Feasibility of using an automated call service to collect quality of life and functional outcome data in trauma patients.

Objectives: Following up trauma patients after discharge, to evaluate their subsequent quality of life and functional outcomes, is notoriously difficult, time consuming, and expensive. Automated systems are a conceptually attractive solution. We prospectively assessed the feasibility of using a series of automated phone calls administered by Emmi Patient Engagement to survey trauma patients after discharge. Methods: Recruitment into the study was incorporated into the patient discharge process by nursing staff. For this pilot, we included trauma patients discharging home and who were able to answer phone calls. A script was created to evaluate the Extended Glasgow Outcome Scale and the EuroQol EQ-5D to assess functional status and quality of life, respectively. Call attempts were made at 6 weeks, 3 months, 6 months, and 1 year after discharge. Results: A total of 110 patients initially agreed to participate. 368 attempted patient encounters (calls or attempted calls) took place, with 104 (28.3%) patients answering a least one question in the study. 21 unique patients (19.1% of those enrolled) completed 27 surveys. Conclusions: Automated, scripted phone calls to survey patients after discharge are not a feasible way of collecting functional and quality of life data. Level of evidence: Level II/prospective.

Determinants of pressure injury development in patients with COVID-19.

OBJECTIVE: Pressure injuries (PIs) often develop in critically ill patients due to immobility, and underlying comorbidities that decrease tissue perfusion and wound healing capacity. This study sought to provide epidemiological data on determinants and current managements practices of PI in patients with COVID-19. METHOD: A US national insurance-based database consisting of patients with coronavirus or COVID-19 diagnoses was used for data collection. Patients were filtered by International Classification of Diseases (ICD) codes corresponding to coronavirus or COVID-19 diagnosis between 2019-2020. Diagnosis of PI following COVID-19 diagnosis was queried. Demographic data and comorbidity information was compared. Logistic regression analysis was used to determine predictors for both PI development and likelihood of operative debridement. RESULTS: A total of 1,477,851 patients with COVID-19 were identified. Of these, 15,613 (1.06%) subsequently developed a PI, and 8074 (51.7%) of these patients had an intensive care unit (ICU) admission. The average and median time between diagnosis of COVID-19 and PI was 39.4 and 26 days, respectively. PI was more likely to occur in patients with COVID-19 with: diabetes (odds ratio (OR): 1.39, 95% confidence interval (CI): 1.29-1.49; p<0.001); coronary artery disease (OR: 1.11, 95% CI: 1.04-1.18, p=0.002), hypertension (OR: 1.43, 95% CI: 1.26-1.64; p<0.001); chronic kidney disease (OR: 1.18, 95% CI: 1.10-1.26; p<0.001); depression (OR: 1.45, 95% CI 1.36-1.54; p<0.001); and long-term non-steroidal anti-inflammatory drug use (OR: 1.21, 95% CI: 1.05-1.40; p=0.007). They were also more likely in critically ill patients admitted to the ICU (OR: 1.40, 95% CI: 1.31-1.48; p<0.001); and patients requiring vasopressors (OR:1.25, 95% CI: 1.13-1.38; p<0.001), intubation (OR: 1.21, 95% CI 1.07-1.39; p=0.004), or with a diagnosis of sepsis (OR: 2.38, 95% CI 2.22-2.55; p<0.001). ICU admission, sepsis, buttock and lower back PI along with increasing Charlson Comorbidity Index (CCI) (OR: 1.04, 95% CI 1.00-1.08; p=0.043) was associated with surgical debridement. The vast majority of patients with COVID-19 did not undergo operative debridement or wound coverage. CONCLUSION: PIs are widely prevalent in patients with COVID-19, especially in those who are critically ill, yet the vast majority do not undergo operative procedures. DECLARATION OF INTEREST: The authors have no conflicts of interest to declare.

Abdominal Panniculectomy: Determining the Impact of Diabetes on Adverse Outcomes and Complications.

