Educating the Leaders and Clinicians of Tomorrow: An Innovative Emergency Medicine Research Curriculum for Resident Physicians.

BACKGROUND: Academic productivity is a requirement by the Accreditation Council for Graduate Medical Education (ACGME). In addition to the requirements by the ACGME, residency training programs are required to provide education on medical research with the end-goal of teaching physicians how to read, interpret, and apply medical evidence in the form of evidence-based medicine. An understanding of research design, evidencebased medicine, and critical appraisal of available literature is central to practicing medicine and applying new research to clinical practice. However, residency programs vary significantly in research curricula provided to residents. We describe an innovative integrated military-civilian emergency medicine research curriculum that provides foundational knowledge in research design and critical appraisal.

Interrater Agreement and Reliability of Burn Size Estimations Between Emergency Physicians and Burn Unit.

The initial approach to burn injuries has remained relatively unchanged over the past several decades and revolves around trauma assessment and fluid resuscitation, frequently initiated in the emergency department (ED). While previous research suggests that emergency physicians (EP) are poor estimators at total body surface area (TBSA) affected, we believe that estimation differences are improving, specifically at academic centers with co-located burn units that emphasize burn injury education. This study investigated the interrater agreement and reliability of burn size estimations at an academic ED and its co-located burn unit. This single-center, retrospective study was conducted at a large academic ED with a co-located burn unit. The study included adult patients admitted to the burn unit after receiving paired burn size estimations from EPs and the burn unit. The primary endpoint was the interrater agreement, measured by the kappa coefficient, κ, of 10% TBSA estimation intervals. The secondary endpoint was the intraclass correlation coefficient (ICC), evaluating the reliability of exact, nonranged, and TBSA estimations. A chart review was performed for patients evaluated from November 1, 2016 to July 31, 2019. One thousand one hundred and eighty-four patients were admitted to the burn unit, 1176 of which met inclusion criteria for the primary endpoint. The κ of TBSA between EPs and the burn unit was 0.586, while the weighted κ was 0.775. These values correlate with moderate and substantial agreements, respectively. Additionally, 971 patients had exact TBSA estimations from paired EPs and the burn unit which were used for the secondary endpoint. The ICC between EPs and the burn unit was 0.966, demonstrating an excellent reliability. Further sub-analysis was performed, revealing mean over- and underestimation differences of exact TBSA estimations of 3.93 and 2.93, respectively. EPs at academic institutions with co-located burn units are accurate estimators of TBSA in the assessment of burn injuries. We believe that burn education, to include core rotations within the burn unit, plays a major role in improved burn size estimations.

Pretransplant malignancy among lung transplant recipients in the modern era.

BACKGROUND: Malignancy is a relative contraindication in transplant candidates, given the increased neoplastic risk accompanying posttransplant immunosuppression. However, the number of patients receiving a lung transplant despite pretransplant malignancy is rising, and their outcomes remain unclear. Our purpose was to examine the outcomes of lung transplant recipients with pretransplant malignancy in the modern era. METHODS: We evaluated the United Network for Organ Sharing registry for adult lung transplants that were completed between June 2005 and September 2016. Transplant recipients were stratified by pretransplant malignancy, with subgroup analysis by sex and active malignancy. The primary outcome was 5-year survival and the secondary outcome was cause of death. Kaplan-Meier estimates illustrated 5-year survival and multivariable Cox proportional hazards regressions controlled for demographics and comorbidities. RESULTS: Of 18,032 transplant patients, 1,321 transplant recipients (7.3%) possessed a pretransplant malignancy. Patients with pretransplant malignancy faced significantly greater mortality within 5 years (36.0% vs 32.8%, P = .017), an effect greatest in men with pretransplant malignancy (39.2% vs 33.7%, P = .002). Patients with pretransplant malignancy also faced greater risk of death from posttransplant malignancy (15.6% vs 9.4%, P < .001), particularly for those with active malignancy at transplant (34.8% vs 9.8%, P < .001). Pretransplant malignancy remained a significant predictor of 5-year mortality in adjusted Cox regressions (hazard ratio: 1.16 [1.05-1.27], P = .003). CONCLUSION: Patients with pretransplant malignancy, and particularly men with pretransplant malignancy and those with active malignancy at transplant, are at an increased risk of 5-year mortality and posttransplant death from malignancy. Balancing individual risk of posttransplant malignancy with immunosuppressive care is necessary to optimize outcomes for pretransplant malignancy patients.

