Craniofacial Microsurgery: An Integrated Approach to Management of Cleft and Craniofacial Syndromes, Surgical Experience, and Insights.

ABSTRACT: Ian Jackson and Jack Fisher published one of the earliest reports on microsurgical applications for craniofacial patients in 1989. Since that time, applications of craniofacial surgery and microsurgery have significantly expanded and become more refined. However, there remain certain specific clinical problems in cleft and craniofacial surgery in which traditional craniofacial methods provide variable success or suboptimal outcomes. The purpose of the current study is to share our experience using an integrated approach of craniofacial and microsurgical methods to provide optimal surgical solutions to this complex patient population. The authors performed a retrospective review of 17 patients that utilized craniofacial microsurgery in setting of cleft and craniofacial syndromes performed by the senior author from July 2013 to July 2020. 22 free flaps were performed for 17 patients. The patient age at time of flap reconstruction ranged from 10 to 48 years (mean 21.4 years). There were 8 females and 9 males. There was one total flap loss. Based on our collective experience, the authors present a comprehensive algorithm for the role of microsurgical reconstruction in cleft and craniofacial patients. There are several situations in craniofacial surgery which traditional reconstructive methods require numerous operative interventions to achieve suitable outcomes. Craniofacial Microsurgery techniques can bring in new tissue and may prevent the need to manipulate scarred and multiply operated tissues. The craniofacial surgery team should not hesitate to apply microsurgical solutions to these situations for optimal results.

The use of national collaborative to promote advanced practice registered nurse-led high-value care initiatives.

BACKGROUND: High-value healthcare focuses on improving healthcare to produce cost effective care, however limited information on the role of advanced practice registered nurses (APRNs) exists. PURPOSE: This descriptive report describes APRN-led initiatives implemented as part of a national collaborative promoting the Choosing Wisely® campaign and high-value care measures. METHOD: An APRN national collaborative focuses on developing and implementing high-value care initiatives. Monthly calls, podcasts, and a file sharing platform are used to facilitate the work of the national collaborative. FINDINGS: A total of 16 APRN teams from 14 states are participating and have implemented a number of initiatives to reduce unnecessary testing and treatments, promote appropriate antibiotic use, and promote optimal clinical practices such as mobility for hospitalized elderly patients, among others. DISCUSSION: A national collaborative has proven to be a successful way to engage APRN teams to focus on targeting high-value care and promoting evidence-based practices in clinical care.

Providing end-of-life care in a Nightingale hospital.

Lauren Oliver, formerly Clinical Nurse Advisor, NHS Nightingale North West, outlines the challenges faced by staff in providing good-quality end-of-life care for patients in a temporary hospital during the initial peak of the COVID-19 pandemic.

Systematics and biogeography of the Hylarana frog (Anura: Ranidae) radiation across tropical Australasia, Southeast Asia, and Africa.

We present an inclusive molecular phylogeny for Hylarana across its global distribution, utilizing two mitochondrial and four nuclear gene regions for 69 of the 97 currently described species. We use phylogenetic methods to test monophyly of Hylarana, determine relationships among ten putative subgenera, identify major clades, reconstruct biogeographic history, and estimate continental dispersal dates. Results support Hylarana as a monophyletic group originating approximately 26.9MYA and comprising eight clades that partly correspond to currently described subgenera plus two new groups. The African and Australasian species each form clades embedded within a paraphyletic Southeast Asian group. We estimate that Africa and Australasia were colonized by Hylarana s.l. from SE Asia approximately 18.7 and 10.8MYA, respectively. Biogeographic reconstructions also support three separate colonization events in India from Southeast Asia. Examination of museum specimens identified morphological characters useful for delineating subgenera and species. We herein elevate all supported subgenera to genus rank and formally describe two new genera to produce a revised taxonomy congruent with our new phylogenetic and biogeographic findings.

Breast Conserving Therapy for Patients With Prior Cosmetic Implant-Based Breast Augmentation: Outcomes and Comparison Against a Matched Cohort.

