Small flaps in microsurgical breast reconstruction: Selection between the profunda artery perforator and small deep inferior epigastric artery perforator flaps and associated outcomes and complications.

BACKGROUND: The deep inferior epigastric artery perforator (DIEP) flap is widely used in breast reconstruction and the profunda artery perforator (PAP) flap as alternative. However, the difference between the two flaps in smaller breast reconstruction remains lacking, in particular, the donor site complications. In this case series, the results of small breast reconstruction (≤300 g) using PAP or small DIEP flaps were explored. METHODS: Unilateral immediate breast reconstruction using a free PAP flap or small DIEP flap (≤300 g) from 2011 to 2021 were reviewed retrospectively. Excluding patients with delayed reconstruction, 28 patients, including 17 PAP flaps and 11 small DIEP flaps were enrolled. Flap characteristics, breast and donor site complications, and revision surgeries were reviewed. BREAST-Q™ was used for quality-of-life assessment. RESULTS: Compared with a small DIEP flap, a PAP flap was narrow (7.5 ± 1.1 vs. 10.6 ± 0.7 cm, p < .001), short (20.0 ± 2.6 vs. 25.5 ± 1.8 cm, p < .001) and had a shorter pedicle (5.9 ± 1.6 vs. 9.1 ± 1.0 cm, p < .001). There were no significant differences in acute and late complications of wound healing and fat necrosis, but the average number of revisions in the PAP group was significantly higher (1.9 ± 1.3 vs. 0.8 ± 1.4, p = .041). Patient-reported outcomes using BREAST-Q™ displayed no significant difference between the two groups. CONCLUSION: The outcomes of PAP and small DIEP flaps at the breasts and donor sites are satisfactory, despite that a higher tendency of donor site complications in PAP flap and more aesthetic refinement required in the PAP group. The overall outcomes are acceptable.

A Multilevel Primary Care Intervention to Improve Follow-Up of Overdue Abnormal Cancer Screening Test Results: A Cluster Randomized Clinical Trial.

Importance: Realizing the benefits of cancer screening requires testing of eligible individuals and processes to ensure follow-up of abnormal results. Objective: To test interventions to improve timely follow-up of overdue abnormal breast, cervical, colorectal, and lung cancer screening results. Design, Setting, and Participants: Pragmatic, cluster randomized clinical trial conducted at 44 primary care practices within 3 health networks in the US enrolling patients with at least 1 abnormal cancer screening test result not yet followed up between August 24, 2020, and December 13, 2021. Intervention: Automated algorithms developed using data from electronic health records (EHRs) recommended follow-up actions and times for abnormal screening results. Primary care practices were randomized in a 1:1:1:1 ratio to (1) usual care, (2) EHR reminders, (3) EHR reminders and outreach (a patient letter was sent at week 2 and a phone call at week 4), or (4) EHR reminders, outreach, and navigation (a patient letter was sent at week 2 and a navigator outreach phone call at week 4). Patients, physicians, and practices were unblinded to treatment assignment. Main Outcomes and Measures: The primary outcome was completion of recommended follow-up within 120 days of study enrollment. The secondary outcomes included completion of recommended follow-up within 240 days of enrollment and completion of recommended follow-up within 120 days and 240 days for specific cancer types and levels of risk. Results: Among 11 980 patients (median age, 60 years [IQR, 52-69 years]; 64.8% were women; 83.3% were White; and 15.4% were insured through Medicaid) with an abnormal cancer screening test result for colorectal cancer (8245 patients [69%]), cervical cancer (2596 patients [22%]), breast cancer (1005 patients [8%]), or lung cancer (134 patients [1%]) and abnormal test results categorized as low risk (6082 patients [51%]), medium risk (3712 patients [31%]), or high risk (2186 patients [18%]), the adjusted proportion who completed recommended follow-up within 120 days was 31.4% in the EHR reminders, outreach, and navigation group (n = 3455), 31.0% in the EHR reminders and outreach group (n = 2569), 22.7% in the EHR reminders group (n = 3254), and 22.9% in the usual care group (n = 2702) (adjusted absolute difference for comparison of EHR reminders, outreach, and navigation group vs usual care, 8.5% [95% CI, 4.8%-12.0%], P < .001). The secondary outcomes showed similar results for completion of recommended follow-up within 240 days and by subgroups for cancer type and level of risk for the abnormal screening result. Conclusions and Relevance: A multilevel primary care intervention that included EHR reminders and patient outreach with or without patient navigation improved timely follow-up of overdue abnormal cancer screening test results for breast, cervical, colorectal, and lung cancer. Trial Registration: ClinicalTrials.gov Identifier: NCT03979495.

