An Uncommon Case of Upper-Extremity Mucormycosis in a Patient With Acute Myeloid Leukemia.

Upper-extremity mucormycosis is a rare, life-threatening fungal infection mainly affecting immunocompromised patients. We report a case of a 30-year-old woman with acute myelogenous leukemia who developed this infection during her hospital stay. The culprit was Mucorales, a subgroup of Zygomycetes species known for fast-progressing, highly lethal infections. She presented with fever, chills, and a lesion on her left forearm that worsened despite initial broad-spectrum antibiotics. A punch biopsy confirmed the diagnosis, leading to antifungal therapy with isavuconazonium sulfate and later amphotericin B, combined with surgery. Timely intervention is critical because delayed treatment can result in severe complications and death. Early suspicion, histology, microscopy, and fungal cultures are vital for accurate diagnosis. Treatment primarily involves amphotericin B, whereas adjunctive therapies such as topical amphotericin B and hyperbaric oxygen show promise. This case underscores the importance of prompt medical and surgical action, enhancing early detection of mucormycosis in immunocompromised patients.

Cadaveric Meniscus Arthroplasty for Post-Traumatic Arthritis: A Case Report.

We present a novel treatment for post-traumatic arthritis of the hand and fingers using joint resurfacing with cadaveric meniscus. A 20-year-old man presented to the clinic with chronic pain and stiffness after an intra-articular fifth metacarpal fracture. Meniscus allograft, which has been used successfully in treatments for thumb carpometacarpal and radiocarpal degenerative osteoarthritis, was used to reconstruct the joint surface with complete resolution of stiffness and pain.

Peripheral nerve stimulation for saphenous neuralgia.

BACKGROUND: Injury to saphenous nerve branches is frequent during knee surgery and can result in chronic pain. This saphenous neuralgia remains challenging to treat. Peripheral nerve stimulation (PNS) is a new potential non-pharmacologic treatment option. We present our outcomes experience using this technology in 12 patients. METHODS: We retrospectively reviewed PNS placement for saphenous neuralgia between 2000 and 2022 at a single institution. Demographic information was collected as well as response to the device. Four-question short-form Patient-Reported Outcome Measurement Information System (PROMIS) Scores were collected before and 2 weeks, 6 weeks, and 6 months postprocedure. Specific scores included pain interference and behavior, functional mobility, depression, anxiety, and sleep impairment. Change in pain interference measured by the short-form PROMIS tool at 6 months was chosen as the primary outcome. RESULTS: Twelve patients met inclusion criteria, with 10 patients having the full 6-month follow-up. In these 10 patients, the mean change from baseline in the short-form adjusted pain interference score (greater difference means improved pain) at 6 months was 5.8 (SD 6.5). Among all patients, average follow-up was 11.5 months (range 3-35 months). Most patients' symptoms developed after knee surgery (84%). Prior to PNS, patients underwent other treatments including cryoablation (8%), radiofrequency ablation (16%), saphenous neurectomy (16%), or surgical release of adjacent nerves (25%). Ten patients (83%) reported any improvement in symptoms while two reported no benefit. Complications occurred in four patients (33%). Two patients had the device removed and a third discontinued use. PROMIS Scores for pain, functional mobility, mood, and sleep impairment all improved. DISCUSSION: Limited effective treatments exist for saphenous neuralgia. Our case series demonstrates the potential of PNS as a treatment for saphenous neuralgia. Comparative effectiveness studies are warranted to assess whether our effect size is clinically relevant.

Capacity Assessment Tool to Promote Capacity Building in Global Orthopaedic Surgical Outreach.

