Robot-Assisted Nasal Reconstruction: A Cadaveric Study.

OBJECTIVE: Manual contouring of cartilage for nasal reconstruction is tedious and time-consuming. The use of a robot could improve the speed and precision of the contouring process. This cadaveric study evaluates the efficiency and accuracy of a robot methodology for contouring the lower lateral cartilage of the nasal tip. METHODS: An augmented robot with a spherical burring tool attached was utilized to carve 11 cadaveric rib cartilage specimens. In phase 1, the right lower lateral cartilage was harvested from a cadaveric specimen and used to define a carving path for each rib specimen. In phase 2, the cartilage remained in situ during the scanning and 3-dimensional modeling. The final carved specimens were compared with the preoperative plans through topographical accuracy analysis. The contouring times of the specimens were compared with 14 retrospectively reviewed cases (2017-2020) by an experienced surgeon. RESULTS: Phase 1 root mean square error of 0.40±0.15 mm and mean absolute deviation of 0.33±0.13 mm. Phase 2 root mean square error of 0.43 mm and mean absolute deviation of 0.28 mm. The average carving time for the robot specimens was 14±3 minutes and 16 minutes for Phase 1 and Phase 2, respectively. The average manual carving by an experienced surgeon was 22±4 minutes. CONCLUSIONS: Robot-assisted nasal reconstruction is very precise and more efficient than manual contouring. This technique represents an exciting and innovative alternative for complex nasal reconstruction.

Barriers and Translational Solutions to Improving Community Living Outcomes among People of Color with Disabilities with Opioid Use Disorder: A Focus Group Perspective.

This investigation examined vocational rehabilitation, substance abuse, and mental health service providers' perceptions about barriers and potentially translational solutions to poor community living outcomes for people of color with disabilities (i.e., African Americans, Latinx, Native Americans and Alaskan Natives, Asian Americans, and Pacific islanders) who have opioid use disorder. We conducted one focus group discussion (N = 12) that identified the proliferation of opioids in the community, treatment access, employment, and transportation as community living outcome barriers. The findings point to the need for further research that address poor outcomes among target group members.

Peer Multiple Mentor Model (P3M) for Training Disability/Health and Rehabilitation Equity Researchers: Case Study at a Historically Black College/University.

Post-doctoral mentorship and training is considered a critical research capacity building approach vital to successful research career development. Existing models, however, may be insufficient for improving research skills among fellows at minority-serving institutions. This study evaluated a Peer Multiple Mentor Model (P3M) at a historically Black college and/or University (HBCU) designed to provide advanced research training to post-doctoral fellows and alleviate long-standing employment, health and function, and community participation inequities among multiply marginalized people of color with disabilities. The results showed that fellows experienced improved research skills, scientific productivity, and collaboration/networking opportunities. The model represents a promising research training pipeline component.

Emerging Conceptual Frameworks for Co-Serving Veterans of Color Across the State-Federal Vocational Rehabilitation Program: SVRAs, AIVRPs, and VA-VR&E.

Existing models of interagency collaborations serving the United States (U.S.) Armed Forces veterans of color, i.e., African Americans, Latinx, Native Americans/Alaskan Natives and Asian Americans and/or Pacific islanders are sparse, and few co-service partnership models are available. This article proposes two different emerging conceptual frameworks, i.e., state vocational rehabilitation agency (SVRA) and the U.S. Department of Veterans Affairs Veterans Readiness and Employment Program (VA-VR&E) co-service model, and American Indian Vocational Rehabilitation Program (AIVRP) and VA-VR&E co-service model designed to enhance successful employment outcomes for these veterans. Diffusions of innovations Theory was used to develop the Co-Service Models. A set of recommended approaches that these agencies and researchers can consider are presented.

Factors in Utilization of Telehealth Treatment by Rural African-Americans with Opioid Use Disorder and Disabilities.

This study explored factors that impact telehealth service utilization for treatment of African Americans with disabilities with opioid use disorder in rural communities. A focus group was conducted involving 12 different mental health, substance use, and rehabilitation counseling professionals. The analysis was completed using NVivo (Version 12). The results identified critical barriers that included historical distrust of technology and healthcare systems, digital divide/unavailability of Internet modems, fear of losing confidentiality, and agency non-approval. The benefits were improved communication, reduction of stigma, continuity of care, and convenience of collaboration. The findings indicate the need for additional research in this topic area.