INTRODUCTION: Controversy exists regarding potential increased toxic effects in patients with cosmetic implant-based augmentation (CIBA) who receive radiation therapy. We evaluated acute and chronic toxic effects associated with radiation therapy in women with prior CIBA treated with whole-breast irradiation (WBI) as part of breast conserving therapy (BCT) and compared these results against a cohort of patients without prior breast augmentation who received similar therapy. METHODS: A retrospective review was performed to identify patients with a prior history of CIBA who subsequently underwent BCT with WBI. The control group consisted of consecutively treated patients without prior CIBA who also underwent BCT with WBI. Analyses included a comparison of baseline and treatment-associated factors between the augmentation and control groups, evaluation of toxic effects between both groups, and multivariable analysis of factors associated with the receipt of additional surgery following radiation. RESULTS: Thirty-six patients with prior CIBA and 135 consecutively treated patients without CIBA were identified. Patients with prior CIBA were treated from 2006 through 2019, and patients without CIBA were treated from 2016 through 2019, though treatment characteristics and median follow-up time were similar between the two groups. Patients with prior CIBA were significantly less likely to experience acute moist desquamation (0% vs. 18%; P = .005). There were otherwise no statistically significant differences in acute (≤ 6 months) or chronic (> 6 months) toxic effects between the two groups. Rates of excellent/good chronic cosmetic outcome were 89% for the CIBA group and 97% in the control group (P = .094). On multivariable analysis, patients without prior CIBA (OR = 0.04; CI = 0.01-0.13; P < .001) and patients treated with moderately hypofractionated irradiation (OR = 0.08; CI = 0.02-0.23; P < .001) were significantly less likely to undergo additional surgery following receipt of WBI. Two patients experienced implant loss following radiation therapy. CONCLUSIONS: WBI as part of BCT in patients with prior implant-based breast augmentation appears safe and is associated with favorable cosmetic outcomes. There was an increased need for additional surgery in patients with prior CIBA, but rates of acute and chronic toxic effects appeared similar to those in nonaugmented patients.

Storylines of family medicine VIII: clinical approaches.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'VIII: clinical approaches', authors address the following themes: 'Evaluation, diagnosis and management I-toward a working diagnosis', 'Evaluation, diagnosis and management II-process steps', 'Interweaving integrative medicine and family medicine', 'Halfway-the art of clinical judgment', 'Seamless integration in family medicine-team-based care', 'Technology-uncovering stories from noise' and 'Caring for patients with multiple long-term conditions'. May readers recognise in these essays the uniqueness of a family medicine approach to care.

Phylogeny and phylogeography of Mantophryne (Anura: Microhylidae) reveals cryptic diversity in New Guinea.

New Guinea is one of five high biodiversity wilderness areas, and frog diversity is exceptionally large, with more than 400 species described to date. The microhylid frog genus Mantophryne is endemic to New Guinea and consists of four species, three of which have narrow geographic distributions and a fourth, M. lateralis, with a broad range that spans the eastern half of the island. Here, we sequence 104 Mantophryne samples for three mitochondrial and three nuclear loci to reconstruct the first phylogeny of the genus and to examine spatial patterns of diversity within M. lateralis. Results indicate that the wide-ranging M. lateralis is composed of at least nine geographically separated and well-supported lineages that represent putative species. Biogeographic analysis suggests that Mantophryne evolved on the eastern Papuan peninsula with subsequent dispersal westward, as well as overwater dispersal events to the Louisiade and D'Entrecasteaux archipelagos.

Revalidation of Pyxicephalus angusticeps Parry, 1982 (Anura: Natatanura: Pyxicephalidae), a bullfrog endemic to the lowlands of eastern Africa.