BACKGROUND: A growing number of nongovernmental organizations from high-income countries aim to provide surgical outreach for patients in low- and middle-income countries in a manner that builds capacity. There remains, however, a paucity of measurable steps to benchmark and evaluate capacity-building efforts. Based on a framework for capacity building, the present study aimed to develop a Capacity Assessment Tool for orthopaedic surgery (CAT-os) that could be utilized to evaluate and promote capacity building. METHODS: To develop the CAT-os tool, we utilized methodological triangulation-an approach that incorporates multiple different types of data. We utilized (1) the results of a systematic review of capacity-building best practices in surgical outreach, (2) the HEALTHQUAL National Organizational Assessment Tool, and (3) 20 semistructured interviews to develop a draft of the CAT-os. We subsequently iteratively used a modified nominal group technique with a consortium of 8 globally experienced surgeons to build consensus, which was followed by validation through member-checking. RESULTS: The CAT-os was developed and validated as a formal instrument with actionable steps in each of 7 domains of capacity building. Each domain includes items that are scaled for scoring. For example, in the domain of partnership, items range from no formalized plans for sustainable, bidirectional relationships (no capacity) to local surgeons and other health-care workers independently participating in annual meetings of surgical professional societies and independently creating partnership with third party organizations (optimal capacity). CONCLUSIONS: The CAT-os details steps to assess capacity of a local facility, guide capacity-improvement efforts during surgical outreach, and measure the impact of capacity-building efforts. Capacity building is a frequently cited and commendable approach to surgical outreach, and this tool provides objective measurement to aid in improving the capacity in low and middle-income countries through surgical outreach.

The Impact of Virtual Reality on the Patients and Providers Experience in Wide-Awake, Local-Only Hand Surgery.

Purpose: Virtual reality (VR) is an emerging technology with the potential to enhance patient care by reducing pain and anxiety for a variety of medical procedures. The aim of this study was to evaluate an immersive VR program as a nonpharmacologic intervention to reduce anxiety and increase satisfaction in patients undergoing wide-awake, local-only hand surgery. The secondary aim was to assess providers' experience with the program. Methods: An implementation evaluation was employed to assess the experience of 22 patients who used VR during outpatient, wide-awake hand surgery at a veterans affairs hospital. We assessed the patients' anxiety scores and vital signs before and after the procedure as well as postprocedural satisfaction measures. The providers' experience was also assessed. Results: Patients who used VR exhibited lower anxiety scores after the procedure compared with what they exhibited before the procedure and had high satisfaction levels with their VR experience. Surgeons who used the system reported that VR improved their ability to teach learners and better focus on the procedure. Conclusions: Virtual reality, as a nonpharmacologic intervention, reduced anxiety and contributed to the patients' perioperative satisfaction with wide-awake, local-only hand surgery. As a secondary finding, VR positively impacted the providers' experience by increasing their ability to concentrate on tasks during the surgery. Clinical relevance: Virtual reality represents a novel technology that can reduce anxiety and contribute to a positive experience for both patients and providers during wide-awake, local-only hand procedures.

Capacity Building During Short-Term Surgical Outreach Trips: A Review of What Guidelines Exist.

INTRODUCTION: While short-term surgical outreach trips improve access to care in low- and middle-income countries (LMIC), there is rising concern about their long-term impact. In response, many organizations seek to incorporate capacity building programs into their outreach efforts to help strengthen local health systems. Although leading organizations, like the World Health Organization (WHO), advocate for this approach, uniform guidelines are absent. METHODS: We performed a systematic review, using search terms pertaining to capacity building guidelines during short-term surgical outreach trips. We extracted information on authorship, guideline development methodology, and guidelines relating to capacity building. Guidelines were classified according to the Global-QUEST framework, which outlines seven domains of capacity building on surgical outreach trips. Guideline development methodology frequencies and domain classifications frequencies were calculated; subsequently, guidelines were aggregated to develop a core guideline for each domain. RESULTS: A total of 35 studies were included. Over 200 individual guidelines were extracted, spanning all seven framework domains. Guidelines were most frequently classified into Coordination and Community Impact domains and least frequently into the Finance domain. Less than half (46%) of studies collaborated with local communities to design the guidelines. Instead, guidelines were predominantly developed through author trip experience. CONCLUSION: As short-term surgical trips increase, further work is needed to standardize guidelines, create actionable steps, and promote collaborations in order to promote accountability during short-term surgical outreach trips.

Functional Outcomes for Basilar Joint Arthroplasty with Meniscus Allograft Compared with Trapeziectomy Alone.

