Neonatal serial creatinine levels as an adjunct biomarker in timing of fetal neurologic injury.

Objective: To investigate the rise and clearance of newborn creatinine in perinatal asphyxia as an adjunct biomarker to support or refute allegations of acute intrapartum asphyxia. Study design: In this retrospective chart review, newborns > 35 weeks gestational age were evaluated from closed medicolegal cases of confirmed perinatal asphyxia and reviewed for causation. Data collected included newborn demographic data, patterns of hypoxic ischemic encephalopathy, brain magnetic resonance imaging, Apgar scores, cord and initial newborn blood gases, and serial newborn creatinine levels during the first 96 h of life. Newborn serum creatinine values were collected at 0-12, 13-24, 25-48, and 49-96 h. Newborn brain magnetic resonance imaging was used to define 3 patterns of asphyxial injury: acute profound, partial prolonged, or Both. Results: Two hundred and eleven cases of neonatal encephalopathy from multiple institutions were reviewed from 1987 to 2019 with only 76 cases having serial creatinine values during the first 96 h of life. A total of 187 creatinine values were collected. Partial prolonged and Both had significantly greater degree of metabolic acidosis in the first newborn arterial blood gas in comparison to acute profound. Acute profound and Both had significantly lower 5- and 10- minute Apgar scores in comparison to partial prolonged. Newborn creatinine values were stratified by asphyxial injury. Acute profound injury showed minimally elevated creatinine trends with rapid normalization. Partial prolonged and Both demonstrated higher creatinine trends with delayed normalization. Mean creatinine values were significantly different between the three types of asphyxial injuries within 13-24 h of life at the time when creatinine values peaked (p = 0.01). Conclusion: Serial newborn serum creatinine levels taken within the first 96 h of life can provide objective data of timing and duration of perinatal asphyxia.

A Systematic Review of Primary Rhinoplasty in Patients With Bilateral Cleft Lip.

BACKGROUND: Primary rhinoplasty (PR)at the time of cleft lip repair is controversial. We previously performed a systematic review that supported PR during unilateral cleft lip repair. We now aim to determine whether the same idea translates to care of patients with bilateral cleft lip. METHODS: A systematic review was conducted adhering to Preferred Reporting Items for Systematic Reviews and Meta-analysis statement guidelines. PubMed and Embase databases were searched for studies that met our inclusion criteria: (1) English language, (2) human subjects, (3) rhinoplasty at the time of bilateral cleft lip repair, and (4) evaluation of nasal outcome. Studies were excluded in case of: (1) inclusion of a large proportion of syndromic patients, (2) case reports, (3) editorials, (4) letters, (5) reviews, and (6) exclusive to unilateral clefts. Out of 281 studies that showed up on initial search, 12 were included in our review. Research quality and level of evidence rating were determined for each study. RESULTS: Of the 12 included studies, 9 supported PR at the time of bilateral cleft lip repair; 8 studies evaluated nasal growth and found no restriction over time; 4 studies followed 158 patients to an average of 15 years and showed 77% did not need secondary rhinoplasty. CONCLUSION: Although the available literature supports PR in patients with bilateral cleft lip with respect to subjective and objective outcomes, nasal growth, and reducing the need for secondary/revision rhinoplasty, there are significant limitations, necessitating large volume studies.

The Effect of Wearing a Mask on Facial Attractiveness.

Background: The COVID-19 pandemic necessitated masking in public spaces. Masks may impact the perceived attractiveness of individuals and hence, interpersonal relations. Objectives: To determine if facial coverings affect attractiveness. Methods: An online survey was conducted using 114 headshot images, 2 each-unmasked and masked-of 57 individuals. Two hundred and seven participants rated them on an ordinal scale from 1 (least attractive) to 10 (most attractive). Parametric and nonparametric tests were performed, as appropriate, for comparison. Results: For the first quartile, the average rating increased significantly when wearing a mask (5.89 ± 0.29 and 6.54 ± 0.67; P = 0.01). For control images ranked within the fourth quartile, the average rating decreased significantly when wearing a mask (7.60 ± 0.26 and 6.62 ± 0.55; P < 0.001). In the female subgroup (n = 34), there was a small increase in average rating when masked, whereas in the male subgroup (n = 23), there was a small decrease in average rating when masked, but the change was not statistically significant (P > 0.05). For unmasked female images ranked within the first quartile, the average rating increased significantly when wearing a mask (5.77 ± 0.27 and 6.76 ± 0.36; P = 0.001). For the female subgroup with mean ratings within the fourth quartile, the average decreased significantly when wearing a medical mask (7.53 ± 0.30 and 6.77 ± 0.53; P < 0.05). For unmasked male images ranked within the first quartile, the average rating increased when wearing a medical mask but the change was not statistically significant (P > 0.05), whereas for the control male images within the fourth quartile, the average rating decreased significantly when masked (7.72 ± 0.18 and 6.50 ± 0.54; P < 0.05). Conclusions: While wearing a facial covering significantly increased attractiveness for images less attractive at baseline, and decreased attractiveness for those that are more attractive at baseline; it did not cause a significant overall change in attractiveness in the study population.

