Replacing the Scalpel With a Computer Mouse: An Evaluation of Time Spent on Electronic Health Record for Plastic Surgery Residents and Its Impact on Resident Training.

BACKGROUND: Following the integration of the electronic health record (EHR) into the healthcare system, concern has grown regarding EHR use on physician well-being. For surgical residents, time spent on the EHR increases the burden of a demanding, hourly restricted schedule and detracts from time spent honing surgical skills. To better characterize these burdens, we sought to describe EHR utilization patterns for plastic surgery residents. METHODS: Integrated plastic surgery resident EHR utilization from March 2019 to March 2020 was extracted via Cerner Analytics at a tertiary academic medical center. Time spent in the EHR on-duty (0600-1759) and off-duty (1800-0559) in the form of chart review, orders, documentation, and patient discovery was analyzed. Statistical analysis was performed in the form of independent t tests and Analysis of Variance (ANOVA). RESULTS: Twelve plastic surgery residents spent a daily average of 94 ± 84 minutes on the EHR, one-third of which was spent off-duty. Juniors (postgraduate years 1-3) spent 123 ± 99 minutes versus seniors (postgraduate years 4-6) who spent 61 ± 49 minutes (P < 0.01). Seniors spent 19% of time on the EHR off-duty, compared with 37% for juniors (P < 0.01). Chart review comprised the majority (42%) of EHR usage, followed by patient discovery (22%), orders (14%), documentation (12%), other (6%), and messaging (1%). Seniors spent more time on patient discovery (25% vs 21%, P < 0.001), while juniors spent more time performing chart review (48% vs 36%, P = 0.19). CONCLUSION: Integrated plastic surgery residents average 1.5 hours on the EHR daily. Junior residents spend 1 hour more per day on the EHR, including more time off-duty and more time performing chart review. These added hours may play a role in duty hour violations and detract from obtaining operative skill sets.

Directed evolution of enzymatic silicon-carbon bond cleavage in siloxanes.

Volatile methylsiloxanes (VMS) are man-made, nonbiodegradable chemicals produced at a megaton-per-year scale, which leads to concern over their potential for environmental persistence, long-range transport, and bioaccumulation. We used directed evolution to engineer a variant of bacterial cytochrome P450BM3 to break silicon-carbon bonds in linear and cyclic VMS. To accomplish silicon-carbon bond cleavage, the enzyme catalyzes two tandem oxidations of a siloxane methyl group, which is followed by putative [1,2]-Brook rearrangement and hydrolysis. Discovery of this so-called siloxane oxidase opens possibilities for the eventual biodegradation of VMS.

LAMP (Loop-mediated isothermal amplification) assay for rapid identification of Varroa mites.

Varroa mites are serious pests of European honeybees (Apis mellifera). For detection of Varroa mite, a new molecular LAMP-based assay has been developed, which retains the body of the mite intact for morphological identification. Six novel Varroa LAMP primers were designed from existing DNA sequences of the COI locus to target V. destructor and V. jacobsoni, providing the ability to tell them apart from other non-target beehive associated mite and insect species. This LAMP assay is specific in detecting these Varroa species and has been tested on specimens originating from multiple countries. It produces amplification of V. destructor and V. jacobsoni in 16 ± 3.4 min with an anneal derivative of 78 ± 0.5 °C whilst another Varroa species,V. underwoodi, showed late amplification. A gBlock gene fragment, used here as a positive control has a different anneal derivative of 80 °C. Three non-destructive DNA extraction methods (HotShot, QuickExtract and Xtract) were tested and found to be suitable for use in the field. The LAMP assay was sensitive to very low levels of Varroa DNA, down to 0.24 picogram (~ 1 × 10 copies/µL of Varroa gBlock). This is a new molecular tool for rapid and accurate detection and identification of Varroa mites for pest management, in areas where these mites do not occur.

Evolutionarily diverse origins of deformed wing viruses in western honey bees.

