Internal Distraction Resulted in Improved Patient-Reported Outcomes for Midface Hypoplasia.

BACKGROUND: Both internal and external distraction devices have been used successfully in correcting midface hypoplasia. Although the indication for surgery and the osteotomy techniques may be similar, deciding when to use internal versus external devices has not been studied. The authors studied patient-reported outcomes with FACE-Q and functional surveys for internal and external devices for midface distraction patients. METHODS: Patients who underwent distraction advancement after Le Fort I and Le Fort III were surveyed using the FACE-Q survey and a functional survey. Equal groups of internal and external device patients were compared (n = 64). Data recorded included: sex, age, follow-up, diagnosis, operating room time, expected blood loss, length of stay, distraction length, consolidation time, and complications. RESULTS: Internal and external device groups were similar with regards to patient diagnosis, operative time, expected blood loss, distraction length but consolidation times differed (internal = 3.6 versus external = 1.1 months). For FACE-Q appearance appraisal, there were similarities in domain and scale. For the functional survey (airway/breathing, ocular/vision, occlusion/eating, speech/articulation), there was also similar scoring. However, internal device patients had superior FACE-Q scores for Quality of Life: Social Function (80.9 versus 68.9), Early Life Impact (92.9 versus 62.4), Dental Anxiety (70.2 versus 48.3), Psychological Well-being (87.8 versus 68.6); and Decision Satisfaction (81.2 versus 56.9) and Outcome Satisfaction (91.0 versus 84.7). CONCLUSIONS: Internal and external midface distraction patients had similar patient-reported outcomes for appearance and functional improvement; however, internal device patients were more satisfied with their quality of life and their decision to undergo the procedure.

Correction of Unilateral Congenital Zygomatico-Mandibular Fusion.

Sygnathia, or fusion of the jaw, is a rare condition in children, occurring either in isolation or as part of a larger overall syndrome. Consequences of this bony fusion may range from feeding difficulties to a complete inability to protect the airway. Owing to the uncommon nature of this problem and the high recurrence of bony fusion, standardized treatment protocols do not yet exist, making individual reports particularly useful for guiding the first-time management of such patients. In this report, we describe the case of a male infant with complete bony fusion of the right zygomatic maxillary complex to the mandible. Fusion was separated by osteotomy, repair of soft tissue with acellular dermal matrix/grafting, and plate separation. Serial jaw manipulation and operative stretching was necessary to prevent refusion of syngnathia even in the long term.

The changing paradigm of air pollution monitoring.

The air pollution monitoring paradigm is rapidly changing due to recent advances in (1) the development of portable, lower-cost air pollution sensors reporting data in near-real time at a high-time resolution, (2) increased computational and visualization capabilities, and (3) wireless communication/infrastructure. It is possible that these advances can support traditional air quality monitoring by supplementing ambient air monitoring and enhancing compliance monitoring. Sensors are beginning to provide individuals and communities the tools needed to understand their environmental exposures with these data individual and community-based strategies can be developed to reduce pollution exposure as well as understand linkages to health indicators. Each of these areas as well as corresponding challenges (e.g., quality of data) and potential opportunities associated with development and implementation of air pollution sensors are discussed.

A National Study on Training Innovation in US Medical Education.

Introduction Traditional medical education has leaned heavily on memorization, pattern recognition, and learned algorithmic thinking. Increasingly, however, creativity and innovation are becoming recognized as a valuable component of medical education. In this national survey of Association of American Medical Colleges (AAMC) member institutions, we seek to examine the current landscape of exposure to innovation-related training within the formal academic setting. Methods Surveys were distributed to 168 of 171 AAMC-member institutions (the remaining three were excluded from the study for lack of publicly available contact information). Questions assessed exposure for medical students among four defined innovation pillars as follows: (1) medical humanities, (2) design thinking, (3) entrepreneurship, or (4) technology transfer. Chi-squared analysis was used to assess statistical significance between schools, comparing schools ranked in the top 20 by the US News and World Report against non-top 20 respondents, and comparing schools that serve as National Institutes of Health (NIH) Clinical and Translational Science Awards (CTSA) program hubs against non-CTSA schools. Heat maps for geospatial visualization of data were created using ArcGIS (ArcMAP 10.6) software (Redlands, CA: Environmental Systems Research Institute). Results The overall response rate was 94.2% with 161 schools responding. Among respondents, 101 (63%) reported having medical humanities curricula at their institution. Design thinking offerings were noted at 51/161 (32%) institutions. Support for entrepreneurship was observed at 51/161 institutions (32%), and technology transfer infrastructure was confirmed at 42/161 (26%) of institutions. No statistically significant difference was found between top 20 schools and lower 141 schools when comparing schools with no innovation programs or one or more innovation programs (p=0.592), or all four innovation programs (p=0.108). CTSA programs, however, did show a statistically significant difference (p<0.00001) when comparing schools with no innovation programs vs. one or more programs, but not when comparing to schools with all four innovation programs (p=0.639). Conclusion This study demonstrated an overwhelming prevalence of innovation programs in today's AAMC medical schools, with over 75% of surveyed institutions offering at least one innovation program. No statistically significant trend was seen in the presence of zero programs, one or more, or all four programs between top 20 programs and the remaining 141. CTSA hub schools, however, were significantly more likely to have at least one program vs. none compared to non-CTSA hub schools. Future studies would be valuable to assess the long-term impact of this trend on medical student education.

