A New Measure of Posterior Morphology in Sagittal Craniosynostosis: The Occipital Bullet Index.

INTRODUCTION: Sagittal craniosynostosis (SC) is associated with scaphocephaly, an elongated narrow head shape. Assessment of regional severity in the scaphocephalic head is limited by the use of serial computed tomographic (CT) imaging or complex computer programing. Three-dimensional measurements of cranial surface morphology provide a radiation-free alternative for assessing cranial shape. This study describes the creation of an occipital bulleting index (OBI), a novel tool using surface morphology to assess the regional severity in patients with SC. METHODS: Surface imaging from CT scans or 3D photographs of 360 individuals with SC and 221 normocephalic individuals were compared to identify differences in morphology. Cartesian grids were created on each individual's surface mesh using equidistant axial and sagittal planes. Area under the curve (AUC) analyses were performed to identify trends in regional morphology and create measures capturing population differences. RESULTS: The largest differences were located in the medial regions posteriorly. Using these population trends, a measure was created to maximize AUC. The OBI has an AUC of 0.72 with a sensitivity of 74% and a specificity of 61%. When the frontal bossing index is applied in tandem, the two have a sensitivity of 94.7% and a specificity of 93.1%. Correlation between the two scores in individuals with SC was found to be negligible with an intraclass correlation coefficient of 0.018. Severity was found to be independent of age under 24 months, sex, and imaging modality. CONCLUSIONS: This index creates a tool for differentiating control head shapes from those with SC and has the potential to allow for objective evaluation of the regional severity, outcomes of different surgical techniques, and tracking shape changes in individuals over time, without the need for radiation.

Morphology of the Occipital Bones and Foramen Magnum Resulting From Premature Minor Suture Fusion in Crouzon Syndrome.

To identify skull-base growth patterns in Crouzon syndrome, we hypothesized premature minor suture fusion restricts occipital bone development, secondarily limiting foramen magnum expansion.Skull-base suture closure degree and cephalometric measurements were retrospectively studied using preoperative computed tomography (CT) scans and multiple linear regression analysis.Evaluation of multi-institutional CT images and 3D reconstructions from Wake Forest's Craniofacial Imaging Database (WFCID).Sixty preoperative patients with Crouzon syndrome under 12 years-old were selected from WFCID. The control group included 60 age- and sex-matched patients without craniosynostosis or prior craniofacial surgery.None.2D and 3D cephalometric measurements.3D volumetric evaluation of the basioccipital, exo-occipital, and supraoccipital bones revealed decreased growth in Crouzon syndrome, attributed solely to premature minor suture fusion. Spheno-occipital (ß = -398.75; P < .05) and petrous-occipital (ß = -727.5; P < .001) suture fusion reduced growth of the basioccipital bone; lambdoid suture (ß = -14 723.1; P < .001) and occipitomastoid synchondrosis (ß = -16 419.3; P < .001) fusion reduced growth of the supraoccipital bone; and petrous-occipital suture (ß = -673.3; P < .001), anterior intraoccipital synchondrosis (ß = -368.47; P < .05), and posterior intraoccipital synchondrosis (ß = -6261.42; P < .01) fusion reduced growth of the exo-occipital bone. Foramen magnum morphology is restricted in Crouzon syndrome but not directly caused by early suture fusion.Premature minor suture fusion restricts the volume of developing occipital bones providing a plausible mechanism for observed foramen magnum anomalies.

Effects of psychosocial support interventions on survival in inpatient and outpatient healthcare settings: A meta-analysis of 106 randomized controlled trials.