G-protein coupled receptor-associated sorting protein 1 (GASP-1), a ubiquitous tumor marker, promotes proliferation and invasion of triple negative breast cancer.

We have identified the novel protein GASP-1 (G protein coupled receptor-associated sorting protein 1) that appears to be a universal cancer marker and the expression of which in tumor tissue and patient sera is predictive of cancer severity (Tuszynski et al. 2011; Zheng et al. 2012; Zheng 2013; Chang and Tuszynski, 2020). In preliminary results we discovered that a GASP-1 antibody inhibited the growth of the triple negative breast cancer cell line MDA-MB-231 and transient reduction of GASP-1 in these cells decreased their proliferation. To further substantiate these results, we over and under-expressed GASP-1 in stable clones of MDA-MB-231 cells and evaluated their growth and invasive activities. Cells under-expressing GASP-1 failed to grow after 4 days in culture and eventually died. In contrast GASP-1 expressing cells grew exponentially. Similarly, GASP-1 under-expressing cells formed 30% fewer colonies in soft agar as compared to controls and whereas GASP-1 over-expressing cells formed 2-fold more colonies than controls. In tumor cell invasion assays GASP-1 over-expressing cells were over 10-fold more invasive than controls whereas GASP-1 under-expressing cells were over 10-fold less invasive than controls. In IHC staining studies of breast cancer cells, we found that the overexpressed GASP-1 appear in granules of different sizes that are directly correlated with cancer invasiveness. Our results strongly indicate that GASP-1 promotes proliferation and invasion of the triple negative breast cancer cell line MDA-MB-231 and targeting GASP-1 for treatment of breast cancer is indicated.

Redefining the Reconstructive Ladder in Vulvoperineal Reconstruction: The Role of Pedicled Perforator Flaps.

BACKGROUND: Gynecological reconstruction is difficult, particularly in cases with recurrence and received previous surgeries and/or radiotherapy and necessitate secondary reconstruction. Perforator flaps can preserve other donor sites for potential later reconstruction, and they also can be better tailored to the defect. We hypothesized that the use of perforator-based flaps can better restore the defect with less complications. METHODS: A retrospective review was conducted of all patients who underwent vulvar-perineum reconstruction between 2011 and 2018 by the senior author, and oncologic and reconstructive outcomes and complications were analyzed. RESULTS: Thirty-three patients underwent 55 soft tissue reconstructions for vulvar-perineum defects during the study period. The mean follow-up time was 27.6 ± 28.9 months. Squamous cell carcinoma was the most common cancer (45.5%). For 11 patients (33.3%), the procedures were performed for the treatment of recurrent cancer. The average defect size was 39.8 ± 34.3 cm2. The overall survival rate was 90.3%. Profunda artery perforator flaps were the most commonly applied flap for reconstruction in both the primary and recurrent groups. Poor wound healing was the most common complication which occurred in 10 of the 55 flaps (18.2%). Perforator flaps presented fewer complications than myocutaneous flaps or traditional random flaps. Similarly, Island pedicle flap design also presented fewer complications than traditional rotation flaps. With proper reconstruction, previous surgery or radiotherapy did not contribute to an increase in complications. CONCLUSION: In our experience, perforator flaps can provide satisfactory reconstruction for perineum reconstruction with low postoperative complications while preserving other donor sites in the event of disease recurrence for repeat resection and reconstruction. Previous surgery or radiotherapy did not increase the complications or preclude its usage. A redefined reconstructive ladder was created to help selecting the best state-of-the-art technique for reconstruction to achieve better results.

Creation of a rat lymphedema model using extensive lymph node dissection and circumferential soft tissue resection: Is this a reliable model?