The THINK (Treatment of Headache with Intranasal Ketamine) Trial: A Randomized Controlled Trial Comparing Intranasal Ketamine with Intravenous Metoclopramide.

BACKGROUND: Headache is a common chief complaint in the emergency department (ED) setting. OBJECTIVES: To compare analgesia with metoclopramide and diphenhydramine vs. intranasal ketamine among ED patients with primary headache. METHODS: We enrolled a convenience sample of adults with a primary headache in a randomized, single-blind, placebo-controlled trial. We randomized patients to either a control arm (intravenous metoclopramide and diphenhydramine) or intranasal ketamine. The primary outcome was change in pain 0-100 mm visual analog scale (VAS) score measured at study start and 30 min post completion of initial medication administration. Secondary outcomes included side effects, hospital admission, and return to care within 48-72 h. RESULTS: All 53 enrolled subjects completed the study, 26 of whom were allocated to the control arm and 27 to intranasal ketamine. The mean change in pain VAS score at 30 min post intervention was 22.2 mm in the control arm vs. 29.0 in the intranasal ketamine arm (effect size difference 6.8 mm, 95% confidence interval -5.8-19.4). The incidence of reported side effects was 65.4% in the control arm vs. 66.7% in the ketamine arm. Three patients (11.5%) allocated to the control arm required admission for headache pain control vs. 1 patient (3.7%) in the intranasal ketamine arm. Three (11.5%) additional patients in the control arm returned to the ED within 48-72 h for headache pain vs. none in the ketamine arm. CONCLUSIONS: In this small randomized study, intranasal ketamine was not superior to standard therapy among ED patients with primary headache syndromes.

High sensitivity troponin: The Sisyphean pursuit of zero percent miss rate for acute coronary syndrome in the ED.

BACKGROUND: The United States Food and Drug Administration recently approved a high sensitivity troponin (hsTn) assay for use. Recent literature has investigated the diagnostic accuracy of hsTn for acute coronary syndrome (ACS) in the emergency department (ED) and its use in accelerated diagnostic protocols. OBJECTIVE: This article evaluates the existing literature and discusses incorporation of hsTn testing into ED clinical practice based on best available evidence. DISCUSSION: Interpretation of this literature for clinical application is challenging due to heterogeneity across studies with regards to the hsTn assays examined, time intervals for delta troponin tests, and study populations. The high sensitivity of these assays is predicated upon the ability of the physician to clinically determine a patient to have a low pre-test probability of disease. Physicians may further ensure maximal sensitivity by defining the cut-off for a positive value as the limit of detection and utilizing delta troponin testing. These assays do not obviate the need to consider follow-up for risk stratification for discharged patients. Higher sensitivity compared to standard troponin tests comes at the expense of lower specificity. Indiscriminate testing may translate to greater numbers of abnormal troponin results in patients with non-ACS syndromes, potentially leading to increased healthcare costs, hospital admissions, increased ED lengths of stay, and unnecessary interventions. CONCLUSION: As hsTn becomes more widespread, it is imperative emergency physicians understand its potential and limitations. Knowledge of test characteristics is vital to ensure appropriate use. Further study of hsTn is required to optimize use.

Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients: A Randomized Controlled Trial.

STUDY OBJECTIVE: We compare aromatherapy with inhaled isopropyl alcohol versus oral ondansetron for treating nausea among emergency department (ED) patients not requiring immediate intravenous access. METHODS: In a randomized, blinded, placebo-controlled trial, we enrolled a convenience sample of adults presenting to an urban tertiary care ED with chief complaints including nausea or vomiting. We randomized subjects to 1 of 3 arms: inhaled isopropyl alcohol and 4 mg oral ondansetron, inhaled isopropyl alcohol and oral placebo, and inhaled saline solution placebo and 4 mg oral ondansetron. The primary outcome was mean nausea reduction measured by a 0- to 100-mm visual analog scale from enrollment to 30 minutes postintervention. Secondary outcomes included receipt of rescue antiemetic medications and adverse events. RESULTS: We enrolled 122 subjects, of whom 120 (98.3%) completed the study. Of randomized subjects, 40 received inhaled isopropyl alcohol and oral ondansetron, 41 received inhaled isopropyl alcohol and oral placebo, and 41 received inhaled saline solution placebo and oral ondansetron. The mean decrease in nausea visual analog scale score in each arm was 30 mm (95% confidence interval [CI] 22 to 37 mm), 32 mm (95% CI 25 to 39 mm), and 9 mm (95% CI 5 to 14 mm), respectively. The proportions of subjects who received rescue antiemetic therapy in each arm were 27.5% (95% CI 14.6% to 43.9%), 25.0% (95% CI 12.7% to 41.2%), and 45.0% (95% CI 29.3% to 61.5%), respectively. There were no adverse events. CONCLUSION: Among ED patients with acute nausea and not requiring immediate intravenous access, aromatherapy with or without oral ondansetron provides greater nausea relief than oral ondansetron alone.

