The Statistical Fragility of Outcomes on Breast Reconstruction with Acellular Dermal Matrix: A Systematic Review of Randomized Controlled Trials.

INTRODUCTION: Acellular dermal matrix (ADM) is pivotal in breast surgery, yet the statistical robustness of surgical outcomes remains underexplored. This study employs the fragility index (FI), reverse fragility index (rFI), and fragility quotient (FQ) to investigate the statistical fragility of ADM breast reconstruction outcomes. METHODS: Randomized controlled trials (RCTs) (2013-present) with dichotomous outcomes were sourced from PubMed, Embase, SCOPUS, Medline, and Cochrane databases. FI and rFI-event reversals needed to alter outcome significance-and FQ-standardized fragility across trials-were computed and reported as median (IQR). Subgroup analysis focused on intervention types. RESULTS: Out of 33 studies screened, 19 RCTs comprising 204 outcomes were included, with a median FI of 4 (3 - 5) and FQ of 0.039 (0.029 - 0.070). Twenty-six outcomes achieved statistical significance, with a median FI of 3.5 (1 - 5) and FQ of 0.033 (0.010 - 0.073). The remaining 178 outcomes were nonsignificant, exhibiting a median FI of 4 (3 - 5) and FQ of 0.040 (0.030 - 0.070). Of the 204 outcomes, 18% had a number of patients lost to follow up equal to or surpassing the FI. By intervention type, the median FIs were similar in value but remained low. CONCLUSION: ADM-related breast reconstruction outcomes are statistically fragile, so reversal of a few outcomes or maintaining follow-up with patients may alter the significance of findings. Future researchers are thus recommended to report FI and FQ metrics with P-values to accurately portray reconstructive surgery outcomes.

Assessing Clinical Variables Associated With Femoral Muscle Decay as Measured by Point-of-Care Ultrasound in Critically Ill Children.

OBJECTIVES: Skeletal muscle wasting is a common occurrence in critical illness, often resulting in intensive care unit (ICU)-acquired weakness. This study aims to identify clinical factors associated with muscle decay in mechanically ventilated critically ill children. Utilizing point-of-care ultrasound, a noninvasive and cost-effective tool, we assess muscle decay through ultrasound of the quadriceps femoris. METHODS: A prospective observational study was conducted in a single-center quaternary-care pediatric intensive care unit at a children's hospital. A convenience sample of 103 sedated and mechanically ventilated patients were enrolled in this study. Ultrasound measurements of quadriceps femoris muscle thickness were taken, and daily muscle decay rates were calculated. Demographic, clinical, and outcome data were analyzed for correlations with muscle decay. RESULTS: Among the enrolled patients, 67 had repeat measurements. Muscle thickness change aligned with prior studies, with a mean daily change of -1.9% [IQR -0.8, -5.0]. Adequate cumulative caloric intake (>60% of goal) correlated with less muscle decay compared with inadequate intake (-1.8 vs -2.4%, P < .001). Average daily muscle change correlated with both ICU and hospital length of stay (LOS) (r = .328, P = .007 and r = .393, P = .001). No significant correlations emerged between muscle change and mortality, disease severity, fluid balance, early mobilization, steroid exposure, or sedative and paralytic use. CONCLUSION: This study demonstrates early and frequent muscle decay in critically ill children, as detected by point-of-care ultrasound. Average daily muscle decay was associated with longer ICU and hospital LOS. Adequate cumulative caloric intake is linked to reduced muscle decay. These findings contribute to understanding muscle wasting in critically ill pediatric patients.

Enhancing training in spiritual and religious competencies in mental health graduate education: Evaluation of an integrated curricular approach.