INTRODUCTION: The medical demand for lymphedema treatment is huge since the disease mechanism remains unclear, and management are difficult. Our purpose was to develop a reliable lymphedema model mimicking the clinical scenario and allows a microsurgical approach. MATERIALS AND METHODS: Male Lewis rats weighing 400 to 450 g were used to create lymphedema with groin and popliteal lymph node dissection and creation of 5 mm circumferential skin defect (n = 6). A skin incision was made and closed primarily for control group (n = 5). Evaluation included indocyanine green (ICG) lymphangiography 1 and 2 months postoperatively, volume difference between bilateral hindlimbs measured using micro-CT, and the skin was harvested for histological evaluation 2 months postoperatively. RESULTS: Larger volume differences present in the lymphedema group (17.50 ± 7.76 vs. 3.73 ± 2.66%, p < .05). ICG lymphangiography indicated dermal backflow only in the lymphedema group. Increased thickness of the epidermis was noted in lymphedema group (28.50 ± 12.61 µm vs. 15.10 ± 5.41 µm, p < .0001). More CD45+ (35.6 ± 26.68 vs. 2.8 ± 4.23 cells/high power field [HPF], p < .0001), CD3+ (38.39 ± 20.17 vs. 9.73 ± 8.62 cells/HPF, p < .0001), and CD4+ cell infiltration (11.7 ± 7.71 vs. 2.0 ± 2.67 cells/HPF, p < .0001) were observed in the lymphedema group. Collagen type I deposition was more in the lymphedema group (0.15 ± 0.06 vs. 0.07 ± 0.03, p < .0005). CONCLUSIONS: A rat lymphedema model was successfully established. The model can be applied in lymphedema related research.

Simultaneous Orthognathic Surgery With Asian Double Eyelid Suture Blepharoplasty.

BACKGROUND: The main objective of contemporary orthognathic surgery is to correct dentofacial deformities. Nonetheless, many adjunct procedures to enhance the esthetic outcome in orthognathic surgical cases have been successfully incorporated to improve patient satisfaction. The authors report our preliminary experience of performing simultaneous orthognathic surgery with Asian double eyelid suture method blepharoplasty in the same surgical setting. METHOD: This case series report includes all 19 consecutive cases presenting to the Chang Gung Craniofacial Center for combined orthognathic surgery with Asian double eyelid suture method blepharoplasty. The double eyelid crease height was measured as the vertical line between the upper eyelid margin (eyelid lash) and the upper eyelid crease, observed at the mid-pupillary line with the eyes in primary gaze. RESULTS: There were no complications or relapse reported within this time period. There was significant improvement in the left and right mid-pupillary double eyelid crease height postsurgery. There were no statistically significant differences between the left and right mid-pupillary double eyelid crease heights after surgery indicating good eyelid crease height symmetry bilaterally was obtained. CONCLUSIONS: Orthognathic surgery combined with suture method blepharoplasty can be safely performed in the same surgical setting without inappropriate rise in costs or operating room time. This case series demonstrates that excellent esthetic results can be obtained in simultaneous bimaxillary orthognathic surgery with suture method Asian blepharoplasty.

Nursing Documentation Variation Across Different Medical Facilities Within an Integrated Healthcare System.

The purpose of this study was to demonstrate nursing documentation variation based on electronic health record design and its relationship with different levels of care by reviewing how various flowsheet measures, within the same electronic health record across an integrated healthcare system, are documented in different types of medical facilities. Flowsheet data with information on patients who were admitted to academic medical centers, community hospitals, and rehabilitation centers were used to calculate the frequency of flowsheet entries documented. We then compared the distinct flowsheet measures documented in five flowsheet templates across the different facilities. We observed that each type of healthcare facility appeared to have distinct clinical care foci and flowsheet measures documented differed within the same template based on facility type. Designing flowsheets tailored to study settings can meet the needs of end users and increase documentation efficiency by reducing time spent on unrelated flowsheet measures. Furthermore, this process can save nurses time for direct patient care.

Fate of Fat Grafting In Vivo and In Vitro: Does the Suction-Assisted Lipectomy Device Matter?

