementation. In this descriptive pilot study, we report neurophysiological patterns and the potential prognostic capability of an abbreviated frontal EEG electrode montage in critically ill COVID-19 patients. MATERIALS AND METHODS: Patients receiving mechanical ventilation for SARS-CoV-2 respiratory failure were monitored with Sedline Root Devices using EEG electrodes were placed over the forehead. Qualitative EEG assessments were conducted daily. The primary outcome was mortality, and secondary outcomes were duration of endotracheal intubation and lengths of intensive care and hospitalization stay. RESULTS: Twenty-six patients were included in the study, and EEG discontinuity was identified in 22 (84.6%) patients. The limited sample size and patient heterogeneity precluded statistical analysis, but certain patterns were suggested by trends in the data. Survival was 100% (4/4) for those patients in which a discontinuous EEG pattern was not observed. The majority of patients (87.5%, 7/8) demonstrating activity in the low-moderate frequency range (7 to 17 Hz) survived compared with 61.1% (11/18) of those without this observation. CONCLUSIONS: The majority of COVID-19 patients showed signs of EEG discontinuity during monitoring with an abbreviated electrode montage. The trends towards worse survival among those with EEG discontinuity support the need for additional studies to investigate these associations in COVID-19 patients.

Case report: Disseminated histoplasmosis in a renal transplant recipient from a non-endemic region.

Histoplasmosis is the most common endemic fungal infection in the USA. The majority of cases are asymptomatic and have clear exposure to endemic regions. In contrast, we present an adolescent immunocompromised patient with systemic and relatively non-specific symptoms including abdominal pain, weight loss, lower extremity edema, and scabbing skin lesions, without known exposure to endemic areas for histoplasmosis. Histologic analysis of gastrointestinal and skin biopsies eventually revealed a diagnosis of disseminated histoplasmosis; the patient was successfully treated with amphotericin B followed by itraconazole maintenance therapy. Ultimately, a high bar of suspicion for fungal disease must be maintained in immunosuppressed individuals even without apparent exposure history to endemic areas. This case report serves as a valuable reference for practitioners evaluating differential diagnosis of infections in immunocompromised patients.