Modeling the evolution of the US opioid crisis for national policy development.

The opioid crisis is a major public health challenge in the United States, killing about 70,000 people in 2020 alone. Long delays and feedbacks between policy actions and their effects on drug-use behavior create dynamic complexity, complicating policy decision-making. In 2017, the National Academies of Sciences, Engineering, and Medicine called for a quantitative systems model to help understand and address this complexity and guide policy decisions. Here, we present SOURCE (Simulation of Opioid Use, Response, Consequences, and Effects), a dynamic simulation model developed in response to that charge. SOURCE tracks the US population aged ≥12 y through the stages of prescription and illicit opioid (e.g., heroin, illicit fentanyl) misuse and use disorder, addiction treatment, remission, and overdose death. Using data spanning from 1999 to 2020, we highlight how risks of drug use initiation and overdose have evolved in response to essential endogenous feedback mechanisms, including: 1) social influence on drug use initiation and escalation among people who use opioids; 2) risk perception and response based on overdose mortality, influencing potential new initiates; and 3) capacity limits on treatment engagement; as well as other drivers, such as 4) supply-side changes in prescription opioid and heroin availability; and 5) the competing influences of illicit fentanyl and overdose death prevention efforts. Our estimates yield a more nuanced understanding of the historical trajectory of the crisis, providing a basis for projecting future scenarios and informing policy planning.

Affiliative Parent-Adolescent Bedtime and Waketime Interactions are Associated with Adolescent Sleep.

OBJECTIVES: The current study examined whether evening and morning affiliation (i.e., warmth) and autonomy (i.e., more or less in charge) around sleep routines predicted adolescent sleep on weekdays. METHOD: Participants were 28 parent (Mage = 43.19; 85.17% mothers) and adolescent (Mage = 12.34 years) dyads who completed the same electronic diaries morning and evening for 10 days, with a total number of 221 nights observed across dyads. Sleep duration and sleep quality were assessed via the Pittsburgh Sleep Diary; degree of affiliation and autonomy around bedtime and waketime routines were assessed with single items on a visual analog scale. Multilevel modeling was utilized to evaluate the effects of more or less affiliation or autonomy on sleep outcomes (i.e., duration and quality) between and within dyads. RESULTS: Across all participants, adolescents who reported more affiliative interactions with their parent around bedtime and waketime slept longer and had better sleep quality at night. Further, when adolescents experienced greater than average affiliative interactions with their parent than was typical for them, they had better sleep quality that night. Adolescent sleep quality and duration were not impacted by whether or not adolescents were in charge of their bedtime and waketime routines. CONCLUSIONS: Findings support parents' role in social and emotional security and highlight the importance of affiliative parent interactions around the sleep period for optimal sleep for young adolescents.

A Work in Progress: Women's Status in the Plastic Surgery Workforce and Recommendations for Success.

BACKGROUND: Only 20% of the current plastic surgery workforce is female, but since 2022, most matched applicants in integrated plastic surgery programs have been women. This study aimed to examine current practice models among female plastic surgeons, including those outside of academia, as the field continues to evolve. OBJECTIVES: This study surveyed female plastic surgeons in different practice models to elicit perspectives, career path advice, characterize/project trends, and provide recommendations for success. METHODS: A 37-question survey focusing on demographics, practice models, career paths, desire for practice changes and advice for women trainees was emailed to 1342 members of the American Society of Plastic Surgeons and The Aesthetic Society. Chi square analyses compared practice type characteristics (academia, employed roles, private practice), at a significance level of 0.05. RESULTS: Response rate was 53%. Most respondents were age 35-45, in solo practice, trained via traditional pathways, without fellowships, and lacked female mentors. Private practice surgeons were very satisfied in their career, employed surgeons were moderately satisfied and academic surgeons were mildly satisfied. Academic surgeons reported a higher number of working hours (>60) and cases per month (20-30) than employed or private practice surgeons. Recommendations for success included seeking female mentorship, enhancing business skills and building a social media platform during training. CONCLUSIONS: Results highlight the importance of female mentorship, acquiring business skills, and indicate private practice leads to greater career satisfaction. Training programs should consider accounting for these factors to better promote women's success and improve equity in academic practice.

To Operate or Not to Operate? Reconstructive Surgical Burden and Quality of Life of Pediatric Patients with Facial Differences.