Association between seatbelt sign and internal injuries in the contemporary airbag era: A retrospective cohort study.

BACKGROUND: Literature predating routine availability of airbags reported an association between seatbelt signs and internal injuries. We measured this association among patients involved in motor vehicle crashes (MVCs) with airbag deployment. METHODS: We conducted a retrospective cohort study by chart review of all MVC patients presenting to our Emergency Department (ED) during 1 January 2008-30 September 2015. We included all adult MVC patients in the driver or front passenger seats with both shoulder and lap seatbelts and airbag deployment. Two trained chart abstractors recorded data regarding restraints and airbag deployment. We obtained all other data via electronic medical record abstraction including demographics, injuries, and survival. We compared the prevalence of cervicothoracic and intra-abdominopelvic injuries between patients with a documented seatbelt sign versus no seatbelt sign using a logistic regression model. RESULTS: Of 1379 MVC patients, 350 met inclusion criteria. Of these, 138 (39.4%) had a seatbelt sign. The prevalence of cervicothoracic injury was higher among subjects with a documented seatbelt sign (54.3% versus 42.9%, p=0.036) Seatbelt sign predicted cervicothoracic injury with a positive likelihood ratio of 1.3 (95% CI 1.0-1.7) and negative likelihood ratio of 0.8 (95% CI 0.7-1.0). The odds ratio of cervicothoracic injury among patients with a seatbelt sign versus no seatbelt sign was 1.58 (95% confidence interval 1.02-2.46) in the logistic regression model. There was no association between seatbelt sign and intra-abdominopelvic injury (p=0.418). CONCLUSIONS: In the setting of airbag deployment, there is an association between seatbelt sign and cervicothoracic injury but not intra-abdominopelvic injury.

Lung Transplant Outcomes in Systemic Sclerosis with Significant Esophageal Dysfunction. A Comprehensive Single-Center Experience.

RATIONALE: Consideration of lung transplantation in patients with systemic sclerosis (SSc) remains guarded, often due to the concern for esophageal dysfunction and the associated potential for allograft injury and suboptimal post-lung transplantation outcomes. OBJECTIVES: The purpose of this study was to systematically report our single-center experience regarding lung transplantation in the setting of SSc, with a particular focus on esophageal dysfunction. METHODS: We retrospectively reviewed all lung transplants at our center from January 1, 2000 through August 31, 2012 (n = 562), comparing the SSc group (n = 35) to the following lung transplant diagnostic subsets: all non-SSc (n = 527), non-SSc diffuse fibrotic lung disease (n = 264), and a non-SSc matched group (n = 109). We evaluated post-lung transplant outcomes, including survival, primary graft dysfunction, acute rejection, bronchiolitis obliterans syndrome, and microbiology of respiratory isolates. In addition, we defined severe esophageal dysfunction using esophageal manometry and esophageal morphometry criteria on the basis of chest computed tomography images. For patients with SSc referred for lung transplant but subsequently denied (n = 36), we queried the reason(s) for denial with respect to the concern for esophageal dysfunction. MEASUREMENTS AND MAIN RESULTS: The 1-, 3-, and 5-year post-lung transplant survival for SSc was 94, 77, and 70%, respectively, and similar to the other groups. The remaining post-lung transplant outcomes evaluated were also similar between SSc and the other groups. Approximately 60% of the SSc group had severe esophageal dysfunction. Pre-lung transplant chest computed tomography imaging demonstrated significantly abnormal esophageal morphometry for SSc when compared with the matched group. Importantly, esophageal dysfunction was the sole reason for lung transplant denial in a single case. CONCLUSIONS: Relative to other lung transplant indications, our SSc group experienced comparable survival, primary graft dysfunction, acute rejection, bronchiolitis obliterans syndrome, and microbiology of respiratory isolates, despite the high prevalence of severe esophageal dysfunction. Esophageal dysfunction rarely precluded active listing for lung transplantation.

