Risk Factors for Missed Follow-up Appointments among Facial Trauma Patients.

OBJECTIVE: A retrospective case-control study was performed to characterize the rate of missed follow-up appointments after facial trauma and identify associated risk factors. METHODS: Follow-up appointments for facial trauma over a three-month period at a single, safety-net hospital were analyzed. Appointment-specific, sociodemographic, trauma, and management data were compared between cases (missed appointments) and controls (attended appointments). Univariate testing and multivariable logistic regression were employed. RESULTS: A total of 116 cases and 259 controls were identified, yielding a missed appointment rate of 30.9% (116/375). Missed appointments were significantly associated with initial clinic appointments compared to return visits (odds ratio [OR] 2.21 [1.38 - 3.54]), afternoon visits compared to morning (OR 3.14 [1.94 - 5.07]), lack of private health insurance (OR 2.91 [1.68 - 5.18]), and presence of midface fractures (OR 2.04 [1.28 - 3.27]). Missed appointments were negatively associated with mandible fractures (OR 0.56 [0.35 - 0.89]), surgical management (OR 0.48 [0.30 - 0.77]), and the presence of non-removable hardware (OR 0.39 [0.23 - 0.64]). Upon multivariable logistic regression, missed appointments remained independently associated with afternoon visits (adjusted OR [aOR] 1.95 [1.12 - 3.4]), lack of private health insurance (aOR 2.73 [1.55 - 4.8]), and midface fractures (aOR: 2.09 [1.21 - 3.59]). CONCLUSION: Nearly one-third of facial trauma patients missed follow-up appointments, with the greatest risk among those with afternoon appointments, lacking private health insurance, and with midface fractures.

Cost-effectiveness of postoperative imaging surveillance strategies for nonfunctional pituitary adenomas after resection with curative intent.

OBJECTIVE: The aim of this study was to determine an optimal follow-up imaging surveillance strategy in terms of cost-effectiveness after resection of nonfunctioning pituitary adenomas with curative intent. METHODS: An individual-level state-transition microsimulation model was used to simulate costs and outcomes associated with three postoperative imaging strategies over a lifetime time horizon: 1) annual MRI surveillance, 2) tapered MRI surveillance (annual surveillance for 5 years followed by surveillance every 2 years), and 3) personalized surveillance (annual surveillance for 5 years followed by surveillance every 2 years when MRI shows remnant disease/postoperative changes, and surveillance at 7, 10, and 15 years for disease-free MRI). Transition probabilities, utilities, and costs were estimated from recent published data and discounted by 3% annually. Model outcomes included lifetime costs (2022 US dollars), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). RESULTS: Under base case assumptions, annual surveillance yielded higher costs and lower health effects (QALYs) compared with the tapered and personalized surveillance strategies (dominated). Personalized surveillance demonstrated an additional 0.1 QALY at additional cost ($1298) compared with tapered surveillance (7.7 QALYs at a cost of $12,862). The ICER was $11,793/QALY. The optimal decision was most sensitive to the probability of postoperative changes on MRI after surgery and MRI cost. Accounting for parameter uncertainty, personalized surveillance had a higher probability of being a cost-effective surveillance option compared with the alternative strategies at 79%. CONCLUSIONS: Using standard cost-effectiveness thresholds in the US ($100,000/QALY), personalized surveillance that accounted for remnant disease or postoperative changes on MRI was cost-effective compared with alternative surveillance strategies.

Post-operative surveillance for somatotroph, lactotroph and non-functional pituitary adenomas after curative resection: a systematic review.