BACKGROUND: Recently, there has been increasing research interest in identifying the effect of liposuction procedures on fat graft survival in order to clarify whether different harvest techniques affect the quality of fat grafts. OBJECTIVES: The aim of this study was to investigate the effect of 2 liposuction methods on the survival and regeneration potential of grafted fat tissue. The proliferation and differentiation potentials of adipose-derived stem cells (ASCs) isolated by both methods was also investigated. METHODS: Fat grafts were collected from patients who underwent liposuction procedures by 2 different methods: traditional suction-assisted liposuction (TSAL) and vibration amplification of sound energy at resonance (VASER). One portion of the lipoaspirates was implanted into the subcutaneous layer of nu mice for 4 and 12 weeks. ASCs were isolated from the other portion of the lipoaspirate and subjected to proliferation and differentiation assays. RESULTS: Although in vivo fat grafting presented similar adipose tissue survival for the 2 different liposuction methods, more angiogenesis and less fibrosis was observed in the VASER group based on histologic evaluation. Furthermore, VASER-derived ASCs presented better quality in terms of cell differentiation capacity. CONCLUSIONS: The in vivo study confirmed better graft angiogenesis with less inflammation, apoptosis, and scar formation in the VASER group. ASCs harvested with VASER exhibited increased differentiation capacity compared with those obtained by TSAL, and represent an excellent source for fat grafting and regenerative medicine.

Botulinum Toxin to Improve Lower Blepharoplasty Scar: A Double-Blinded, Randomized, Vehicle-Controlled Clinical Trial.

BACKGROUND: Lower blepharoplasty is a common cosmetic operation that relies on minimal postoperative scarring, but Asian patients are at higher risk than Caucasians for hypertrophic and/or widened scars. Botulinum toxin type A (BTX) injections are widely employed to alleviate dynamic facial rhytids and also can improve scar quality by reducing scar tension. The authors assessed whether simultaneous transcutaneous lower blepharoplasty and BTX injections could improve subciliary scar quality. OBJECTIVES: The objective of this study was to assess whether simultaneous transcutaneous lower blepharoplasty and BTX injections could improve subciliary scar quality. METHODS: This is a prospective, randomized, vehicle-controlled, double-blinded clinical trial. Between May 2015 and May 2018, 40 adults who underwent bilateral transcutaneous lower blepharoplasties were randomized to receive BTX (n = 20) or vehicle (normal saline; n = 20) injections into the lateral orbicularis oculi muscle immediately after wound closure. Vancouver Scar Scale, Visual Analogue Scale, and photographic scar width measurements at 3 reference points were recorded at the final clinical follow-up. RESULTS: Thirty-seven patients completed the trial. Vancouver Scar Scale and Visual Analogue Scale scores in the experimental and vehicle control groups were similar, but scar widths in the experimental group at all measured points were significantly narrower than in the vehicle control group (P < 0.001, P = 0.027, and P < 0.001 at each measured point, respectively). CONCLUSIONS: Transcutaneous lower blepharoplasty scars in Asians can be significantly narrowed by simultaneous BTX injections without additional complications.

Patient-Controlled Analgesia and Length of Hospital Stay in Orthognathic Surgery: A Randomized Controlled Trial.

PURPOSE: The objective of this prospective, randomized controlled pilot study of patients undergoing orthognathic surgery was to compare the hospital length of stay (LOS) in patients using intravenous patient-controlled analgesia (PCA) versus patients receiving scheduled and as-needed oral analgesia. PATIENTS AND METHODS: A total of 40 patients (19 male and 21 female patients) aged 16 to 56 years (mean, 20.73 years; standard deviation, 6.87 years) were recruited prospectively and randomized to PCA and non-PCA groups of equal size. Recording of the patient-reported pain score using a visual analog scale was commenced at 8:00 am on day 1 after surgery until discharge. The pain score from routine nursing observations during the postoperative period was recorded until the patient was discharged from the hospital. RESULTS: Randomization resulted in approximately equal proportions of male patients (45% vs 50%) and median ages (18.5 years vs 20 years) for the PCA group versus the non-PCA group; however, the PCA group was noted to have a higher proportion of double-jaw surgery (65% vs 40%). The median LOS was 2 days for both the PCA and non-PCA groups (P = .06). No statistically significant difference in pain scores was found between the 2 groups either at rest (P = .27) or on movement (P = .13). CONCLUSIONS: No evidence was found to indicate the superiority of either the PCA or non-PCA regimen with respect to LOS and pain scores; however, this is not evidence of equivalence of the 2 pain management approaches.

