Ambulatory facial feminization surgery: a comparative analysis of outcomes and complications.

BACKGROUND: To date, there are no studies investigating the safety and outcomes of facial feminization surgery (FFS) as an outpatient procedure. This is the first study of its kind analyzing the outcomes of ambulatory FFS based on a comparison of complications, post-operative emergency department or urgent care (ED/UC) visits, and readmissions between patients who underwent FFS with admission versus same-day surgery. METHODS: A retrospective analysis was conducted on all patients who underwent FFS in a single integrated healthcare system. Patient charts were reviewed for operative details, complications, post-operative ED/UC visits, readmission, and demographic factors. Major outcomes including complications, readmissions, and ED/UC visits were compared between groups with same-day discharge and post-operative hospital admission. RESULTS: Of 242 patients included in the study, ED/UC visits were comparable between patients discharged same-day (18.2%) and patients admitted post-operatively (21.6%, p = 0.52). Logistic regression showed no significant difference in the composite outcomes of minor complications, major complications, and readmissions (15.6% for ambulatory versus 19.3% for admission, p = 0.46). Temporary nerve palsy, infection, and hematoma were the most common post-operative complications. However, covariates of a lower face procedure and operative time were shown to have significant differences in the composite complication outcome (p = 0.04 and p = 0.045, respectively). CONCLUSION: Ambulatory FFS is a safe practice with no associated increase in adverse outcomes including complications, ED/UC visits, and readmission when compared to post-operative admission. Adoption of same-day FFS should be considered by high-volume gender health centers to potentially benefit from increased scheduling flexibility and efficiency, increased access to care, and lower healthcare costs.

Risk Factors for Delayed Diagnosis of Positional Plagiocephaly: A Review of 25,322 Patients.

OBJECTIVE: This study identifies risk factors for late positional plagiocephaly (PP) diagnosis and impact on helmet therapy. DESIGN: We conducted a retrospective review of all patients diagnosed with PP over 10 years at five Southern California hospitals. SETTING: Patients diagnosed with PP at an included hospital. PATIENTS: 25,332 patients were diagnosed with PP over 10 years. INTERVENTIONS: Patients diagnosed with PP early (< = 6 months) and late (>6 months) were compared. MAIN OUTCOME MEASURES: Cohorts were evaluated for demographics, gestational history, associated conditions, and hospitalizations through direct comparison, logistic regression, and correlation analyses. Rates of referrals and helmet orders were compared. RESULTS: Of patients reviewed, 4.8% (n = 1216) were diagnosed late. On multivariate analysis, late diagnoses were more likely Hispanic or Black/African-American. Early gestational age, hydrocephalus, and VP shunt were more frequent in late diagnoses. Patients diagnosed late had longer NICU and overall hospital stays. Earlier gestational age, longer NICU or overall hospital stay correlated with later age at PP diagnosis. 8.9% of patients were referred for helmet therapy evaluation. Patients diagnosed late were 2.63 and 1.64 times as likely to be referred and require helmet therapy, respectively. CONCLUSIONS: Patients who are Hispanic or Black/African-American, premature, have hydrocephalus, or VP shunt have higher rates of delayed PP diagnosis. Shorter gestational age or longer NICU or hospital stay correlates with later diagnosis, which increases helmet therapy requirements. Additional interventions are needed for at risk patients to routinely evaluate for and minimize the risk of developing PP.

Complexity of Online Facial Feminization Surgery Material Exceeds Patient Health Literacy.

