Washington State Assault Weapon Firearm Violence Before and After Firearm Legislation Reform.

BACKGROUND: In January of 2019, Washington State (WA) passed Initiative 1639 making it illegal for persons <21 years-old to buy assault weapons (AWs). This study aimed to evaluate the effects of WA-1639 on firearm-related incidents involving AWs by those <21 years-old in WA, hypothesizing a decrease in incidents after WA-1639. METHODS: Retrospective (2016-2021) data on firearm violence (FV) events were gathered from the Gun Violence Archive. The rate of FV was weighted per 100,000 people. Total monthly incidents, injuries, and deaths were compared pre-law (January 2016-December 2018) vs post-law (January 2019-December 2021) implementation. Mann-Whitney U tests and Poisson's regression were used for analysis. RESULTS: From 4091 FV incidents (2210 (54.02%) pre-law vs 1881 (45.98%) post-law), 50 involved AWs pre- (2.3%) and 15 (.8%) post-law. Of these, 11 were committed by subjects <21 years-old pre-law and only one occurred post-law. Total incidents of FV (z = -3.80, P < .001), AW incidents (z = -4.28, P < .001), and AW incidents involving someone <21 years-old (z = -3.01, P < .01) decreased post-law. Additionally, regression analysis demonstrated the incident rate ratio (IRR) of all FV (1.23, 95% CI [1.10-1.38], P < .001), all AW FV incidents (3.42, 95% CI [1.70-6.89], P = .001), and AW incidents by subjects <21 years-old (11.53, 95% CI [1.52-87.26], P = .02) were greater pre-law vs post-law. DISCUSSION: Following implementation of WA-1639, there was a significant decrease in FV incidents and those involving AWs by individuals <21 years-old. This suggests targeted firearm legislation may help curtail FV. Further studies evaluating FV after legislation implementation in other states is needed to confirm these findings.

Defining Preferred Esthetics of the Ideal Phallus via Crowdsource Survey.

OBJECTIVE: To describe phalloplasty subunits and determine the preferred crowdsourced esthetics. Esthetic ideals are often used to guide reconstruction, and there has been an increase in the number of gender-affirming surgeries and reconstructive phalloplasties performed. However, there is a paucity of literature describing ideal phalloplasty esthetics. METHODS: Phallus esthetic subunits were defined, and a split testing-based survey was used. Subjects were solicited via Craigslist, Amazon Mechanical Turk, and Reddit and distributed among health care co-workers. Computer-generated images with variable ratios of glans, corona, and shaft were provided and respondents were asked to select the most esthetically pleasing photo. Demographic information was gathered. Univariate and multivariate regression were performed. RESULTS: A total of 1029 people responded to the survey request and 909 people (88.3%) completed the entire survey. There were 440 respondents who self-identified as male, 334 female, 92 transgender male, and 25 transgender female. The health care field was the profession for 55.4%. Health care providers had 65.3% higher odds of preferring the longer shaft length-to-width ratio, 30.3% less odds of preferring a bilateral taper of the glans, and 48.4% less odds of preferring an angulated shaft compared to non-health care providers (P = .006, P = .021, P <.001, respectively). When compared to males, transgender females were more than 13 times likely to prefer an angulated glans corona junction (P = .008). CONCLUSION: The ideal phallic esthetic varies by individual, and there were statistically significant preferences across age, education, health care status, gender, and sexual orientation. This study can serve as a guide on phalloplasties for patients and gender-affirming surgeons.

The Implications of Virtual Learning on Plastic Surgery Education: A National Survey of Plastic Surgery Residents and Fellows.

Background: Graduate medical education during the COVID-19 pandemic has seen the shift to a "virtual learning" format in many aspects of training. The purpose of this study was to describe the perceived strengths and weaknesses of virtual learning compared with a conventional, in-person format. Methods: A 45-question survey was sent to independent and integrated plastic surgery residents and postresidency fellows nationally. The survey collected basic demographic information and evaluated three general categories of virtual learning in comparison to an in-person format: (1) time, (2) learning proficiency, and (3) collaboration. Results: In total, 108 surveys were submitted from 48 different training programs. Participants reported that virtual learning was more efficient (mean: 3.9), conducive to more free time (mean: 3.9), and a more comfortable medium for expressing opinions (mean: 3.5) and asking questions (mean: 3.6) compared with an in-person format. When stratified between training levels, the PGY 1-3 group reported more difficulties in exam preparedness (P = 0.05), motivation to study (P = 0.01) and less time-saving benefits (P = 0.05) with a virtual format than the PGY 4+ group. Lastly, respondents who had higher self-reported levels of multitasking were found to have lower mean Likert scale scores on all questions related to "time," "learning proficiency," and "collaboration" (P < 0.01). Conclusions: A virtual and in-person hybrid approach toward plastic surgery education may be beneficial for encouraging flexibility. Our results demonstrate impairment with collaboration and learning proficiency with a virtual format, especially with increased multitasking, but increased comfort with expressing opinions and asking questions.

Effective Local Anesthetic Use in Nasal Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Studies.