Normal Percentile Reference Curves and Correlation of Acetabular Index and Acetabular Depth Ratio in Children.

BACKGROUND: Radiographic surveillance of the hip is vital in the diagnosis and treatment of developmental dysplasia of the hip (DDH) in children. The acetabular index (AI) and the acetabular depth ratio (ADR) are radiographic parameters for evaluation of acetabular morphology. Normal reference curves for these parameters that allow for serial evaluation of acetabular development in a manner that is independent of age are necessary and clinically useful. The purpose of this study was (1) to establish normal values of AI and ADR in the normally developing pediatric hip up to age 14, (2) to generate percentile reference curves of both parameters, (3) to determine the extent of correlation between AI and ADR, and (4) to assess intrarater and interrater reliability of AI measurement. METHODS: We identified 1734 patients who underwent anterior-posterior pelvic radiography between 2004 and 2014. A total of 1152 patients (age range, 0.15 to 13.97 y; 2304 hips) were identified as radiographically normal in the radiology report, signed by the attending pediatric radiologist on the basis of the absence of structural deformity of the hip and previously established reference values for DDH assessment. A review of the medical records confirmed that patients had no diagnosis of DDH or any other orthopaedic hip pathology. The AI and ADR were measured in all radiographs. Normal values and fully parametric percentile curves were generated from birth to skeletal maturity. Correlation between AI and ADR was assessed using linear regression analysis. RESULTS: Normal AI decreased, and ADR increased, with age. Percentile curves were generated for AI and ADR. Using the provided equations, measured values can be converted to age-appropriate percentile and Z-score. The 2 parameters exhibited strong correlation (Pearson correlation=-0.789, P<0.001). For every unit increase in ADR, AI decreased by 0.94 degrees. CONCLUSIONS: We present updated normative values of AI that expand up to age 14, and novel reference values for ADR. The reference curves allow for the easy conversion of measured values to percentile and Z-score. Using the presented method during surveillance of the pathologic hip, change in acetabular development can now be assessed in a manner that is independent of age and the natural development of the acetabulum. LEVEL OF EVIDENCE: Level IV-case series.

Outcomes of Isolated Varus Derotational Osteotomy in Children With Cerebral Palsy Hip Dysplasia and Predictors of Resubluxation.

BACKGROUND: The appropriate intervention for hip subluxation or dislocation in children affected by cerebral palsy (CP) remains controversial. The purpose of this retrospective study was to report radiographic and clinical outcomes following isolated femoral varus derotational osteotomy (VDRO) in children with CP hip dysplasia. Risk factors for resubluxation and avascular necrosis (AVN) were also examined. METHODS: A cohort of 100 patients (199 hips) with CP treated with isolated VDRO between 2003 and 2009 was reviewed. All but 1 patient received bilateral surgery. Patients were followed for an average of 5.4 years (range, 1.03 to 10.20 y). Anteroposterior pelvic radiographs were used to assess migration percentage (MP), Shenton's line, and presence of AVN. Resubluxation was defined as a postoperative break in Shenton's line. Radiographic outcomes and risk analysis was performed in the 91 subjects (179 hips) with radiographic follow-up >1 year. RESULTS: Significant improvement was observed in MP, and all hips had a reconstituted Shenton's line following surgery. Over the course of follow-up, 16% of hips were noted to have a repeat break in Shenton's line. Univariate risk analysis showed preoperative MP, Gross Motor Function Classification System (GMFCS) level, and age at surgery were risk factors for a recurrent line break. Preoperative MP and GMFCS level were found to be predictors of resubluxation in multivariate analysis. AVN was detected in 10 hips (5.7%). GMFCS level V patients were more at risk for resubluxation, but less at risk for AVN when compared with ambulatory (GMFCS I/II/II) patients and GMFCS level IV patients. CONCLUSIONS: Performing a VDRO without additional procedures provided a stable and concentrically reduced hip joint in this population of children with CP. Attention should be paid to initial ambulatory status during the postoperative period. Concomitant procedures such as pelvic osteotomy should be considered for patients of GMFCS level IV and V, as these patients were more at risk for recurrent subluxation. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Prospective Evaluation of a Multifaceted Intervention to Improve Outcomes in Intensive Care: The Promoting Respect and Ongoing Safety Through Patient Engagement Communication and Technology Study.