Pyxicephalus currently contains three recognized species, viz. P. adspersus, P. edulis and P. obbianus, the former two of which have a long history of confusion. Parry (1982) described P. adspersus angusticeps from Beira, Mozambique, which was synonymized with P. edulis. We re-examine the taxonomic status of Pyxicephalus taxa from Mozambique, examining the types and contrasting them to congeners throughout Africa. Morphological characters previously used to delimit species in Pyxicephalus are examined, and problems with some identified. Additional diagnostic characters and their variation in Pyxicephalus are discussed, and a revised key is provided. Confusion among species in the genus, type localities, literature and folklore led to P. adspersus angusticeps being incorrectly synonymized with P. edulis. We formally revalidate P. angusticeps, and designate a lectotype for P. edulis. The identity of voucher specimens from previous work suggests that the breeding ecology of P. angusticeps is distinct from that of P. adspersus and P. edulis, and that the advertisement call of P. angusticeps was used as part of the evidence for elevating P. edulis out of synonymy with P. adspersus. The previous confusion of P. adspersus and P. edulis does not affect the recognition of P. angusticeps. The wider implication of the previous misidentification of P. angusticeps as P. edulis is that most of the museum material labeled as P. adspersus from East Africa is P. edulis, and most of the museum material labeled as P. edulis from East Africa is P. angusticeps. This conclusion has been confirmed from East African museum material thus far examined.

An Innovative Resource to Guide and Track Medical Resident Activity and Wellness During At-Home Assignments.

Background and objectives Medical residents may work from home for various reasons, including study electives, isolation due to exposure to illness, or during parental leave when they choose to work at home instead of taking extended time off. The University of Arkansas for Medical Sciences (UAMS) Little Rock Family Medicine residency program recognized the need for a tool that provided residents with a list of resources and approved activities for at-home work and a means of tracking their performance in those activities. Methods The administration team at the UAMS Little Rock Family Medicine residency program custom-designed a Daily Activities Log that served multiple purposes. Family medicine residents used it to choose what activities to participate in from a comprehensive list of activities and resources including virtual conferences, recorded didactics, modules, and other online materials. The program provided the framework on the log, while residents used it to document time spent on those activities. The log also gave the program a daily update on the resident's health, as one question specifically asked about well-being. Since it was built in an electronic survey format already owned by the residency program, it was completely customizable and available at no additional cost. Results In the two years covered by this project, residents logged a total of 593 hours of at-home work. In response to a survey, 76% of participating residents (N=14) rated the log as extremely or very easy to use; 64% indicated that it was a helpful resource; and 50% said that it simplified the reporting of their daily status. The residency program faculty found that having one source to track all off-site residents was an efficient means of monitoring their well-being and their work. Conclusions The Daily Activities Log is a versatile tool that provides comprehensive information, resources, and approved activities for residents, documents their work, and provides updates to residency management. It can be readily modified for use in other programs that have residents working at home.

Near-Surface Dose Correlates With Moist Desquamation and Unplanned Reconstructive Surgery in Patients With Implant-Based Reconstruction Receiving Postmastectomy Radiation Therapy.

Purpose: Postmastectomy radiation therapy (PMRT) reduces disease recurrence in appropriately selected patients but may compromise implant-based reconstruction. We investigated whether near-surface dose correlates with radiation-related toxic effects in these patients. Methods and Materials: Patients receiving PMRT at a single institution from 2016 to 2019 were retrospectively reviewed. Patient demographics and treatment information were collected. Three near-surface structures were retrospectively generated, bound by the chest wall tangent beam as well as the skin surface and the skin-3 mm contour (SR3), skin surface and skin-5 mm contour (SR5), or skin-5 and skin-10 mm contours. Dosimetric analysis of these near-surface contours was performed in 2 Gy intervals. Univariate and multivariate analyses were used to identify predictors of moist desquamation, grade 2+ chest wall pain, use of opiate pain medication, unplanned reconstructive surgery, and implant failure. Logistic regression for each outcome and near-surface contour was performed for receiver-operator area under the curve (AUC) analysis and the Youden J Statistic was used to determine the optimal threshold for each dosimetric parameter. Results: Of 126 patients reviewed, 109 met the study's eligibility criteria. Median follow-up was 2.3 years. Twenty-five patients (23%) underwent unplanned reconstructive surgery, and 10 (9.2%) experienced implant failure. Among clinical variables, low body mass index and history of smoking predicted unplanned surgery on univariate and multivariate analyses, and moist desquamation predicted grade 2+ chest wall pain. The top dosimetric parameters by AUC for moist desquamation, grade 2+ chest wall pain, use of opiates, unplanned reconstructive surgery, and implant failure were SR5 D10 cc (AUC = 0.701, optimal threshold 57.8 Gy, P < .001), SR3 D10 cc (AUC = 0.600, optimal threshold 56.8 Gy, P = .079), SR5 D10 cc (AUC = 0.642, optimal threshold 57.3 Gy, P = .041), SR3 V44 Gy (AUC = 0.711, optimal threshold 81%, P = .001), and SR3 V44 Gy (AUC = 0.688, optimal threshold 82%, P = .052), respectively. Conclusions: Near-surface dose correlates with moist desquamation and unplanned reconstructive surgery after PMRT. Further evaluation of prospective optimization of dosimetric parameters related to SR3 and SR5 should be considered.