The increase in healthcare coverage for transgender populations has made facial feminization surgeries (FFS) more accessible. Majority of patients interested in surgery regularly check online medical information to help understand surgical procedures, risks, and recovery. National health organizations recommend that patient information material should be written at a sixth-grade-reading level, but online material often surpasses patient health literacy. This study evaluates the readability of online FFS resources. An Internet search of the top 100 Web sites was conducted using the keywords "facial feminization surgery." Web sites were analyzed for relevant patient information articles on FFS and categorized into health care and nonhealth care groups. Readability examinations were performed for written text using the Automated Readability Index, Coleman-Liau Index, Flesch-Kincaid Grade Level, Gunning Fog Index, and Simple Measure of Gobbledygook Index. Statistical analysis was performed using 2-tailed z tests, with statistical significance set at P≤0.05. A total of 100 articles from 100 Web sites were examined. The average readability for all online FFS resources was at a 12th-grade-writing level. Articles from health care organizations were at a 13th-grade-reading level and nonhealth care organization articles were at a 12th-grade-reading level (P<0.01). Online patient information for FFS is more complex than nationally recommended writing levels, which may interfere with patient decision making and outcomes. Patient resources for FFS should be written at a lower reading level to promote patient education, satisfaction, and compliance.

Challenging the Norm: Is Routine Use of Cranial CT in Evaluation of Craniosynostosis Necessary?

BACKGROUND: Cranial CT is routinely taught to be the gold standard for diagnosis of craniosynostosis and used by craniofacial teams for suspected nonsyndromic single suture craniosynostosis. Given the risks associated with infant CTs, do these scans provide significantly enhanced diagnostic accuracy compared to the physical exam when performed by an experienced clinical provider? METHOD: A retrospective chart review was performed for children who underwent corrective surgery for nonsyndromic, single-suture craniosynostosis over an 11 year period by a single craniofacial team. Ages at presentation and surgery, preoperative clinical diagnosis and imaging, co-existing radiographic findings, and correlation with the intraoperative diagnosis were analyzed. RESULTS: A total of 138 patients were included in this study. The mean age was 4.2 months at initial craniofacial evaluation, and 8.0 months at time of surgery. Twenty-seven patients received imaging prior to our clinic. Of those, 21 had plain radiography and 6 had CT scans. Of the remaining 111 patients referred without imaging, craniosynostosis was clinically diagnosed in 102 (92%), whereas 9 (8%) had an unclear clinical diagnosis. Of these 9, 1 (1%) was diagnosed clinically at follow-up exam, and the remaining 8 (7%) were diagnosed using radiography (3 CT scans, 5 plain radiographs). In all patients, the preoperative diagnosis was confirmed during intraoperative assessment. CONCLUSIONS: Cranial CT was not needed by experienced craniofacial providers in 93% of nonsyndromic, single-suture craniosynostosis. Imaging obtained before craniofacial clinic referral may have been unnecessary. These findings question the classic teaching that preoperative cranial CT is the gold standard for diagnosis in infants with nonsyndromic, single-suture craniosynostosis.

Publisher Correction: A dynamically cold disk galaxy in the early Universe.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

A dynamically cold disk galaxy in the early Universe.

The extreme astrophysical processes and conditions that characterize the early Universe are expected to result in young galaxies that are dynamically different from those observed today1-5. This is because the strong effects associated with galaxy mergers and supernova explosions would lead to most young star-forming galaxies being dynamically hot, chaotic and strongly unstable1,2. Here we report the presence of a dynamically cold, but highly star-forming, rotating disk in a galaxy at redshift6 z = 4.2, when the Universe was just 1.4 billion years old. Galaxy SPT-S J041839-4751.9 is strongly gravitationally lensed by a foreground galaxy at z = 0.263, and it is a typical dusty starburst, with global star-forming7 and dust properties8 that are in agreement with current numerical simulations9 and observations10. Interferometric imaging at a spatial resolution of about 60 parsecs reveals a ratio of rotational to random motions of 9.7 ± 0.4, which is at least four times larger than that expected from any galaxy evolution model at this epoch1-5 but similar to the ratios of spiral galaxies in the local Universe11. We derive a rotation curve with the typical shape of nearby massive spiral galaxies, which demonstrates that at least some young galaxies are dynamically akin to those observed in the local Universe, and only weakly affected by extreme physical processes.

Overview of acute renal manifestations in cancer patients.