OBJECTIVE: The Craniofacial Condition Quality of Life Scale (CFC-QoL) was used to evaluate the relationship between surgical burden and quality of life (QoL). DESIGN: Patient-parent dyads completed the CFC-QoL which queries the following QoL domains: Bullying, Peer Problems, Psychological Impact, Family Support, Appearance Satisfaction, and Desire for Appearance Change. Stepwise multivariate linear regressions were performed for each QoL domain. SETTING: Urban tertiary care center. PATIENTS, PARTICIPANTS: Pediatric patients with facial differences, and their parents. INTERVENTION: Survey study. MAIN OUTCOME MEASURE(S): Demographic, diagnostic, and surgical characteristics were collected. Surgical burden was calculated as the standard deviation from the mean number of surgeries per diagnostic cohort. RESULT: Patients (N = 168) were majority female (57.1%) and Hispanic (64.3%). Diagnoses were cleft lip and/or palate (CLP,n = 99) or other craniofacial conditions (CFC,n = 69). Average patient age was 2.3 ± 5.6 years at first reconstructive surgery and 12.3 ± 3.4 years at study enrollment. Patients received an average of 4.3 ± 4.1 reconstructive surgeries.Worse Bullying was associated with higher surgical burden. Worse Peer Problems was associated with higher surgical burden, but only for children with non-CLP CFCs. Worse Family Support was associated with CFC diagnosis, female sex, and higher surgical burden. Worse Psychological Impact was associated with higher surgical burden. Worse Appearance Satisfaction was associated with younger age and with lower surgical burden. Greater Desire for Appearance Change was associated with older age, higher surgical burden, CLP diagnosis, female sex, and non-Hispanic ethnicity. Socioeconomic status did not predict QoL per patient self- or parent-proxy report. CONCLUSIONS: Higher surgical burden was associated with worse QoL outcomes in multiple domains.

Prevalence and Severity of Burn Scars in Rural Mozambique.

BACKGROUND: Burn injuries are common in low- and middle-income countries (LMICs) and their associated disability is tragic. This study is the first to explore burn scars in rural communities in Mozambique. This work also validated an innovate burn assessment tool, the Morphological African Scar Contractures Classification (MASCC), used to determine surgical need. METHODS: Using a stratified, population-weighted survey, the team interviewed randomly selected households from September 2012 to June 2013. Three rural districts (Chókwè, Nhamatanda, and Ribáuè) were selected to represent the southern, central and northern regions of the country. Injuries were recorded, documented with photographs, and approach to care was gathered. A panel of residents and surgeons reviewed the burn scar images using both the Vancouver Scar Scale and the MASCC, a validated visual scale that categorizes patients into four categories corresponding to levels of surgical intervention. RESULTS: Of the 6104 survey participants, 6% (n = 370) reported one or more burn injuries. Burn injuries were more common in females (57%) and most often occurred on the extremities. Individuals less than 25 years old had a significantly higher odds of reporting a burn scar compared to people older than 45 years. Based on the MASCC, 12% (n = 42) would benefit from surgery to treat contractures. CONCLUSION: Untreated burn injuries are prevalent in rural Mozambique. Our study reveals a lack of access to surgical care in rural communities and demonstrates how the MASCC scale can be used to extend the reach of surgical assessment beyond the hospital through community health workers.

Tissue Expander-Assisted Component Separation for Pediatric Abdominal Wall Reconstruction.