CONTEXT: Pituitary tumors are the third most common brain tumor and yet there is no standardization of the surveillance schedule and assessment modalities after transsphenoidal surgery. EVIDENCE ACQUISITION: OVID, EMBASE and the Cochrane Library databases were systematically screened from database inception to March 5, 2020. Inclusion and exclusion criteria were designed to capture studies examining detection of pituitary adenoma recurrence in patients 18 years of age and older following surgical resection with curative intent. EVIDENCE SYNTHESIS: A total of 7936 abstracts were screened, with 812 articles reviewed in full text and 77 meeting inclusion criteria for data extraction. A pooled analysis demonstrated recurrence rates at 1 year, 5 years and 10 years for non-functioning pituitary adenomas (NFPA; N = 3533 participants) were 1%, 17%, and 33%, for prolactin-secreting adenomas (PSPA; N = 1295) were 6%, 21%, and 28%, and for growth-hormone pituitary adenomas (GHPA; N = 1257) were 3%, 8% and 13%, respectively. Rates of recurrence prior to 1 year were 0% for NFPA, 1-2% for PSPA and 0% for GHPA. The mean time to disease recurrence for NFPA, PSPA and GHPA were 4.25, 2.52 and 4.18 years, respectively. CONCLUSIONS: This comprehensive review of the literature quantified the recurrence rates for commonly observed pituitary adenomas after transsphenoidal surgical resection with curative intent. Our findings suggest that surveillance within 1 year may be of low yield. Further clinical trials and cohort studies investigating cost-effectiveness of surveillance schedules and impact on quality of life of patients under surveillance will provide further insight to optimize follow-up.

Facial Nerve Paralysis and COVID-19: A Systematic Review.

OBJECTIVE: Several cases of facial nerve paralysis (FNP) post-COVID-19 infection have been reported with varying presentations and management. This study aims to identify FNP clinical characteristics and recovery outcomes among patients acutely infected with COVID-19. We hypothesize that FNP is a potentially unique sequalae associated with COVID-19 infections. METHODS: A systematic review of PubMed-Medline, OVID Embase, and Web of Science databases from inception to November 2021 was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: This search identified 630 studies with 53 meeting inclusion criteria. This resulted in 72 patients, of which 30 (42%) were diagnosed with Guillain-Barré Syndrome (GBS). Non-GBS patients were on average younger (36 vs. 53 years) and more likely to present with unilateral FNP (88%) compared to GBS patients who presented predominantly with bilateral FNP (74%). Among non-GBS patients, majority (70%) of FNP presented a median of 8 [IQR 10] days after the onset of initial COVID-19 symptom(s). Treatment for non-GBS patients consisted of steroids (60%), antivirals (29%), antibiotics (21%), and no treatment (21%). Complete FNP recovery in non-GBS patients was achieved in 67% patients within a median of 11 [IQR 24] days. CONCLUSION: FNP is a possible presentation post COVID-19 infections, associated with both GBS and non-GBS patients. Although no causation can be assumed, the clinical course of isolated FNP associated with COVID-19 raises the possibility of a unique presentation differing from Bell's palsy, seen with higher proportion of patients developing bilateral FNP and a shorter duration to complete recovery. Laryngoscope, 133:1007-1013, 2023.

Porcine small intestine graft for reconstruction of oral defects.

OBJECTIVE: To evaluate the feasibility and outcomes of porcine submucosal allograft (Biodesign Sinonasal Repair Graft [Cook Medical, Bloomington, IN]) in oral cavity and oropharynx reconstruction after ablative surgery. METHODS: We conducted a prospective and retrospective review of patients who underwent Biodesign Sinonasal Repair Graft reconstruction for oral and oropharyngeal surgical defects at a single institution between 2018 and 2020. A total of 11 patients were included in the study. Data points included their perioperative medical and demographic data, immediate postoperative course, and follow-up visits at 10 days and at 2 months. The clinicopathologic characteristics of their disease, postoperative esthetic, and functional outcomes were recorded and analyzed. RESULTS: Eleven procedures have been performed, and all patients received Biodesign reconstruction either immediately after ablation or after they failed a previous reconstruction. None of the patients had bone exposure. The subsites included oral tongue (n = 6), floor of the mouth (n = 3), buccal mucosa (n = 1), and soft palate (n = 1). In all cases, the operations and the postoperative course were uneventful. The mean defect size was 22 cm2. The median start of oral intake was at 2 days postoperatively. The Biodesign graft healed well in all patients with no total graft loss. There was one complication that required revision surgery due to obstruction of Wharton's duct by the Biodesign material. CONCLUSIONS: Biodesign can be a viable option for small and medium-sized oral and oropharyngeal defects in patients who are medically unfit or do not want to undergo a free flap surgery. LEVEL OF EVIDENCE: 4.