Incidence of Emergency Department Presentations of Symptomatic Stone Disease in Pediatric Patients: A Southeastern Study.

Background The incidence of nephrolithiasis during childhood has increased significantly over recent decades. Some studies indicate a rapid rise in adolescents, particularly in African American women. This study serves to identify trends in symptomatic pediatric nephrolithiasis presentations to the emergency department (ED) as a result of increasing incidence and to determine associations between demographic variables at our single-site tertiary pediatric hospital in the Southeast United States. Methods After IRB approval, a review of the data provided by the Pediatric Health Information System, a pediatric database that includes clinical and resource utilization data for 51 of the largest children's hospitals in the nation, yielded 644 pediatric occurrences of nephrolithiasis at single-site emergency departments from 2006 to 2020. The percent change and average percent change in three-year intervals were calculated to establish a trend over time. A chi-square test of independence was performed to assess associations between race, gender, and age groups. Results A total of 780 stone occurrences and associated patient demographic data were reviewed for 644 children (364, 56.52% female) with median age of 183 ± 45.11 months (9-397 months). Of the 644 children, 79 (12.3%) were noted to have recurrent symptomatic nephrolithiasis, contributing to 136/780 stone events. There was a marked increase of 84.4% in confirmed pediatric nephrolithiasis occurrences over 15 years, with an average percent increase of 16.1% every three years. A Chi2 test of independence was performed between gender and age group (>/< 10yr), gender and race, and race and age group. No expected cell frequencies were less than five. There is no statistically significant relationship between gender and age group, χ2 (1, N=644) = 3.30, p=0.692. There is no significant association between race (Caucasian vs. non-Caucasian) and age group (>/< 10yr), χ2 (1, N=644) = 0.393, p=0.531. There is a statistically significant relationship between gender and race (Caucasian vs. non-Caucasian), χ2 (1, N=644) = 5.28, p=0.021. Caucasian females were more likely to present to our tertiary pediatric hospital's emergency department with nephrolithiasis than Caucasian males or non-Caucasian males or females. Additionally, our data reflected a greater percentage of symptomatic nephrolithiasis presentations occurred in the second decade of life (85.4% vs 14.3%, 552 vs 92 stone events). Conclusion Based on our data, there is a marked increase of 84.4% in pediatric nephrolithiasis occurrences from 2006 to 2020, with a mean increase of 16.1% every three years at our single-site tertiary referral pediatric hospital in the Southeast. Among demographic groups, white adolescent females have an increased risk of developing kidney stones.

A novel e-learning tool to improve knowledge and awareness of pelvic radiotherapy late effects: qualitative responses amongst therapeutic radiographers.

Objectives: This study aimed to investigate the effectiveness of a novel e-learning intervention to increase knowledge, awareness and confidence surrounding pelvic radiotherapy late effects amongst therapeutic radiographers (RTTs), and to change staff perceptions of responsibility in providing such information to patients. Methods: The e-learning intervention was developed using blended learning software (Articulate Global, New York). 23 therapeutic radiographers within a single UK radiotherapy institution received the e-learning. Semi-structured interviews and questionnaires were utilised pre- and post-intervention to obtain qualitative and quantitative results. Thematic analysis of coded interview responses identified recurring themes, whilst statistical analysis was conducted using a Wilcoxon signed-rank test. This first paper presents the qualitative results. Results: Thematic analysis revealed increased knowledge and awareness of pelvic radiotherapy late effects amongst participants. Five key themes were identified: Knowledge/Confidence; Consent; Professional Responsibility; Gaps within Practice and Time/Space. Whilst several staff reported increased confidence in discussing late effects with patients, further training utilising "blended" pedagogical approaches may be required to achieve longstanding improvements. Following e-learning, participants demonstrated increased professional responsibility to deliver late effects information to patients. Conclusion: The novel e-learning intervention increased staff knowledge, awareness and confidence surrounding pelvic radiotherapy late effects, whilst changing staff perceptions on professional responsibility in delivering such information. Advances in knowledge: The e-learning has been disseminated to all hospitals within the region including a new "Radiotherapy Late Effects Clinic", educating various healthcare professionals. Study recommendations have led to introduction of dedicated radiotherapy late effects modules on a novel MSc programme at a UK University.