BACKGROUND: Advanced thumb carpometacarpal (CMC) joint arthritis is widely treated with trapeziectomy. To obviate the need for autologous tissue, maintain thumb length, and reduce the risk of scaphoid impingement, the senior author developed an interposition arthroplasty technique using meniscal allograft. We hypothesize that the use of meniscus improves outcomes and subsequent functionality compared with trapeziectomy alone. METHODS: Twenty-three patients with Eaton stage III-IV CMC osteoarthritis underwent arthroplasty with meniscal allograft, and 7 patients underwent trapeziectomy alone. Preoperative Disabilities of the Arm, Shoulder, and Hand (DASH), pain, grip and pinch strength, and range of motion scores were compared with postoperative scores at 6 weeks, 6 months, and 1 year. RESULTS: The study group consisted of 17 women and 6 men, and the control group consisted of 5 women and 2 men. The mean age was similar at 61.4 (48-72) years and 65.7 (56-78) years for the study and control groups, respectively. The DASH scores dropped by 61.8% in the study group compared with 38.8% in the control group (<0.01), whereas pain decreased 86.0% and 69.8%, respectively (P < .01). Strength and range of motion improvement was similar between the groups. Subsidence of the joint space was 1% in the study group compared with 18.4% in the control group. There were no surgical complications in either group. CONCLUSIONS: Joint resurfacing with meniscal allograft represents a viable joint salvage option in severe cases of CMC arthritis. Early results suggest that, compared with trapeziectomy alone, the approach results in greater reduction in subjective pain and disability scores, similar improvement in strength measures and range of motion, and less subsidence.

Surgical Complexity and Physician Compensation: An Analysis of Relative Under-Valuation for Pediatric Brachial Plexus Surgery.

BACKGROUND: Brachial plexus reconstruction (BPR) is a rapidly advancing field within hand surgery. BPR procedures are complex, time-intensive, and require microsurgical expertise. As physician reimbursement rates for BPR are poorly defined, relative to more common hand procedures, we sought to analyze compensation for BPR across different payor groups and understand the factors contributing to their reimbursement. METHODS: A retrospective review was performed of surgeries by a single senior staff member in a 4-year period to evaluate Current Procedural Terminology (CPT) codes from BPR cases. For comparison, all finger fracture fixations and skin graft reconstructions performed by the same surgeon over the same time period were analyzed as well. RESULTS: A total of 57 BPR cases, 94 finger fracture fixation cases, and 69 skin grafting cases met inclusion criteria. Among the top 5 insurance providers, average work relative value unit (wRVU)/hour was 6.55, 3.49, and 12.67 for BPR, fracture fixation, and skin grafts, respectively. Reimbursements were an average $685.76/hour for BPR, compared to $590.10/hour for fracture fixation and $1,197.94/hour for skin grafts. CONCLUSIONS: BPR demonstrates a relative undervaluation, in terms of reimbursement per hour, given the time and surgical skill required for such cases, particularly compared to shorter, less complex cases such as skin grafting and fracture fixation. We find that this discrepancy is amplified across multiple levels of coding, billing, and reimbursement. We suggest specific strategies for physician leadership to more directly participate in the financial decisions that affect themselves, their patients, and their specialty.

The Smile Index: Part 3. A Simple, Prognostic Severity Scale for Unilateral Cleft Palate.

BACKGROUND: Unilateral cleft palates have a large spectrum of variability. Key morphologic factors such as cleft width and palatal length are not represented in current classification systems. Palate length and velopharyngeal port size are clinically linked to speech outcomes, as the soft palate must close the posterior pharynx for proper phonation. This study investigates the relationship between objective preoperative measures and postoperative velopharyngeal port size, to define a reproducible severity scale. METHODS: Surgical data were prospectively collected from unilateral cleft palate patients in Morocco, Bolivia, Vietnam, and Madagascar. Key measurements were cleft width and palate width at the hard-soft palate junction, alveolar cleft width, vertical alveolar discrepancy, velopharyngeal port size. Cleft width ratio (CWR) was defined as the width of the cleft at the hard-soft junction, divided by the palate width. RESULTS: Seventy-six patients were evaluated. Thirty-one had complete clefts and average age at surgical repair was 2.9 years. Mean CWR was 0.50 ± 0.12. Palate length was increased by an average of 2.2 mm (11%) after palatoplasty. Multivariate analysis determined greater CWR and larger preoperative velopharyngeal ports were significantly correlated with a smaller percent change in palate length after palatoplasty (P < 0.01). CONCLUSIONS: A wider palatal cleft decreases the surgeon's ability to decrease velopharyngeal port size through palatoplasty. Given the ease of measurement even in low-resource settings, CWR may be a valuable tool for setting expectations for speech results, modifying surgical technique, and correlating future speech outcomes in evidence-based cleft care.