Acute kidney injury is frequently encountered in patients with malignancy and is associated with prolonged hospitalization, significant morbidity, and increased mortality. Thorough evaluation is required to identify possible contributing factors, which may range from relatively easily reversible pre-renal causes to complex cancer-specific aetiologies. This review will serve as a practical guide for acute care physicians on the acute medical unit to the assessment and initial management of cancer patients presenting with acute kidney injury.

A Single Lab Test to Aid Pierre Robin Sequence Severity Diagnosis.

OBJECTIVE: The workup of patients with Pierre Robin sequence (PRS) consists of a physical examination, O2 saturation, and polysomnography to determine the severity of respiratory obstruction and need for surgery. We suggest that capillary blood gas (CBG) may be a better physiologic representation of airway obstruction and should be routinely used in the management of patients with PRS. DESIGN: This is a multicenter study based on a retrospective review of medical records. SETTING: The study was performed at tertiary care centers. INTERVENTIONS: Patients with PRS <1 year old underwent mandibular distraction osteogenesis. MAIN OUTCOME MEASURE: Using successful treatment outcome as a reference standard, receiver operating characteristic (ROC) curve was used to determine the accuracy of the diagnostic test and values for the best sensitivity and specificity to determine the need for surgical intervention. RESULTS: Of 73 patients, 48 had sporadic PRS, 23 had syndromes, 2 had micrognathia, not otherwise specified. Mandibular distraction osteogenesis was performed in 62 patients at a mean age of 39 days. The mean initial Apnea-Hypopnea Index (AHI) in nonsurgical versus surgical groups was 10 versus 31 ( P = .063), pH 7.41 versus 7.34 ( P = .003), pCO2 43 versus 56 ( P < .001), and HCO3 27 versus 30 ( P = .022). The ROC curve showed that pCO2 of 49.5 has the best specificity (100%) and sensitivity (72.6%) profile in terms of need for definitive airway. CONCLUSION: A simple CBG heel stick may better predict the physiologic effects of obstructive apnea; therefore, it should be added to the algorithm of PRS workup.

To Admit or Not to Admit: That is the Cleft Lip Question. Confirming the Safety of Outpatient Cleft Lip Repair.

BACKGROUND: There is no accepted protocol for inpatient versus ambulatory cleft lip surgery. The aim of this study was to review the safety of outpatient repair and develop guidelines. METHODS: A retrospective review of patients younger than 2 years undergoing primary cleft lip repair from 2008 to 2015 at six centers was performed. Patients were divided into two groups: predominantly ambulatory (discharged or admitted for specific concerns) and inpatient (admitted due to surgeon's preference). The impact of independent variables on admission, emergency department visits, and readmission within 1 month of discharge was analyzed. RESULTS: Of 546 patients, 68.1 percent were boys, 4.4 percent had syndromes, and 23.6 percent had comorbidities. One hundred forty-two patients were admitted postoperatively. Forty-nine admissions were attributable to the surgeon's preference. After excluding this subset, our ambulatory surgery rate was 81 percent. There was no difference in emergency department visits (3 percent versus 2.2 percent; p = 0.6) or readmissions (0 percent versus 1.45 percent; p = 0.5) between groups. None of the ambulatory surgery patients were readmitted within 36 hours, for a successful ambulatory surgery rate of 100 percent. Female sex; surgical time; prematurity and/or postconceptional age younger than 52 weeks; and cardiac, respiratory, central nervous system, gastrointestinal, genitourinary, and other congenital comorbidities had significant impact on admission rates in the predominantly ambulatory group (p < 0.05). Respiratory comorbidities and syndromes were risk factors for readmission if patients presented to the emergency department (p < 0.05). CONCLUSIONS: Ambulatory cleft lip repair can be performed safely in most patients with no difference in emergency department visits or readmission. Patients with comorbidities should be admitted for observation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Characterization of disease burden, comorbidities, and treatment use in a large, US-based cohort: Results from the Corrona Psoriasis Registry.