Tumor burden negatively impacts protein turnover as a proteostatic process in noncancerous liver, heart, and muscle, but not brain.

Cancer survivors are more susceptible to pathologies such as hypertension, liver disease, depression, and coronary artery disease when compared with individuals who have never been diagnosed with cancer. Therefore, it is important to understand how tumor burden negatively impacts nontumor-bearing tissues that may impact future disease susceptibility. We hypothesized that the energetic costs of a tumor would compromise proteostatic maintenance in other tissues. Therefore, the purpose of this study was to determine if tumor burden changes protein synthesis and proliferation rates in heart, brain, and liver. One million Lewis lung carcinoma (LLC) cells or phosphate-buffered saline (PBS, sham) were injected into the hind flank of female mice at ∼4.5 mo of age, and the tumor developed for 3 wk. Rates of proliferation and protein synthesis were measured in heart, brain, liver, and tumor tissue. Compared with sham, rates of protein synthesis (structural/nuclear, cytosolic, mitochondrial, and collagen) relative to proliferation were lower in the heart and liver of LLC mice, but higher in the brain of LLC mice. In the tumor tissue, the ratio of protein synthesis to DNA synthesis was approximately 1.0 showing that protein synthesis in the tumor was used for proliferation with little proteostatic maintenance. We further provide evidence that the differences in tissue responses may be due to energetic stress. We concluded that the decrease in proteostatic maintenance in liver, heart, and muscle might contribute to the increased risk of disease in cancer survivors.NEW & NOTEWORTHY We present data showing that simultaneously measuring protein synthesis and cell proliferation can help in the understanding of protein turnover as a proteostatic process in response to tumor burden. In some tissues, like hepatic, cardiac, and skeletal muscle, there was a decrease in the protein to DNA synthesis ratio indicating less proteostatic maintenance. In contrast, the brain maintained or even increased this protein to DNA synthesis ratio indicating more proteostatic maintenance.

Use of Pericranial Flaps with Dermal Substitute for Scalp Reconstruction: A Case Series.

Skin cancer incidence has been rapidly increasing over the past 2 decades, and the resulting defects from excision have significant aesthetic and functional implications. In particular, wound coverage for large scalp and forehead defects with calvarial exposure can lead to hairline distortion, contour irregularities, and alopecia. We describe a 2-stage technique for scalp reconstruction, which preserves the normal hairline, covers exposed bone with vascularized tissue, and restores an aesthetic soft-tissue contour. METHODS: This is a retrospective case series of 13 adults with ages ranging from 50 to 89 years. All patients underwent Mohs surgery on the forehead or scalp between July 2014 and April 2017. Patients underwent a 2-staged reconstruction with an initial pericranial flap and dermal substitute placement followed by the placement of a split-thickness skin graft within 4-6 weeks. RESULTS: Over a 3-year period, 13 patients had successful reconstruction of the scalp defect without alteration of the hairline or contour irregularity. Two patients had minor complications after the first-stage procedure with successful aesthetic reconstruction. CONCLUSIONS: Full-thickness defects of the scalp and forehead with bone exposure provide a reconstructive challenge for plastic surgeons. Reconstructive algorithms continue to evolve and should be tailored to best suit patients' needs and medial comorbidities. Two-staged reconstruction with local pericranial flap provides a safe and efficacious reconstruction that minimizes hairline distortion, contour irregularity, and donor site morbidity.

Outcome Study after Nasal Alar/Peri-alar Subunit Reconstruction: Comparing Paramedian Forehead Flap to Nasolabial Flap.

