Comparing Fibula Flap Insetting Techniques for Pediatric Oncologic Extremity Reconstruction.

BACKGROUND: Extremity reconstruction in skeletally immature patients presents unique challenges in terms of operative technique, bone healing, and limb function. A variety of insetting techniques have been described, with no clearly superior option. The authors hypothesized that vascularized fibula flaps placed in the intramedullary space are associated with shorter union times and better functionality compared with onlay flaps. METHODS: In a cohort study, the authors retrospectively reviewed the medical records of all pediatric patients who underwent fibula flap extremity reconstruction at a single center from 2001 through 2018. Comorbidities, complications, and outcomes were analyzed. Complete fibula union was based on radiographic evidence of significant cortical bridging. RESULTS: Thirty-three patients (mean age, 13.6 years; range, 2 to 18 years) underwent pedicled ( n = 7) or free ( n = 26) fibula flap reconstructions in 12 upper extremities and 21 lower extremities. Median follow-up was 69.5 months (interquartile range, 16.3 to 114.6 months). Onlay and intramedullary fibula position compared with intercalary placement (median, 13.5 and 14.6 months versus 3.4 months; P = 0.002) were associated with longer time to complete bone union. Complications including allograft fracture ( P = 0.02) and hardware removal ( P = 0.018) were also associated with longer time to complete union and eventual conversion to megaprosthesis ( P = 0.02, P = 0.038). Thirty-two patients (97%) achieved full union and a functional reconstruction. CONCLUSIONS: Fibula flap reconstruction is safe and effective for pediatric long-bone reconstruction. Longer fibula union times were associated with onlay and intramedullary fibula placement, allograft fracture, and hardware removal. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A non-pharmacological multi-modal therapy to improve sleep and cognition and reduce mild cognitive impairment risk: Design and methodology of a randomized clinical trial.

Aging populations are at increased risk of sleep deficiencies (e.g., insomnia) that are associated with a variety of chronic health risks, including Alzheimer's disease and related dementias (ADRD). Insomnia medications carry additional risk, including increased drowsiness and falls, as well as polypharmacy risks. The recommended first-line treatment for insomnia is cognitive behavioral therapy for insomnia (CBTi), but access is limited. Telehealth is one way to increase access, particularly for older adults, but to date telehealth has been typically limited to simple videoconferencing portals. While these portals have been shown to be non-inferior to in-person treatment, it is plausible that telehealth could be significantly improved. This work describes a protocol designed to evaluate whether a clinician-patient dashboard inclusive of several user-friendly features (e.g., patterns of sleep data from ambulatory devices, guided relaxation resources, and reminders to complete in-home CBTi practice) could improve CBTi outcomes for middle- to older-aged adults (N = 100). Participants were randomly assigned to one of three telehealth interventions delivered through 6-weekly sessions: (1) CBTi augmented with a clinician-patient dashboard, smartphone application, and integrated smart devices; (2) standard CBTi (i.e., active comparator); or (3) sleep hygiene education (i.e., active control). All participants were assessed at screening, pre-study evaluation, baseline, throughout treatment, and at 1-week post-treatment. The primary outcome is the Insomnia Severity Index. Secondary and exploratory outcomes span sleep diary, actiwatch and Apple watch assessed sleep parameters (e.g., efficiency, duration, timing, variability), psychosocial correlates (e.g., fatigue, depression, stress), cognitive performance, treatment adherence, and neurodegenerative and systemic inflammatory biomarkers.

Effective interventions to increase routine childhood immunization coverage in low socioeconomic status communities in developed countries: A systematic review and critical appraisal of peer-reviewed literature.