BACKGROUND: Psoriasis is an immunodysregulatory inflammatory disease associated with comorbidities affecting quality of life. With the advent of new treatments, there is growing need to assess the long-term safety and efficacy of treatments in a real-world setting. OBJECTIVE: The objective of the Corrona Psoriasis Registry is to study the comparative safety and efficacy of Food and Drug Administration-approved biologic treatments. METHODS: A cross-sectional study of patients enrolled in the registry, who initiated or switched to a systemic therapy at enrollment or previous 12 months. Descriptive characteristics (demographics, clinical and patient-reported outcomes, comorbidities, and treatment history) were examined at registry enrollment. RESULTS: As of October 1, 2016, there were 1942 patients enrolled in the registry: 23% on apremilast, 4% on other nonbiologic systemic medications, 25% on interleukin (IL) 17A inhibitors, 22% on an IL-12/23 inhibitor, and 26% on tumor necrosis factor inhibitors. Overall, mean disease duration was 15.6 years, and 40% had a concurrent psoriatic arthritis diagnosis. About 66% had >3% body surface area involvement and 49% had a moderate or severe Investigator Global Assessment. LIMITATIONS: Selection and channeling bias can result in potential confounding that needs to be addressed in modeled analyses. CONCLUSION: This disease-based registry cohort represents a population exposed to multiple therapies, long disease duration, and multiple comorbidities and can be used to examine comparative safety and efficacy of various therapies.

End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported.

Although end-of-life medical spending is often viewed as a major component of aggregate medical expenditure, accurate measures of this type of medical spending are scarce. We used detailed health care data for the period 2009-11 from Denmark, England, France, Germany, Japan, the Netherlands, Taiwan, the United States, and the Canadian province of Quebec to measure the composition and magnitude of medical spending in the three years before death. In all nine countries, medical spending at the end of life was high relative to spending at other ages. Spending during the last twelve months of life made up a modest share of aggregate spending, ranging from 8.5 percent in the United States to 11.2 percent in Taiwan, but spending in the last three calendar years of life reached 24.5 percent in Taiwan. This suggests that high aggregate medical spending is due not to last-ditch efforts to save lives but to spending on people with chronic conditions, which are associated with shorter life expectancies.

Sympathetic Activity Assessed during Exercise Recovery in Young Obese Females.

OBJECTIVE: To evaluate differences in sympathetic activity, as assessed by an exercise recovery index (ERI; heart rate/oxygen consumption [VO2] plateau), between black and white obese female adolescents. An additional aim was to determine the association of ERI with insulin resistance (homeostasis model assessment of insulin resistance [HOMA-IR]), cardiovascular fitness per fat-free mass (VO2 per fat-free mass), systolic blood pressure (SBP), and percent body fat (%FAT) in both black and white obese adolescents. STUDY DESIGN: Sixty-one females volunteered to participate in this study. HOMA-IR, SBP, and %FAT were assessed during resting conditions in black (n = 49, 13.7 ± 1.6 years, 38.1 ± 6.1 kg/m(2)) and white (n = 12, 13.3 ± 2.2 years, 34.3 ± 4.9 kg/m(2)) obese adolescents. An ERI was calculated during a 5-minute passive recovery period immediately following a graded treadmill exercise test to exhaustion. RESULTS: The ERI was significantly greater in black compared with white obese adolescent females (29.8 ± 6.4 vs 24.1 ± 3.1 bpm·mLO2(-1)·min(-1), P = .004). Using multiple linear regression modeling, there was a significant independent association between ERI and VO2 per fat-free mass (r = -0.310, P = .027) and %FAT (r = 0.326, P = .020) in black obese adolescents after controlling for HOMA-IR and SBP. CONCLUSIONS: These results suggest that black obese adolescent females have greater sympathetic activity, as assessed by an ERI, than white obese adolescent females. These findings support the need for weight management efforts aimed at both reducing %FAT and improving fitness in obese adolescents, specifically black females. TRIAL REGISTRATION: Registered with Clinicaltrials.gov: NCT00562293.