Background: Despite its association with obesity, the relation between diabetes and the abdominal panniculectomy is less well-established. The purpose of this study was to evaluate the result of diabetes on post-panniculectomy complications in a large cohort and to establish the risk factors associated with unfavorable post-operative outcomes. Methods: Patients that underwent a panniculectomy between 2010 and 2018 were identified in PearlDiver, a national insurance claims database, and identified by Current Procedural Terminology code 15380. Patient demographics and comorbidities were elucidated, and various complications were then identified. Descriptive statistics as well as a multivariate analysis were used to evaluate the association of risk factors and complications. Results: A total of 8282 panniculectomy patients were identified-4245 with diabetes, 4037 without. Obesity, tobacco use, and diabetes were all identified as significant risk factors in developing a surgical site infection, wound disruption, as well as needing to undergo reoperation. Diabetic panniculectomy patients had a higher rate of readmission as well as reoperation and sustained a higher rate of surgical complications, even when matched for. Conclusion: Diabetic panniculectomy patients are at a greater risk for developing complications. Identifying potential risk factors in this patient population could help reduce post-operative complications following a panniculectomy.

Contexte: En dépit de son association avec l'obésité, la relation existant entre le diabète et la panniculectomie abdominale est moins bien établie. Cette étude avait pour objectif d'évaluer le résultat du diabète sur les complications post-panniculectomie dans une vaste cohorte et de déterminer les facteurs de risque associés aux évolutions postopératoires défavorables. Méthodes: Des patients ayant subi une panniculectomie entre 2010 et 2018 ont été identifiés dans la base de données PearlDiver, une base de données nationale de réclamations de remboursement d'assurances, et identifiés par le code CPT 15380. Les données démographiques et les comorbidités des patients ont été élucidées et différentes complications ont alors été identifiées. Des statistiques descriptives ainsi qu'une analyse multifactorielle ont permis d'évaluer l'association des facteurs de risque et des complications. Résultats: 8 282 patients ayant subi une panniculectomie ont été identifiés, parmi lesquels 4 245 avaient un diabète et 4 037 n'en avaient pas. L'obésité, le tabagisme et le diabète ont tous été identifiés comme étant des facteurs de risque significatifs pour le développement d'une infection du site opératoire, une perturbation de la plaie, ainsi que le besoin d'une réintervention. Les patients diabétiques ayant subi une panniculectomie ont eu des taux de réadmission et de réintervention plus élevés; leur taux de complications chirurgicales a été plus important, même après appariement. Conclusion: Les patients subissant une panniculectomie ont un risque plus élevé de complications postopératoires. L'identification des facteurs de risque potentiels dans cette population de patients pourrait contribuer à réduire les complications postopératoires après panniculectomie.

The Cost of Ambulatory Breast Reduction: Hospital Reimbursement Versus Surgeon Payments.

Introduction: Reduction mammoplasty (RM) is one of the most common operations performed in plastic surgery. While US national surgical expenditures have risen in recent years, studies have reported decreasing reimbursement rates for plastic surgeons. The purpose of this study is to characterize the trends in charges and payments for a common plastic surgery operation, ambulatory RM, for facilities and physicians. Methods: A Medicare patient records database was used to capture hospital, surgeon, and anesthesiologist charges and payments for ambulatory RM from 2005 to 2014. Values were adjusted for inflation. A ratio of hospital to surgeon charges and payments were calculated: charge multiplier (CM) and payment multiplier (PM), respectively. Charges, payments, Charlson comorbidity index, CM, and PM values were analyzed for trends. Results: This study included 1001 patients. During the study period, the facility charge for RM per patient increased from $8477 to $11,102 (31% increase; p < .0005), and the surgeon charge increased from $7088 to $7199 (2% increase; p = .0009). Facility payments increased from $3661 to $3930 (7% increase; p < .0005), and surgeon payments decreased from $1178 to $1002 (15% decrease; p < .0005). CM increased from 1.2 to 1.54, and PM increased from 3.11 to 3.92. Conclusions: Charges and payments to facilities for ambulatory RM increased disproportionately to that of surgeons, likely due in part to rising administrative costs in health care delivery. This may disincentivize plastic surgeons from offering RM at hospital-based surgical centers, limiting patient access to this operation.