OBJECTIVES: Childhood immunization coverage rates are known to be disproportionate according to population's socioeconomic status (SES). This systematic review examined and appraised quality of interventions deemed effective to increase routine childhood immunization uptake in low SES populations in developed countries. METHODS: A literature search was conducted using Medline, Embase, CINAHL, EBMR, PsycInfo, PubMed, and Health STAR. We systematically searched and critically appraised articles published between January 1990 and December 2019 using the Effective Public Health Practice Project Quality Assessment tool. This systematic review provides a synthesis of the available evidence for childhood immunization interventions deemed effective for low SES parents or families of children ≤ 5 years of age. SYNTHESIS: The search yielded 3317 records, of which 2975 studies met the inclusion criteria. From the 100 relevant studies, a total of 40 were included. The majority of effective and strongly rated studies synthesized consisted of multi-component interventions. Such interventions addressed access, community-based mobilization, outreach, appointment reminders, education, clinical tracking and incentives, and were language and health literacy appropriate to support low SES parents. Improving access to low SES parents was deemed effective in the vast majority of strongly rated studies. Incorrect contact information of low SES parents due to increased social mobility (i.e. household moves) rendered reminders ineffective, and therefore, updating contact information should be pursued proactively by front-line healthcare providers. In addition, plain language communication with low SES parents regarding immunization was deemed effective in improving immunization uptake. CONCLUSION: Comprehensive multi-component interventions including improved access, appointment reminders, education and precision health communication are effective for addressing health inequities in immunization coverage amongst marginalized populations. Most low SES parents still believe that the benefits of immunization outweigh the risks.

Splenic marginal zone B-cell lymphoma associated with ruptured breast implants: case report and review of the literature.

We describe splenomegaly and bilateral grade 2 Baker breast capsular contracture in a woman who had undergone augmentation mammoplasty. This case represents the first documented instance of splenic marginal zone lymphoma, and is among the rare reports of B-cell lymphoma, arising in a patient with breast implants.

Asymptomatic Stroke After Hyaluronic Acid Filler Injection: Case Report and Literature Review.

Vascular compromise and blindness are reported but rare complications of facial soft tissue filler injections. Stroke is an even rarer complication resulting from intraarterial injection of fillers. We present a case of a patient suffering all 3 complications following hyaluronic acid filler injection: forehead skin vascular compromise, unilateral blindness, and ipsilateral subclinical strokes. Were it not for a stroke workup protocol, the incidental strokes may have otherwise gone undetected, suggesting the incidence of stroke from intraarterial injection may be higher than reported. Further, we review the literature and recommendations for prevention and management of threatened tissue ischemia and vision loss from facial filler injection.

Pediatric Mandible Reconstruction for Osteomyelitis During Largest Reported Mycobacterium Abscessus Outbreak.

In 2016, water lines at a children's dental clinic in Orange County, California were contaminated with Mycobacterium abscessus (MA), a non-tuberculosis rapidly-growing mycobacterium, leading to the largest MA outbreak ever reported. Mandatory reporting and active case finding directed by the Public Health Department was conducted in collaboration with community Pediatric Infectious Disease physicians for patients who underwent dental pulpotomies at the contaminated Dental Clinic from January 1 to September 6, 2016. Seventy-one cases (22 confirmed and 49 probable) were identified. One case that required extensive debridement and reconstruction of the mandible is presented in detail. CT maxillofacial demonstrated osteomyelitis extending from the right mandibular angle to the left ramus with multifocal periapical lucencies. CT chest and neck revealed numerous pulmonary nodules and bilateral cervical lymphadenopathy. Extraction of several involved teeth, bilateral selective neck dissection, and extensive mandibular debridement was performed, followed by mandibular stabilization with a custom pre-bent 2.0-mm locking plate. CT images 1-year post-operative showed clearance of infection and sufficient bony stability. Subsequent removal of hardware and bone grafting was performed and the patient is doing well. In the event of a future odontogenic mycobacterium outbreak, the experience at our institution can inform multidisciplinary treatment approaches. Prophylactic extraction of primary teeth that received pulpotomies with contaminated water should be performed. Early and thorough debridement of affected bone, including enucleation of secondary teeth, should be performed if necessary for early source control.

An Evaluation of Emergency Hand Coverage in Tennessee After Implementation of the Affordable Care Act.