OBJECTIVE: Contours of the lower nasal third are unique and present challenges in surgical reconstruction. The nasal alar intricate curved anatomy makes the area easily compromised after Mohs surgery. Managing patient and surgeon expectations with regard to aesthetics and functionality remains the reconstructive goal. The purpose of the study was to compare patients' perspective on aesthetics and functional outcomes of nasal alar reconstruction post Mohs ablative surgery using nasolabial or forehead flaps. METHODS: A single surgeon's results of 23 patients, who underwent nasal alar reconstruction post Mohs surgery, were included for analysis (15 forehead and 8 nasolabial flaps). Initially, 103 consecutive patients undergoing nasal reconstruction were reviewed, with 67 excluded due to nonalar subunit involvement and an additional 13 excluded for other discussed reasons. Mean follow-up period was 2.3 years. Evaluation of a patient satisfaction questionnaire assessed aesthetics and functionality and also surgical scar noticeability. Additionally, 3 board-certified plastic surgeons assessed postoperative images. RESULTS: Twenty-three patients completed the survey. There was no statistically significant difference in gender ratio, follow-up time, or scar noticeability among groups. A difference was noted in both aesthetics and functionality score (P < 0.03) for both variables favoring forehead flaps. Results from the surgeon's questionnaire also confirmed the superiority of forehead flaps concerning scar, alar contour/symmetry, and nostril opening symmetry. CONCLUSIONS: The forehead flap has a better functional and aesthetic outcome and an overall superior level of satisfaction post Mohs ablative surgery.

Deimplementation of Routine Chest X-rays in Adult Intensive Care Units.

BACKGROUND: Choosing Wisely® is a national initiative to deimplement or reduce low-value care. However, there is limited evidence on the effectiveness of strategies to influence ordering patterns. OBJECTIVE: We aimed to describe the effectiveness of an intervention to reduce daily chest X-ray (CXR) ordering in two intensive care units (ICUs) and evaluate deimplementation strategies. DESIGN: We aimed to describe the effectiveness of an intervention to reduce daily chest X-ray (CXR) ordering in two intensive care units (ICUs) and evaluate deimplementation strategies. SETTING: The study was performed in the medical intensive care unit (MICU) and cardiovascular intensive care unit (CVICU) of an academic medical center in the United States from October 2015 to June 2016. PARTICIPANTS: The initiative included the staff of the MICU and CVICU (physicians, surgeons, nurse practitioners, fellows, residents, medical students, and X-ray technologists). INTERVENTION COMPONENTS: We utilized provider education, peer champions, and weekly data feedback of CXR ordering rates. MEASUREMENTS: We analyzed the CXR ordering rates and factors facilitating or inhibiting deimplementation. RESULTS: Segmented linear time-series analysis suggested a small but statistically significant decrease in CXR ordering rates in the CVICU (P < .001) but not in the MICU. Facilitators of deimplementation, which were more prominent in the CVICU, included engagement of peer champions, stable staffing, and regular data feedback. Barriers included the need to establish goal CXR ordering rates, insufficient intervention visibility, and waning investment among medical residents in the MICU due to frequent rotation and competing priorities. CONCLUSIONS: Intervention modestly reduced CXRs ordered in one of two ICUs evaluated. Understanding why adoption differed between the two units may inform future interventions to deimplement low-value diagnostic tests.

Estimated net acid excretion inversely correlates with urine pH in vegans, lacto-ovo vegetarians, and omnivores.