OBJECTIVES: Studies comprehensively assessing interventions to improve team communication and to engage patients and care partners in ICUs are lacking. This study examines the effectiveness of a patient-centered care and engagement program in the medical ICU. DESIGN: Prospective intervention study. SETTING: Medical ICUs at large tertiary care center. PATIENTS: Two thousand one hundred five patient admissions (1,030 before and 1,075 during the intervention) from July 2013 to May 2014 and July 2014 to May 2015. INTERVENTIONS: Structured patient-centered care and engagement training program and web-based technology including ICU safety checklist, tools to develop shared care plan, and messaging platform. Patient and care partner access to online portal to view health information, participate in the care plan, and communicate with providers. MEASUREMENTS AND MAIN RESULTS: Primary outcome was aggregate adverse event rate. Secondary outcomes included patient and care partner satisfaction, care plan concordance, and resource utilization. We included 2,105 patient admissions, (1,030 baseline and 1,075 during intervention periods). The aggregate rate of adverse events fell 29%, from 59.0 per 1,000 patient days (95% CI, 51.8-67.2) to 41.9 per 1,000 patient days (95% CI, 36.3-48.3; p < 0.001), during the intervention period. Satisfaction improved markedly from an overall hospital rating of 71.8 (95% CI, 61.1-82.6) to 93.3 (95% CI, 88.2-98.4; p < 0.001) for patients and from 84.3 (95% CI, 81.3-87.3) to 90.0 (95% CI, 88.1-91.9; p < 0.001) for care partners. No change in care plan concordance or resource utilization. CONCLUSIONS: Implementation of a structured team communication and patient engagement program in the ICU was associated with a reduction in adverse events and improved patient and care partner satisfaction.

Comparison of Allograft and Bovine Xenograft in Calcaneal Lengthening Osteotomy for Flatfoot Deformity in Cerebral Palsy.

BACKGROUND: The Evan's calcaneal lengthening osteotomy is a treatment method for spastic flatfoot deformity in patients with cerebral palsy that fail nonoperative measures. Autograft and allograft have been reported as potential graft choices. Bovine xenograft has been introduced as an alternative, but limited human data exists supporting its efficacy. This study compares the long-term results of allograft versus xenograft in isolated Evan's procedure performed for correction of flexible spastic flatfoot deformity. METHODS: This retrospective study accessed charts of 4- to 18-year-olds diagnosed with cerebral palsy who received an Evan's procedure. Preoperative and postoperative radiographic measurements (lateral calcaneal pitch, lateral talocalcaneal, lateral talo-first metatarsal, anteroposterior talonavicular coverage, anteroposterior talo-first metatarsal), graft incorporation, recurrence, secondary procedures, and complications were recorded and analyzed between graft types. RESULTS: Sixty-three feet (34 allograft and 29 xenograft) in 36 patients (mean age 9.3 y) were included. Gross Motor Function Classification System between groups was significant (P=0.001). Mean time for preoperative x-rays was 5.3 months before day of surgery (DOS) for allograft and 3.6 months for xenograft. Mean time of first and last postoperative x-ray for allograft was 3.6 and 39.5 months, respectively; for xenograft, 1.8 and 35.1 months, respectively. There was a significant difference in timing of preoperative x-ray to DOS and DOS to first postoperative x-ray (P=0.012, 0.006, respectively). Radiographically, xenograft retained postoperative improvement better than allograft, yet allograft had a higher grade 4 incorporation rate (P=0.036). The allograft group experienced significantly more cast pressure ulcers (P=0.006), but no other differences in complications between groups, and no infections were reported in either group. CONCLUSIONS: Allograft incorporated better than xenograft, likely with a greater potential to reach grade 5 incorporation, yet both groups retained postoperative improvement. Results indicate both grafts are appropriate; yet incorporation rate could affect correction maintenance, and should be considered during graft selection for Evan's procedure. LEVEL OF EVIDENCE: This study presents clinical results using a novel bone graft material. Level III-retrospective comparative study.