Scalable deep learning algorithm to compute percent pulmonary contusion among patients with rib fractures.

BACKGROUND: Pulmonary contusion exists along a spectrum of severity, yet is commonly binarily classified as present or absent. We aimed to develop a deep learning algorithm to automate percent pulmonary contusion computation and exemplify how transfer learning could facilitate large-scale validation. We hypothesized that our deep learning algorithm could automate percent pulmonary contusion computation and that greater percent contusion would be associated with higher odds of adverse inpatient outcomes among patients with rib fractures. METHODS: We evaluated admission-day chest computed tomography scans of adults 18 years or older admitted to our institution with multiple rib fractures and pulmonary contusions (2010-2020). We adapted a pretrained convolutional neural network that segments three-dimensional lung volumes and segmented contused lung parenchyma, pulmonary blood vessels, and computed percent pulmonary contusion. Exploratory analysis evaluated associations between percent pulmonary contusion (quartiles) and odds of mechanical ventilation, mortality, and prolonged hospital length of stay using multivariable logistic regression. Sensitivity analysis included pulmonary blood vessel volumes during percent contusion computation. RESULTS: A total of 332 patients met inclusion criteria (median, 5 rib fractures), among whom 28% underwent mechanical ventilation and 6% died. The study population's median (interquartile range) percent pulmonary contusion was 4% (2%-8%). Compared to the lowest quartile of percent pulmonary contusion, each increasing quartile was associated with higher adjusted odds of undergoing mechanical ventilation (odds ratio [OR], 1.5; 95% confidence interval [95% CI], 1.1-2.1) and prolonged hospitalization (OR, 1.6; 95% CI, 1.1-2.2), but not with mortality (OR, 1.1; 95% CI, 0.6-2.0). Findings were similar on sensitivity analysis. CONCLUSION: We developed a scalable deep learning algorithm to automate percent pulmonary contusion calculating using chest computed tomography scans of adults admitted with rib fractures. Open code sharing and collaborative research are needed to validate our algorithm and exploratory analysis at a large scale. Transfer learning can help harness the full potential of big data and high-performing algorithms to bring precision medicine to the bedside. LEVEL OF EVIDENCE: Prognostic and epidemiological, Level III.

Surgical Infection Society: Chest Wall Injury Society Recommendations for Antibiotic Use during Surgical Stabilization of Traumatic Rib or Sternal Fractures to Reduce Risk of Implant Infection.

Background: Surgical stabilization of rib fractures is recommended in patients with flail chest or multiple displaced rib fractures with physiologic compromise. Surgical stabilization of rib fractures (SSRF) and surgical stabilization of sternal fractures (SSSF) involve open reduction and internal fixation of fractures with a plate construct to restore anatomic alignment. Most plate constructs are composed of titanium and presence of this foreign, non-absorbable material presents opportunity for implant infection. Although implant infection rates after SSRF and SSSF are low, they present a challenging clinical entity often requiring prolonged antibiotic therapy, debridement, and potentially implant removal. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee and Chest Wall Injury Society's Publication Committee convened to develop recommendations for antibiotic use during and after surgical stabilization of traumatic rib and sternal fractures. Clinical scenarios included patients with concomitant infectious processes (sepsis, pneumonia, empyema, cellulitis) or sources of contamination (open chest, gross contamination) incurred as a result of their trauma and present at the time of their surgical stabilization. PubMed, Embase, and Cochrane databases were searched for pertinent studies. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: For patients undergoing SSRF or SSSF in the absence of pre-existing infectious process, there is insufficient evidence to suggest existing peri-operative guidelines or recommendations are inadequate. For patients undergoing SSRF or SSSF in the presence of sepsis, pneumonia, or an empyema, there is insufficient evidence to provide recommendations on duration and choice of antibiotic. This decision may be informed by existing guidelines for the concomitant infection. For patients undergoing SSRF or SSSF with an open or contaminated chest there is insufficient evidence to provide specific antibiotic recommendations. Conclusions: This guideline document summarizes the current Surgical Infection Society and Chest Wall Injury Society recommendations regarding antibiotic use during and after surgical stabilization of traumatic rib or sternal fractures. Limited evidence exists in the chest wall surgical stabilization literature and further studies should be performed to delineate risk of implant infection among patients undergoing SSSRF or SSSF with concomitant infectious processes.