Novel transmission routes can allow infectious diseases to spread, often with devastating consequences. Ectoparasitic varroa mites vector a diversity of RNA viruses, having switched hosts from the eastern to western honey bees (Apis cerana to Apis mellifera). They provide an opportunity to explore how novel transmission routes shape disease epidemiology. As the principal driver of the spread of deformed wing viruses (mainly DWV-A and DWV-B), varroa infestation has also driven global honey bee health declines. The more virulent DWV-B strain has been replacing the original DWV-A strain in many regions over the past two decades. Yet, how these viruses originated and spread remains poorly understood. Here, we use a phylogeographic analysis based on whole-genome data to reconstruct the origins and demography of DWV spread. We found that, rather than reemerging in western honey bees after varroa switched hosts, as suggested by previous work, DWV-A most likely originated in East Asia and spread in the mid-20th century. It also showed a massive population size expansion following the varroa host switch. By contrast, DWV-B was most likely acquired more recently from a source outside East Asia and appears absent from the original varroa host. These results highlight the dynamic nature of viral adaptation, whereby a vector's host switch can give rise to competing and increasingly virulent disease pandemics. The evolutionary novelty and rapid global spread of these host-virus interactions, together with observed spillover into other species, illustrate how increasing globalization poses urgent threats to biodiversity and food security.

The final frontier: ecological and evolutionary dynamics of a global parasite invasion.

Studying rapid biological changes accompanying the introduction of alien organisms into native ecosystems can provide insights into fundamental ecological and evolutionary theory. While powerful, this quasi-experimental approach is difficult to implement because the timing of invasions and their consequences are hard to predict, meaning that baseline pre-invasion data are often missing. Exceptionally, the eventual arrival of Varroa destructor (hereafter Varroa) in Australia has been predicted for decades. Varroa is a major driver of honeybee declines worldwide, particularly as vectors of diverse RNA viruses. The detection of Varroa in 2022 at over a hundred sites poses a risk of further spread across the continent. At the same time, careful study of Varroa's spread, if it does become established, can provide a wealth of information that can fill knowledge gaps about its effects worldwide. This includes how Varroa affects honeybee populations and pollination. Even more generally, Varroa invasion can serve as a model for evolution, virology and ecological interactions between the parasite, the host and other organisms.

Surveillance for Avocado Sunblotch Viroid Utilizing the European Honey Bee (Apis mellifera).

Avocado is one of the world's fastest growing tropical fruit industries, and the pathogen avocado sunblotch viroid (ASBVd) is a major threat to both production and access to international export markets. ASBVd is seed transmissible, with infection possible via either the male (pollen) or female gametes. Surveillance for ASBVd across commercial orchards is a major logistical task, particularly when aiming to meet the stringent standards of evidence required for a declaration of pest freedom. As with many fruit crops, insect pollination is important for high avocado yields, and honey bee (Apis mellifera) hives are typically moved into orchards for paid pollination services. Exploiting the foraging behavior of honey bees can provide a complementary strategy to traditional surveillance methods. High-throughput sequencing (HTS) of bee samples for plant viruses shows promise, but this surveillance method has not yet been tested for viroids or in a targeted plant biosecurity context. Here, we tested samples of bees and pollen collected from pollination hives in two ASBVd orchard locations, one in Australia, where only four trees in a block were known to be infected, and a second in South Africa, where the estimated incidence of infection was 10%. Using real-time RT-PCR and HTS (total RNA-seq and small RNA-seq), we demonstrated that ASBVd can be confidently detected in bees and pollen samples from hives within 100 m of infected trees. The potential for using this approach in ASBVd surveillance for improved orchard management and supporting market access is discussed.

Reawakening Neuritis of the Median Nerve after Carpal Tunnel Release: Defining and Predicting Patients at Risk.