Introduction: La mammoplastie de réduction (MR) est l'une des interventions les plus courantes pratiquées en chirurgie plastique. Alors que les dépenses chirurgicales aux États-Unis ont augmenté au niveau national au cours des dernières années, les études ont signalé une diminution des taux de remboursement pour les chirurgiens plasticiens. L'objectif de cette étude est de définir les tendances dans les frais et paiements pour une intervention courante de chirurgie plastique, une MR ambulatoire, pour les établissements et pour les médecins. Méthodes: Une base de données des dossiers de patients Medicare a été utilisée pour collecter les frais pour les hôpitaux, les chirurgiens et les anesthésiologistes ainsi que les paiements pour MR ambulatoires de 2005 à 2014. Les valeurs ont été ajustées pour tenir compte de l'inflation. Des ratios des frais hôpital/chirurgien et des paiements ont été calculés : respectivement, un facteur de multiplication des frais (MF) et des paiements (MP). Les tendances de la valeur des frais, des paiements, de l'indice de comorbidité de Charlson, du MF et du MP ont été analysées. Résultats: Cette étude a inclus 1001 patients. Au cours de la période de l'étude, les frais pour MR par patient à la charge de l'établissement ont augmenté de 8 477 $ à 11 102 $, soit une augmentation de 31 % (P < 0,0005) et les frais du chirurgien sont passés de 7 088 $ à 7 199 $, soit une augmentation de 2 % (P = 0,0009). Les paiements de l'établissement ont augmenté de 3 661 $ à 3 930 $, soit une augmentation de 7 % (P < 0,0005) et les paiements du chirurgien ont diminué de 1 178 $ à 1 002 $, soit une diminution de 15 % (P < 0,0005). Le facteur MF est passé de 1,2 à 1,54 et le facteur MP est passé de 3,11 à 3,92. Conclusions: Les frais et paiements aux établissements pour MR ambulatoire ont augmenté de manière disproportionnée par rapport à ceux des chirurgiens, probablement en partie à cause de l'augmentation des coûts administratifs croissants de l'administration des soins. Cela pourrait inciter les chirurgiens plasticiens à ne plus offrir de MR dans les centres chirurgicaux hospitaliers et pourrait donc limiter l'accès des patients à cette opération.

Measurement Matters: MRI Analysis of Differing Anatomic Measurement Techniques for Velar Length and the Velopharyngeal Needs Ratio.

Background: Advances in imaging tools provide opportunities to enhance how velopharyngeal (VP) variables are quantified to facilitate surgical decisions. The purpose of this study was to use magnetic resonance imaging (MRI) to determine if quantitative differences were present between measures of linear and curvilinear velar length, and subsequently, the VP needs ratio. Methods: Data were prospectively collected from patients presenting with repaired cleft palate and/or congenital palatal insufficiency with or without VPI at a single center tertiary children's hospital. Quantitative measures of the velopharynx using a novel nonsedated MRI protocol were obtained. Paired samples t tests were conducted to assess if differences were present between the VP needs ratio and measurements of linear and curvilinear velar length at rest and during sustained phonation. Intraclass correlation coefficients were calculated to assess intra/inter-rater reliability. Results: Significant differences were present between measurements of linear and curvilinear velar length at rest (P ≤ 0.001) and during sustained phonation (P ≤ 0.001). Significant differences were also present in the VP needs ratio (P ≤ 0.001). Curvilinear velar length at rest and during sustained phonation was longer than that of linear velar length at rest and during sustained phonation. No significant differences were observed between measures of effective velar length (P = 0.393). Conclusions: Measurement differences influence the VP needs ratio. This may have implications for comparisons to previously reported normative reference values and for those who are anatomically at risk for VPI. MRI provides an enhanced imaging modality to assess normative benchmarks and the anatomic variables used to define VP anatomy for clinical decision-making.

Feeding Outcomes After Mandibular Distraction for Airway Obstruction in Infants.

Robin sequence is a congenital issue resulting in airway obstruction, difficulty feeding, and failure to thrive. Mandibular Distraction Osteogenesis is used to improve airway obstruction in these patients, but little data exists characterizing feeding outcomes following surgery. This study aims to evaluate feeding outcomes and weight gain following mandibular distraction for airway correction in infants. A single-center retrospective chart review was conducted, and patients under 12 months old who underwent mandibular distraction between December 2015 and July 2021 were included in the study. The presence of cleft palate, distance of distraction, and polysomnography results were recorded. The primary outcomes were the length of distraction, need for nasogastric tube or G-tube at discharge, time lapsed to achieve full oral feeds, and weight gain (kilogram). Ten patients met the criteria. Of those 10 patients, 4 were syndromic, 7 had a cleft palate, and 4 had a congenital cardiac diagnosis. The average length of stay postsurgery was 28 days. Eight patients achieved full oral feeds in an average of 65.6 days. Five patients required nasogastric tube or G-tube at discharge, with 3 of these patients later transitioning to full oral feeds. All patients gained weight 3 months postsurgery with an average of 0.521 kg/mo. Patients who achieved full oral feeds gained an average of 0.549 kg/mo. Patients with supplementation gained an average of 0.454 kg/mo. All patients demonstrated improvement in airway obstruction with an average postoperative apnea hypopnea index of 1.64. Further investigation is necessary to identify challenges seen in feeding after mandibular distraction osteogenesis and improve care.