Lung transplantation and concomitant cardiac surgery: Is it justified?

OBJECTIVE: Increasing numbers of lung transplant candidates have cardiac conditions that affect their survival after transplantation. Our objective was to determine if patients who undergo concomitant cardiac surgery (CCS) during the lung transplant procedure have similar outcomes, as a cohort of isolated lung transplant recipients. METHODS: This was a retrospective, observational, matched-cohort analysis. The records of lung transplant recipients who underwent CCS from August 2000 to August 2013 were reviewed. A cohort of isolated lung transplant recipients, matched on the basis of age, lung allocation score, diagnosis, type of procedure, and era, was identified. The primary endpoint of this trial was 5-year survival. The secondary endpoints were primary graft dysfunction, grade III, at 72 hours, intensive care unit and hospital length of stay, and 5-year major adverse cardiac event rates. RESULTS: A total of 120 patients underwent lung transplantation and CCS. Compared with the isolated lung transplant group, the donor, recipient, and operation characteristics were similar. No difference was found in the survival of the 2 groups for up to 5 years, or in the incidence of primary graft dysfunction Grade III at 72 hours, intensive care unit length of stay, invasive ventilation, hospital length of stay, or incidence of 5-year major adverse cardiac events. CONCLUSIONS: Lung transplant recipients undergoing CCS have early and midterm clinical outcomes similar to those of isolated lung transplant recipients. Given that this report is the largest published experience, offering cardiac surgery at the time of lung transplantation, to selected patients, remains justified.

Isopropyl Alcohol Nasal Inhalation for Nausea in the Emergency Department: A Randomized Controlled Trial.

STUDY OBJECTIVE: We compare nasal inhalation of isopropyl alcohol versus placebo in treating nausea among emergency department (ED) patients. METHODS: A convenience sample of adults with chief complaints of nausea or vomiting was enrolled in a randomized, double-blind, placebo-controlled trial conducted in an urban tertiary care ED. Patients were randomized to nasally inhaled isopropyl alcohol versus nasally inhaled normal saline solution. Patient nausea and pain were measured with previously published 11-point verbal numeric response scale scores; patient satisfaction was measured by a 5-point Likert scale. The primary outcome was reduction in nausea 10 minutes poststart. Secondary outcomes included patient satisfaction and pain reduction measured at 10 minutes poststart. RESULTS: Of 84 recruited patients, 80 (95.2%) completed the study. Thirty-seven (46.3%) received nasally inhaled isopropyl alcohol and 43 (53.8%) received nasally inhaled normal saline solution. At 10 minutes postintervention, median nausea verbal numeric response scale score was 3 in the isopropyl alcohol arm versus 6 in the placebo arm, for an effect size of 3 (95% confidence interval 2 to 4). Median satisfaction score was 4 in the isopropyl alcohol arm versus 2 in the placebo arm, for an effect size of 2 (95% confidence interval 2 to 2). There were no significant differences between the 2 arms in median pain verbal numeric response scale scores or subsequent receipt of rescue antiemetics. CONCLUSION: We found that nasally inhaled isopropyl alcohol achieves increased nausea relief compared with placebo during a 10-minute period.

Do preoperative ß-blockers improve postoperative outcomes in patients undergoing cardiac surgery? Challenging societal guidelines.