BACKGROUND: Patients with long-standing carpal tunnel symptoms may develop transient and, paradoxically, worsened neuropathic pain immediately following release. The authors have termed this "reawakening phenomenon." The purpose of this study was to compare the characteristics of patients with this phenomenon to those with a standard postoperative course. METHODS: A retrospective chart review was performed on all patients who underwent carpal tunnel release at a single institution between January of 2012 to December of 2017. Patients demonstrating increased neuropathic pain in the median nerve distribution postoperatively without evidence of complex regional pain syndrome were included. A comparison cohort was composed of the remaining patients identified. Demographic data, medical history, carpal tunnel history, and electromyogram and nerve conduction study findings were recorded. RESULTS: A total of 640 patients were identified; 440 met criteria. Seventeen patients were found to have symptoms consistent with median nerve reawakening phenomenon. The reawakening cohort was older (71.1 versus 56.8 years), more likely to have evidence of thenar muscle atrophy (58.8 percent versus 13.48 percent), and more likely to have fibrillations and sharp waves on electrodiagnostic studies. Although not statistically significant, they also had a longer duration of symptoms (4.9 versus 2.9 years). Of those patients with reawakening phenomenon, 14 had resolution of their symptoms at an average period of 4.4 months. Three remaining patients who were subjectively symptomatic had normal or improved postoperative electromyogram and nerve conduction studies. CONCLUSIONS: Reawakening of the median nerve has not been previously described but occurs in 3.9 percent of hands following routine carpal tunnel release. Preoperative counseling of patients at high risk for reawakening phenomenon is recommended. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Cold case: The disappearance of Egypt bee virus, a fourth distinct master strain of deformed wing virus linked to honeybee mortality in 1970's Egypt.

In 1977, a sample of diseased adult honeybees (Apis mellifera) from Egypt was found to contain large amounts of a previously unknown virus, Egypt bee virus, which was subsequently shown to be serologically related to deformed wing virus (DWV). By sequencing the original isolate, we demonstrate that Egypt bee virus is in fact a fourth unique, major variant of DWV (DWV-D): more closely related to DWV-C than to either DWV-A or DWV-B. DWV-A and DWV-B are the most common DWV variants worldwide due to their close relationship and transmission by Varroa destructor. However, we could not find any trace of DWV-D in several hundred RNA sequencing libraries from a worldwide selection of honeybee, varroa and bumblebee samples. This means that DWV-D has either become extinct, been replaced by other DWV variants better adapted to varroa-mediated transmission, or persists only in a narrow geographic or host range, isolated from common bee and beekeeping trade routes.

The first steps toward a global pandemic: Reconstructing the demographic history of parasite host switches in its native range.

Host switching allows parasites to expand their niches. However, successful switching may require suites of adaptations and also may decrease performance on the old host. As a result, reductions in gene flow accompany many host switches, driving speciation. Because host switches tend to be rapid, it is difficult to study them in real-time, and their demographic parameters remain poorly understood. As a result, fundamental factors that control subsequent parasite evolution, such as the size of the switching population or the extent of immigration from the original host, remain largely unknown. To shed light on the host switching process, we explored how host switches occur in independent host shifts by two ectoparasitic honey bee mites (Varroa destructor and V. jacobsoni). Both switched to the western honey bee (Apis mellifera) after being brought into contact with their ancestral host (Apis cerana), ~70 and ~12 years ago, respectively. Varroa destructor subsequently caused worldwide collapses of honey bee populations. Using whole-genome sequencing on 63 mites collected in their native ranges from both the ancestral and novel hosts, we were able to reconstruct the known temporal dynamics of the switch. We further found multiple previously undiscovered mitochondrial lineages on the novel host, along with the genetic equivalent of tens of individuals that were involved in the initial host switch. Despite being greatly reduced, some gene flow remains between mites adapted to different hosts. Our findings suggest that while reproductive isolation may facilitate the fixation of traits beneficial for exploiting the new host, ongoing genetic exchange may allow genetic amelioration of inbreeding effects.

Biocatalytic Transformations of Silicon-the Other Group 14 Element.

Significant inroads have been made using biocatalysts to perform new-to-nature reactions with high selectivity and efficiency. Meanwhile, advances in organosilicon chemistry have led to rich sets of reactions holding great synthetic value. Merging biocatalysis and silicon chemistry could yield new methods for the preparation of valuable organosilicon molecules as well as the degradation and valorization of undesired ones. Despite silicon's importance in the biosphere for its role in plant and diatom construction, it is not known to be incorporated into any primary or secondary metabolites. Enzymes have been found that act on silicon-containing molecules, but only a few are known to act directly on silicon centers. Protein engineering and evolution has and could continue to enable enzymes to catalyze useful organosilicon transformations, complementing and expanding upon current synthetic methods. The role of silicon in biology and the enzymes that act on silicon-containing molecules are reviewed to set the stage for a discussion of where biocatalysis and organosilicon chemistry may intersect.