National Benchmark Study of Employment Equity Among Multiply Marginalized Persons of Color with Disabilities During the COVID-19 Pandemic: A Bootstrap Approach.

BACKGROUND: Research examining state vocational rehabilitation agency (SVRA) sponsored service patterns during the COVID-19 pandemic is needed to improve employment outcomes among multiply marginalized persons of color with disabilities (i.e., African Americans, Asian Americans, Native Americans or Alaska Natives, Latinx, and Native Hawaiians/Pacific Islanders). Scarce attention has been paid to examining outcome inequities in the crisis. OBJECTIVE: This study applied a stratified bootstrap data expansion approach to assess the relationship between race/ethnicity, gender, level of educational attainment at closure and employment outcomes among target group members. METHODS: National fiscal year (FY) 2019 Rehabilitation Services Administration (RSA)-911 case records (N =114,229) closed between January 20, 2020 (date of first reported COVID-19 infection in the U.S.) to June 30 2020 were extracted and re-sampled across multiple trials using bootstrap procedures to increase logistic regression model accuracy. RESULTS: The findings indicated that African Americans, Asian Americans and Native American or Alaska Natives were statistically significantly less likely to achieve successful employment than non-Latinx Whites. Success probabilities in the COVID-19 pandemic were 'poorest' for Native American or Alaska Native VR consumers followed by African Americans, Asian Americans, Latinx, non-Latinx Whites, and then Native Hawaiians/Pacific Islanders. African Americans and Native Americans or Alaska Natives were more often closed unsuccessful because they could not be located when compared to non-Latinx Whites. CONCLUSIONS: These findings call for new targeted SVRA service initiatives.

A Scoping Review of Opioid Use Disorder Treatment Barriers and Telehealth for African Americans with Disabilities in Rural Communities.

This article provided a comprehensive overview of challenges that African Americans with disabilities residing in rural areas often face in the United States when accessing telehealth treatment to mitigate opioid misuse. A scoping literature review was conducted focusing on this target population, telehealth, disabilities, opioid treatment, and rural healthcare systems. Systematic searches on eight electronic databases were carried out in line with the study's aims. The results identified treatment benefits and advantages, expansion challenges, and multicultural considerations for telehealth delivery. There may be a need to increase rehabilitation research in this area to inform needed changes in policies and practice.

Assistive Technology Workplace Accommodation and Employment among Diverse Populations with Disabilities: Does Race/Ethnicity Matter?

The purpose of this study was to examine the relationship between assistive technology workplace accommodation (AT-WA) usage and employment status among racial/ethnic populations with disabilities. Chi-square tests and logistic regression were used to analyze secondary data from the 2015 Kessler Foundation National Employment and Disability Survey (KFNEDS). Results indicated that significantly more consumers who used AT-WA were currently working, and a significantly greater proportion of them were White. Moreover, a significantly lower proportion of those who did not use AT-WA had less expected odds of being currently employed. Specific implications are discussed to inform practices, policy, and/or future research.

Community Living Outcome Factors for People of Color with Disabilities and Concomitant Opioid Use Disorder: A Scoping Review.

This scoping review mapped the pertinent extant published and grey literature and policy to assess factors that promote positive community living outcomes among people of color with disabilities and concomitant opioid use disorder (OUD) in the United States (U.S.). Forty-three publications covering OUD and people of color with disabilities and people of color with disabilities and community living content were reviewed. Select community living barriers and potential interventions were identified for people of color with disabilities in general; however, the review failed to classify such factors for those with OUD. Authors offered recommendations for practice, research, and policy.

Near-infrared heating of skin to delineate non-melanoma skin cancer lesions: A pilot study.

BACKGROUND: Surgical excision is a mainstay of treatment for non-melanoma skin cancer (NMSC); improving margin delineation can reduce the need for further monitoring/treatment. The objective of this pilot study was to determine if near-infrared radiation (NIR) application to skin causes visible changes in normal and NMSC skin, to help delineate margins. MATERIALS/METHODS: Eleven biopsy-proven NMSC lesions were included. The skin was then heated under a 175W NIR heating bulb; margins were traced onto acetate film before and after heating. Lesions were then randomly assigned to excision based on pre- or post-heating margins. Composite images were generated by overlaying the heat and no-heat lesion contours. All specimens were sent for histopathology. RESULTS: The range of closest margins in the control group was 2.0-3.0 mm with a median of 2.0 mm; the range in the intervention group was 4.0-9.0 mm with a median of 5.0 mm. Composite images showed larger heat contours when the initial lesion was larger. There was a statistically significant difference between the two groups. Overall, NIR light caused visible hyperaemia to skin, and more intense erythema to malignant skin lesions. CONCLUSION: Near-infrared light may have use in an outpatient setting for skin cancer delineation, possibly reducing the rate of positive margins.