Despite practice guidelines for multiculturally competent care, including spiritual/religious diversity, most mental health graduate training programs do not formally address spiritual/religious competencies. Thus, we enhanced the Spiritual Competency Training in Mental Health (SCT-MH) course curriculum to train graduate students in foundational attitudes, knowledge, and skills for addressing clients' spirituality and/or religion (S/R). The hybrid (online and in-person) SCT-MH course curriculum was integrated into existing required graduate clinical courses (replacing 15% of a course's curriculum) and taught to 309 students by 20 instructors in 20 different graduate training programs across counseling, psychology, and social work disciplines. Using a multiple baseline waitlist control design in which students served as their own controls, students completed validated assessments at three timepoints evaluating their spiritual/religious competencies for understanding the intersection between S/R and mental health. We also collected qualitative data from the students to evaluate acceptability of the content and format of the training program. Students' scores on all seven measures of spiritual/religious competencies had a statistically significant positive increase after engaging with the SCT-MH curriculum compared to the control period. At the end of the course, 97% of the students envisioned using spiritually integrated therapy techniques with their clients at least some of the time, 92% or more rated the materials as helpful and relevant, and 96% were satisfied with the training modules. Results demonstrate that dedicating a small (i.e., 6 hours of class time; 10 hours outside class time) but intentional amount of course time to teaching spiritual/religious competencies increases students' attitudes, knowledge, and skills for attending to clients' S/R in clinical practice. The SCT-MH hybrid course content is freely available to all graduate programs on our website. https://www.spiritualandreligiouscompetenciesproject.com/resources/sct-mh.

Understanding the role of intraoperative hypothermia in perioperative opioid requirements in immediate implant-based breast reconstruction.

BACKGROUND: The relationship between perioperative temperatures and postoperative pain is unknown. The present study investigated the relationship of intraoperative hypothermia and perioperative opioid requirements after immediate implant-based breast reconstruction. METHODS: A retrospective chart review was conducted on patients undergoing immediate implant-based breast reconstruction from 2019-2023. Patients were classified into the hypothermic group (majority of procedure <36.0 °C) or normothermic group (majority of procedure ≥36.0 °C). Cumulative inpatient opioid requirements (morphine milli-equivalents [MMEs]) and frequency of patients requiring "high-dose opioids" (≥100 MMEs) were collected and compared between the groups. RESULTS: In total, 536 patients (835 breasts) were included, among whom 135 (25.1%) were hypothermic. The hypothermic group had lower mean intraoperative (88.4 vs. 99.1 MMEs, P = 0.007) and postoperative (45.6 vs. 56.8 MMEs, P = 0.006) than the normothermic group. Mean (B = 14.6, P = 0.004) and nadir (B = 10.4, P = 0.038) intraoperative temperatures directly predicted higher opioid requirements while higher percentages of the procedure time spent under 36 °C (B = -27.6, P = 0.004) predicted lower opioid requirements. The hypothermic group was associated with 66% decreased odds of requiring high-dose opioids after adjusting for differences in patient and operative characteristics (P = 0.007). CONCLUSION: Hypothermia is associated with decreased perioperative opioid requirements. Future studies should further investigate ideal temperature thresholds for warming protocols to minimize postoperative pain.

Robotic colorectal resections are associated with less postoperative pain, decreased opioid use, and earlier return to work as compared to the laparoscopic approach.

While robotic and laparoscopic surgeries are both minimally invasive in nature, they are intrinsically different approaches and it is critical to understand outcome differences between the two. Studies evaluating pain outcomes and opioid requirement differences between the robotic and laparoscopic colorectal resections are conflicting and often underpowered. In this retrospective, cohort study, we compare postoperative opioid requirements, reported as morphine milligram equivalents (MME), postoperative average and highest pain scores across postoperative days (POD) 0-5, and return to work in patients who underwent robotic versus laparoscopic colorectal resections. The sample size was selected based on power calculations. Daily pain scores and MME were used as outcomes in linear mixed effect models with unstructured covariance between time points. Propensity score weighting was used to adjust for imbalances. Patients in the robotic group required significantly less opioids as measured by MME on all postoperative days (p = 0.004), as well as lower average and highest daily pain scores for POD 0-5 (p = 0.02, and p = 0.006, respectively). In a linear mixed-effects model, robotic resections were associated with a decrease in average pain scores by 0.36 over time (p = 0.03) and 35 fewer MME requirements than the laparoscopic group (p = 0.0004). Patients in the robotic arm had earlier return to work (2.1 vs 3.8 days, p = 0.036). The robotic approach to colorectal resections is associated with significantly less postoperative pain, decreased opioid requirements, and earlier return to work when compared to laparoscopy, suggesting that the robotic platform provides important clinical advantages over the laparoscopic approach.