A novel DNAH11 variant segregating in a sibship with heterotaxy and implications for genetic counseling.

BACKGROUND: Isomerism or heterotaxy syndrome is the loss of normal asymmetry of the internal thoraco-abdominal organs in the left-right axis and is associated with cardiovascular malformations. Mutations within DNAH11 can be associated with primary ciliary dyskinesia and heterotaxy syndromes. METHODS: We report a family of healthy, nonconsanguinous parents with subsequent pregnancies demonstrating a novel likely pathogenic variant in DNAH11 segregating in a sibship with varied presentations. RESULT: The first affected pregnancy presented with right atrial isomerism. Further DNA testing identified three variants in DNAH11 related to primary ciliary dyskinesia: a maternally inherited heterozygous variant of unknown significance (VUS) c.2772G>A (p.Met924Ile), a maternally inherited novel likely pathogenic variant c.11662C>T (p.Arg3888Cys) as well as a paternally inherited pathogenic c.1648delA variant (p.Arg550GlyfsX16). The second pregnancy inherited the same variants including the pathogenic and likely pathogenic DNAH11 variants and presented with left isomerism and extracardiac abnormalities. CONCLUSION: We present a novel likely pathogenic variant (c.11662C>T) in DNAH11 that has manifested in heterotaxy with variability in phenotypes for subsequent pregnancies of common parents. This report demonstrates that sibship illustrates potential variability in phenotypes associated with the same pathogenic variants within a family and highlights the difficulty in genetic counseling due to the variation in clinical presentation.

Postoperative Monitoring Following Adenotonsillectomy for Severe Obstructive Sleep Apnea.

INTRODUCTION: Patients undergoing adenotonsillectomy (T&A) for severe obstructive sleep apnea (OSA) are usually admitted for observation, and many surgeons use the intensive care unit (ICU) for observation due to the risk of postsurgical airway obstruction. Given the limited resources of the pediatric ICU (PICU), there is a push to better define the patients who require postoperative monitoring in the PICU for monitoring severe OSA. METHODS: Forty-five patients were evaluated. Patients who had cardiac or craniofacial comorbidities were excluded. Patients undergoing T&A for severe OSA were monitored in the postanesthesia care unit (PACU) postoperatively. If patients required supplemental oxygen or developed hypoxia while in the PACU within the 3-hour monitoring period, they were admitted to the PICU. RESULTS: Overall, 16 of 45 patients were admitted to the ICU for monitoring. Patients with an Apnea-Hypopnea Index (AHI) >50 or with an oxygen nadir <80% were significantly more likely to be admitted to the PICU. The mean AHI of patients admitted to the PICU was 40.5, and the mean oxygen nadir was 69.9%. Patients younger than 2 years were significantly more likely to be admitted to the PICU. CONCLUSION: Based on the data presented here and academy recommendations, not all patients with severe OSA require ICU monitoring.

Comparing Cancellous Bone Volume of the Manubrium to Iliac Crest in Fresh Cadavers.

Objective The iliac crest is the gold standard for cancellous bone grafting. This site is distant from head and neck reconstruction and may lead to significant postoperative morbidity. We propose an alternative harvest site within the head and neck with potentially less mobility deficits, the manubrium. Study Design Fresh-frozen cadaveric study. Setting Gross anatomy laboratory. Subjects and Methods Access to 18 cadavers was granted from the Medical Education and Research Institute in Memphis, Tennessee. The anterior iliac crests were exposed and H-type osteotomies performed. The manubrium was accessed through a substernal notch incision and a cortical window created through the anterior manubrium. Cancellous bone was harvested from these sites. Cadaveric demographics and noncompressed and compressed volumes were recorded with statistical comparisons. Results The population was predominantly male (12/18) with a mean age of 69.6 (95% confidence interval [CI], 64.0-75.3) years. The mean body mass index was 22.9 (95% CI, 18.8-27.1) kg/m2 with no sex propensity. Uncompressed volumes did not vary, ranging from 6.4 to 7.5 mL. Compressed volumes (mL) for the right iliac crest (4.3; 95% CI, 3.0-5.6), left iliac crest (3.5; 95% CI, 2.7-4.2), and manubrium (2.4; 95% CI, 1.8-3.0) varied (1-way analysis of variance: F(2, 51) = 4.63; P < .02). Furthermore, there was correlation between compressed volumes taken from either area ( r = 0.58; P < .02). Conclusions The manubrium can be used for cancellous bone grafting. This site affords a proximity to the head and neck rather than the distant iliac crest but with slightly lower yields. Potential applications include reconstructing small mandibular defects, mandible nonunion, or alveolar bone grafting.