BACKGROUND: Tissue expander-assisted component separation can be used to increase the amount of skin, muscle, and fascial components available for repair of congenital abdominal wall defects via a staged approach without the need for flap reconstruction. We present the largest case series to date using a tissue expander-assisted component separation technique for treatment of congenital abdominal wall defects in a pediatric patient population. METHODS: A retrospective chart review of 9 patients with large congenital abdominal wall defects not initially amenable to primary repair between 2009 and 2020 was performed. Patients first underwent placement of tissue expanders, followed by removal once they had reached a sufficient expander volume. Component separation, with and without mesh placement, was performed to achieve abdominal wall closure. RESULTS: The average age of patients at primary repair was 3.2 years (SD ±1.7 years). Eight patients (88.8%) had congenital omphalocele, and 1 patient (11.1%) had gastroschisis; none were amenable to primary repair. The average size of the defects before closure was 87.6 cm2 (SD = 33.6 cm2). Eighteen tissue expanders were placed in 9 patients, 72.2% of which were placed in the plane between the external and internal oblique muscles. Patients were seen in clinic an average of 6.8 times (SD, ±3.3 visits) for volume expansion into the tissue expander, receiving an average of 32.0 mL in each per visit. An average of 4.3 months (SD, ±1.8 months) elapsed between placement and removal of the expanders. At the time of tissue expander removal and abdominal wall closure, the defects ranged from 30 to 132 cm2 (mean, 54 cm2). All defects were successfully repaired using a component separation and bilateral fasciocutaneous flap advancement. Two patients (18.2%) experienced infection of the surgical site and seroma, both of which required debridement. One patient (9.1%) experienced partial thickness skin necrosis that was managed nonsurgically. The overall complication rate was 36.4%. CONCLUSIONS: Omphalocele and gastroschisis can produce abdominal wall defects that are not amenable to primary repair. Staged reconstruction using tissue expander-assisted component separation is a safe and effective method of obtaining adequate local soft tissue to achieve primary closure.

Long-Term Treatment Outcomes of Primary Alveolar Bone Grafts for Alveolar Clefts: A Qualitative Systematic Review.

BACKGROUND: Alveolar bone grafting is utilized to manage alveolar clefts in patients with cleft lip and palate. However, the timing of bone grafting is variable with conflicting evidence supporting the use of primary alveolar bone grafting (PABG) in clinical practice. PRIMARY AIM: To provide a qualitative systematic review analysis of long-term outcomes after PABG. MATERIALS AND METHODS: A qualitative systematic review was performed following the Cochrane Handbook and reported using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Summative findings were evaluated using Confidence in the Evidence from Reviews of Qualitative research to assess the quality of evidence supporting the findings. RESULTS: After removing duplication, 2182 publications were identified, and 2131 were excluded after screening through titles and abstracts. Inclusion criteria for this study included patients who underwent PABG at 24 months of age or younger and a minimum of 5 year follow-up. Thirty-two publications met the inclusion criteria and were included for qualitative analysis. Primary outcome measures included cephalometric analysis, bone graft survival, occlusal analysis, hypomineralization, tooth eruption, radiograph analysis, and arch relationships. Four assessment themes were characterized from the systematic review: (1) bone graft survival, (2) craniofacial skeletal relationships, (3) occlusion and arch forms, and (4) recommendations for utilizing PABG in practice. CONCLUSION: The reported systematic review provides evidence that performing PABG leads to poor long-term outcomes related to bone graft survival and maxillary growth restriction despite some reported positive outcomes.

Orbital Volumetric Analysis in Patients With Unicoronal Craniosynostosis: A Comparison Between Distraction Osteogenesis and Fronto-Orbital Advancement.

BACKGROUND: Unicoronal craniosynostosis is associated with orbital restriction and asymmetry. Surgical treatment aims to both correct the aesthetic deformity and prevent the development of ocular dysfunction. We used orbital quadrant and hemispheric volumetric analysis to assess orbital restriction and compare the effectiveness of distraction osteogenesis with anterior rotational cranial flap (DO) and bilateral fronto-orbital advancement and cranial vault remodeling (FOAR) with respect to the correction of orbital restriction in patients with unicoronal craniosynostosis. METHODS: A retrospective review of all patients with a diagnosis of unicoronal craniosynostosis and treated with either DO or FOAR from 2000 to 2019 was performed. Preoperative and postoperative total orbital volumes, as well as quadrant and hemispheric volume ratios, were calculated from 3-dimensional head computed tomography scans. Selected preoperative and postoperative orbital measurements, including the maxillary length of the orbit (MLO; zygomaticofrontal suture to the top of zygomatic arch) and the sphenoid length of the orbit (SLO; the top of sphenoid suture to the top of zygomatic arch), were also obtained. RESULTS: Data were available for 28 patients with unicoronal craniosynostosis. Mean preoperative total orbital volume was significantly smaller on the synostotic side compared with the nonsynostotic side (10.94 vs 12.20 cm3, P = 0.04). Preoperative MLO and SLO were significantly longer on the synostotic side compared with the nonsynostotic side (MLO: 20.26 vs 17.75 mm, P < 0.001; SLO: 26.91 vs 24.93 mm, P = 0.01). Distraction osteogenesis and FOAR produced significantly different changes in orbital quadrant and/or hemispheric volume ratios on the nonsynostotic side but not on the synostotic side. CONCLUSIONS: Before correction, patients with unicoronal craniosynostosis have significantly smaller total orbital volumes on the synostotic side compared with the nonsynostotic side and significantly greater MLO and SLO on the synostotic side compared with the nonsynostotic side. There is no significant difference between DO and FOAR with regard to correcting the observed orbital restriction in these patients.