Anesthesiologists' Role in Recognition, Prevention, and Treatment of Childbirth-Related Posttraumatic Stress Disorder.

Childbirth-related posttraumatic stress disorder (CB-PTSD) is increasingly common and consequential for pregnant patients. Throughout the labor experience and beyond, anesthesiologists are central to creating a psychological safe space for patients and play an essential role in preventing, recognizing, and treating CB-PTSD. This narrative review summarizes the current literature surrounding risk factors for CB-PTSD that are relevant to anesthesiologists; patients' symptoms or signs anesthesiologists should look out for; and ways anesthesiologists may be involved in preventing and treating this condition.

Neighborhood Deprivation is Associated With Increased Postoperative Complications After Implant-Based Breast Reconstruction.

PURPOSE: The Area Deprivation Index (ADI) ranks neighborhoods by deprivation based on US Census data. This study utilizes ADI scores to investigate the impact of neighborhood deprivation on complication rates following breast reconstruction. PATIENTS AND METHODS: Patients who received implant-based reconstruction from 2019 to 2023 were identified at a single institution in New York. Patients were linked to a state-specific ADI score and categorized into groups: "High ADI" (6-10) and "Low ADI" (1-5). Patient characteristics and complication rates were compared between the ADI groups with Chi-Square analysis and t-tests. The predictive value of ADI scores on complication rates was assessed using logistic regression models. RESULTS: In total, 471 patients were included, of which 16% (n = 73) were in the High ADI group, and 84% (n = 398) were in the Low ADI group. There were no baseline differences between the 2 groups, except that there were more patients of Hispanic descent in the High ADI group (30% vs. 15%, P < .01). The High ADI group had a higher overall complication rate than the Low ADI group (34% vs. 21%, P < .01), as well as higher individual rates of hematoma (12% vs. 3%, P < .01) and unexpected reoperations (18% vs. 7%, P < .01). After adjusting for differences in race, High ADI scores predicted hematoma, reoperations, and any complication (P < .05). CONCLUSION: Patients living in neighborhoods with high ADI had a higher incidence of postoperative complications, independent of comorbidities and race. This measure of disparity should be considered when counselling patients about their risk of complications following procedures like implant-based breast reconstruction.

Evaluating Access and Outcomes in Gender-affirming Breast Augmentation: A Comparative Study of a County Hospital and an Academic Center.

Background: Research on the diverse patient population undergoing gender-affirming breast augmentation remains scarce. We compared patients undergoing this procedure at San Francisco General Hospital (ZSFG), a county hospital, and the University of California, San Francisco (UCSF), an academic medical center. Methods: This was a retrospective cohort study of patients who underwent primary gender-affirming breast augmentation at ZSFG (August 2019 to June 2023) and UCSF (March 2015 to June 2023). Differences in sociodemographic characteristics, surgical access, and outcomes between sites were assessed. Results: Of 195 patients, 122 patients had surgery at UCSF and 73 patients at ZSFG. ZSFG patients were more likely to be unstably housed (P < 0.001), Spanish-speaking (P = 0.001), and to have obesity (P = 0.011) and HIV (P = 0.004). Patients at ZSFG took hormones for longer before surgical consultation (P < 0.001) but had shorter referral-to-surgery intervals (P = 0.024). Patients at ZSFG more frequently underwent a subglandular approach (P = 0.003) with longer operative times (P < 0.001). Major surgical complications were uncommon (2.1%) with no differences between sites. Aesthetically, implant malposition/rotation occurred more often in patients at UCSF (P = 0.031), but revision rates were similar at both sites. Patients at UCSF had longer follow-up periods (P = 0.008). Conclusions: County hospital patients seeking gender-affirming breast augmentation have distinct sociodemographic profiles and more comorbidities than academic medical center patients. County patients might experience greater barriers that delay surgical eligibility, such as stable housing. Nevertheless, this procedure can be safely and effectively performed in both patient populations.