Utility of Regional Maxillary Nerve Blocks in Improving Cleft Palate Postoperative Outcomes.

BACKGROUND: Palatoplasty procedures used to repair cleft palates are commonly associated with limiting postoperative pain. Regional anesthetic blocks have been utilized to improve pain outcomes and decrease opioid intake, yet additional data is needed to fully explore its utility in this setting. OBJECTIVE: To explore whether ultrasound-guided suprazygomatic maxillary blocks (SMB) improve postoperative pain, postoperative opioid use, time to oral feeding, and length of stay compared with a palatal field block in cleft palate repair. METHODS: In this retrospective chart review, 47 patients aged 9 to 25 months who underwent cleft palate repair between 2013 and 2020 were allocated into 2 groups: a control group where patients received only palatal local anesthetic in a field block fashion (N=29), and Maxillary block group who received ultrasound-guided SMB (N=18). Patients were matched by age and cleft Veau type. The primary outcomes were total postoperative morphine equivalent consumption, average pain scores, length of stay, and time to first oral feed. RESULTS: Comparing field block versus SMB groups, there was not a statistical difference in the overall dose of postoperative morphine equivalent opioid administration (11.71 vs. 13.36 mg; P =0.483), average pain scores (5.78 vs. 5.27; P =0.194), time to first oral feed [17.21 vs. 14.48 h; P =0.407, 95% CI: (-3.85, 9.32)] or length of stay ( P =0.292). CONCLUSION: The use of SMBs did not demonstrate a difference in the postoperative outcomes evaluated by this study. Further study is needed to define its utility in cleft palate repair.

Incorporating Velopharyngeal MRI into the Clinical Decision-Making Process for a Patient Presenting with Velopharyngeal Dysfunction Following a Failed Palatoplasty.

This clinical report describes the implementation of magnetic resonance imaging (MRI) to evaluate a patient with long-standing velopharyngeal dysfunction. She was referred to the craniofacial clinic at age 10 with no prior surgical history and subsequently completed a Furlow palatoplasty due to a suspected submucous cleft palate. However, results were unfavorable with minimal improvement in speech or resonance. The clinical presentation, treatment, outcomes, and contributions from MRI for secondary surgical planning are described. Addition of MRI into the clinical workflow provided insights into the anatomy and physiology of the velopharyngeal mechanism that were unable to be obtained from nasendoscopy and speech evaluation alone.

Cost-Effectiveness of Universal Screening for Blunt Cerebrovascular Injury: A Markov Analysis.

BACKGROUND: Blunt cerebrovascular injury (BCVI) is a significant cause of morbidity and mortality after blunt trauma. Numerous screening strategies exist, although which is used is institution- and physician-dependent. We sought to identify the most cost-effective screening strategy for BCVI, hypothesizing that universal screening would be optimal among the screening strategies studied. STUDY DESIGN: A Markov decision analysis model was used to compare the following screening strategies for identification of BCVI: (1) no screening; (2) Denver criteria; (3) extended Denver criteria; (4) Memphis criteria; and (5) universal screening. The base-case scenario modeled 50-year-old patients with blunt traumatic injury excluding isolated extremity injures. Patients with BCVI detected on imaging were assumed to be treated with antithrombotic therapy, subsequently decreasing risk of stroke and mortality. One-way sensitivity analyses were performed on key model inputs. A single-year horizon was used with an incremental cost-effectiveness ratio threshold of $100,000 per quality-adjusted life-year. RESULTS: The most cost-effective screening strategy for patients with blunt trauma among the strategies analyzed was universal screening. This method resulted in the lowest stroke rate, mortality, and cost, and highest quality-adjusted life-year. An estimated 3,506 strokes would be prevented annually as compared with extended Denver criteria (incremental cost-effectiveness ratio of $71,949 for universal screening vs incremental cost-effectiveness ratio of $12,736 for extended Denver criteria per quality-adjusted life-year gained) if universal screening were implemented in the US. In 1-way sensitivity analyses, universal screening was the optimal strategy when the incidence of BCVI was greater than 6%. CONCLUSIONS: This model suggests universal screening may be the cost-effective strategy for BCVI screening in blunt trauma for certain trauma centers. Trauma centers should develop institutional protocols that take into account individual BCVI rates.