Convolutional Neural Network Models for Automatic Preoperative Severity Assessment in Unilateral Cleft Lip.

BACKGROUND: Despite the wide range of cleft lip morphology, consistent scales to categorize preoperative severity do not exist. Machine learning has been used to increase accuracy and efficiency in detection and rating of multiple conditions, yet it has not been applied to cleft disease. The authors tested a machine learning approach to automatically detect and measure facial landmarks and assign severity grades using preoperative photographs. METHODS: Preoperative images were collected from 800 unilateral cleft lip patients, manually annotated for cleft-specific landmarks, and rated using a previously validated severity scale by eight expert reviewers. Five convolutional neural network models were trained for landmark detection and severity grade assignment. Mean squared error loss and Pearson correlation coefficient for cleft width ratio, nostril width ratio, and severity grade assignment were calculated. RESULTS: All five models performed well in landmark detection and severity grade assignment, with the largest and most complex model, Residual Network, performing best (mean squared error, 24.41; cleft width ratio correlation, 0.943; nostril width ratio correlation, 0.879; severity correlation, 0.892). The mobile device-compatible network, MobileNet, also showed a high degree of accuracy (mean squared error, 36.66; cleft width ratio correlation, 0.901; nostril width ratio correlation, 0.705; severity correlation, 0.860). CONCLUSIONS: Machine learning models demonstrate the ability to accurately measure facial features and assign severity grades according to validated scales. Such models hold promise for the creation of a simple, automated approach to classifying cleft lip morphology. Further potential exists for a mobile telephone-based application to provide real-time feedback to improve clinical decision making and patient counseling.

Functional Outcomes for Meniscal Allograft Interposition Arthroplasty of the Hand.

BACKGROUND: Osteochondral defects of the carpometacarpal (CMC), metacarpophalangeal (MCP), and proximal interphalangeal (PIP) joints often necessitate arthrodesis or arthroplasty. Meniscal allograft has been used for large joint resurfacing, but its application to smaller joints is less well understood. We propose its use for hand joint resurfacing as an off-the-shelf alternative to address osteochondral defects and restore articular function. METHODS: Thirty-one patients with osteoarthritis of the CMC, MCP, or PIP joints underwent arthroplasty with meniscal allograft. Patient demographics and operative information were recorded. Preoperative Disability of the Shoulder, Arm, and Hand, Wong Baker pain, grip and pinch strength, and range of motion were compared to postoperative scores at 6 weeks, 6 months, and 1 year. RESULTS: Twenty-three women and 8 men, mean age 62.8 years, underwent 39 joint reconstructions, including CMC (n = 26), thumb MP (n = 2), thumb IP (n = 2), digit MP (n = 2), and digit PIP (n = 7). At 1 year, mean Disability of the Shoulder, Arm, and Hand scores decreased from 41.3 to 15.6 (P < 0.001) and pain scores from 6.9 to 1.0 (P < 0.001). Grip strength increased from 38.1 to 42.9 (P = 0.017) and radial and palmar abduction from 43.1 to 49.2 (P = 0.039) and 43.7 to 51.6 (P = 0.098), respectively. There were no complications related to the meniscus. CONCLUSIONS: Meniscal allograft represents an alternative to arthrodesis which obviates the need for a donor site and avoids many of the complications inherent to synthetic alternatives. Our early results demonstrate its successful use to reduce subjective pain and disability scores, improve objective strength measures, and maintain range of motion.

The Use of Crowdsourcing Technology to Evaluate Preoperative Severity in Patients With Unilateral Cleft Lip in a Multiethnic Population.