Preoperative ß-blockers (BBs) are widely administered to reduce morbidity and mortality among surgical patients. In fact, the Society of Thoracic Surgeons uses the administration of preoperative BBs as a quality metric. Recent reports, however, have questioned the benefit and safety of preoperative BB administration. The aim of our study was to investigate whether preoperative BBs lead to improved surgical outcomes in patients undergoing cardiac surgery. A review of our prospectively maintained institutional database was done to identify adults undergoing cardiac operations at our institution from 2008 to 2013. Survival to discharge was the primary outcome with several additional secondary measures of morbidity included. A total of 2120 patients were included in the analysis and a multivariate logistic regression model was developed to adjust for differences between patient groups. After adjustment, BB administration was associated with lower odds of both prolonged ventilation (odds ratio [OR], 0.73; P = 0.032) and prolonged length of stay (OR, 0.79; P = 0.044). BB use was not associated with significant differences in other outcomes such as mortality or postoperative atrial fibrillation. Our study found that preoperative BBs may not be associated with sufficiently improved outcomes to justify their use as a quality metric in this population. Thus, prospective studies are warranted.

Postdischarge secobarbital after ED migraine treatment decreases pain and improves resolution.

OBJECTIVE: The objective of the study was to determine whether the addition of postdischarge oral secobarbital to standard emergency department (ED) migraine headache therapy improves pain relief and headache resolution compared with placebo. SETTING: The setting is an urban ED with 70 000 yearly visits. METHODS: This is an Institutional Review Board-approved, randomized, nonconsecutive, double-blinded, concealed, and placebo-controlled clinical trial. Patients with a clinical diagnosis of migraine underwent standard ED treatment and were discharged with 2 tablets of either secobarbital 100 mg or placebo. At home arrival, subjects recorded headache pain on a visual analog scale (VAS), took 1 tablet, and went to bed, taking the second tablet after 1 hour if not asleep. Upon awakening, subjects completed a second VAS and survey. STATISTICAL ANALYSIS: The VAS data were analyzed using 2-tailed t test with unequal variance. Headache resolution data were analyzed using Fisher exact test. RESULTS: Fifty subjects were enrolled. Complete data and follow-up were available for 30 subjects (60%). Fourteen subjects received placebo; 16 received secobarbital. Secobarbital subjects reported an average headache pain decrease of 25 mm (-13 to -38) compared with an average increase of 3 mm (-13 to 19) in the placebo group (P = .01). Ninety-four percent of the secobarbital group vs 50% of the placebo group had complete or partial headache resolution (P < .02). All subjects in the secobarbital group reported some relief. CONCLUSIONS: Addition of postdischarge oral secobarbital to a standard ED migraine treatment regimen decreased headache pain at 24 hours after discharge and improved the rate of headache resolution compared with placebo.

Cardiopulmonary resuscitation in the combat hospital and forward operating base: use of automated external defibrillators.

OBJECTIVE: Time to defibrillation (t(defib)) directly correlates with survival from cardiac arrest. We investigated whether automated external defibrillators (AED) in a combat setting would improve this crucial variable. METHODS: We performed a randomized simulation study to compare two systems of cardiac arrest response: public access AED vs. standard manual defibrillation. The study was conducted in two phases at two different settings: (1) in a contiguous United States (CONUS)-based training combat support hospital (CSH) and (2) at a deployed CSH within a combat forward operating base (FOB). The primary outcome was t(defib) and the secondary outcome was difficulty of use. RESULTS: For the training CSH setting, t(defib) the AED model was significantly faster than the conventional model (1.3 vs. 2.0 minutes, p <0.001, 95% CI of the mean difference = 0.39-1.1). In the combat environment, t(defib) was between 2.2 and 8.4 minutes faster for the AED system. The AED system was found to be significantly easier to use than the standard model. CONCLUSION: In simulated cardiac arrest, the AED model demonstrated significantly improved t(defib) compared to the standard response for both training and combat settings.

Beneficial effects of complement inhibition with soluble complement receptor 1 (TP10) during cardiac surgery: is there a gender difference?