Intraoperative Fluorescence Angiography in Implant-Based Breast Reconstruction: Identifying Risk Factors and Outcomes.

BACKGROUND: Intraoperative fluorescence angiography (FA) has been described as a useful adjunct to physical examination in predicting mastectomy skin flap viability for immediate breast reconstruction. Its use has been described as a screening tool for mastectomy skin flap viability as well as a test used only for patients at high risk for mastectomy skin flap loss. We performed a national database review of implant-based breast reconstruction surgeries to determine the practice patterns of FA in this patient cohort and to determine if this technology impacted clinical outcomes. METHODS: A national insurance claims database was reviewed to select patients having undergone direct-to-implant (DTI) and immediate tissue expander (TE) placement with and without intraoperative FA as well as patients who had FA at the time of mastectomy without reconstruction. Patient characteristics that prompted FA and postoperative outcomes with and without FA were evaluated to determine its clinical impact in the observed practice pattern. RESULTS: Of the 48,464 patients identified, 836 had FA. More than twice as many patients undergoing DTI had FA than patients undergoing immediate TE placement (10.4% vs 5%, P < 0.0001). Twelve percent of patients receiving FA at the time of mastectomy had reconstruction delayed. Fluorescence angiography was associated with a trend toward lower overall complication rates in DTI patients (8.0% vs 11.9% without FA) but a significantly higher overall complication rate with immediate TE placement (13.8% vs 10.5% without FA, P = 0.018) and was associated with higher reoperation (12.0% vs 8.3% without FA, P = 0.037) in the TE group. There was no difference in other individual complications, readmission, or explantation for either clinical group with and without FA. Regression analysis identified obesity (odds ratio, 1.32; P < 0.001) and younger age (odds ratio, 1.74; P < 0.001) to be associated with performing FA, whereas obesity, diabetes, and tobacco use were associated with higher complication rates. CONCLUSIONS: Younger and otherwise healthier obese patients were more likely to have FA. A greater proportion of DTI patients had FA than TE patients with improved outcomes in the former group and worse outcomes in the latter group. Obesity, tobacco use, and diabetes were associated with worse outcomes, whereas only obesity was associated with FA use.

Prolonged Opioid Use Among Opioid-Naive Women Undergoing Breast Reconstructive Surgery.

Background Patients that undergo mastectomy for breast cancer with reconstruction may be prone to prolonged opioid use. As risk factors are not well-established, this article sought to better understand the risk factors that may be associated with this. Methods Patients that underwent breast reconstruction between 2010 and 2018 were identified in PearlDiver, a national insurance claims database. Patient demographics and comorbidities were elucidated, and various complications were then identified. Descriptive statistics as well as a multivariate analysis was used to evaluate the association of risk factors and complications. Results Breast reconstruction patients of 24,765 were identified from this database. Obesity, tobacco use, benzodiazepine use, and anticonvulsant use were all associated with prolonged opioid prescriptions greater than 90 days after both alloplastic and autologous reconstruction. Conclusion Prolonged opioid use continues to remain a topic of concern, and particularly in cancer patients that undergo breast reconstruction. Providers should be aware of potential risk factors for this to reduce this chance following breast reconstruction surgery.

"Abdominal panniculectomy: Identifying complications and potential risk factors".