Microblog use and student engagement in the large-classroom setting.

BACKGROUND AND OBJECTIVES: Encouraging student engagement in the large-classroom setting can be difficult. Challenges include the depersonalized nature of the environment and the fact that students frequently find asking questions and participating in class discussion intimidating. Social media has the potential to address these barriers, but this has not yet been formally evaluated. Our study analyzed the impact of microblog use on students' question-asking behaviors (an indicator of student engagement) in a large-classroom setting. METHODS: Formative evaluation of a large-classroom medical humanities course identified microblog use as a potential tool to facilitate greater student engagement. A microblog was thereafter incorporated into the course. Student engagement was operationalized as question-asking behaviors before and after microblog incorporation. RESULTS: Paired t tests showed that the total number of questions asked was significantly greater in the microblog-available classes, t (2)=12.12. In addition, significantly more individual students asked questions in the microblog-available classes, t (2)=17.39. CONCLUSIONS: Our study, demonstrating an increase in question-asking behavior after incorporation of a microblog, has important implications for educators who seek to enhance student engagement and learning in the large-classroom setting. In addition, innovative use of emerging technologies (such as microblogs) as educational tools requires continuous assessment and iterative change to maximize benefit. More research is needed to evaluate what specific barriers to engagement are overcome by microblog use and whether microblog use can similarly benefit other courses.

Heart Failure in an Infant With Pierre Robin Sequence: Is There a Diagnostic Test to Aid in Treatment Planning and Monitoring?

This case report describes an infant with Pierre Robin sequence who was managed conservatively until he presented at 4 months of age with right-sided heart failure. This rare clinical presentation displays the physiologic response to chronic respiratory obstruction and the acid-base disturbances, which become evident on metabolic panel and blood gas. We suggest that these tests can be added to the workup, especially in conservatively managed infants, to help predict which infants may fail conservative treatment and to avoid the rare complication of heart failure in infants with Pierre Robin sequence.

Sex differences in pulmonary oxygen uptake kinetics in obese adolescents.

OBJECTIVE: To determine whether sex differences exist in the pulmonary oxygen uptake (VO2) uptake on-kinetic response to moderate exercise in obese adolescents. We also examined whether a relationship existed between the VO2 on-transient response to moderate intensity exercise, steady-state VO2, and peak VO2 between obese male and female adolescents. STUDY DESIGN: Male (n = 12) and female (n = 28) adolescents completed a graded exercise test to exhaustion on a treadmill. Data from the initial 4 minutes of treadmill walking were used to determine the time constant. RESULTS: The time constant was significantly different (P = .001) between obese male and female adolescents (15.17 ± 8.45 seconds vs 23.07 ± 8.91 seconds, respectively). No significant relationships were observed between the time constant and variables of interest in either sex. CONCLUSIONS: Sex differences exist in VO2 uptake on-kinetics during moderate exercise in obese adolescents, indicating an enhanced potential for male subjects to deliver and/or use oxygen. It may be advantageous for female subjects to engage in a longer warm-up period before the initiation of an exercise regimen to prevent an early termination of the exercise session.

Surgical management of tricuspid valve endocarditis in systemically infected patients.