Analysis of Actual Versus Predicated Intracranial Volume Changes for Distraction Osteogenesis Using Virtual Surgical Planning in Patients With Craniosynostosis.

INTRODUCTION: The primary outcome metric in patients with craniosynostosis are changes in intracranial volumes (ICVs). In patients who undergo distraction osteogenesis (DO) to treat craniosynostosis, changes are also dependent on the length of distraction. Virtual surgical planning (VSP) has been used to predict anticipated changes in ICV during cranial vault reconstruction. The purpose of this study is to analyze the actual versus predicted ICV changes using VSP in patients who undergo DO for craniosynostosis management. METHODS: All patients with craniosynostosis treated with DO at a single institution, Rady Children's Hospital, between December 2013 and May 2019 were identified. Inclusion criteria are as follows: VSP planning with predicted postoperative ICV values and preoperative and postdistraction CT scans to quantify ICV. Postoperative ICV and VSP-estimated ICV were adjusted for age-related ICV growth. The primary outcome measure calculated was age-adjusted percent volume change per millimeter distraction (PVCPD), and results were analyzed using paired Wilcoxon signed rank tests. RESULTS: Twenty-seven patients underwent DO for cranial vault remodeling. Nineteen patients were nonsyndromic, and 8 patients were syndromic. The median postoperative PVCPD was 0.30%/mm, and the median VSP-estimated PVCPD was 0.36% per millimeter (P < 0.001). A subanalysis of nonsyndromic patients showed a median postoperative PVCPD of 0.29%/mm in nonsyndromic patients that differed significantly from the VSP estimate of 0.34%/mm (P = 0.003). There was also a significant difference in syndromic patients' observed PVCPD of 0.41%/mm versus VSP estimate of 0.79%/mm (P = 0.012). CONCLUSIONS: Virtual surgical planning overestimates the change in ICV attributable to DO in both syndromic and nonsyndromic patients.

A Single-Center Retrospective Review of Perioperative Complications and Reoperation Rates Between Open Cranial Vault Remodeling and Distraction Osteogenesis for Unilateral Coronal Craniosynostosis.

BACKGROUND: Unilateral coronal craniosynostosis (UCS) is the third most prevalent form of craniosynostosis. Traditional treatment of UCS has been achieved with fronto-orbital advancement and cranial vault remodeling (FOAR), but utilization of cranial distraction osteogenesis (DO) techniques has increased. This study aims to compare perioperative complications and reoperation trends in FOAR versus DO techniques at a single institution. METHODS: An Institutional Review Board-approved retrospective review was performed from January 1999 to November 2018 at a single institution. Patients were those that have undergone FOAR or DO with an anterior rotational flap technique as previously described. Indications for secondary procedures included: contour deformities, relapse, surgical site infection, and persistent cranial defects. RESULTS: Eighty-one patients with UCS were identified, 64 patients underwent FOAR and 17 patients underwent DO. When perioperative characteristics were compared, patients who underwent DO were younger in age, however, there was no significant difference in transfusion requirement or length of stay between patient cohorts. Surgery time was increased in DO patients. When perioperative complications were compared, more intraoperative dural tears were observed in the FOAR cohort. When unplanned reoperation rates were compared, patients who had undergone FOAR had a statistically significant higher reoperation rates at 5 years of follow up. When including routine distractor removal as a reoperation, reoperative rate was increased in the DO cohort. No difference in reoperation rates was noted at 5 years following index operation. CONCLUSIONS: The safety profile of DO is similar to that of traditional FOAR techniques for treatment of UCS. Longer-term follow-up studies are needed to elucidate whether outcomes are durable, but the unplanned reoperation rate in DO is less than that of FOAR at 5 years and presents several advantages that warrants its use in patients with UCS.

A Comparison of Intracranial Volumes and Metopic Index in Patients With Isolated Metopic Ridge, Metopic Craniosynostosis, and Normal Healthy Children.