BACKGROUND: The abdominal panniculectomy is a common procedure that patients choose to undergo for the purpose of restoring hygiene, reducing infection, and improving personal esthetic. A panniculectomy is often indicated after bariatric surgery, which defines a high-risk patient population. This study sought to better establish the association of known risk factors that can complicate the postoperative care of the panniculectomy patient, and whether or not bariatric surgery plays a role in the development of these complications. METHODS: Patients that underwent a panniculectomy between 2010 and 2018 were identified in PearlDiver, a national insurance-claims database, and identified by CPT code 15,380. Patient demographics and associated medical problems were elucidated, and various complications were then identified. Descriptive statistics as well as a multivariate analysis were used to evaluate the association of risk factors and complications. RESULTS: A total of 8,282 panniculectomy patients were identified. Of these, 1,420 underwent bariatric weight loss surgery prior to their panniculectomy, whereas the remaining 6,869 underwent a panniculectomy alone. Obesity, tobacco use, and diabetes were significant in developing a surgical site infection, wound disruption, and the need to undergo reoperation. Charlson Comorbidity Index greater than one (CCI>1), male gender, age greater than 60, COPD, and HTN identified as potential risk factors in developing various complications. Although patients with prior weight loss surgery had a history significant for prior comorbidities, the overall postoperative complication rate was decreased compared to those who did not undergo preoperative bariatric surgery. CONCLUSION: In the face of the obesity epidemic, the incidence of undergoing a panniculectomy has increased significantly, particularly following bariatric surgery. Identifying potential risk factors in this patient population could better help identify postoperative complications following a panniculectomy and perhaps allow for targeted intervention and medical optimization prior to surgery.

Local estrogen for nonsurgical recontouring of auricular cartilage.

INTRODUCTION: 5% of children are born with auricular deformities. Permanent recontouring can be achieved through splinting during early infancy. Beyond this time, splinting is ineffective, and patients require surgical correction. Neonatal cartilage malleability is hypothesized to be secondary to retained maternal estrogens, increasing hyaluronic acid concentration. In this article, we evaluate the efficacy of local estrogen treatments for the nonsurgical recontouring of mature auricular cartilage. METHODS: Ears of New Zealand rabbits were folded and splinted and then were randomly assigned to an experimental group, n = 10 (injected estrogen, topical estrogen, saline, or untreated). Treatment ears received injected estrogen or saline twice weekly or topical estrogen daily for 4 weeks. Two weeks post-treatment, splints were removed, and ear angles were measured. Biopsies were taken for histologic and mechanical analysis, and systemic estrogen levels were assayed. RESULTS: Ear angles stabilized by 9 days post-splinting. Topical estrogen led to a significantly smaller resting angle (121.6° ± 13.5°) compared with saline and control (135.9° ± 11.2° and 145.3° ± 13.0°, respectively). Injected estrogen led to the most pronounced angle decrease (64.5° ± 35.3°). Ears injected with estrogen also showed a significant increase in cartilage thickness. Hyaluronic acid concentration was increased in both estrogen treatment groups compared with saline. At 3 weeks post-treatment, there was no significant differences in the elastic modulus of the cartilage or serum estrogen levels among the groups. CONCLUSION: Results show the potential result of local estrogen treatment to achieve a stable nonsurgical remodeling of mature auricular cartilage. Further study is needed to evaluate the molecular mechanism and improve the transdermal estrogen delivery to optimize treatment regimen.

Imaging analysis of ischemic strokes due to blunt cerebrovascular injury.

BACKGROUND: The timing of stroke onset among patients with blunt cerebrovascular injury (BCVI) is not well understood. All blunt trauma patients at our institution undergo a screening computed tomographic angiography (CTA) of the neck. Most patients with CTA evidence of BCVI are treated with aspirin, and all patients with clinical evidence of stroke are treated with aspirin and undergo magnetic resonance imaging (MRI) of the brain. We conducted a retrospective review to determine the incidence of stroke upon admission and following admission. METHODS: All neck CTAs and head MRIs obtained in blunt trauma patients were reviewed from August 2017 to August 2019. All CTAs that were interpreted as showing BCVI were individually reviewed to confirm the diagnosis of BCVI. Stroke was defined as brain MRI evidence of new ischemic lesions, and each MRI was reviewed to identify the brain territory affected. We extracted the time to aspirin administration and the timing of stroke onset from patients' electronic health records. RESULTS: Of the 6,849 blunt trauma patients, 479 (7.0%) had BCVIs. Twenty-four patients (5.0%) with BCVI had a stroke on admission. Twelve (2.6%) of the remaining 455 patients subsequently had a stroke during their hospitalization. The incidence of stroke among patients with BCVI was 7.5%; 2.6% were potentially preventable. Only 5 of the 12 patients received aspirin before the onset of stroke symptoms. All 36 patients with BCVI and stroke had thromboembolic lesions in the territory supplied by an injured vessel. CONCLUSION: With universal screening, CTA evidence of BCVI is common among blunt trauma patients. Although acute stroke is also relatively common in this population, two thirds of strokes are already evident on admission. One third of BCVI-related strokes occur after admission and often relatively early, necessitating rapid commencement of preventative treatment. Further studies are required to demonstrate the value of antithrombotic administration in preventing stroke in BCVI patients. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level IV.