BACKGROUND AND AIM OF THE STUDY: Isolated bacterial tricuspid valve (TV) endocarditis is usually managed medically. Whilst the indications and optimal timing for surgical treatment of the condition have not been clearly defined, it is hypothesized that early surgery in patients who are bacteremic and/or have evidence of systemic seeding is superior to medical treatment. METHODS: All cases of isolated TV endocarditis reported between 2006 and 2011 at the authors' institution were reviewed. Patients with bacteremia and/or systemic seeding who were treated surgically after short-term medical therapy were compared to an equivalent group of patients who remained under long-term medical treatment only. RESULTS: A total of 45 patients with isolated TV endocarditis showed evidence of bacteremia and/or systemic seeding. Of these patients, 10 (22.2%) were treated surgically with valve repair or replacement, and 35 (77.8%) received long-term medical therapy only. The 30-day and one-year survival rates in both groups were comparable (100% versus 88.6%, p = 0.27). Patients treated surgically had clear blood cultures sooner (2.0 versus 6.7 days, p = 0.04), defervesced earlier (0 versus 9.0 days, p = 0.02), and demonstrated a complete resolution of TV vegetations (100% versus 30.0%, p = 0.003). Change in creatinine clearance (+22.1 versus +11.6 ml/min, p = 0.40) and durations of vasopressor support (6.8 versus 8.9 h, p = 0.86), mechanical ventilation (8.5 versus 32.2 h, p = 0.44), ICU stay (148.1 versus 53.8 h, p = 0.14) and total hospital stay (32.1 versus 24.6 days, p = 0.22) were not different between groups. Long-term echocardiogram surveillance demonstrated a higher prevalence of moderate-severe tricuspid regurgitation in the medically treated patients (75.0 versus 0.0%, p < 0.001). None of the patients treated surgically was readmitted with prosthetic valve endocarditis. CONCLUSION: Early surgery is warranted in patients with isolated TV endocarditis who are bacteremic and/or systemically infected despite optimal medical therapy.

Caffeine for the prevention of postoperative nausea and vomiting.

CONTEXT: Postoperative nausea and vomiting (PONV) is common after ambulatory surgery performed under general anesthesia. Anecdotal evidence suggests that caffeine may be useful in preventing PONV. AIMS: The aim of the study was to determine efficacy of intravenous (IV) caffeine given prior to surgery is effective prophylaxis against PONV. SETTINGS AND DESIGN: We conducted a prospective, randomized, double-blind, placebo-controlled study. SUBJECT AND METHODS: Patients at moderate or high risk of PONV were randomized to receive IV caffeine (500 mg) or saline placebo during general anesthesia; all patients received dexamethasone and dolasetron. STATISTICAL ANALYSIS: Statistical comparisons were tested using bivariable linear and logistic regression for each outcome and then adjusted for high/low risk. RESULTS: Nausea in the postanesthesia care unit (PACU) was more common in the caffeine (16 of 62 patients) than the placebo group (seven of 69; P = 0.02). There were no significant differences in the use of rescue antiemetics in the PACU, in the incidence of nausea or vomiting over 24 h postoperatively, nor in other outcomes (headache, fatigue, or overall satisfaction) either in the PACU or at 24 h; time-to-discharge was similar for both groups. CONCLUSION: Caffeine was not effective in the prevention of PONV or headache, and did not improve time-to-discharge or patient satisfaction.

Cardiac transplantation can be safely performed with low donor-to-recipient body weight ratios.

BACKGROUND: United Network for Organ Sharing adult heart transplant criteria recommend against using same-sex donors with a donor-recipient body weight ratio <0.7. The same criteria recommend against a female donor to male recipient body weight ratio <0.9. We attempted to determine if transplantation with low donor-recipient body weight ratios can be safely performed. METHODS AND RESULTS: Transplants with same-sex donor-recipient body weight ratio <0.7 and female donor-male recipient body weight ratio <0.9 were compared with age- and sex-matched control subjects with ideally matched donor weights. Of the 123 patients undergoing transplantation, 23 met low donor-recipient body weight ratio criteria. This cohort was compared with 22 ideally weight-matched patients. There was no difference in survival at 1, 5, and 10 years (P = .68). Freedom from rejection (52.2 vs 50.0%; P = 1.0), creatinine clearance change (-1.3 vs 5.7 mL/min; P = .88), duration of inotropic support (191.5 vs 208.8 h; P = .65), and duration of mechanical ventilation (156.3 vs 84.5 h; P = .52) were similar. Intensive care (290.5 vs 368.6 h; P = .71) and hospital length of stay (35.4 vs 36.7 d; P = .94) were not different. CONCLUSIONS: Accepted donor-recipient weight match criteria may be extended to increase the donor pool.