Acute limb shortening or creation of an intentional deformity to aid in soft tissue closure for IIIB/IIIC open tibia fractures.

BACKGROUND: Ring fixator techniques can precisely correct complex long bone deformities. In select patients, controlled shortening or intentional fracture deformation with delayed correction can also aid in complex wound coverage and limb salvage. METHODS: This retrospective cohort study analyzed all patients who underwent acute limb shortening or intentional temporary fracture deformation between 2005 and 2020. Patients were divided into three groups based on reason for acute shortening or intentional deformity: (1) skeletal indications alone, with traditional flap coverage; (2) skeletal and soft tissue indications, to augment traditional reconstructive measures; and (3) skeletal and soft tissue indications, to avoid microsurgery altogether. Comorbidities, orthopedic and reconstructive methods, and functional outcomes were recorded. RESULTS: Eighteen patients were identified: six in Group 1, five in Group 2, and seven in Group 3. Fractures were primarily in the distal third of the tibia. On initial assessment, all wounds would have required free tissue transfer. Group 1 patients were reconstructed with free flaps. Among Group 2, closure was accomplished by skin grafting (N = 1), local flaps (N = 1), pedicled muscle flaps (N = 1), and free flaps (N = 2). In Group 3, five wounds were closed primarily and two were skin grafted. All limbs were shortened, averaging 25.1 mm; seven were intentionally deformed, most commonly varus (10-20°). After skeletal correction, residual leg length discrepancy averaged 5.7 mm. No patients required amputation. CONCLUSIONS: Acute skeletal shortening with or without intentional temporary deformation in select IIIB/IIIC open tibial fractures can facilitate soft tissue coverage and limb salvage in patients who might otherwise require amputation.

Genetic variation of Ascosphaera apis and colony attributes do not explain chalkbrood disease outbreaks in Australian honey bees.

Chalkbrood infection caused by the fungus Ascosphaera apis currently has a significant impact on Australia's apicultural industry. We investigated the genetic variation of A. apis and colony and apiary level conditions to determine if an emerging, more virulent strain or specific conditions were responsible for the prevalence of the disease. We identified six genetically distinct strains of A. apis, four have been reported elsewhere and two are unique to Australia. Colonies and individual larvae were found to be infected with multiple strains of A. apis, neither individual strains, combinations of strains, or obvious colony or apiary characteristics were found to be predictive of hive infection levels. These results suggest that host genotype plays an important role in colony level resistance to chalkbrood infection in Australia.

Choice of Corticosteroid Solution and Outcome After Injection for Trigger Finger.

Background: Many techniques for injection of trigger fingers exist. The purpose of this study was to determine whether the type of steroid or technique used for trigger finger injection altered clinical outcomes. Methods: Six hand surgeons at a single institution were surveyed regarding their injection technique, preferred steroid used, and protocol for repeat injection or indication for surgery for symptomatic trigger finger. A retrospective chart review of patients who underwent trigger finger injections was performed by randomly selecting 35 patients for each surgeon between January 2013 and December 2015. Demographic data at the time of presentation were collected. Outcome data during follow-up appointments were also recorded. Results: A total of 210 patient charts were reviewed. Demographic data and initial presenting grade of triggering were similar among all groups. There was no significant difference in clinical course or eventual outcomes noted with injection technique. There were 70 patients in each steroid cohort. Patients receiving triamcinolone required additional injections compared with those receiving methylprednisolone and dexamethasone. Eventual surgical intervention was significantly higher in those patients receiving methylprednisolone. The methylprednisolone group also underwent operative release significantly earlier. Conclusions: Trigger finger injections with triamcinolone demonstrate a higher rate of additional injections when compared with dexamethasone and methylprednisolone. Patients who underwent methylprednisolone injection had surgical release performed earlier and more frequently than the other 2 groups. The choice of corticosteroid significantly affected clinical outcome in this study population. Clinicians performing steroid injections for trigger finger may wish to consider these results when selecting a specific agent.