Pediatric Cranial Defects: What Size Warrants Repair?

PURPOSE: Identifying which cranial defects among children warrant surgical repair is integral to providing adequate protection of the skull whereas minimizing exposure to surgical complications. This review examines the available evidence regarding the role of defect size in determining the appropriateness of nonsurgical versus surgical management. METHODS: An electronic literature review was performed using PubMed and Google Scholar to identify publications that provided rationales for nonsurgical management of cranial defects in the pediatric population based on size. Titles and abstracts were reviewed by the authors to determine eligibility for full-text analysis. Ineligible studies were categorized and relevant data from fully analyzed texts were recorded. RESULTS: Of the 523 articles that were reviewed, 500 were ineligible for full-text analysis due to the following most common reasons: no cranial defect described (227, 45%), did not discuss management of cranial defects (68, 14%), or surgery was performed on all defects in evaluation of a technique or protocol (86, 17%). Ten publications provided relevant data. The suggested size below which surgery was not recommended varied widely between articles. Beyond the age of 1 to 2 years, no general agreement on recommended management in children was found. Craniofacial surgeons had divergent views on the minimum diameter for a "critical" defect and the size for which surgical repair is necessary. CONCLUSIONS: Little guidance or consensus exists regarding the indications for surgical correction of cranial defects based on the size of the defect. Objective data is needed to classify "clinically critical defects" in the pediatric population.

A new definition for massive transfusion in the modern era of whole blood resuscitation.

BACKGROUND: Multiple thresholds are defined to identify patients at risk of death from hemorrhage, including massive transfusion (MT), critical administration threshold (CAT), and resuscitation intensity (RI). All fail to account for the use of whole blood (WB). We hypothesized that a definition including WB transfusion would better predict early mortality following trauma. METHODS: This is a retrospective review of all trauma patients with activation of the MT protocol from December 2018 to February 2020. Combinations of WB, RBCs, and fresh frozen plasma (FFP) units transfused during the initial hour of resuscitation were compared using receiver operating characteristic and area under the receiver curve (AUC) for 3- and 6-h mortality. WB massive transfusion (WB MT) score was defined as the sum of each unit RBC plus three times each unit of WB transfused within the first hour of resuscitation. RESULTS: There were 235 patients eligible for analysis with 60 resuscitated using ≥1 unit of WB. Overall, 27 and 29 patients died in the first 3 and 6 h, respectively. WB MT ≥7 had the greatest 3-h and 6-h mortality AUC values (0.78 and 0.79, respectively) when compared to MT, CAT, RI4+, and other attempted definitions using units of WB, RBC, and FFP. Compared to WB MT-, WB MT+ patients died at significantly higher rates at 3 h (28.9% vs. 3.1%, p < .001), 24 h (35.5% vs. 5.7%, p < .001), and 28 days (42.1% vs. 11.9%, p < .001). CONCLUSION: WB MT is the first measure of massive resuscitation to incorporate WB and better identifies early mortality than other definitions.

Complications of Hemorrhagic Shock and Massive Transfusion-a Comparison Before and After the Damage Control Resuscitation Era.

ABSTRACT: Trauma remains a leading cause of death, and hemorrhage is the leading cause of preventable trauma deaths. Resuscitation strategies in trauma have changed dramatically over the last 20 years. In the pre damage control resuscitation (DCR) era, we used large volume crystalloid resuscitation and packed red blood cells as the primary resuscitative fluids. Now, a 1:1:1 ratio of packed red blood cells, fresh plasma, and platelets with minimal crystalloids is the preferred resuscitative strategy (DCR era). As we have changed how we resuscitate patients, the detrimental effects associated with large volume resuscitation have also changed. In this article, we review the effects of large volume blood product resuscitation, and where possible present a contrast between the pre-DCR era and the DCR era resuscitation strategies.