Although the upper extremity is the most commonly injured part of the body, many studies have indicated that there is a lack of emergency hand coverage in the United States. In 2010, our laboratory evaluated on-call hand coverage in Tennessee (TN) and found that only 7% of hospitals had a hand surgeon on call for emergency cases at all times. In 2014, the Affordable Care Act (ACA) was implemented with the goal of increasing overall access to care and decreasing health care costs. Hand surgeons were surveyed on their attitudes toward the ACA, and the majority of surgeons surveyed disagreed or strongly disagree that the ACA would improve access to emergent hand surgery. This study aimed to determine if there has been an increase in emergency hand coverage in TN since the implementation of the ACA. A survey was administered to all hospitals in TN with both an emergency department and operating room to determine the percentage of TN hospitals offering elective hand surgery and on-call emergency hand coverage. With 94% of TN hospitals responding to the emergency department survey, we determined that there has been a 138% significant increase in the percentage of hospitals reporting 24/7 emergency hand coverage by a hand specialist since our last study in 2010. There has also been a significant increase in elective hand coverage in TN, although much smaller at 13% since 2010. This study suggests that there has been an overall increase in access to hand care in TN since the implementation of the ACA, most profoundly seen in the increase in hand specialists available for emergent cases.

Maternal perceptions of childhood vaccination: explanations of reasons for and against vaccination.

BACKGROUND: Understanding reasons for and against vaccination from the parental perspective is critical for designing vaccination campaigns and informing other interventions to increase vaccination uptake in Canada. The objective of this study was to understand maternal vaccination decision making for children. METHODS: Mothers participating in a longitudinal community-based pregnancy cohort, the All Our Babies study in Calgary, Alberta, completed open-ended survey questions providing explanations for the vaccination status of their child by 24 months postpartum. Qualitative responses were linked to administrative vaccination records to examine survey responses and recorded child vaccination status. RESULTS: There were 1560 open-ended responses available; 89% (n = 1391) provided explanations for vaccinating their children, 5% (n = 79) provided explanations for not vaccinating/delaying, and 6% (n = 90) provided explanations for both. Themes were similar for those vaccinating and not vaccinating/delaying; however, interpretations were different. Two broad themes were identified: Sources of influence and Deliberative Processes. Sources of influence on decision making included personal, family, and external experiences. Deliberative Processes included risk, research, effectiveness, and balancing risks/benefits. Under Deliberative Processes, responsibility was a category for those vaccinating; while choice, instrumental/practical, and health issues were categories for those not vaccinating/delaying. Mothers' levels of conviction and motivation provided a Context for understanding their decision making perspectives. CONCLUSIONS: Vaccination decision making is complex and impacted by many factors that are similar but contribute to different decisions depending on mothers' perspectives. The results of this study indicate the need to examine new intervention approaches to increase uptake that recognize and address feelings of pressure and parental commitment to choice.

Microsurgery Training Resource Variation among US Integrated Plastic Surgery Residency Programs.

BACKGROUND: Given emerging focus on competency-based surgical training and work-hour limitations, surgical skills laboratories play an increasingly important role in resident education. This study was designed to investigate educational opportunities in microsurgery across integrated residency programs. METHODS: Senior residents (PGY 4-6) at integrated plastic surgery programs were surveyed during the 2016 to 2017 academic year to determine each program's access to: training microscopes and anastomosis models, video-based skills assessment, pre-requisite skills exams, flap courses, or a formal microsurgical training curriculum. Programs were stratified based on large size (>18 residents) and presence of microsurgery fellows. Chi-squared analysis was performed with p < 0.05 to assess statistical significance. RESULTS: Survey responses were collected from 32 of 60 eligible programs (53% response rate). Sixty-nine percent provide access to one to two training microscopes, 25% provide three or more, and 6% provide none. Sixty-nine percent of programs train anastomosis with nonliving prosthetics, 66% with living biologics, and 50% with nonliving biologics. Large program size or having microsurgical fellows was not associated with increased access to training microscopes or specific anastomosis models. Programs without microsurgery fellows reported more often that a formal microsurgery curriculum would be helpful (90 vs. 58% of programs with fellows, p = 0.0003). Respondents who indicated that creating a formal curriculum would not be helpful elaborated that their program already has a formal curriculum or a high volume of microsurgery cases. CONCLUSION: This study demonstrates the current variation in microsurgery training at integrated plastic surgery residency programs. A formal microsurgical training curriculum is commonly viewed as being helpful, particularly at programs without microsurgery fellows.