Biomechanical Impact of a Zygoma Complex Fracture Using Human Cadaver.

ABSTRACT: Zygomaticomaxillary complex fractures are common in midface trauma, with treatment often involving repair using titanium mini plates. However, the need for plate fixation along the zygomaticomaxillary suture on the infraorbital rim remains controversial. This study utilized a previously reported bite force simulator to investigate craniofacial strain patterns following zygomaticomaxillary complex fracture repairs with and without plating of the infraorbital rim. Osteotomies were made to 6 fresh-frozen cadaveric heads to simulate 2 types of zygomatic complex fractures: a dipod fracture with osteotomies at the zygomaticofrontal and zygomaticomaxillary sutures, and a tripod fracture with an additional osteotomies at the zygomaticotemporal suture. Repairs with and without the use of a titanium mini plate across the infraorbital rim were compared in both dipod and tripod fractures. Physiologically proportional masticatory loads were applied using the bite force simulator by actuating intrinsic muscle lines of action. The outcome metric was facial bone strains measured using uniaxial strain gauges. Mixed-effects linear models did not find a significant main effect on the overall strain pattern with the use of an infraorbital rim plate in both dipod (P = 0.198) and tripod (P = 0.117) fracture repairs. However, statistically significant differences were found locally at the zygomatic buttress (P = 0.019) and the zygomatic arch (P = 0.027) on the fractured side in dipod fractures. This is the first known study that successfully utilized a mechanical simulator to reproduce physiological intrinsic masticatory loads in a fracture fixation study. This new technology opens avenues for future biomechanical investigations on maxillofacial fracture repairs and other surgical treatments.

Bite Force Simulator: A Novel Technique to Simulate Craniofacial Strain In Vitro.

Existing in vitro simulators rely on external manipulation of the skull to replicate masticatory forces; however, external manipulations do not accurately represent internal loads as in physiological muscle forces.The purpose of the project is to develop an in vitro simulator that internally replicates the forces of mastication. The simulator has 3-dimensional-printed piston mounts that are reverse-engineered using a computed tomography scan of the specimen. The mounts are attached to the skull at muscle attachment sites using adhesive. The pneumatic pistons are sutured to muscle tendons; when the pistons are activated, they pull on the tendons which proportionally replicate muscle loads. The force output of the pistons can be individually modified by a custom software. Strain gauges are attached to craniofacial bones to measure deformation under replicated muscle loads. A 6 degrees-of freedom force sensor is placed intraorally to measure the generated bite force.The methodology was validated on 6 fresh-frozen cadaveric heads. Change in strain measurements was observed with change in simulated muscle loads. The simulator can validate computer simulation models and provide an experimental platform for craniofacial and dental implants. It sets the framework for a new, more physiologically consistent way of studying craniofacial stresses.

Impact of nasal surgery on speech resonance.

OBJECTIVES: The nose and paranasal sinuses contribute to speech resonance and changes to these structures may alter speech nasality. This change may influence one's vocational and social functioning and quality of life. Our investigation explored objective and subjective changes in nasality following nasal surgery in a prospective and longitudinal fashion. METHODS: Recordings of sustained vowel and sentence stimuli and voice-related quality of life measurements were obtained preoperatively and at 2, 4, 8, and 24 weeks postoperatively from individuals undergoing nasal and/or sinus surgery. Objective measures of fundamental frequency, jitter, shimmer, and harmonic to noise ratio (HNR) were determined. Pre- and postoperative speech samples were assessed by 15 naïve listeners. RESULTS: In all, 15 subjects completed the study. Neither speakers nor listeners perceived a subjective change in nasality following surgery. No statistically significant change in microacoustic measures were identified. Although nasal sentences did not reveal differences for 3 microacoustic measures, a difference in HNR was identified. CONCLUSIONS: Patients undergoing nasal surgery did not exhibit subjective changes in resonance postoperatively. Aside from a difference in HNR for the nasal sentence, objective microacoustics remained unchanged. These results demonstrate the stability of oranasal resonance despite nasal surgery and provide valuable data for patient informed decision-making.

Clinical and longitudinal patterns of frequent presenters to emergency departments: A multi-centre data linkage analysis.