The mechanical and microstructural properties of the pediatric skull.

The pediatric skull differs drastically from the adult skull in terms of composition, rigidity, and structure. However, there is limited data which quantifies the mechanical properties of the pediatric skull. The lack of mechanical data may inhibit desired pediatric craniofacial surgical outcomes as current methodologies and materials employed for the pediatric population are adapted from those used for adults. In this study, normally discarded parietal bone tissue from eight pediatric craniosynostosis surgery patients (aged 4 to 10 months) was collected during reconstructive surgery and prepared for microstructural analysis and mechanical testing. Up to 12 individual coupon samples of fresh, never frozen tissue were harvested from each specimen and prepared for four-point bending testing to failure. The microstructure of each sample was analyzed using micro-computed tomography before and after each mechanical test. From this analysis, effective geometric and mechanical properties were determined for each sample (n = 68). Test results demonstrated that the pediatric parietal skull was 2.0 mm (±0.4) thick, with a porosity of 36% (±14). The effective modulus of the tissue samples, determined from the initial slope of the sample stress-strain response using Euler beam theory and a nonlinear Ramberg-Osgood stress-strain relationship, was 4.2 GPa (±2.1), which was approximately three times less stiff than adult skull tissue reported in the literature. Furthermore, the pediatric skull was able to bend up to flexural failure strains of 6.7% (±2.0), which was approximately five times larger than failure strains measured in adult skull. The disparity between the measured mechanical properties of pediatric skull tissue and adult skull tissue points towards the need to reevaluate current surgical technologies, such as pediatric cranial surgical hardware, so that they are more compatible with pediatric tissue.

Three-dimensional printing and craniosynostosis surgery.

OVERVIEW: The goal of this study was to review the current application and status of three-dimensional printing for craniosynostosis surgery. METHODS: A literature review was performed using the PubMed/MEDLINE databases for studies published between 2010 and 2020. All studies demonstrating the utilization of three-dimensional printing for craniosynostosis surgery were included. RESULTS: A total of 15 studies were ultimately selected. This includes studies demonstrating novel three-dimensional simulation and printing workflows, studies utilizing three-dimensional printing for surgical simulation, as well as case reports describing prior experiences. CONCLUSION: The incorporation of three-dimensional printing into the domain of craniosynostosis surgery has many potential benefits. This includes streamlining surgical planning, developing patient-specific template guides, enhancing residency training, as well as aiding in patient counseling. However, the current state of the literature remains in the validation stage. Further study with larger case series, direct comparisons with control groups, and prolonged follow-up times is necessary before more widespread implementation is justified.

The Impact of Palatal Fistulae on the Success of Alveolar Bone Grafting.

ABSTRACT: Palatal fistulae are common complications of cleft palate surgery with a frequency of 5% to 29% and are challenging to repair. Optimal timing to repair palatal fistulae, in a staged fashion before alveolar bone grafting, or at the same time, still remains controversial. The primary aim of this study is to compare outcomes of 2 groups with regard to successful alveolar bone grafting in patients with cleft lip and palate and palatal fistulae. We describe a review of 85 consecutive patients identified as undergoing bone grafting from a single institution craniofacial team during 2003 to 2018. Twenty-eight required palatal fistula repair. All patients had a diagnosis of unilateral or bilateral complete cleft lip and palate. Patients with cleft lip and palate repairs were stratified based on preoperative or simultaneous palatal fistula repair. Panoramic radiographs were reviewed by 2 physicians to evaluate success of bone grafting. Comparison between cohorts was made by statistical analysis. Of the 28 that required palatal fistula repair, 15 (53.6%) patients underwent prebone grafting palatal fistula repair and 13 (46.4%) patients underwent simultaneous bone grafting with palatal fistula repair. Mean age at time of bone grafting and palatal fistula repair were 10.60 years old and 9.39 years old, respectively. Length to follow-up was 54.82 months. The average height of the healed alveolar cleft site for patients in the prebone grafting or simultaneous groups was 10.57 mm and 11.46 mm, respectively. Patients who underwent palatal fistula repair and simultaneous bone grafting had similar outcomes as those with palatal fistula repair preoperatively.