Preconception health interventions delivered in public health and community settings: A systematic review.

OBJECTIVES: The objective of this systematic review was to assess the effects of preconception health interventions, delivered to individuals of reproductive age in public health and community settings, on reproductive, maternal, and child health outcomes. METHODS: A search of Ovid MEDLINE, CINAHL, EMBASE, PsychINFO, Scopus, Gender Studies Database, and SocINDEX from July 1999 through July 2016 was performed. We included studies that reported original data, used an interventional study design, included reproductive-aged women or men, were written in English, and were published in peer-reviewed journals. Two reviewers independently used standardized instruments for data extraction and quality assessment. A narrative synthesis was performed. SYNTHESIS: Twelve studies met the inclusion criteria. These studies included randomized controlled trials and quasi-experimental, pre-post, and time-series designs. Most studies were conducted in the United States; all but one study included only women. Interventions were mainly educational initiatives focused on nutrition, immunization, and lifestyle behaviours and were delivered in a single contact. The studies reported positive effects on health knowledge (n = 9), behaviour change (n = 4), and health outcomes (n = 1). Study quality was weak (n = 11) or moderate (n = 1), with limitations related to selection bias, blinding, data collection methods, and participant attrition. CONCLUSION: To develop a comprehensive, standardized approach to preconception health promotion and care in Canada, there is a clear need for high-quality research evaluating the effectiveness of preconception health interventions. Studies should use a health equity lens that includes all individuals of reproductive age and addresses the broad determinants of preconception health.

Novel Approach for Maximizing Follow-Up in Cosmetic Surgery Clinical Trials: The Ideal Implant Core Trial Experience.

BACKGROUND: High follow-up rates are critical for robust research with minimal bias, and are particularly important for breast implant Core Studies seeking U.S. Food and Drug Administration approval. The Core Study for IDEAL IMPLANT, the most recently U.S. Food and Drug Administration-approved breast implant, used a novel incentive payment model to achieve higher follow-up rates than in previous breast implant trials. METHODS: At enrollment, $3500 was deposited into an independent, irrevocable trust for each of the 502 subjects and invested in a diversified portfolio. If a follow-up visit is missed, the subject is exited from the study and compensated for completed visits, but the remainder of her share of the funds stay in the trust. At the conclusion of the 10-year study, the trust will be divided among those subjects who completed all required follow-up visits. For primary and revision augmentation cohorts, the U.S. Food and Drug Administration published follow-up rates from Core Studies were compared for all currently available breast implants. RESULTS: Five-year follow-up rates for the IDEAL IMPLANT Core Study are higher for both primary augmentation and revision augmentation cohorts (94.9 percent and 96.7 percent, respectively) when compared to all other trials that have used U.S. Food and Drug Administration standardized follow-up reporting (MemoryShape, Allergan 410, and Sientra Core Studies). CONCLUSIONS: This trial demonstrates the utility of a novel incentive strategy to maximize follow-up in cosmetic surgery patients. This strategy may benefit future cosmetic surgery trials and perhaps any prospective research trial by providing more complete data. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Enantioseparation of α-Hydroxyallylphosphonates and Phosphonoallylic Carbonate Derivatives on Chiral Stationary Phases Using Sequential UV, Polarimetric, and Refractive Index Detection.