ABSTRACT: Crowd sourcing has been used in multiple disciplines to quickly generate large amounts of diverse data. The objective of this study was to use crowdsourcing to grade preoperative severity of unilateral cleft lip phenotype in a multiethnic cohort with the hypothesis that crowdsourcing could efficiently achieve similar rankings compared to expert surgeons. Deidentified preoperative photos were collected for patients with primary, unilateral cleft lip with or without cleft palate (CL ±â€ŠP). A platform was developed with C-SATS for pairwise comparisons utilizing Elo rankings by crowdsource workers through Amazon Mechanical Turk. Images were independently ranked by 2 senior surgeons for comparison. Seventy-six patients with varying severity of unilateral (CL ±â€ŠP) phenotype were chosen from Operation Smile missions in Bolivia, Madagascar, Vietnam, and Morocco. Patients were an average of 1.2 years' old, ranging from 3 months to 3.3 years. Each image was compared with 10 others, for a total of 380 unique pairwise comparisons. A total of 4627 total raters participated with a median of 12 raters per pair. Data collection was completed in <20 hours. The crowdsourcing ranking and expert surgeon rankings were highly correlated with Pearson correlation coefficient of R = 0.77 (P = 0.0001). Crowdsourcing provides a rapid and convenient method of obtaining preoperative severity ratings, comparable to expert surgeon assessment, across multiple ethnicities. The method serves as a potential solution to the current lack of rating systems for preoperative severity and overcomes the difficulty of acquiring large-scale assessment from expert surgeons.

A Sustainable Approach to Prepectoral Breast Reconstruction Using Meshed Acellular Dermal Matrix.

BACKGROUND: Prepectoral implant-based breast reconstruction provides an alternative to submuscular reconstruction, but the increased acellular dermal matrix (ADM) required has the potential to lead to increased costs and decreased supply of this limited-resource material. We present a method for prepectoral reconstruction utilizing skin-graft meshing techniques to increase the surface area of usable ADM. METHODS: Forty-four patients underwent this technique from February 2019 to February 2020. Patient characteristics, operative details, and outcomes, including complications and patient satisfaction utilizing the BREAST-Q, were analyzed. Cost analysis relative to projected cost of nonmeshed techniques was performed. RESULTS: There were 20 unilateral and 24 bilateral procedures, for a total of 68 breast reconstructions. Mean age was 45.9 years (32-71). Mean implant volume was 485 cm3 (265-800), and one sheet of ADM was used for each breast with an average surface area of 161 cm2. Median follow-up was 350 days (212-576). Minor complications included an infection treated with oral antibiotics. Major complications included one axillary hematoma and one delayed implant loss. One patient underwent revision for asymmetry. Mean BREAST-Q score was 47.4/60. Cost ranged from $4113 to 5025 per breast, compared with the projected $9125-18250 per breast for other techniques in the literature. CONCLUSIONS: In contrast to previously described uses of ADM in prepectoral reconstruction, meshing maximizes resource utilization by expanding the coverage of a single sheet. Early findings demonstrate minimal complications and high patient satisfaction, suggesting the approach has potential to provide the benefits of prepectoral reconstruction while responsibly preserving product availability and tempering healthcare costs.

A 5-Year Review of the Designated Leadership Positions of the American Society for Surgery of the Hand (ASSH).

PURPOSE: Despite near equal representation of women in medical schools since 2008, the percentage of women in surgical subspecialties has remained low. Hand surgery accounts for one of the highest percentages of women, at 19%. Ascension to leadership positions has not yet been fully studied among this group. Our study examined whether increased female representation translated to representation at different levels within the organization. METHODS: The 2014 to 2018 membership rosters were obtained from the American Society for Surgery of the Hand (ASSH) and compared by gender. Leadership and volunteer committee positions were evaluated as published in the annual ASSH Committee Reference Book. Leadership positions were defined as appointment to committee chair or Council or acceptance to the Young Leaders Program. Rates of engagement were compared for each of the leadership activities. When available, the time for advancement through various leadership positions was also analyzed by gender. RESULTS: Between 2014 and 2018, the percentage of female ASSH Active Members steadily increased from 11% to 14%. Engagement in early career activities such as committees and the Young Leaders Program also increased: committee positions from 16% to 17% and Young Leaders Program membership from 27% to 40% female representation across the same period. Relative to the overall number of eligible females in the society, women applied at a greater rate and achieved positions at an average of 2 years earlier than their male counterparts. CONCLUSIONS: There is a steady increase in the percentage of women within the ASSH. Female ASSH members applied for early career leadership positions at a higher rate and achieved these positions earlier than their male counterparts. This may indicate that future women leaders are appropriately supported in the organization. CLINICAL RELEVANCE: The ASSH has been committed to increasing gender and ethnic diversity. Early analysis demonstrates an increase in women surgeons' participation in early career leadership activities within the society.