BACKGROUND: Previous research has shown that patients with metopic craniosynostosis have significantly reduced intracranial volumes (ICVs) compared to normal healthy children. Furthermore, the metopic index (ratio of midfrontozygomatic diameter to maximal cranial width) has been described as an anthropometric cranial index for patients with metopic craniosynostosis. We aimed to determine whether patients with isolated metopic ridge have significantly different ICVs or metopic indices than normal children and patients with metopic craniosynostosis. METHODS: A retrospective chart review of all patients with a diagnosis of a metopic ridge or metopic craniosynostosis was performed from 2000 to 2015 at Rady Children's Hospital. Patients were grouped based on computed tomographic scans consistent with metopic craniosynostosis versus metopic ridge. RESULTS: Data were available for 15 metopic ridge patients, 74 metopic craniosynostosis patients, and 213 normal patients. Mean metopic ridge ICV was greater than mean metopic craniosynostosis ICV at 4 to 6 months and 7 to 12 months. Controlling for age and sex, the difference in ICV associated with metopic ridging was 197.484 cm3 and 137.770 cm3 at 4 to 6 and 7 to 12 months, respectively. Similarly, mean metopic index was significantly greater in metopic ridge patients compared to mean metopic craniosynostosis at 4 to 6 months and at 7 to 12 months. CONCLUSIONS: Our study provides volumetric and anthropometric data to support the hypothesis that isolated metopic ridge is an intermediate phenotype between metopic craniosynostosis and normal cranial anatomy. We hope that characterizing the spectrum of disease involving premature closure of the metopic suture with regard to ICV and metopic index will aid physicians in their management of patients with isolated metopic ridge.

A Posterior Rotational Flap Technique Using Distraction Osteogenesis for Unilateral Lambdoid Craniosynostosis.

INTRODUCTION: The craniofacial asymmetry seen in unilateral lambdoid craniosynostosis may not be effectively treated by posterior cranial vault remodeling, endoscopic suturectomy, and helmet therapy, or suturectomy and distraction osteogenesis alone due to limitations in soft-tissue envelope expansion and relapse of the deformity. The authors report a series of unilateral lambdoid craniosynostosis patients treated with a posterior rotational cranial-flap technique using internal distraction osteogenesis. METHODS: Posterior cranial vault reconstruction combined with internal distraction was used, aided by preoperative virtual surgical planning. An in situ posterior rotational flap osteotomy was utilized to maximize dural preservation. Primary outcome measures included age-adjusted volume change and age-adjusted percent volume change per mm distraction. Distraction characteristics and perioperative characteristics were also assessed. RESULTS: A total of 5 patients were identified. Mean predistraction intracranial volume was 1087.5 cc (SD  = 202.3 cc) and mean postdistraction included intracranial volume was 1266.1cc (SD  = 131.8cc). Mean age-adjusted percent included intracranial volume change was 14.1% (SD  = 9.6%), and mean percent intracranial volume change per mm distraction was 0.43%/mm distraction (SD  = 0.37%/mm distraction). One patient developed a distractor site infection postoperatively that was treated successfully with oral antibiotics. All patients had a Whitaker score of 1 at one year follow up. CONCLUSIONS: Posterior cranial vault remodeling using osteogenesis and a rotational cranial flap technique with dural preservation can be effectively used to maximize bone flap viability and limit postoperative relapse in patients with unilateral lambdoid craniosynostosis. Long term analysis as well as comparison to open techniques will need to be interrogated.

Screening Intrathecal Baclofen Pump Systems for Catheter Patency via Catheter Access Port Aspiration.

OBJECTIVES: To screen all of our patients being treated with intrathecal baclofen (ITB) therapy for catheter patency. METHOD: Catheter patency was examined by performing a catheter access port study in 91 pediatric and adult patients undergoing ITB therapy at our institution. RESULTS: Despite no preoperative clinical suspicion of a problem with the ITB system in all but one case, 16.5% of the catheters in our patient population were not patent. After replacement, prerevision and stable postrevision dosage was examined to determine the impact system replacement had on the daily dosage. There was a significant 65% reduction in the daily ITB dosage from before catheter exploration (M = 823.8 mcg/day, SD = 390.51) to stable post replacement/revision dosage after catheter replacement or revision (M = 289.43 mcg/day, SD = 187.76), t11 = 4.09, p = .002, 95% CI [246.80, 822.00]. CONCLUSIONS: These results suggest that catheters need to be routinely screened for patency. Routine maintenance and screening can minimize or more quickly detect nonpatent systems and ensure proper functioning of the ITB system.