Chromatographic separation of the enantiomers of parent compounds dimethyl α-hydroxyallyl phosphonate and 1-(dimethoxyphosphoryl) allyl methyl carbonate was demonstrated by high-performance liquid chromatography (HPLC) using Chiralpak AS-H and ad-H chiral stationary phases (CSP), respectively, using a combination of UV, polarimetric, and refractive index detectors. A comparison was made of the separation efficiency and elution order of enantiomeric α-hydroxyallyl phosphonates and their carbonate derivatives on commercially available polysaccharide AS, ad, OD, IC-3, and Whelk-O 1 CSPs. In general, the α-hydroxyallyl phosphonates were resolved on the AS-H CSP, whereas the carbonate derivatives and were preferentially resolved on the ad-H CSP. The impact of aryl substitution on the resolution of analytes and was evaluated. Thermodynamic parameters determined for enantioselective adsorption hydroxyphosphonates and on the AS-H CSP and carbonate on the ad-H CSP demonstrated enthalpic control for separation of the enantiomers. Chirality 28:656-662, 2016. © 2016 Wiley Periodicals, Inc.

Circumferential truncal contouring: the belt lipectomy.

The primary goal of belt lipectomy surgery is to improve the contour of the inferior truncal circumferential unit and to place the resultant scar in natural junctions. Excessive intra-abdominal content is a contraindication for belt lipectomy. The higher the presenting patient's body mass index (BMI), the higher the risk of postoperative complications and the less impressive the results. The converse is also true: the lower the BMI, the lower the risk of complications and the better the results. The most common complications are small wound separations and seromas.

Discovery of a leptospirosis cluster amidst a pneumonic plague outbreak in a miners' camp in the Democratic Republic of the Congo.

Conditions in the Democratic Republic of the Congo provide an ideal environment for leptospirosis and plague, both of which can cause severe pulmonary manifestations. In December 2004, an outbreak of lethal pneumonia occurred in a local mining camp, affecting 130 persons and killing 57 of them. Clinical signs, fast disease spread, and initial laboratory investigations suggested pneumonic plague. While leptospirosis had not recently been described in the region, it was considered as a differential diagnosis. Anti-Leptospira antibodies were detected by microscopic agglutination test (MAT). A confirmed case of leptospirosis was defined as having consistent clinical signs and any one of the following: seroconversion or four-fold increase in MAT titre for paired serum samples, or a MAT titre ≥ 1:400 for acute-phase serum samples. Twenty-nine of the 54 patients or convalescents tested for leptospirosis were seropositive. Two cases showed a confirmed infection for both plague and leptospirosis. While evidence supports the plague nature of this outbreak, the results suggest that some of the suspected plague cases might be due to leptospirosis. In any case, this diagnosis will have to be evoked in the future if a similar outbreak occurs in this region of Africa.

Dimethyl sulfoxide (DMSO) exacerbates cisplatin-induced sensory hair cell death in zebrafish (Danio rerio).

Inner ear sensory hair cells die following exposure to aminoglycoside antibiotics or chemotherapeutics like cisplatin, leading to permanent auditory and/or balance deficits in humans. Zebrafish (Danio rerio) are used to study drug-induced sensory hair cell death since their hair cells are similar in structure and function to those found in humans. We developed a cisplatin dose-response curve using a transgenic line of zebrafish that expresses membrane-targeted green fluorescent protein under the control of the Brn3c promoter/enhancer. Recently, several small molecule screens have been conducted using zebrafish to identify potential pharmacological agents that could be used to protect sensory hair cells in the presence of ototoxic drugs. Dimethyl sulfoxide (DMSO) is typically used as a solvent for many pharmacological agents in sensory hair cell cytotoxicity assays. Serendipitously, we found that DMSO potentiated the effects of cisplatin and killed more sensory hair cells than treatment with cisplatin alone. Yet, DMSO alone did not kill hair cells. We did not observe the synergistic effects of DMSO with the ototoxic aminoglycoside antibiotic neomycin. Cisplatin treatment with other commonly used organic solvents (i.e. ethanol, methanol, and polyethylene glycol 400) also did not result in increased cell death compared to cisplatin treatment alone. Thus, caution should be exercised when interpreting data generated from small molecule screens since many compounds are dissolved in DMSO.

Epidemiology of operative burns at Kijabe Hospital from 2006 to 2010: pilot study of a web-based tool for creation of the Kenya Burn Repository.