Homoconjugated Acids as Low Cyclosiloxane-Producing Silanol Polycondensation Catalysts.

Polycondensation of α,ω-disilanols is a foundational technology for silicones producers. Commercially, this process is carried out with strong Brønsted acids and bases, which generates cyclosiloxane byproducts. Homoconjugated acids (a 2:1 complex of acid:base or a 1:1 complex of acid:salt), a seldom used class of silanol polycondensation catalysts, were evaluated for their ability to polymerize α,ω-disilanols while forming low levels of cyclosiloxane byproducts. Homoconjugated acid catalysts were highly active for silanol polycondensation, even when made from relatively mild acids such as acetic acid. Both the acid and base (or cation) component of the homoconjugated species was important for activity and avoiding cyclosiloxane byproduct formation. Stronger acids and bases were found to positively affect reactivity, and the pK a of the acid was found to correlate with cyclosiloxane byproduct formation. The individual components of the homoconjugated species (the acid and base) were ineffective as catalysts by themselves, and compositions with fewer than 2 mol of acid to 1 mol of base were much less reactive. Homoconjugated trifluoroacetic acid tetramethylguanidinium and tetrabutylphosphonium complexes were found to be privileged catalysts, able to give high-molecular-weight siloxanes (M n > 60 kDa) while generating less than 100 ppm of octamethylcyclotetrasiloxane byproduct. Finally, a mechanism has been proposed where silanols are electrophilically and nucleophilically activated by the homoconjugated species, leading to silanol polycondensation.

Tolerance of Honey Bees to Varroa Mite in the Absence of Deformed Wing Virus.

The global spread of the parasitic mite Varroa destructor has emphasized the significance of viruses as pathogens of honey bee (Apis mellifera) populations. In particular, the association of deformed wing virus (DWV) with V. destructor and its devastating effect on honey bee colonies has led to that virus now becoming one of the most well-studied insect viruses. However, there has been no opportunity to examine the effects of Varroa mites without the influence of DWV. In Papua New Guinea (PNG), the sister species, V. jacobsoni, has emerged through a host-shift to reproduce on the local A. mellifera population. After initial colony losses, beekeepers have maintained colonies without chemicals for more than a decade, suggesting that this bee population has an unknown mite tolerance mechanism. Using high throughput sequencing (HTS) and target PCR detection, we investigated whether the viral landscape of the PNG honey bee population is the underlying factor responsible for mite tolerance. We found A. mellifera and A. cerana from PNG and nearby Solomon Islands were predominantly infected by sacbrood virus (SBV), black queen cell virus (BQCV) and Lake Sinai viruses (LSV), with no evidence for any DWV strains. V. jacobsoni was infected by several viral homologs to recently discovered V. destructor viruses, but Varroa jacobsoni rhabdovirus-1 (ARV-1 homolog) was the only virus detected in both mites and honey bees. We conclude from these findings that A. mellifera in PNG may tolerate V. jacobsoni because the damage from parasitism is significantly reduced without DWV. This study also provides further evidence that DWV does not exist as a covert infection in all honey bee populations, and remaining free of this serious viral pathogen can have important implications for bee health outcomes in the face of Varroa.

Selective Enzymatic Oxidation of Silanes to Silanols.

Compared to the biological world's rich chemistry for functionalizing carbon, enzymatic transformations of the heavier homologue silicon are rare. We report that a wild-type cytochrome P450 monooxygenase (P450BM3 from Bacillus megaterium, CYP102A1) has promiscuous activity for oxidation of hydrosilanes to give silanols. Directed evolution was applied to enhance this non-native activity and create a highly efficient catalyst for selective silane oxidation under mild conditions with oxygen as the terminal oxidant. The evolved enzyme leaves C-H bonds present in the silane substrates untouched, and this biotransformation does not lead to disiloxane formation, a common problem in silanol syntheses. Computational studies reveal that catalysis proceeds through hydrogen atom abstraction followed by radical rebound, as observed in the native C-H hydroxylation mechanism of the P450 enzyme. This enzymatic silane oxidation extends nature's impressive catalytic repertoire.

Effectiveness of control strategies for Varroa jacobsoni and Tropilaelaps mercedesae in Papua New Guinea.