BACKGROUND: TP10, a potent inhibitor of complement activation during cardiopulmonary bypass (CPB) has been shown to significantly reduce the incidence of death and myocardial infarction (MI) in high-risk male patients undergoing cardiac surgery. However, the effect of TP10 in females was undefined because of the limited number of females studied. To examine the possibility of a gender effect, this phase 2 multi-center trial was undertaken to determine whether TP10 would also limit ischemic damage in a larger sample size of high-risk females undergoing cardiac surgery on cardiopulmonary bypass (CPB). METHODS AND RESULTS: This prospective, double-blind, placebo-controlled, multi-center trial involved 297 high-risk (urgent surgery, CABG + Valve, reoperations, ejection fraction <30%) female patients randomized to receive a 5 mg/kg dose of TP10 (n=150) or placebo (n=147) as a 30-minute intravenous infusion before surgery. The primary end point was the incidence of death or MI at 28 days after surgery. Complement activation was assessed by levels of CH50 and SC5b-9 during and after CPB. TP10 was well tolerated and there were no differences in the safety profiles of the 2 groups. Although TP10 effectively suppressed complement activation (at 2 hours after CPB CH50 (mean+SD % change from baseline) 50+/-17% placebo versus 4+/-14% TP10; P=0.0001; SC5b-9 (ng/mL) 917+/-1067 placebo versus 204+/-79 TP10; P=0.0001), there was no difference in the primary end point between the groups (17% placebo versus 21% TP10; P=0.2550). CONCLUSIONS: The benefits of TP10 appear to be gender-related. and mechanisms other than complement activation may be responsible for myocardial injury in high-risk female patients during cardiac surgery on CPB.

Location as an important predictor of lymph node involvement for pulmonary adenocarcinoma.

BACKGROUND: Increasing data implicate histologic grade and radiographic appearance along with tumor size as key prognostic indicators for pulmonary adenocarcinoma. The impact of tumor location on prognosis has not been examined. METHODS: The records of 530 consecutive patients with pulmonary adenocarcinoma pathologically staged between June 1979 and July 2002 were reviewed. All patients had a preoperative computed tomographic scan of the chest and underwent surgical staging by mediastinoscopy, lymph node sampling, or lymph node dissection. Patients with bronchioalveolar cell carcinoma were excluded. Peripheral tumors were compared with central tumors with regard to stage and survival. A tumor was considered to be central if visualized within the inner third of the lung field or seen bronchoscopically. Patients with T1 cancers were further analyzed on the basis of tumor size. Survival was determined by the Kaplan-Meier analysis and comparisons were made by the log-rank method. RESULTS: Central tumors were more advanced and demonstrated a significantly (P < .0001) poorer survival than peripheral tumors (median 18 vs 39 months). Sixty percent of patients with central tumors had stage III or stage IV disease compared with 25% of those with peripheral tumors. Central T1 tumors, however, demonstrated a 50% incidence of lymph node involvement. Although the incidence of lymph node metastases increased incrementally with the size of peripheral T1 tumors, it remained 50% for central T1 tumors irrespective of size. CONCLUSION: Tumor location for pulmonary adenocarcinoma should be considered when planning therapy. Central tumors have a high incidence of lymph node metastases (regardless of size) and a poorer prognosis.

Endoscopic versus conventional radial artery harvest--is smaller better?

BACKGROUND: We sought to assess our initial experience with the recently introduced technique of endoscopic radial artery harvest (ERH) for coronary artery bypass grafting (CABG). METHODS: Data were prospectively collected on 108 consecutive patients undergoing isolated CABG with ERH, and compared to 120 patients having conventional harvest (CH). Follow-up was achieved in 227 patients (99%). At the time of follow-up the severity of motor and sensory symptoms, as well as cosmetic result in the harvest forearm, were subjectively graded using a 5-point scale. Grade 1-- high intensity deficits, poor cosmetic result. Grade 5 -- no deficits, excellent cosmetic result. RESULTS: Hospital mortality, myocardial infarction, and stroke rates were similar between the groups. Follow-up mortality, reintervention rate, and average angina class were also similar. Harvest time was longer in the ERH group (61 +/- 24 min vs. 45 +/- 11 min, p < 0.001). Three patients in the ERH group were converted to CH and one radial artery was discarded. There were no vascular complications of the hand in either group. Average score of motor (ERH 4.4 +/- 0.9, CH 4.2 +/- 1.0) or sensory symptoms (ERH 3.7 +/- 1.1, CH 3.8 +/- 1.2) were similar. In the CH group sensory deficits were observed in the distribution of both the lateral antebrachial cutaneous and the superficial radial nerves (SRN). In contrast, sensory deficits in the ERH group were limited to the distribution of the SRN. Cosmetic result score was higher in the ERH group (ERH 4.2 +/- 1.0, CH 3.1 +/- 1.4, p < 0.0001). CONCLUSIONS: ERH is safe. It is technically demanding with a significant learning curve. Motor and sensory symptoms are not completely eliminated by using a smaller incision, but cosmetic results are clearly superior.