Congenital Heart Disease in Patients With Cleft Lip/Palate and Its Impact on Cleft Management.

OBJECTIVE: To evaluate characteristics of congenital heart disease (CHD) in patients with cleft lip and/or palate (CL/P) and assess potential associations with cleft outcomes. DESIGN: Retrospective review of all patients with CL/P who underwent primary cleft treatment from 2009 to 2015. SETTING: Children's Hospital Los Angeles, a tertiary hospital. PATIENTS: Exclusion criteria included microform cleft lip diagnosis, international patients, and patients presenting for secondary repair or revision after primary repair at another institution. MAIN OUTCOMES MEASURED: Patient demographics, prenatal and birth characteristics, CL/P characteristics, syndromic status, postoperative complications, and other outcomes were analyzed relative to CHD diagnoses and management. Patients with CL/P with (+CHD) were compared to those without (-CHD) CHD using χ2 tests and analysis of variance. RESULTS: Among 575 patients with CL/P, 83 (14.4%) had CHD. Congenital heart disease rates were significantly higher in patients with cleft palate (CP) compared to other cleft types (χ2, P = .009). Eighty-one (97.6%) out of 83 +CHD patients were diagnosed prior to initial CL/P surgical assessment. Twenty-three (27.7%) +CHD patients required surgical repair of 10 cardiac anomalies prior to cleft care. Congenital heart disease was associated with delayed CP repair and increased rates of fistula in isolated patients with CP. CONCLUSIONS: Congenital heart disease is known to be more prevalent in patients with CL/P. These data suggest the condition is particularly increased in patients with CP. Severe forms of CHD are diagnosed and treated prior to cleft care however postoperative fistula may be more common in patients with CHD. Therefore, careful attention is required for patient optimization and palatal flap dissection in patients with coexisting CHD and CL/P.

Surgical Outcomes, Complications, and Long-Term Functionality for Free Vascularized Fibula Grafts in the Pediatric Population: A 17-Year Experience and Systematic Review of the Literature.

BACKGROUND: In the pediatric population, bony defects of the extremities pose a significant challenge for which free vascularized fibular grafts (FVFGs) represent a valuable reconstructive option. The purpose of this study was to explore surgical outcomes, complications, and long-term functionality of FVFG for this patient group. METHODS: Using MEDLINE and PubMed databases, studies were identified of pediatric extremity reconstruction using FVFG which reported functional outcomes and/or complications. The operative logs at a tertiary pediatric center were then reviewed for cases of FVFG between January 2000 and 2017. Demographic characteristics, surgical indications, operative details, graft survival, bony union, complications, and functionality of the reconstruction were recorded. RESULTS: A total of 366 studies were identified with 23 ultimately meeting inclusion criteria in the systematic review. In the institutional series, 29 patients were included with mean age of 9.7 years (1-17 years). Indications for reconstruction included malignant bone tumor (n = 11), osteomyelitis (n = 9), congenital pseudoarthrosis (n = 6), and osteofibrous dysplasia (n = 3). Major postoperative complications included graft nonunion (24.1%), fracture (17.2%), and hardware failure (17.2%). Thirteen patients (44.8%) experienced delayed complications, while two (6.8%) experienced an immediate complication. Complications occurred in the donor site in 2 cases and the recipient site in all 13 cases. Long-term graft survival was achieved in 27 patients (93.1%), and 23 (79.3%) had full functional recovery, with an average Musculoskeletal Tumor Society score of 90% (60-100%). Mean follow-up was 5.17 years (2-12 years). CONCLUSION: This review and institutional series demonstrate the versatility of FVFG to facilitate limb reconstruction in large defects or serve as a salvage option in complex cases. While immediate and donor-site complications are uncommon, delayed recipient-site complications are frequent, and patients and families should be counseled regarding this expectation. Though technically challenging, excellent long-term graft viability and functional recovery can be achieved in the large majority of patients.