Intraoperative nerve blocks have shown promise in managing pain after nasal surgery. The purpose of this systematic review and meta-analysis was to analyze existing level I and II evidence on intraoperative nerve blocks in nasal surgery to optimize postoperative recovery. Methods: The primary outcome of this systematic review and meta-analysis was postoperative pain scores; secondary outcomes included perioperative opioid requirements, patient satisfaction scores, and time to first analgesic requirement. PubMed, Embase, and MEDLINE databases were searched, and two independent reviewers conducted article screening. Methodological quality assessment of studies utilized the Jadad instrument, and interrater reliability was assessed using Cohen kappa. An inverse-variance, fixed-effects model was used for meta-analysis with Cohen d used to normalize effect size between studies. I2 and Q statistics were used to assess interstudy variability. Results: Four studies were included for meta-analysis, totaling 265 randomized patients. The nerve blocks assessed included infraorbital nerve, sphenopalatine ganglion, external nasal nerve, central facial nerve blocks, and total nerve blocks. All demonstrated significantly reduced postoperative pain compared with controls, with a large effect size (P < 0.001). Opioid requirements were lower in the nerve block groups (P < 0.001), and patient satisfaction scores were higher (P < 0.001). Supplemental meta-analyses showed a longer time to first analgesic requirement for patients who received a nerve block (P < 0.001). Conclusions: These findings support the efficacy of nerve blocks in providing postoperative pain relief and enhancing patient satisfaction with pain management. Perioperative nerve blocks, in combination with general anesthesia, should be considered for postoperative pain control.

Targeting Myofibroblasts as a Treatment Modality for Dupuytren Disease.

PURPOSE: Currently, no treatment corrects the contractile nature of Dupuytren myofibroblasts (DMFs) or prevents recurrence following surgery. Antifibrotic and proadipogenic growth factors are released when adipose-derived stem cells (ASCs) are cultured with platelet-rich plasma (PRP), a platelet concentration from whole blood. Reprograming myofibroblasts into adipocytes via growth factors is proposed as a powerful potential tool to target fibrosis. We aimed to assess whether the combination of ASCs and PRP reprograms DMFs into adipocytes in vitro and alters their contractile nature in vivo. METHODS: Normal human dermal fibroblasts (NHDFs) and DMFs from Dupuytren patients were isolated and cocultured with ASCs and PRP either alone or together. Adipocytes were detected by Oil Red O and perilipin staining. DMFs and NHDFs were transplanted into the forepaws of rats (Rowett Nude [rnu/rnu]) and treated with saline, PRP+ASCs, or collagenase Clostridium histolyticum (clinical comparison) 2 months later. After 2 weeks, the tissue was harvested and subjected to Masson trichrome staining, and collagen I and III and alpha-smooth muscle actin detection by immunohistochemistry. RESULTS: Myofibroblasts transform into adipocytes upon coculture with PRP+ASCs. DMFs show increased alpha-smooth muscle actin expression in vivo compared with NHDFs, which is significantly decreased after PRP+ASCs and collagenase Clostridium histolyticum treatments. DMFs induce collagen I and III expressions in rat paws compared with NHDFs, with a type III to I ratio increase. Treatment with PRP+ASC reduced the ratio, but collagenase Clostridium histolyticum did not. CONCLUSIONS: Treating DMFs with PRP+ASCs provides factors that induce myofibroblast to adipocyte transformation. This treatment reduces the contractile phenotype and fibrosis markers in vivo. Future studies should detail the mechanism of this conversion. CLINICAL RELEVANCE: The combination of PRP and ASCs to induce the differentiation of DMFs into adipocytes may serve to limit surgery to a percutaneous contracture release and biological injection, rather than a moderate or radical fasciectomy, and reduce the recurrence of Dupuytren contracture.

Prospective single-center paradigm shift of surgical stabilization of rib fractures with decreased length of stay and operative time with an intrathoracic approach.

INTRODUCTION: Intrathoracic surgical stabilization of rib fractures allows for a novel approach to rib fracture repair. This approach can help minimize muscle disruption, which may improve patient recovery compared with traditional extrathoracic plating. We hypothesized patients undergoing intrathoracic plating (ITP) to have a shorter length of stay (LOS) and intensive care unit (ICU) LOS compared with extrathoracic plating (ETP). METHODS: A prospective observational paradigm shift study was performed from November 2017 until September 2021. Patients 18 and older who underwent surgical stabilization of rib fractures were included. Patients with ahead Abbreviated Injury Scale score ≥3 were excluded. Patients undergoing ETP (July 2017 to October 2019) were compared with ITP (November 2019 to September 2021) with Pearson χ 2 tests and Mann-Whitney U tests, with the primary outcome being LOS and ICU LOS. RESULTS: Ninety-six patients were included, 59 (61%) underwent ETP and 37 (38%) underwent ITP. The most common mechanism of injury was motor vehicle collision (29%) followed by falls (23%). There were no differences between groups in age, comorbidities, insurance, discharge disposition and injury severity score (18 vs. 19, p = 0.89). Intrathoracic plating had a shorter LOS (10 days vs. 8 days, p = 0.04) when compared with ETP but no difference in ICU LOS (4 days vs. 3 days, p = 0.12) and ventilator days. Extrathoracic plating patients more commonly received epidural anesthesia (56% vs. 24%, p < 0.001) and intercostal nerve block (56% vs. 29%, p = 0.01) compared with ITP. However, there was no difference in median morphine equivalents between cohorts. Operative time was shorter for ITP with ETP (279 minutes vs. 188 minutes, p < 0.001) after adjusting for numbers of ribs fixed. CONCLUSION: In this single-center study, patients who underwent ITP had a decreased LOS and operative time in comparison to ETP in patients with similar injury severity. Future prospective multicenter research is needed to confirm these findings and may lead to further adoption of this minimally invasive technique. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Post-Trauma Follow-up Phone Call Shows Lower Readmission Rates for Patients Discharged From Emergency Department Compared to Inpatient Stay.