Video-Enhanced Telemedicine Improves the Care of Acutely Injured Burn Patients in a Rural State.

The acute care of burn patients is critical and can be a daunting experience for emergency personnel because of the scarcity of burn injuries. Telemedicine that incorporates a visual component can provide immediate expertise in the treatment and management of these injuries. The authors sought to evaluate the addition of video telemedicine to our current telephone burn transfer program. During a 2-year period, 282 patients, 59.4% of all burn patients transferred from outside hospitals, were enrolled in the study. In addition to the scripted call with the charge nurse (ChargeRN) and the accepting physician, nine hospitals also transmitted video images of the wounds before transfer as part of a store and forward telemedicine transfer program (77, 27.6%). The accuracy of burn size estimations (BSA burned) and management changes (fluid requirements, transfer mode, and final disposition) were analyzed between the telephones-only sites (T only) and the video-enhanced sites. Referringstaff participating in video-enhanced telemedicine were sent a Google survey assessing their experience the following day. The referring staff (Referringstaff) was correct in their burn assessment 20% of the time. Video assessment improved the ChargeRN BSA burned and resulted in more accurate fluid resuscitation (P = .030), changes in both transportation mode (P = .042), and disposition decisions (P = .20). The majority of the Referringstaff found that video-enhanced telemedicine helped them communicate with the burn staff more effectively (3.4 ± 0.37, scale 1-4). This study reports the successful implementation of video-enhanced telemedicine pilot project in a rural state. Video-enhanced telemedicine using a store and forward process improved burn size estimation and facilitated management changes. Although not quantitatively assessed, the low cost of the system coupled with the changes in transportation and disposition strongly suggests a decrease in healthcare costs associated with the addition of video to a telephone-only transfer program.

An Evaluation of Factors Related to Postoperative Pain Control in Burn Patients.

Satisfactory treatment of burn pain continues to be elusive. The perioperative period is particularly challenging. The contributions of acute tolerance and opioid-induced hyperalgesia have not been previously explored in burn patients. As these phenomena have been identified perioperatively in other patient populations, we sought to characterize the burn perioperative period and to determine variables associated with poor postoperative (post-OR) pain control. A retrospective review of 130 adult burn patients who underwent surgical treatment for their burn injuries was performed. Variables collected included: demographics, burn injury data, perioperative self-reported pain scores, and perioperative opioid amounts. Correlations and multiple logistic regressions were used to assess the relationship between these variables and post-OR pain control. Pain increased throughout the perioperative period from 2.64 24 hours prior to the operation (pre-OR) to 3.81 24 hours following the OR (post-OR, P < .0001). Post-OR pain was correlated with pre-OR pain, pre-OR opioid amounts, OR opioid amounts, and post-OR opioid amounts. When the subgroup of patients with controlled pre-OR pain (<3 pain rating) was analyzed, only pre-OR opioids and post-OR opioids remained correlated with worse post-OR pain. While this study is retrospective, there is a suggestion that opioid amounts given pre-OR and intraoperatively are correlated with worse post-OR pain. While an increase in pain ratings postoperatively are anticipated, the additional contributions of acute tolerance and opioid-induced hyperalgesia need to be determined. Pharmacologic intervention directed at these mechanisms can then be administered to achieve better postoperative pain control.

A novel supermicrosurgery training model: the chicken thigh.