INTRODUCTION: In order to implement effective burn prevention strategies, the WHO has called for improved data collection to better characterize burn injuries in low and middle income countries (LMIC). This study was designed to gather information on burn injury in Kenya and to test a model for such data collection. METHODS: The study was designed as a retrospective case series study utilizing an electronic data collection tool to assess the scope of burn injuries requiring operation at Kijabe Hospital from January 2006 to May 2010. Data were entered into a web-based tool to test its utility as the potential Kenya Burn Repository (KBR). RESULTS: 174 patients were included. The median age was 10 years. There was a male predominance (59% vs. 41%). Findings included that timing of presentation was associated with burn etiology (p=0.009). Length of stay (LOS) was associated with burn etiology (p<0.001). Etiology differed depending on the age group, with scald being most prominent in children (p=0.002). CONCLUSIONS: Burn injuries in Kenya show similarities with other LMIC in etiology and pediatric predominance. Late presentation for care and prolonged LOS are areas for further investigation. The web-based database is an effective tool for data collection and international collaboration.

Tennessee emergency hand care distributions and disparities: Emergent hand care disparities.

BACKGROUND: Hand trauma is the most frequently treated injury in emergency departments, but presently there is a crisis of insufficient emergency coverage. This study evaluates the discrepancy of emergent and elective hand care trends based on socioeconomic factors in the state of Tennessee. METHODS: We identified 119 hospitals in Tennessee that contained operating and emergency room facilities. Of these, 111 hospitals participated in a survey to determine the availability of elective and emergency hand surgery. Wilcoxon rank-sum test or permutation chi-square test and logistic regression were used to analyze reported measures. RESULTS: Our results revealed that hospitals in counties with the lowest per capita income and median household income are less likely to have hand specialists or offer hand call. There are also significantly fewer hospitals that have hand specialists and offer hand call that are located in medically underserved areas. In the state of TN, level 1 trauma facilities are required by the Tennessee Department of Health to have staffed hand specialists and 24/7 hand call. Our study revealed that while 7/8 (87.5 %) level 1 trauma facilities have hand specialists, only 2/8 (25 %) provide 24/7 hand specialist call. CONCLUSION: Our results strongly suggest the presence of a health care disparity for hand trauma in counties with a low income and in medically underserved areas.

Solution structure of the cold-shock-like protein from Rickettsia rickettsii.

Rocky Mountain spotted fever is caused by Rickettsia rickettsii infection. R. rickettsii can be transmitted to mammals, including humans, through the bite of an infected hard-bodied tick of the family Ixodidae. Since the R. rickettsii genome contains only one cold-shock-like protein and given the essential nature of cold-shock proteins in other bacteria, the structure of the cold-shock-like protein from R. rickettsii was investigated. With the exception of a short α-helix found between ß-strands 3 and 4, the solution structure of the R. rickettsii cold-shock-like protein has the typical Greek-key five-stranded ß-barrel structure found in most cold-shock domains. Additionally, the R. rickettsii cold-shock-like protein, with a ΔG of unfolding of 18.4 kJ mol(-1), has a similar stability when compared with other bacterial cold-shock proteins.

Lack of emergency hand surgery: discrepancy between elective and emergency hand care.

Wrist, hand, and finger trauma are the most common injuries presenting to emergency departments. Shortage of emergency hand care is an emerging problem, as on-call hand coverage declines. This study evaluates the availability of elective and emergency hand surgery services in Tennessee, with the use of telephone surveys administered to emergency department and operating facility management. One hundred eleven Tennessee hospitals completed the surveys (93% response rate). In all, 77% of hospitals offer elective hand surgery, 58% offer basic emergency hand services, 18% offer occasional hand specialist call coverage and only 7% of hospitals have 24/7 hand specialist call coverage. Hospitals with hand specialists have significantly more payer charges from commercial insurance than hospitals without hand specialists (26.1% vs. 16.1%, P < 0.001). Our results strongly support the need for increased emergency hand coverage. Solutions include creating multihospital coordinated call schedules, increasing incentives for call coverage, and training more hand specialists.