BACKGROUND: Hospitals, clinics, and health organizations have provided psychosocial support interventions for medical patients to supplement curative care. Prior reviews of interventions augmenting psychosocial support in medical settings have reported mixed outcomes. This meta-analysis addresses the questions of how effective are psychosocial support interventions in improving patient survival and which potential moderating features are associated with greater effectiveness. METHODS AND FINDINGS: We evaluated randomized controlled trials (RCTs) of psychosocial support interventions in inpatient and outpatient healthcare settings reporting survival data, including studies reporting disease-related or all-cause mortality. Literature searches included studies reported January 1980 through October 2020 accessed from Embase, Medline, Cochrane Library, CINAHL, Alt HealthWatch, PsycINFO, Social Work Abstracts, and Google Scholar databases. At least 2 reviewers screened studies, extracted data, and assessed study quality, with at least 2 independent reviewers also extracting data and assessing study quality. Odds ratio (OR) and hazard ratio (HR) data were analyzed separately using random effects weighted models. Of 42,054 studies searched, 106 RCTs including 40,280 patients met inclusion criteria. Patient average age was 57.2 years, with 52% females and 48% males; 42% had cardiovascular disease (CVD), 36% had cancer, and 22% had other conditions. Across 87 RCTs reporting data for discrete time periods, the average was OR = 1.20 (95% CI = 1.09 to 1.31, p < 0.001), indicating a 20% increased likelihood of survival among patients receiving psychosocial support compared to control groups receiving standard medical care. Among those studies, psychosocial interventions explicitly promoting health behaviors yielded improved likelihood of survival, whereas interventions without that primary focus did not. Across 22 RCTs reporting survival time, the average was HR = 1.29 (95% CI = 1.12 to 1.49, p < 0.001), indicating a 29% increased probability of survival over time among intervention recipients compared to controls. Among those studies, meta-regressions identified 3 moderating variables: control group type, patient disease severity, and risk of research bias. Studies in which control groups received health information/classes in addition to treatment as usual (TAU) averaged weaker effects than those in which control groups received only TAU. Studies with patients having relatively greater disease severity tended to yield smaller gains in survival time relative to control groups. In one of 3 analyses, studies with higher risk of research bias tended to report better outcomes. The main limitation of the data is that interventions very rarely blinded personnel and participants to study arm, such that expectations for improvement were not controlled. CONCLUSIONS: In this meta-analysis, OR data indicated that psychosocial behavioral support interventions promoting patient motivation/coping to engage in health behaviors improved patient survival, but interventions focusing primarily on patients' social or emotional outcomes did not prolong life. HR data indicated that psychosocial interventions, predominantly focused on social or emotional outcomes, improved survival but yielded similar effects to health information/classes and were less effective among patients with apparently greater disease severity. Risk of research bias remains a plausible threat to data interpretation.

Acute-on-Chronic Liver Failure From Acquired Hemochromatosis in a Patient With Sickle Cell Disease.

Late presentations of liver failure were previously rare in clinical practice given the high mortality of sickle cell disease (SCD) and shorter life expectancy compared to the general population. With advancements in therapeutics for SCD, patients with SCD have increased lifespans, and with them, patients are placed at increased risk for differing patterns of chronic and end-organ failures. We describe a case of an elderly patient who had multiple chronic complications from her years of SCD, including end-stage renal disease (ESRD) on hemodialysis, acquired hemochromatosis, cirrhosis, and pulmonary hypertension. During this presentation for shortness of breath, she developed acute-on-chronic liver failure (ACLF) with a significant lower gastrointestinal bleed and hemorrhagic shock. Her family ultimately elected to pursue comfort care measures, and she passed later that day.

The Need for Additional Surgery after Passive versus Active Approaches to Syndromic Craniosynostosis: A Meta-analysis.