BACKGROUND: Supermicrosurgery is an increasingly important technique in reconstructive surgery. It requires a more technically refined skill set compared with standard microsurgery. All currently available biologic training models involve the use of live rats. A nonliving model would be more accessible and cost-effective for practice. We have developed such a model using chicken thighs purchased from a local grocery store. METHODS: The ischiatic neurovascular bundle was identified in 20 chicken thighs and dissected distally to the end of the specimen. The vessel diameters were measured at several points along the artery, vein, and their respective branches. Vessels with diameters in the 0.3-0.8-mm range were then divided and supermicrosurgical anastomoses were attempted. RESULTS: The branching pattern of the ischiatic artery and vein were anatomically consistent with intermediate and terminal secondary and tertiary branches consistently in the range of 0.3-0.8 mm. In all specimens, at least one 0.3-mm vessel could be identified, though additional intramuscular dissection was sometimes required. It was demonstrated that supermicrosurgical anastomoses could be successfully performed using these branches. CONCLUSIONS: This study introduces a novel, convenient, and economical model for supermicrosurgery utilizing easily obtained chicken thighs. The chicken thighs have an anatomically consistent vascular branching pattern, and vessels of appropriate sizes for training can be easily identified and isolated. Surgeons looking to develop or refine supermicrosurgical skills may find this nonliving, biologic model very useful.

Gabapentin is ineffective as an analgesic adjunct in the immediate postburn period.

Successful treatment of burn pain requires a multimodality approach. Although opioid agents are the mainstay, other nonopioid agents, such as anticonvulsants, are frequently employed for pain control, with unknown benefits. The authors sought to determine the efficacy of gabapentin in acute burn pain management. Patients admitted to the burn center with burns more than 5% total body surface area and expected length of stay more than 48 hours were randomized and prospectively enrolled in this double-blind, placebo-controlled study from February 2010 to September 2011. Drug escalation and titration were done by protocol. Pain was assessed by unit protocol with the Numeric Rating Scale. Neuropathic pain and anxiety were recorded at least biweekly. Psychosocial adjustment was assessed at follow-up. Opioid medications were converted to morphine equivalents. Differences between pain levels and opioid consumption were analyzed between groups with the Student's t-test and χ test, respectively. The study was designed to detect a difference of 22% in opioid use between the two study groups with an enrollment of 50 patients with α of 0.05 and ß of 80%. P < .5 was considered significant. Fifty-three patients consented for the study and received the loading dose. Four patients withdrew. Both an intention-to-treat and actual treatment analysis were performed on all 53 patients. The placebo and drug populations were well matched for demographic variables, body surface area burned, and need for surgical intervention. The average length of stay was 11 ± 6.8 days and did not vary between groups. The study drug group received 10.8 ± 0.67 days of study drug, with eight patients receiving a dosage of 300 mg thrice daily (TID), 24 receiving 600 mg TID, 14 receiving 800 mg TID, and seven receiving 1200 mg TID. The incidence of neuropathic pain was 39% in the study drug arm and 38% in the placebo group. Neither pain scores (rest and procedural) nor opioid consumption differed between the groups. Forty-three patients (81.1%) were assessed at their first clinic visit. There was no difference in psychosocial functioning in either treatment group. In this randomized, double-blind, placebo-controlled study, the use of gabapentin in acute burn pain management did not decrease pain scores or lessen opioid requirements. Further research into nonopioid alternatives for burn pain analgesia is needed.

Roux-en-Y gastric bypass achieves substantial resolution of migraine headache in the severely obese: 9-year experience in 81 patients.