ACR Appropriateness Criteria® Screening for Abdominal Aortic Aneurysm.

Abdominal aortic aneurysm (AAA) is a significant vascular disease found in 4% to 8% of the screening population. If ruptured, its mortality rate is between 75% and 90%, and it accounts for up to 5% of sudden deaths in the United States. Therefore, screening of AAA while asymptomatic has been a crucial portion of preventive health care worldwide. Ultrasound of the abdominal aorta is the primary imaging modality for screening of AAA recommended for asymptomatic adults regardless of their family history or smoking history. Alternatively, duplex ultrasound and CT abdomen and pelvis without contrast may be appropriate for screening. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

The Expression of PRAME as an Aid for Diagnosis and Evaluation of Histologic Margins of Intraepidermal Cutaneous Melanoma in Xeroderma Pigmentosum Patients.

Xeroderma Pigmentosum (XP) is a genetic disorder characterized by photosensitivity, dyschromia, and high risk of skin cancer. From a clinical and histologic view, it can be difficult to diagnose cutaneous melanoma (CM) in XP patients and to define its resection margins. We aimed to study the role of PRAME (PReferentially Expressed Antigen in MElanoma) in differentiating intraepidermal CM from superficial atypical melanocytic proliferation of uncertain significance (SAMPUS) and evaluating the histological margins of CMs. We included XP patients. melanocitic and nonmelanocytic lesions with adjacent skin, and, as control groups, sun-damaged skin from non-XP individuals. Melanocytic lesions with a consensus diagnosis were grouped into CM, SAMPUS, or benign. The selected samples were PRAME-immunoshistochemically stained, and the ratio between immuno-positive cells/mm was recorded, according to Olds and colleagues for intraepidermal lesions. Lezcano and colleagues' method was used for intradermal lesions. Clinical data from XP patients were reviewed. All 9 patients were alive and well at the study closure, even those who developed melanoma metastases. Positive/diffuse PRAME expression was found in 29% (7/24) of intraepidermal CMs and 20% (1/5) SAMPUS samples. All 103 XP control samples and 24 adjacent lesions skin of non-XP patients were PRAME negative. This was a single-center and retrospective study, using a relatively small sample, limiting our conclusions. In XP patients' lesions, PRAME expression could help in the setting of challenging melanocytic tumors and surgical margins evaluation. It is also possible that the method can avoid overdiagnosis and, consequently, more aggressive treatment recommendation in unequivocal CM cases.

Migraine headache in patients with spontaneous coronary artery dissection: A report of the iSCAD Registry.