A Leg to Stand on: Trauma Center Designation and Association with Rate of Limb Salvage in Patients Suffering Severe Lower Extremity Injury.

BACKGROUND: Mangled extremities are one of the most difficult injuries for trauma surgeons to manage. We compare limb salvage rates for a limb-threatening lower extremity injuries managed at Level I vs Level II trauma centers (TCs). STUDY DESIGN: We identified all adult patients with a limb-threatening injury who underwent primary amputation or limb salvage (LS) using the American College of Surgeons (ACS) Trauma Quality Improvement Program database at ACS Level I vs II TCs between 2007 and 2017. A limb-threatening injury was defined as an open tibial fracture with concurrent arterial injury (Gustilo type IIIc). Multivariable analysis and propensity score matching were performed to minimize confounding by indication. RESULTS: There were 712 records for analysis; 391 (54.9%) LS performed and 321 (45.1%) underwent amputation. The rate of LS was statistically higher among patients treated at Level I TCs vs those treated at Level II TCs (47.4% vs 34.8%; p = 0.01). Patients with penetrating injuries (13% vs 9.5%; p = 0.046) and tibial/peroneal artery injury (72.9% vs 50.4%; p < 0.001), as opposed to popliteal artery injury (30.8% vs 58.8%; p < 0.001), were more likely to have LS. The risk-adjusted odds of LS was 3.13 times higher at Level I TCs vs Level II TCs (95% CI, 1.59 to 6.34; p = 0.001). Limb salvage rates were significantly higher at Level I TCs compared with Level II TCs (53.0% vs 34.8%; p = 0.004), even after propensity matching. CONCLUSIONS: In patients with a mangled extremity, limb salvage rates are 50% higher at Level I TCs compared with Level II TCs, independent of case mix and injury severity.

Weekend readmissions associated with mortality following pancreatic resection for cancer.

BACKGROUND: The weekend effect is associated with an increased risk of adverse events, with complex patient populations especially susceptible to its impact. The objective of this study was to determine if outcomes for patients readmitted following pancreas resection differed on the weekend compared to weekdays. METHODS: The Healthcare Cost and Utilization State Inpatient Database for Florida was used to identify patients undergoing pancreas resection for cancer who were readmitted within 30 days of discharge following surgery. Measured outcomes (for readmission encounters) included inpatient morbidity and mortality. RESULTS: Patients with weekend readmissions had an increased odds of inpatient mortality (aOR 2.7, 95% C.I.: 1.1-6.6) compared to those with weekday readmissions despite having similar index lengths of stay (15.9 vs. 15.5 days, P = .73), incidence of postoperative inpatient complications (22.4% vs. 22.3%, P = .98), reasons for readmission, and baseline comorbidity. DISCUSSION: Weekend readmissions following pancreatic resection are associated with increased risk of mortality. This is not explained by measured patient factors or clinical characteristics of the index hospital stay. Developing strategies to overcome the weekend effect can result in improved care for patients readmitted on the weekend.

Many medical students applying for surgical residency feel inadequately prepared to prescribe post-operative opioids.

BACKGROUND: Little is known regarding medical school curricular variability regarding safe prescribing of post-operative opioids for students entering surgical residency. METHODS: Surveys were administered to general surgery residency interviewees at an accredited academic institution for 2018-2019 application season. Responses were anonymously recorded using web-based software on an electronic tablet. Descriptive statistics were evaluated using proportions and medians with interquartile range. RESULTS: Of 103 eligible, 90 (87.4%) interviewees participated. Although 96.7% of students reported opioid pharmacology during medical school, 35.6% reported their curriculum did not include educational material on acute pain management. While 91.1% felt their curriculum adequately covered opioid related adverse events, 34.4% felt adequately prepared to prescribe post-operative opioids to surgical patients. CONCLUSION: Students entering surgical residency from US medical schools have variable exposures to opioid related educational content and many students feel their medical education inadequately prepared them for prescribing postoperative opioids.