Electrical Burn and Amputations in a Burn Center in Addis Ababa, Ethiopia.

Background: Burn injuries are a global public health problem and continue to be one of the leading causes of unintentional death and injury. Electrical injuries, a relatively rare cause of burns, are increasingly being reported with higher rates of mortality in low and middle-income countries due to rapid industrialization in the absence of safety regulations. Electrical burn injuries can result in death, various organ system dysfunctions, or limb amputations. Methods: A 5-year retrospective, cross-sectional study was conducted to assess the rate of amputation and associated risk factors in electrical burn injuries among burn patients at AaBET Hospital in Addis Ababa, Ethiopia. Results: The rate of amputation among the 150 patients admitted with electrical burn in the study period was 33.3% (n = 50). A majority (62%; n = 31) of the patients were men (M:F 1.6:1) in the age range of 18-65 years. A fallen electrical wire coming in contact with the patients was the cause of the electrical burns in 50% of the cases. 65.3% of the patients had upper limb amputations, whereas 34.7% had lower limb amputations. Major amputations were more likely to occur when the entry site was the hand, whereas minor amputations were more likely to occur when the entry site was the scalp (P = 0.005). Conclusions: Younger male patients were identified as the main victims of electrical burns that resulted in amputations. Electrical burns showed substantial morbidity and mortality of patients. Total body surface area and entry site being the hand significantly affected the level and site of amputation.

Do Computerized Tomography Scans Change Management in Carpometacarpal Dislocations and Fracture-Dislocations?

BACKGROUND: Concomitant carpal injuries with dislocations and fracture-dislocations of the carpometacarpal joints (CMCD/FD) are often hard to see on plain radiographs, making advanced imaging a useful diagnostic adjunct. We aim to: (1) characterize bony injury patterns with CMCD/FD; and (2) determine the frequency that preoperative computed tomography (CT) scans change surgical management. METHODS: A retrospective review was performed of patients who underwent operative fixation of CMCD/FD from 2006 to 2021. X-ray and CT scan diagnoses were reviewed and correlated to intraoperative findings and procedures performed. Statistical analyses were performed to evaluate the frequency in which CT scans changed management and the frequency of new intraoperative diagnoses. RESULTS: Seventy-five patients were identified. All patients had a preoperative x-ray, and 27 patients (36%) additionally had a CT scan. Patients who sustained high-velocity trauma were significantly more likely to obtain a CT scan than patients with low-velocity trauma (P = .019); however, the number of additional diagnoses was not significantly associated with trauma velocity (P = .35). Computed tomography scans significantly increased the number of diagnoses (P < .001) and changed operative management in 58% of cases. Six of the 48 patients (12.5%) that did not receive a CT scan had new intraoperative diagnoses, which changed the procedure for five of these patients. New intraoperative diagnoses were identified significantly more when patients did not have a CT scan (P = .04). CONCLUSIONS: Obtaining a CT scan in CMCD/FD patients changed the patient's diagnosis at a significant rate and changed operative management roughly half of the time. The authors recommend routine CT scans be obtained in patients with CMCD/FD.

Game Changers: Plastic and Reconstructive Surgery Innovations of the Last 100 Years.

Background: Innovation is an essential aspect of plastic and reconstructive surgery (PRS), whether it involves improving current processes or implementing radical change that disrupts the status quo. Collaborating and sharing innovations help advance the field of PRS as a whole. Methods: An anonymous survey was administered to members of the American Association of Plastic Surgeons on their opinions of the top five innovations in PRS of the last 100 years. Results: A list of 69 unique innovations were compiled; the top five innovations overall were microsurgery, myocutaneous flaps, craniofacial surgery, negative pressure wound therapy, and organ transplantation. This list was reviewed by the American Association of Plastic Surgeons Technology Committee, and expanded to 100 unique innovations. Conclusions: We discuss why the above innovations were essential to the development of PRS, as well as the unique factors that can make a new product or procedure into something that remodels the field of PRS.

Rehabilitation Outcomes in Children With Acute Flaccid Myelitis From 2014 to 2019: A Multicenter Retrospective Review.