Apiculture in the Pacific island country of Papua New Guinea (PNG) is under significant pressure from emerging parasitic mites, Varroa jacobsoni and Tropilaelaps mercedesae. Although numerous mite control products exist, beekeepers in PNG have limited resources and access to these products and their effectiveness under local conditions is untested. Here we determined the effectiveness of two brood manipulation strategies-queen caging and queen removal-for managing V. jacobsoni and T. mercedesae in comparison to the chemical miticide Bayvarol®. Our results found Bayvarol was the most effective control strategy for V. jacobsoni, maintaining high efficacy (> 90%) over 4 months with significantly reduced levels of V. jacobsoni compared to untreated control hives. In contrast, T. mercedesae were significantly reduced by the brood manipulation strategies over 2 months, but not significantly by Bayvarol compared to the controls. These results highlight that a combination of strategies is likely needed to effectively manage both mite pests in PNG. We discuss how these findings are relevant to informing best practice for honey bee biosecurity and how these strategies can be implemented to improve the effectiveness of mite management for PNG beekeepers.

Venous Flaps for Revascularization and Soft-Tissue Coverage in Traumatic Hand Injuries: A Systematic Review of the Literature.

BACKGROUND: The use of the venous flap for simultaneous revascularization and coverage of soft tissue defects has been documented in the literature for over 30 years. First described in 1981, Nakayama et al demonstrated that a vein and overlying skin, or a venous flap, may be transposed from one area of the body to another with complete survival of the graft. The aim of this study was to conduct a systematic review of the literature to determine predictors of venous flap survival in traumatic hand injuries. METHODS: A literature search of PubMed, MEDLINE, and Cochrane Library was performed with emphasis on venous flap use in traumatic hand injuries. MeSH terms included: vein graft, revascularization, venous flow through flap, arterialized venous flap, bypass, replantation, amputation, avulsion, trauma, injury, amputate, finger, hand, and thumb. RESULTS: Forty-three articles were collected that contained data on 626 free venous flaps. Most patients were males (73.9) and injured their right hand (52.3%). The forearm was the most commonly used venous flap donor site (83.6%), and most of the skin paddles were 10 to 25 cm2 (41.1%). Arterial inflow was used in 93.1% of the flaps. Most venous flaps (79.6%) healed without superficial tissue loss or necrosis. Ninety-two (14.7%) flaps had partial loss while 36 (5.8%) flaps did not survive. CONCLUSION: The use of venous flaps for concomitant revascularization and soft tissue coverage of the hand permits good results with limited morbidity. The overall flap survival rate is nearly 95%. Younger patients whose flaps have arterial inflow and skin paddles of medium size (10-25 cm2) have the best chance for survival.

Current Trends in Unilateral Cleft Lip Care: A 10-Year Update on Practice Patterns.

BACKGROUND: The care of unilateral cleft lip (UCL) patients is extremely variable. Historical benchmarks for perioperative and intraoperative choices by cleft surgeons were produced by Sitzman et al (Plast Reconstr Surg. 2008;121:261e-270e) in 2005. However, emerging data and cleft lip repair methods around this period were not captured by this study. The aim of this study was to update the current practice patterns of cleft lip surgeons. METHODS: An electronic survey was distributed to surgeons in the American Cleft Palate Association. Demographic data about the surgeon were collected as well as their choices regarding perioperative and intraoperative cleft lip care. RESULTS: Eighty-six surgeons responded to the survey. Nearly 40% of surgeons have changed their technique for UCL repair with Fisher anatomical subunit repair gaining significant popularity. Nasoalveolar molding is also being used more frequently (41% vs 22%). At the time of the cleft lip repair, closure of the nasal floor is occurring in 83.1% of patients and primary cleft rhinoplasty is being performed routinely 57% of the time. CONCLUSIONS: Over the last 10 years, there has been an increase in the use of modified rotation advancement repairs and Fisher anatomic subunit approximation technique for treatment of UCL. There continues to be a lack of evidence regarding superiority of specific repair techniques or the benefits of adjunct procedures, which results in varying practice patterns. Educating all cleft surgeons on practices that are well supported is important to improve care to cleft patients.