INTRODUCTION: Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic cause of myocardial infarction. Migraine headache has been reported to be common among patients with SCAD, but the degree of migraine-related disability has not been quantified. METHODS: Clinical data and headache variables were obtained from the baseline assessment of the prospective, multicenter iSCAD Registry. Migraine-related disability was quantified using the self-reported Migraine Disability Assessment (MIDAS). Demographic, clinical, psychosocial, and medical characteristics from data entry forms were compared between patients with and without migraine. RESULTS: Of the 773 patients with available data, 46% reported previous or current migraines. Those with migraines were more likely to be women (96.9% vs 90.3%, p = 0.0003). The presence of underlying carotid fibromuscular dysplasia was associated with migraine (35% vs 27%, p = 0.0175). There was not a significant association with carotid artery dissection and migraine. Current migraine frequency was less than monthly (58%), monthly (24%), weekly (16%), and daily (3%). Triptan use was reported in 32.5% of patients, and 17.5% used daily migraine prophylactic medications. Using the MIDAS to quantify disability related to migraine, 60.2% reported little or no disability, 14.4% mild, 12.7% moderate, and 12.7% severe. The mean MIDAS score was 9.9 (mild to moderate disability). Patients with SCAD had higher rates of depression and anxiety (28.2% vs 17.7% [p = 0.0004] and 35.3% vs 26.7% [p = 0.0099], respectively). CONCLUSIONS: Migraines are common, frequent, and a source of disability in patients with SCAD. The association between female sex, anxiety, and depression may provide some insight for potential treatment modalities.

Endoscopic Repair of Internal Carotid Artery Injury with a Lateral Tongue Muscle Patch Graft: Novel Technique and Literature Review.

Objectives Iatrogenic injury to the internal carotid artery (ICA) is one of the most catastrophic complications of endoscopic sinus and skull base surgery. Previous research has shown that packing with a crushed muscle graft at the injury site can be an effective management technique to control bleeding and prevent the need for ICA sacrifice. Here, we describe a novel and readily available repair donor site-an autologous lateral tongue muscle patch. Design Three representative cases of a successful repair of ICA injuries using a lateral tongue muscle patch are included in this study. The graft measured approximately 2 × 3 cm and was taken from the lateral intrinsic tongue musculature. We describe the harvest of the graft, its advantages, and the details of operative repair. Results The lateral tongue provides a large and readily accessible source of muscle within the surgical field that can be quickly harvested during an endoscopic procedure. For the first case, an expanding parasellar ICA pseudoaneurysm was managed with a tongue muscle patch and nasal packing. In the second case, a cavernous ICA injury was sustained during craniopharyngioma resection. Case three involved an ICA injury during endonasal debridement of invasive fungal rhinosinusitis. None of the patients required embolization or neurovascular stenting. Postoperative angiograms and serial computed tomography angiograms showed complete resolution of the pseudoaneurysm, and the patients continued to do well at least 1 year after repair. Conclusion Lateral tongue muscle graft is an effective and efficient method to manage ICA injuries during endoscopic endonasal surgery. Advantages include the speed of harvest, donor site being readily accessible in the surgical field, and low donor site morbidity. It should be added to the repertoire of possible donor sites for addressing catastrophic sinonasal bleeding.

The complexity of online patient education materials for wound care strategies: A readability analysis.

BACKGROUND: In the United States, over 6 million people are affected by chronic wounds. Patients often rely on the Internet for treatment information; however, these educational materials typically exceed the average eighth-grade health literacy level. This study aimed to assess the readability and language accessibility of online patient education materials on wound care strategies. METHODS: A search was conducted on Google for articles related to wound care strategies. The first 12 unique websites from each search strategy were selected for further analysis. Readability was assessed using 11 tests, with the mean scores calculated for each. RESULTS: A total of 66 articles pertaining to wound care strategies were retrieved from 43 websites. All articles had an average reading grade level of 13.5 ± 2.5 and an average reading age of 18.7 ± 2.5 years. Websites were categorized by the following sources: academic (34.9%), reagent/biologic manufacturers (27.9%), wound care (18.6%), news media organizations (14%), and other (4.7%). Flesch Reading Ease Score, graded from 0 for most difficult to 100 for least difficult, was found to be highest for academic websites (44.2, P = .01) and lowest for news media websites (24.9, P = .01). Academic websites were available in the more languages compared to all other website categories (P < .01). CONCLUSION: Online materials related to wound care strategies often exceed the National Institute of Health recommended eighth-grade reading level. This study emphasizes the need for healthcare providers to create more accessible educational materials to address the gap in health literacy and optimize patient care.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS: A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE: Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS: A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE: Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

Small Hemothoraces Not Drained on Admission: Initial Volume Predicts Need for Intervention.