OBJECTIVE: Diet affects urine pH and acid-base balance. Both excess acid/alkaline ash (EAA) and estimated net acid excretion (NAE) calculations have been used to estimate the effects of diet on urine pH. This study's goal was to determine if free-living vegans, lacto-ovo vegetarians, and omnivores have increasingly acidic urine, and to assess the ability of EAA and estimated NAE calculations to predict urine pH. DESIGN: This study used a cross-sectional design. SETTING AND PARTICIPANTS: This study assessed urine samples of 10 vegan, 16 lacto-ovo vegetarian, and 16 healthy omnivorous women in the Boston metropolitan area. Six 3-day food records from each dietary group were analyzed for EAA content and estimated NAE, and correlations with measured urine pH were calculated. RESULTS: The mean (+/- SD) urine pH was 6.15 +/- 0.40 for vegans, 5.90 +/- 0.36 for lacto-ovo vegetarians, and 5.74 +/- 0.21 for omnivores (analysis of variance, P = .013). Calculated EAA values were not significantly different among the three groups, whereas mean estimated NAE values were significantly different: 17.3 +/- 14.5 mEq/day for vegans, 31.3 +/- 8.5 mEq/day for lacto-ovo vegetarians, and 42.6 +/- 13.2 mEq/day for omnivores (analysis of variance, P = .01). The average deattenuated correlation between urine pH and EAA was 0.333; this value was -0.768 for estimated NAE and urine pH, with a regression equation of pH = 6.33 - 0.014 NAE (P = .02, r = -0.54). CONCLUSIONS: Habitual diet and estimated NAE calculations indicate the probable ranking of urine pH by dietary groups, and may be used to determine the likely acid-base status of an individual; EAA calculations were not predictive of urine pH.

Reconstructive Approach to an Acquired Absence of Multiple Facial Components: A Case Report.

The subject of our case report is a young girl who was attacked by a raccoon when she was 5 months old. She lost the majority of her nose, her entire right ear, and part of her upper lip. She had previous attempts at reconstructive surgery with poor results. Our collective goals were to provide lifelong reconstruction without the use of synthetic implants and to organize the steps in a way that provided psychological benefit early on while allowing her to continue education and childhood activities with minimal disruptions. We approached the patient's many problems in stages by starting with the most obvious deformity and progressing to the least severe deformity. A radial forearm free flap and a forehead flap with rib cartilage were used in stages for nasal reconstruction. An Abbé flap was utilized for lip reconstruction, and a prelaminated radial forearm free flap with a costal cartilage frame was selected to form a new ear. She had neither lasting complications nor any morbidity from her donor sites. She and her family report a drastic improvement in her self-confidence and in her interactions with her peers. A stepwise approach to reconstruction of acquired absence of multiple facial components achieves the benefit of early positive psychological results with necessary breaks from surgery to allow her normal childhood activities and education. Judicious utilization of free flaps negates the need of synthetic implants for lifelong reconstruction.

Prevalence of malnutrition in patients admitted to a major urban tertiary care hospital in Hanoi, Vietnam.

OBJECTIVES: To determine the prevalence of malnutrition using anthropometric measures among hospitalized pediatric and adult patients admitted at Bach Mai Hospital, Hanoi, Vietnam. METHODS: A one-day cross-sectional survey was used in selected wards (Pediatrics, Surgery, Intensive Care Unit, Renal Diseases, Gastroenterology Diseases, Respiratory Diseases, and Endocrinology). Unavailable patients and those discharged within 24 hours were excluded. Anthropometric data included body weight, height (or length), and mid-upper arm circumference. The type, severity, and prevalence rate of malnutrition were defined based on World Health Organization (WHO) criteria. RESULTS: The sample was hospitalized children and adults: 108 and 571 were children aged 6 months to 18.9 years old and adult patients, respectively. The overall rate of pediatric wasting (weight-for-height ≤ -2 SD or BMI ≤ -2 SD, kg/m²) was 19.0% (n= 19/100) and that of stunting (height-for-age ≤ -2 SD) was 13.9% (n=14/101). Using either the mid-upper arm circumference <11.5 cm or the weight-for-height and weight-for-length ≤ -3 SD, the rate of severe wasting among children aged 6-59 months old was 7.0% (n=3/43). None of the children were obese based on weight-for-length, weight-for-height, or BMI. In adults, the prevalence of under-nutrition (BMI<18.5 kg/m²) was 33.3% (n=141/423) while that of obesity (BMI ≥ 30 kg/m²) was 0.9% (n=4/423). Adults admitted to the Respiratory Diseases ward had the highest prevalence of under-nutrition, 40.9% (n=38/93). CONCLUSIONS: The prevalence of malnutrition was high in this cohort of hospitalized patients, particularly in adults, but comparable to other published reports. Obesity was nearly nonexistent in both children and adults.