Treatment of Isolated Zygomatic Arch Fracture: Improved Outcomes with External Splinting.

BACKGROUND: The various approaches to reduction and fixation of isolated displaced zygomatic arch fractures have not been well studied. The authors compared established treatment methods for zygomatic arch fractures for both aesthetic and functional outcomes. METHODS: Consecutive patients with isolated zygomatic arch fractures with a minimum of 6 months' follow-up were studied in five groups: group 1, intraoral approach (no fixation); group 2, temporal approach (no fixation); group 3, coronal flap plate fixation; group 4, external splint fixation; and group 5, no surgery. Perioperative complications, facial contour symmetry (aesthetic outcome), improvement in mouth opening (functional outcome), and reoperations were compared. RESULTS: Patients undergoing external splint fixation had no perioperative complications. Coronal flap plate fixation had the highest rate of perioperative complications (46 percent), with facial nerve injury (4 percent), hematoma (8 percent), and persistent hyperesthesia (8 percent). Reoperations (fat grafting or bony reconstruction) were highest with coronal flap plate fixation (23 percent) and the temporal approach (7.7 percent); external splint fixation and the intraoral approach required no reinterventions. Patients treated with external splint fixation had the largest improvement in mean interincisor mouth opening. Mean postoperative interincisor opening in decreasing order was as follows: external splint fixation (51.6 mm), coronal flap plate fixation (47.1 mm), no surgery (39.8 mm), intraoral approach (39.6 mm), and temporal approach (38.9 mm). The highest volumetric symmetry was seen in external splint fixation (97.9 percent), followed by coronal flap plate fixation (94 percent), temporal approach (76.2 percent), intraoral approach (73 percent), and no surgery (68.3 percent). CONCLUSION: For isolated zygomatic arch fracture, patients undergoing external splint fixation had the lowest risk of perioperative complications and the greatest improvement in functional and aesthetic outcomes compared with the intraoral approach (no fixation), the temporal approach (no fixation), coronal flap plate fixation, and no surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Necessity of latency period in craniofacial distraction: Investigations with in vitro microdistractor and clinical outcomes.

BACKGROUND: To determine the need for latency period in membranous bone distraction, we performed 1) in vitro comparison of preosteoblasts suspended in a 3D microdistraction model and 2) a clinical study comparing mandibular distraction cases with/without latency. METHODS: In the In Vitro study, Preosteoblasts polymerized in 3D-collagen gel were placed in a microdistractor and separated into three groups: 1) distraction with latency, 2) distraction without latency, and 3) static. After 2, 4, 6, and 8 days, cell proliferation, total protein levels, alkaline phosphatase activity, and osteogenic gene expression were assessed through RT-PCR. In the clinical study, patients underwent mandibular distraction in two groups: 1) latency and 2) no latency (n = 45). The rest of the distraction protocol was identical. Outcome was based on clinical examination, radiographs at six months, and 3D CT scans. RESULTS: In the In Vitro study, The distraction without latency group compared to the latency group had delays in: proliferation, total protein count, alkaline phosphatase activity, osteogenic gene expression in CBFA-1 (fourfold vs. eighteenfold), and in osteocalcin (twofold vs. sixfold). The distraction without latency group had higher apoptotic levels during the first four days compared to the latency group (68% vs. 14%). For the clinical study, similar perioperative complications (5% vs. 6%), X-ray mineralization (93% vs. 94%), bone volume, (8.6 vs. 9.1 cc) and bone density of central distraction zone (78% vs. 81%) were observed with or without latency. CONCLUSIONS: In vitro studies showed poorer results in cell survival, proliferation and osteogenic activity compared to distraction with latency; yet, clinically, there were no differences in distraction with latency versus without.