Nurse, Patient, and Care Partner Perceptions of a Personalized Safety Plan Screensaver.

A patient safety plan dashboard was developed that captures disparate data from the electronic health record that is then displayed as a personalized bedside screensaver. The dashboard aligns all care team members, including patients and families, in the safety plan. The screensaver content includes icons that pertain to common geriatric syndromes. In two phases, interviews were conducted with nurses, nursing assistants, patients, and informal caregivers in a large, tertiary care center. End user perceptions of the content and interface of the personalized safety plan screensavers were identified and strategies to overcome the barriers to use for future iterations were defined. Many themes were identified, ranging from appreciation of the clinical decision support provided by the screensavers to the value of the safety-centric content. Differences emerged stemming from each group of end users' role on the care team. All feedback will inform requirements for improvements to the personalized safety plan screensaver. [Journal of Gerontological Nursing, 43(4), 15-22.].

Acetabular Remodeling After a Varus Derotational Osteotomy in Children With Cerebral Palsy.

BACKGROUND: The optimal surgical intervention for hip dysplasia in cerebral palsy (CP) is controversial. The purpose of this study was to determine (1) whether an isolated varus derotation osteotomy (VDRO) for the treatment of CP hip dysplasia allows for acetabular remodeling as measured by acetabular depth ratio (ADR), (2) the predictive factors for acetabular remodeling after an isolated VDRO for the treatment of CP hip dysplasia, and (3) to establish the normal ADR in typical children for comparison. METHODS: Eighty-seven CP patients (174 hips) treated with an isolated VDRO between 2003 and 2009 were retrospectively reviewed. The average age at surgery was 4.6 years (range, 2.4 to 10.6 y) and the average follow-up period was 5.1 years (range, 1.1 to 9.9 y). Acetabular remodeling was assessed on radiographs by the ADR. Changes in preoperative and postoperative ADR were analyzed using linear mixed-effects models. Patients were divided into 2 different groups for the postoperative ADR analysis: Gross Motor Function Classification System (GMFCS) levels I, II, and III compared with GMFCS levels IV and V. The progression of ADR versus age was determined in a set of 917 normal children (1834 hips) for comparison. RESULTS: There was a statistically significant increase (improvement) in ADR postsurgically for the collective CP set (P<0.001) and for both GMFCS categories (I/II/III, IV/V: P<0.001). GMFCS level, sex, and intraoperative neck shaft angle (NSA) were determined to be significant predictors for postoperative ADR improvement. GMFCS level was the most significant predictor for an increase in ADR after surgery (P<0.001). Less improvement in ADR was observed in patients of GMFCS levels IV and V compared with patients of GMFCS levels I, II, and III (P<0.001). A lower intraoperative NSA resulted in greater postoperative increase in ADR (P<0.05). CONCLUSIONS: Overall, isolated VDRO allowed for acetabular remodeling in CP hip dysplasia. Acetabular remodeling was increased in patients of GMFCS levels I, II, and III compared with patients of GMFCS levels IV and V. Increased varization at the time of VDRO improved acetabular remodeling. This study recommends considering GMFCS level and intraoperative NSA during surgical planning for CP hip dysplasia.

Rate of Correction and Recurrence of Ankle Valgus in Children Using a Transphyseal Medial Malleolar Screw.