BACKGROUND: Unlike large hemothoraces (HTX), small HTX after blunt trauma may be observed without drainage. We aimed to study if there were risk factors that would predict the need for intervention in initially observed small HTX. METHODS: A retrospective review of patients with blunt traumatic HTX from 2016 to 2022 was performed. Patients with small HTX (pleural fluid volume <400 mL on admission chest computerized tomography [CT]) were included. Patients were considered as being "initially observed" if there was no intervention for the HTX within 48 hours after admission. Primary outcome was any HTX-related intervention (open, thoracoscopic or percutaneous procedures) occurring after 48 hours and up to 6 months after injury. Univariable and multivariable statistical analyses were employed. A P-value of <.05 was considered significant. RESULTS: Of 335 patients with HTX, 188 (59.6%) met inclusion criteria. Median (interquartile range) HTX volume was 90 (36-134) ml. One hundred and twenty-seven (68%) were initially observed. Of these, 31 (24%) had the primary outcome. These patients had a larger HTX volume (median, 129 vs 68 mL, P = .0001), and number of rib fractures (median, 7 vs 4, P = .0002) compared to those without the primary outcome. Chest-related readmission occurred in 8 (6%) with a median of 20 days from injury. Of these, 7 required an HTX-related intervention. Logistic regression analysis found that both the number of rib fractures and HTX volume independently predicted the primary outcome. CONCLUSION: For small HTX initially observed, number of rib fractures and initial volume predicted delayed HTX-related intervention.

Gender Is a Spectrum: Evaluating Current and Novel Ways to Inquire About Gender Identity in the Health Care Setting.

PURPOSE: The use of visuals to inquire about gender in the clinical setting has been rare. We developed a survey that included a visual spectrum to assess perceptions about the most and least inclusive ways of inquiring about gender in patients with gender dysphoria. METHODS: The survey included a multiple-choice question (MCQ), free-response question, and a visual spectrum on which respondents were asked to select one box that best depicts their gender. The survey was administered to all patients diagnosed with gender dysphoria at our institution between April and June 2022. RESULTS: A total of 223 of 856 patients responded. Those with more masculine gender identities selected boxes near the visual spectrum corner of "man," whereas responses were more variable for more feminine genders. The free-response question was identified by 59% of respondents as the most inclusive. The MCQ was identified as least inclusive by 70.4%. The visual spectrum was considered the most inclusive method by the majority of patients who self-identified as woman and demiwoman/demifemale. Being asked about pronouns was extremely or very important in the health care setting for 52% of respondents, but 68.6% indicated that they are rarely or sometimes asked about their pronouns in this setting. CONCLUSIONS: The traditional MCQ format for self-identifying gender may be lacking in inclusivity and fails to represent the nuances of gender identity. Free response was considered the most inclusive way to inquire about gender among our respondents. These findings highlight the importance of formatting gender identity questionnaires to foster inclusivity for transgender patients.

Autoradiographic labelling of metabotropic glutamate type 2/3 receptors in the hemi-parkinsonian rat brain.