OBJECTIVE: To describe clinical characteristics and longitudinal patterns of representation in a cohort of patients who frequently present to EDs for care. METHODS: A retrospective data analysis linking routinely collected ED data across three hospitals. The study population consisted of patients who presented to any ED on 10 or more occasions in any continuous 365-day period from 1 July 2015 to 30 June 2021. Presenting complaints were divided into those with any mental health, drug and alcohol, or social presentations (MHDAS group) and those without (non-MHDAS group). Outcomes of interest were number of presentations as well as temporal and facility clustering of presentations. A per patient regression analysis was performed to identify independent risk factors for increased presentations. RESULTS: Presentations by 1640 frequent ED presenters in the study constituted 4.6% of total ED presentations. MHDAS study group were younger, predominantly English speaking, twice as likely to be married, had lower hospital admission rates and almost three times as many of them did not wait for treatment. Statistically significant differences were also found between these groups regarding presentation clustering, facility entropy, each of the four categories of the number of ED presentations, and Index of Relative Socio-Economic Advantage and Disadvantage. CONCLUSION: Representations associated with MHDAS have a different trajectory of representation episodes compared to non-MHDAS group. Escalating number of presentations and clustering are important predictors of future representation numbers. Those 'did not waits' who appear to be representing would be the highest risk of ongoing and persistent representations in the future and should be the target of early interventions to ensure they are accessing appropriate care before this happens.

How I do it: lateral canthal web revision-single Z-plasty technique.

BACKGROUND: Lateral canthal webbing is a known complication of blepharoplasty, which occurs when the lateral aspect of the upper blepharoplasty incision is taken below the equator of the lateral canthus. Removing excessive eyelid skin laterally can also result in a lateral canthal web. Currently, there is no standard approach for addressing this complication. METHODS: Retrospective review of single surgeon practice between 2011 and 2019. All patients underwent revision surgery using the proposed single Z-plasty technique. RESULTS: Twenty-three patients referred for lateral canthal web were included in the study. All patients had previous upper lid blepharoplasty, with the initial procedure occurring 8-63 months prior to the referral for revision. The majority of the blepharoplasties occurred in Ontario (n = 19), but some patients also underwent surgery in Alberta (n = 1), British Columbia (n = 1), and United States (n = 1). The initial surgeries were performed by a variety of specialities including plastic surgery (n = 16), otolaryngology (n = 4), ophthalmology (n = 2), and family medicine (n = 1). Following revision surgery using the single Z-plasty technique, all patients reported a subjective increase in functional and aesthetic satisfaction. No further revision surgery was required for any of these patients. CONCLUSION: The single Z-plasty technique is simple, robust, and could be easily incorporated into any cosmetic practice to address this complication of blepharoplasty.

Realistic and inexpensive ultrasound phantoms to demonstrate aortic aneurysm and aortic dissection.

Introduction: Using ultrasound to evaluate for the presence of aortic pathology is a common procedure in the emergency department. Phantoms are models that are used to simulate clinical conditions for teaching ultrasound-related skills. To date, no 'homemade' phantom has been created to model aortic aneurysms, and no phantoms exist to model aortic dissection. Methods: We used several readily available, inexpensive ingredients to create ultrasound phantoms. Results: These phantoms realistically mimic aortic aneurysm and aortic dissection. Discussion: These are the first 'homemade' phantoms that demonstrate aortic pathology. Conclusions: We have created realistic, affordable, easily reproducible phantoms for use in teaching clinicians to use ultrasound when evaluating patients for aortic aneurysm and/or aortic dissection.

Understanding for whom, how and why Sydney Local Health District's Integrated Response was Effective in Addressing COVID-19: A Critical Realist Qualitative Study.

INTRODUCTION: Australia has been comparatively effective in preventing the transmission of COVID-19. The Sydney Local Health District [SLHD] used a "whole of health" integrated approach to respond to the pandemic. The aim of this study was to understand for whom, how and why this response worked, to inform a sustainable system transformation. METHODS: A critical realist qualitative study was conducted with 20 purposively selected key informants. Data were collected through in-depth interviews and analysed using thematic analysis guided by abduction and retroduction. The five strategies of the WHO integrated people-centred health services framework was used to guide the overall study. RESULTS: An enabling environment of a strong governance, emergency preparedness, a committed and adaptable workforce, and a strong core infrastructure underpinned SLHD's effective response. With a culture of embracing innovation, the district adapted virtual care to effectively quarantine people through their special health accommodation, and coordinate care across tertiary and community services. The established interagency relationships prior to the pandemic, enabled service directors to quickly integrate their services, which empowered and engaged the community [and staff], working across relevant sectors to provide care "where the people are"; reaching marginalised populations, and reducing community transmission. DISCUSSION AND CONCLUSION: The SLHD's progress towards a 'whole of health' approach, empowered and enabled the district to effectively work within and across sectors to address the pandemic in a people-centred manner. Sustaining the contextual conditions and mechanisms, that facilitated effective integration, will be beneficial beyond the pandemic.