BACKGROUND: Although migraine headache (MH) is more severe in the obese, the risk of developing MH in the obese population is controversial. The effect of surgical weight loss on morbidly obese patients with MH provides a unique opportunity to evaluate this potential association. METHODS: We analyzed the data from 702 morbidly obese patients who underwent Roux-en-Y gastric bypass (RYGB) from 2000 to 2009. We identified patients with physician-diagnosed MH taking antimigraine medication. RESULTS: The data are presented as the mean ± SEM, with the range in parentheses. Of the 102 patients with preoperative MH, 21 were excluded because they had <12-month follow-up data and 81 were followed up for 38.6 ± 3 months (range 12-123). Of the 81 patients, 90% were women. Their body mass index was 48 ± 1 kg/m(2) (range 37-85), and their age was 40 ± 1 years (range 18-62). After surgical weight loss, clinical improvement in MH was seen in 89% of patients within 5.6 ± .9 months (range 1-36; P < .01, chi-square test), with 57 reporting total resolution and 15 reporting partial resolution (9 experienced no change). Using logistic regression analysis, we showed that the improvement in MH after RYGB was independent of the improvement in migraine-associated co-morbidities, such as sleep apnea, menstrual dysfunction, depression, and anxiety. We also compared patients who developed MH after obesity onset with those who had MH before obesity. The MH after obesity onset group included 51 patients, of whom 48 showed clinical improvement (41 complete, 7 partial, and 3 no improvement). The MH before obesity group included 24 patients, of whom 18 showed clinical improvement (11 complete, 7 partial, and 6 no improvement). The MH after obesity group showed a greater rate of complete resolution of MH after RYGB than did the MH before obesity group (P < .01; chi-square test). CONCLUSIONS: Weight loss after RYGB substantially resolves MH, especially when obesity onset precedes MH onset. It remains to be determined whether RYGB-induced endocrine alterations or a reduction in adipokine burden contribute to migraine improvement.

Trauma and burn education: a global survey.

BACKGROUND: The World Health Assembly recently adopted a resolution to urge improved competency in the provision of injury care through medical education. This survey sought to investigate trauma education experience and competency among final year medical students worldwide. METHODS: An Internet survey was distributed to medical students and conducted from March 2008 to January 2009. Demographic data and questions pertaining to both instruction and attainment of specific skills in burn and trauma care were assessed. RESULTS: There were 776 responses from final year medical students in 77 countries, with at least 10 countries from each economic stratum. Over 93% of final year students reported receiving some form of trauma or burn training, with 79% reporting a minimum compulsory requirement. Students received theoretical instruction without practical exposure. Few felt prepared to undertake basic procedures, such as laceration repair (19%), vascular access (8%), or endotracheal intubation (21%). Over 99% agreed that trauma education should be mandatory, but only half felt prepared to provide basic care. Those from low income and low middle income countries felt better prepared to provide trauma care than students from high middle and high income countries. CONCLUSIONS: Trauma education and experience varies among medical students in different countries. Many critical concepts are not formally taught and practical experience with many basic procedures is often lacking. The present study confirms that the trauma care training received by medical students needs to be strengthened in countries at all economic levels.

Roux-en-Y gastric bypass ameliorates polycystic ovary syndrome and dramatically improves conception rates: a 9-year analysis.

BACKGROUND: Polycystic ovary syndrome (PCOS) is a common cause of infertility, especially in the morbidly obese. We evaluated the long-term effects of Roux-en-Y gastric bypass on PCOS and infertility. METHODS: A total of 566 morbidly obese women underwent Roux-en-Y gastric bypass from 2000 to 2009. A total of 31 patients (5.5%) had a history of PCOS. Of the 31 patients, 6 were postmenopausal and 5 lost to follow-up and were excluded. Telephone interviews were conducted with the 20 eligible patients. RESULTS: The mean age and body mass index was 32 ± 5.8 years (range 22-42) and 52.8 ± 9.08 kg/m(2) (range 37-76) before surgery. All 20 patients had ≥ 2 of 3 diagnostic criteria for PCOS, including clinical or biochemical evidence of hyperandrogenism, anovulation, or polycystic ovaries. Of these, 85% had oligomenorrhea, 70% had hirsutism, and 45% had type 2 diabetes mellitus with medication. Before surgery, 8 patients conceived with or without hormonal treatment, 2 did not desire pregnancy, and 10 did not conceive. The mean follow-up was 46.7 months. After surgical weight loss, menstruation was corrected in 82%, hirsutism had resolved in 29%, and 77.8% of those with diabetes had complete remission. Of the 10 patients who did not conceive before surgery, 4 no longer desired pregnancy, and the remaining 6 patients had become pregnant within 3 years of surgery-5 without any hormonal treatment and 1 with in utero insemination. CONCLUSION: Surgical weight loss after Roux-en-Y gastric bypass achieves excellent amelioration of PCOS manifestations and the postoperative conception rate in infertile PCOS subjects desiring pregnancy was 100%.