L-3,4-dihydroxyphenylalanine (L-DOPA) is the treatment of choice for Parkinson's disease (PD) motor symptoms, but its chronic use is hindered by complications such as dyskinesia. Pre-clinical studies discovered that activation of metabotropic glutamate type 2 and 3 (mGlu2/3) receptors alleviates L-DOPA-induced dyskinesia. To gain mechanistic insight into the anti-dyskinetic activity of mGlu2/3 activation, we performed autoradiographic binding with [3H]-LY-341,495 in brain sections from L-DOPA-treated 6-hydroxydopamine (6-OHDA)-lesioned rats that developed mild or severe dyskinesia, as well as L-DOPA-untreated 6-OHDA-lesioned and sham-lesioned animals. In the ipsilateral hemisphere, mildly dyskinetic 6-OHDA-lesioned rats showed a decrease in [3H]-LY-341,495 binding in the entopeduncular nucleus (EPN, 30 % vs sham-lesioned rats, P<0.05), globus pallidus (GP, 28 % vs sham-lesioned rats, P<0.05; 23 % vs L-DOPA-untreated 6-OHDA-lesioned rats, P<0.001), and primary motor cortex (49 % vs sham-lesioned rats, P<0.05; 45 % vs L-DOPA-untreated 6-OHDA-lesioned rats, P<0.001). Severely dyskinetic 6-OHDA-lesioned rats exhibited an increase in binding in the primary motor cortex (43 % vs mildly dyskinetic 6-OHDA-lesioned rats, P<0.05). In the contralateral hemisphere, mildly dyskinetic 6-OHDA-lesioned rats harboured a decrease in binding in the EPN (30 % vs sham-lesioned rats; 24 % vs L-DOPA-untreated 6-OHDA-lesioned rats, both P<0.05), GP (34 % vs sham-lesioned rats, P<0.05; 23 % vs L-DOPA-untreated 6-OHDA-lesioned rats, P<0.001), and primary motor cortex (50 % vs sham-lesioned rats; 44 % vs L-DOPA-untreated 6-OHDA-lesioned rats, both P<0.05). Severely dyskinetic 6-OHDA-lesioned rats presented a decrease in binding in the GP (30 % vs sham-lesioned rats; 19 % vs L-DOPA-untreated 6-OHDA-lesioned rats, both P<0.05). Abnormal involuntary movements scores of 6-OHDA-lesioned animals were positively correlated with [3H]-LY-341,495 binding in the ipsilateral striatum, ipsilateral EPN, ipsilateral primary motor cortex and contralateral primary motor cortex (all P<0.05). These results suggest that alterations in mGlu2/3 receptor levels may be part of an endogenous compensatory mechanism to alleviate dyskinesia.

Paraspinous Muscle Flaps in Complex Pediatric Spine Surgeries: A 12-Year Single Institution Experience.

PURPOSE: The benefits of paraspinous flaps in adult complex spine surgery patients are established in the literature; however, their use in pediatric patients has not been well described. This study compares clinical outcomes with and without paraspinous muscle flap closure in pediatric patients who have undergone spine surgery. METHODS: We conducted a retrospective review of all pediatric spine surgeries at the University of California, San Francisco from 2011 to 2022. Patients were divided into 2 cohorts based on whether the plastic surgery service closed or did not close the wound with paraspinous muscle flaps. We matched patients by age, American Society of Anesthesiology classification, prior spinal surgical history, and diagnosis. Surgical outcomes were compared between the 2 cohorts. RESULTS: We identified 226 pediatric patients who underwent at least one spinal surgery, 14 of whom received paraspinous flap closure by plastic surgery. They were matched in a 1:4 ratio with controls (n = 56) that did not have plastic surgery closure. The most common indication for plastic surgery involvement was perceived complexity of disease by the spine surgeon with concern for inadequate healthy tissue coverage (78.6%), followed by infection (21.4%). Postoperative complications were similar between the two groups. The plastic surgery cohort had a higher rate of patients who were underweight (57.1% vs 14.3%, P < 0.01) and had positive preoperative wound cultures (28.6% vs 8.9%, P = 0.05), as well as a higher rate of postoperative antibiotic usage (78.6 vs 17.9%, P < 0.01). There was no difference in recorded postoperative outcomes. CONCLUSIONS: Spine surgeons requested paraspinous flap closure for patients with more complex disease, preoperative infections, history of chemotherapy, or if they were underweight. Patients with paraspinous flap coverage did not have increased postoperative complications despite their elevated risk profile. Our findings suggest that paraspinous muscle flaps should be considered in high-risk pediatric patients who undergo spine surgery.