Sydney Local Health District's Integrated Response to the COVID-19 Pandemic: A Descriptive Study.

Introduction: Sydney Local Health District (SLHD) is a local health district in the state of New South Wales in Australia responsible for providing health services to the centre and inner west of the Sydney metropolitan area. SLHD adopted, during the COVID-19 pandemic, an integrated virtual and community care approach to manage quarantine and protect the health and wellbeing of the population. Description: The case study describes the roles of the different agencies and teams in the first six months of the pandemic across four key functions of 1) rapid screening and testing; 2) reaching the community; 3) effective quarantine and ongoing care; and 4) infrastructure, pathology and staff education. Discussion: The "whole of system" approach proved to be an effective method of delivering care that reduced community anxiety, improved and created relationships between existing and new internal and external stakeholders, and changed the community and health sector's perspective on the importance of virtual care. Conclusion: This case study describes the importance of well-integrated, decentralised and funded public health system in response to the COVID-19 pandemic.

Unpacking the design, implementation and uptake of community-integrated health care services: a critical realist synthesis.

INTRODUCTION: Community-integrated care initiatives are increasingly being used for social and health service delivery and show promising outcomes. Nevertheless, it is unclear what structures and underlining causal agents (generative mechanisms) are responsible for explaining how and why they work or not. METHODS AND ANALYSIS: Critical realist synthesis, a theory-driven approach to reviewing and synthesising literature based on the critical realist philosophy of science, underpinned the study. Two lenses guided our evidence synthesis, the community health system and the patient-focused perspective of integrated care. The realist synthesis was conducted through the following steps: (1) concept mining and framework formulation, (2) searching for and scrutinising the evidence, (3) extracting and synthesising the evidence (4) developing the narratives from causal explanatory theories, and (5) disseminate, implement and evaluate. RESULTS: Three programme theories, each aligning with three groups of stakeholders, were unearthed. At the systems level, three bundles of mechanisms were identified, that is, (1) commitment and motivation, (2) willingness to address integrated health concerns and (3) shared vision and goals. At the provider level, five bundles of mechanisms critical to the successful implementation of integrated care initiatives were abstracted, that is, (1) shared vision and buy-in, (2) shared learning and empowerment, (3) perceived usefulness, (4) trust and perceived support and (5) perceived role recognition and appreciation. At the user level, five bundles of mechanisms were identified, that is, (1) motivation, (2) perceived interpersonal trust, (3) user-empowerment, (4) perceived accessibility to required services and (5) self-efficacy and self-determination. CONCLUSION: We systematically captured mechanism-based explanatory models to inform practice communities on how and why community-integrated models work and under what health systems conditions. PROSPERO REGISTRATION NUMBER: CRD42020210442.

Transmission and accumulation of CTL escape variants drive negative associations between HIV polymorphisms and HLA.

Human immunodeficiency virus (HIV)-1 amino acid sequence polymorphisms associated with expression of specific human histocompatibility leukocyte antigen (HLA) class I alleles suggest sites of cytotoxic T lymphocyte (CTL)-mediated selection pressure and immune escape. The associations most frequently observed are between expression of an HLA class I molecule and variation from the consensus sequence. However, a substantial number of sites have been identified in which particular HLA class I allele expression is associated with preservation of the consensus sequence. The mechanism behind this is so far unexplained. The current studies, focusing on two examples of "negatively associated" or apparently preserved epitopes, suggest an explanation for this phenomenon: negative associations can arise as a result of positive selection of an escape mutation, which is stable on transmission and therefore accumulates in the population to the point at which it defines the consensus sequence. Such negative associations may only be in evidence transiently, because the statistical power to detect them diminishes as the mutations accumulate. If an escape variant reaches fixation in the population, the epitope will be lost as a potential target to the immune system. These data help to explain how HIV is evolving at a population level. Understanding the direction of HIV evolution has important implications for vaccine development.