BACKGROUND: Transphyseal medial malleolar screw (TMMS) hemiepiphysiodesis is an effective treatment for ankle valgus in children. There is limited evidence on the effect of age and diagnosis on the rate of correction as well as the deformity recurrence after screw removal. The purpose of this study was to determine (1) the rate of correction of ankle valgus after hemiepiphysiodesis using a TMMS, (2) the effects of clinical diagnosis and age at surgery on the rate of correction, and (3) the rate of valgus recurrence after TMMS removal. METHODS: In this retrospective study we included 16 male and 21 female patients (63 ankles) with an average age at surgery of 11.0 years (range, 5.4 to 14.8 y) who underwent TMMS hemiepiphysiodesis for the treatment of ankle valgus. There was a mean radiographic follow-up of 1.6 years (range, 0.4 to 4.9 y) before screw removal. For subjects who received screw removal (43 ankles), the average time from insertion to removal of the screw was 1.4 years (range, 0.4 to 5.2 y). Valgus deformity was assessed on anteroposterior ankle radiographs by measurement of tibiotalar angle. Linear mixed effects models were used to determine rates of correction and valgus recurrence. RESULTS: The average rate of correction in tibiotalar angle was 0.37±0.04 degrees per month (P<0.001). Clinical diagnosis and age at surgery significantly affected the amount of postoperative correction in tibiotalar angle (P<0.05). Eighteen of 22 ankles (81.8%) demonstrated recurrence of ankle valgus after screw removal. The average recurrence rate in patients who underwent screw removal was 0.28±0.08 degrees per month (22 ankles, P=0.002). CONCLUSIONS: This study supports the effectiveness of the TMMS hemiepiphysiodesis for treating pediatric ankle valgus, but the effects of additional skeletal growth should be considered as the ankle may rebound into valgus after correction and screw removal. The results from this study can help with surgical planning to predict the amount of correction that may be achieved depending on underlying diagnosis and age at surgery. LEVEL OF EVIDENCE: Level IV-retrospective study.

The effect of cleft maxillary distraction osteogenesis on the levator veli palatini and velopharyngeal function.

BACKGROUND: Le Fort I maxillary distraction with the rigid external distraction (RED) device is performed to correct severe midface retrusion in cleft patients, but it may adversely affect velopharyngeal function. OBJECTIVES: This study aims to investigate the angular changes in the levator veli palatini (LVP) and its influence on velopharyngeal function after maxillary distraction using 3-dimensional computed tomography (3D CT) scan volume rendered images. METHODS: This was a retrospective study of 12 patients. Group 1 had no velopharyngeal function deterioration and group 2 had velopharyngeal function deterioration. Preoperative and 1 year postoperative CT scans were analyzed with Mimics v10 software. Segmentation of the LVP and the nasopharyngeal airway was performed and volumetric images were obtained. Six measurements were made: (1) the angle between the levator plane and the Frankfort horizontal, (2) the angle between the levator plane and the soft palate plane, (3) the angle between the 2 LVP muscles, (4) the pharyngeal depth, and (5, 6) the movement of the inferior pharyngeal point with respect to the horizontal and vertical planes. The independent samples t test, Mann-Whitney test, and paired t tests were used for statistical analyses (P < 0.05). RESULTS: Group 2 had statistically significant reduction in the angle between the levator plane and Frankfort horizontal as well as the soft palate plane. Group 1 had a statistically significant increase in the pharyngeal depth and movement of the inferior pharyngeal point with respect to the horizontal plane. CONCLUSION: A decrease in the angle between the levator plane and the Frankfort horizontal or the soft palate plane was associated with velopharyngeal function deterioration.

Mandibular condylar fractures: a 5-year retrospective analysis comparing open versus closed reduction.

BACKGROUND: Mandibular fractures are common facial fractures, and contemporary management of mandibular condylar fractures is controversial. The purpose of this study was to compare the outcomes of patients who sustained a mandibular condylar fracture between 2016 and 2020, who were managed by either open or closed techniques. The outcomes of this study were: post-operative facial nerve function, occlusion, and maximal mouth opening. METHODS: This study is a retrospective multicentre cohort study which assessed clinical records for 246 patients with mandibular condyle fractures in three hospitals in Perth, Western Australia. The primary outcome measure was changes in post-operative facial nerve function. RESULTS: One hundred and thirty-two patients underwent open reduction and internal fixation (ORIF), and 114 patients had closed management. The overall rate of temporary facial nerve injury following ORIF was 3.28%. The overall rate of permanent facial nerve injury was 0.82%. Sialocoele occurred in 2.46% of all patients who underwent ORIF. 6.14% of patients had persisting malocclusion across both groups. There was a statistically significant association between the degree of fragment shortening and facial nerve injury (P = 0.0063), with more facial nerve changes in the group with 5 mm or greater of fragment shortening. CONCLUSIONS: There is still significant debate over the management of mandibular condylar injuries. This study demonstrates a similar rate of temporary and permanent facial nerve injury as previously described, as well as a similar rate of sialocoele occurrence. Further prospective studies may provide clarity about important characteristics that will help guide decision making for mandibular condylar fractures.