Endoscopically assisted craniofacial surgery (EACS) has numerous advantages over traditional, open approaches, such as fronto-orbital advancement in treating nonsyndromic craniosynostosis. However, several articles report high reoperation rates in syndromic patients treated with EACS. This meta-analysis and review examines undesirable outcome rates (UORs), defined as reoperation or Whitaker category III/IV, in syndromic patients undergoing primary EACS compared with procedures that actively expand the cranial vault. Methods: PubMed and Embase were searched in June 2022 to identify all articles reporting primary reoperation or Whitaker outcomes for syndromic patients undergoing cranial vault expanding surgery or suturectomy. A meta-analysis of proportions was performed comparing UORs, and a trim-and-fill adjustment method was used to validate sensitivity and assess publication bias. Results: A total of 721 articles were screened. Five EACS articles (83 patients) and 22 active approach articles (478 patients) met inclusion criteria. Average UORs for EACS and active approaches were 26% (14%-38%) and 20% (13%-28%), respectively (P = 0.18). Reoperation occurred earlier in EACS patients (13.7 months postprimary surgery versus 37.1 months for active approaches, P = 0.003). Relapse presentations and reason for reoperation were also reviewed. Subjectively, EACS UORs were higher in all syndromes except Apert, and Saethre-Chotzen patients had the highest UOR for both approaches. Conclusions: There was no statistically significant increase in UORs among syndromic patients treated with EACS compared with traditional approaches, although EACS patients required revision significantly sooner. Uncertainties regarding the long-term efficacy of EACS in children with syndromic craniosynostosis should be revisited as more data become available.

"Creation of the Scaphocephalic Index: Measurement of Global and Regional Severity in Scaphocephaly".

INTRODUCTION: The recently described frontal bossing index (FBI) and occipital bullet index (OBI) allow for quantification of scaphocephaly. A similar index examining biparietal narrowing has not been described. Addition of such an index measuring width would allow for direct evaluation of the primary growth restriction in sagittal craniosynostosis (SC) and the formation of an optimized global Width/Length measure. METHODS: CT scans and 3D photos were used to recreate scalp surface anatomy. Equidistant axial, sagittal, and coronal planes were overlaid creating a Cartesian grid. Points of intersection were analyzed for population trends in biparietal width. Using the most descriptive point coupled with the sellion's protrusion to control for head size, the vertex narrowing index (VNI) is formed. By combining this index with the FBI and OBI, the Scaphocephalic Index (SCI) is created as a tailored W/L measure. RESULTS: Using 221 control and 360 individuals with sagittal craniosynostosis, the greatest difference occurred superiorly and posteriorly at a point 70% of the head's height and 60% of the head's length. This point had an area under the curve (AUC) of 0.97 and sensitivity and specificity of 91.2% and 92.2% respectively. The SCI has an AUC of 0.9997, sensitivity and specificity >99%, and interrater reliability of 0.995. The correlation coefficients between the CT imaging and 3D photography was 0.96. CONCLUSION: The VNI, FBI, and OBI evaluate regional severity while the SCI is able to describe global morphology in patients with sagittal craniosynostosis. These allow for superior diagnosis, surgical planning, and outcome assessment, independent of radiation.

The Virtual Interview Experience: Advantages, Disadvantages, and Trends in Applicant Behavior.

Residency programs and applicants were forced to hold virtual interviews during the 2020-2021 application cycle. Inability to evaluate a program and/or applicant in person has intangible drawbacks. However, there are obvious advantages: cost, convenience, and comfort. Do the advantages outweigh the disadvantages? How have applicant behaviors changed to learn about programs in a virtual-only interview process? Methods: A survey was distributed to 302 applicants to a single plastic surgery residency program during the 2020 application cycle. Demographics, social media presence and utilization, and experience with the virtual application and interview process were analyzed. A 2018 survey from our institution was compared with a subset of questions for longitudinal analysis. Results: Seventy-six respondents (25.2%) completed the survey. Most applicants (88.2%) spent less than $1000 during the interview and application cycle. Over half (56.6%) did not receive letters of recommendation from outside their home program. A significant minority (27.6%) of applicants attended more than one interview in a single day. Compared to 2018, applicants in 2021 were significantly more likely to access alternative digital resources (forums/discussion boards, social media, and podcasts) when learning about programs. Average number of interviews remains in the range of pre-COVID studies, but the percentage of interviews attended increased. Conclusions: Applicants spent substantially less money on interviews and relied on alternative digital sources to learn about residency programs. This study objectively quantifies the advantages of virtual interviews. Disadvantages include inability to assess "fit" and lack of nonverbal communication.