Glomangioma of Uncertain Malignant Potential: A Case Report.

Glomus tumors are rare benign tumors which commonly affect the hand but are seldom seen extradigitally. Less commonly seen is the glomangioma, a variant of benign glomus tumor, and even rarer is the glomangiosarcoma, a malignant variant. Determining malignancy can be difficult and an intermediate diagnosis, glomus tumor of uncertain malignant potential, has been proposed. We present a case of a 56-year-old male with a recurrent forearm mass diagnosed as a glomangioma of uncertain malignant potential. Although the characteristics and behavior of malignant cases are still incompletely understood, it is important that a high index of suspicion be maintained when approaching these tumors, especially when large or recurrent. Glomangiomas should be included in the differential diagnosis when evaluating soft tissue masses in the forearm and should be evaluated for malignant features.

Combination therapy: Etanercept and intravenous immunoglobulin for the acute treatment of Stevens-Johnson syndrome/toxic epidermal necrolysis.

BACKGROUND: Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is an autoimmune condition with significant morbidity and mortality. METHODS: A retrospective review was performed at a single institution. All patients admitted to the LAC+USC burn unit from May 1st 2015-January 1st 2018 with a histologic diagnosis of SJS/TEN were reviewed. Patient characteristics and outcomes were recorded. These outcomes were compared to our previously published cohort. RESULTS: Thirteen total consecutive SJS/TEN patients were treated with etanercept. Compared to non-etanercept treated patients, etanercept-treated patients did not experience a significant difference in mortality (15.4% vs. 10%, P=0.58), ICU days (6.9 vs. 15.1, P=0.08), length-of-stay (9.8 vs 16.4, P=0.11), or infections (38.5% vs. 57.5%, P=0.58). The standardized mortality ratio in etanercept-treated patients was 0.44 (95% CI, 0.21, 0.65). In general, etanercept-treated patients had higher SCORTENs (3 vs. 2, P=0.03) and longer delays to presentation (5.2 vs. 2.7 days, P<0.01). CONCLUSIONS: Etanercept can be considered in the treatment of SJS/TEN patients in addition to IVIg, and supportive care in a burn unit.

The Smile Index: Part 2. A Simple, Prognostic Severity Scale for Unilateral Cleft Lip.

BACKGROUND: There is no universally accepted classification system for unilateral cleft lip that objectively quantifies the spectrum of disease, making it difficult to evaluate postoperative outcomes in the context of preoperative severity. METHODS: Anthropometric measurements and photographs were prospectively collected from unilateral cleft lip patients in Morocco, Bolivia, Vietnam, and Madagascar. Columellar angle, cleft width, nostril widths, vertical lip heights, and horizontal vermillion lengths were measured preoperatively and postoperatively. "Unacceptable" postoperative outcomes were defined as those with a cleft-side/non-cleft-side vertical lip height discrepancy greater than 3 mm, based on previous sociologic and cleft outcome studies. RESULTS: Of the 147 patients studied, 22 had unacceptable outcomes. Univariate logistic and multivariate logistic stepwise models showed that among preoperative characteristics, cleft width ratio (preoperative cleft width divided by commissure width) was the most significant predictor for unacceptable outcomes, controlling for surgeon experience. Cleft width ratio was normally distributed. Two severity categories were created based on iterative data and regression analysis: "severe" (cleft width ratio >0.5) and "not-severe" (cleft width ratio <0.5). Severe patients had a higher likelihood of unacceptable outcomes versus not-severe patients (OR, 2.9; 95 percent CI, 1.1 to 7.7; p = 0.029; 27 percent versus 11 percent). The probability of having unacceptable outcomes for severe individuals was higher versus not-severe individuals (positive predictive value, 73 percent versus 89 percent). CONCLUSIONS: Preoperative cleft width ratio greater than 0.5 is associated with having an unacceptable surgical outcome. The authors propose a simple, objective, and clinically reproducible scale to unify the language of unilateral cleft lip severity, as a step toward improving algorithms of care, directing surgical technique, guiding patient/family discussions, and optimizing patient outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.