BACKGROUND: Studies show follow-up phone calls decrease readmission rates (RR) in trauma patients and social vulnerabilities may play a role as well. Minimal literature exists comparing RR of trauma patients who required an inpatient stay to those whose treatment was limited to the Emergency Department (ED), as they are at high risk of recidivism. We hypothesized post-trauma follow-up calls would show higher RR for ED patients than those requiring inpatient stay, as well as potentially differing outcomes for minorities. STUDY DESIGN: A retrospective analysis from 2019-2020 of 1328 trauma patients from UCI Medical Center, discharged from inpatient facilities or the ED. A questionnaire script read by a nurse practitioner to patients via phone call following discharge. Data associated with readmission were captured. Multivariable logistic regression analysis was performed, controlling for patient factors including severity of injury. RESULTS: Patients discharged from the ED were 47.4% less likely to be readmitted than those who required an inpatient stay (P < .01). However, ED patients were 88.7% less likely to receive a prescription than inpatient stay patients (P < .01). No difference between ED and inpatient discharge contact rates was noted (P < .99). Furthermore, no difference in readmission rates was noted for minorities. CONCLUSION: Post-trauma follow-up calls showed lower RR for index ED visit patients than those requiring inpatient stay, contrary to expectations. However, ED visit patients were also less likely to receive/fill prescriptions compared to those requiring inpatient stay. Ongoing analysis is warranted to further validate and improve follow-up call programs to ensure equitable health care.

Increased Mortality in Underinsured Penetrating Trauma Patients.

INTRODUCTION: It remains unclear whether an increased mortality risk in uninsured patients exists across Injury Severity Score (ISS) classifications. We hypothesized that penetrating trauma self-pay patients would have a similarly increased mortality risk across all ISS categories. METHODS: The National Trauma Data Bank (2013-2015) was queried for patients presenting with penetrating firearm, explosive, or stab wound injuries. 115 651 patients were identified and a stratified multivariable logistic regression model was used. RESULTS: In the >15 ISS group, self-pay patients had a lower median total hospital Length of Stay (LOS) (3 vs 8, P < .001), lower median Intensive Care Unit LOS (1 vs 3, P < .001), and lower median ventilator days (0 vs 1, P < .001). Self-pay patients had an increased risk for mortality compared to patients with private insurance in both the ≤15 ISS group (OR 2.68, P < .001) and >15 ISS group (OR 1.56, P < .001). CONCLUSION: Uninsured patients have an increased mortality risk in both low and high ISS groups. A higher mortality risk among uninsured patients in the high ISS group can be explained by decreased resource availability and lower ICU days and ventilator time. However, more studies are needed to determine why there is an even greater mortality risk among uninsured patients with mild ISS.

Non-Selective Thoracic Computed Tomography in Trauma Patients Results in Injury Severity Score Inflation.

INTRODUCTION: Extensive research relying on Injury Severity Scores (ISS) reports a mortality benefit from routine non-selective thoracic CTs (an integral part of pan-computed tomography (pan-CT)s). Recent research suggests this mortality benefit may be artifact. We hypothesized that the use of pan-CTs inflates ISS categorization in patients, artificially affecting admission rates and apparent mortality benefit. METHODS: Eight hundred and eleven patients were identified with an ISS >15 with significant findings in the chest area. Patient charts were reviewed and scores were adjusted to exclude only occult injuries that did not affect treatment plan. Pearson chi-square tests and multivariable logistic regression were used to compare adjusted cases vs non-adjusted cases. RESULTS: After adjusting for inflation, 388 (47.8%) patients remained in the same ISS category, 378 (46.6%) were reclassified into 1 lower ISS category, and 45 (5.6%) patients were reclassified into 2 lower ISS categories. Patients reclassified by 1 category had a lower rate of mortality (P < 0.001), lower median total hospital LOS (P < .001), ICU days (P < .001), and ventilator days (P = 0.008), compared to those that remained in the same ISS category. CONCLUSION: Injury Severity Score inflation artificially increases survival rate, perpetuating the increased use of pan-CTs. This artifact has been propagated by outdated mortality prediction calculation methods. Thus, prospective evaluations of algorithms for more selective CT scanning are warranted.