BACKGROUND: Acute flaccid myelitis (AFM) is a childhood illness characterized by sudden-onset weakness impairing function. The primary goal was to compare the motor recovery patterns of patients with AFM who were discharged home or to inpatient rehabilitation. Secondary analyses focused on recovery of respiratory status, nutritional status, and neurogenic bowel and bladder in both cohorts. METHODS: Eleven tertiary care centers in the United States performed a retrospective chart review of children with AFM between January 1, 2014, and October 1, 2019. Data included demographics, treatments, and outcomes on admission, discharge, and follow-up visits. RESULTS: Medical records of 109 children met inclusion criteria; 67 children required inpatient rehabilitation, whereas 42 children were discharged directly home. The median age was 5 years (range 4 months to 17 years), and the median time observed was 417 days (interquartile range = 645 days). Distal upper extremities recovered better than the proximal upper extremities. At acute presentation, children who needed inpatient rehabilitation had significantly higher rates of respiratory support (P < 0.001), nutritional support (P < 0.001), and neurogenic bowel (P = 0.004) and bladder (P = 0.002). At follow-up, those who attended inpatient rehabilitation continued to have higher rates of respiratory support (28% vs 12%, P = 0.043); however, the nutritional status and bowel/bladder function were no longer statistically different. CONCLUSIONS: All children made improvements in strength. Proximal muscles remained weaker than distal muscles in the upper extremities. Children who qualified for inpatient rehabilitation had ongoing respiratory needs at follow-up; however, recovery of nutritional status and bowel/bladder were similar.

Children undergoing outpatient complex penile surgery and hypospadias repair may not require opioid analgesics.

BACKGROUND/PURPOSE: Pain control is important after penile surgery, and opioid use should be minimized as able. We sought to describe our experience performing complex penile surgeries with vs without post-operative opioids. METHODS: A retrospective review of penile surgeries, including 3998 between 2009 and 2019. We identified patients <8 years who underwent outpatient penile surgery requiring either penile degloving or hypospadias repair. Patients who were or were not prescribed opioids were matched 1:1 by age and type of penile surgery. Primary outcomes of interest were pain-related encounters, delayed opioid prescription, and predictors of pain. RESULTS: 200 children were identified, 100 per group, with mean age 1.3 ± 0.8 years. 48% were penile degloving procedures, 31% hypospadias repairs with catheters, and the remaining 21% hypospadias repairs without catheters. Perioperative features were comparable between groups(p > 0.05). 59% of patients without opioids had an impromptu post-operative encounter vs 41%, and 20% had an associated pain complaint vs 9%(p = 0.026). Two patients in both groups received delayed opioid prescription(p = 1.00). The presence of a catheter (OR 2.9) and no opioid prescription (OR 2.6) were independent predictors for pain complaint. CONCLUSIONS: Patients discharged without an opioid were more likely to contact a provider postoperatively and were more likely to endorse pain complaint (number needed to treat: 9).

Intracranial Volumes of Healthy Children in the First 3 Years of Life: An Analysis of 270 Magnetic Resonance Imaging Scans.

BACKGROUND: There is a paucity of data on normal intracranial volumes for healthy children during the first few years of life, when cranial growth velocity is greatest. The aim of this study was to generate a normative predictive model of intracranial volumes based on brain magnetic resonance imaging from a large sample of healthy children to serve as a reference tool for future studies on craniosynostosis. METHODS: Structural magnetic resonance imaging data for healthy children up to 3 years of age was acquired from the National Institutes of Health Pediatric MRI Data Repository. Intracranial volumes were calculated using T1-weighted scans with FreeSurfer (version 6.0.0). Mean intracranial volumes were calculated and best-fit logarithmic curves were generated. Results were compared to previously published intracranial volume curves. RESULTS: Two-hundred seventy magnetic resonance imaging scans were available: 118 were collected in the first year of life, 97 were collected between years 1 and 2, and 55 were collected between years 2 and 3. A best-fit logarithmic growth curve was generated for male and female patients. The authors' regression models showed that male patients had significantly greater intracranial volumes than female patients after 1 month of age. Predicted intracranial volumes were also greater in male and female patients in the first 6 months of life as compared to previously published intracranial volume curves. CONCLUSIONS: To the authors' knowledge, this is the largest series of demographically representative magnetic resonance imaging-based intracranial volumes for children aged 3 years and younger. The model generated in this study can be used by investigators as a reference for evaluating craniosynostosis patients.