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Objective:. To assess the relationship between postoperative opioid consumption and frailty status. Background:. Physiologic reserve can be assessed through both chronologic age as well as measures of frailty. Although prior studies suggest that older individuals may require less opioid following surgery, chronologic age, and frailty do not always align, and little is known regarding postoperative opioid consumption patterns by frailty. Methods:. We conducted a retrospective analysis of opioid-naïve adult patients undergoing common general, vascular, and gynecologic procedures across a statewide quality improvement program from November 6, 2017 to February 28, 2021. Our primary outcome was postoperative patient-reported opioid consumption within 30 days of surgery in oral morphine equivalents (OME). Our primary exposure was frailty status defined by the modified frailty index (mFi-5) criteria. Other covariates included patient demographic and clinical attributes, procedural factors, discharge opioid prescription size, and postoperative complications. Linear regression was performed to assess the association of frailty status and opioid consumption, stratified by age. Results:. In this cohort of 34,854 patients, 10,596 had an mFi-5 score of ≤1 and 3,635 had a score of >1. A score of >1 was associated with increased patient-reported opioid consumption (OMEs 3.3 greater; 95% CI = 1.5–5.1). This held true for individuals over 65 (OMEs 2.7 greater; 95% CI = 0.2–5.1). Frailty status, regardless of score, was negatively associated with an opioid prescription at discharge. Conclusions:. Frailty status is associated with increased opioid consumption after common operations. Future prescribing guidelines and outcomes analyses should consider this marker when reviewing opioid consumption data and related adverse outcomes.

Background:. Delivering ethical care in global plastic surgery is challenging due to the unique complexities of resource-limited settings. Additionally, the rise of medical tourism has highlighted the importance of informed consent and awareness of the potential risks that are associated with seeking medical care in foreign countries. This article aims to consider core medical ethics principles and apply them in the context of delivering global plastic surgery. Methods:. This article examines the application of the four core medical ethics principles in a framework set forth by Beauchamp and Childress, namely autonomy, beneficence, nonmaleficence, and justice, in the context of delivering plastic surgery in international settings. A literature review was performed, where all potential global plastic surgery articles were reviewed to better understand the application of the four core medical ethics framework in this context. Results:. Increased communication between visiting surgeons and local healthcare providers; heightened education of surgeons traveling to low-to-middle-income countries regarding local medical practices, resource availability, and cultural norms before providing surgical education; and a greater emphasis on collecting and publishing data analyzing short- and long-term outcomes in low-to-middle-income countries are all likely to improve the success of international medical missions, ensuring that all patients receive medical treatment in a manner that upholds Beauchamp and Childress’ four core medical ethics principles. Conclusion:. Providing plastic and reconstructive surgery abroad can be done ethically if the four main principles of medical ethics (respect for autonomy, beneficence, nonmaleficence, and justice) are used.

Background: Skeletal dysplasias (SkD) are a rare group of disorders characterized by abnormal growth and development of bone and cartilage, often causing limb deformity. Many patients also have ligamentous instability that can accentuate the malalignment. This ligamentous instability can present either a generalized ligamentous laxity or focal coronal plane intra-articular malalignment. Temporary hemiepiphysiodesis (HE) is a commonly employed minimally invasive surgical technique for correcting coronal plane limb deformities. This study evaluated the effectiveness of HE in the correction of knee coronal plane deformity in children with SkD and the correlation of concurrent joint laxity. Methods: A retrospective cohort study was conducted to evaluate radiological outcomes of HE for coronal plane knee deformities in patients with SkD (aged

Background:. The gold standard of microsurgical breast reconstruction is the deep inferior epigastric perforator (DIEP) free flap. As techniques have evolved, DIEP flaps have significantly reduced the morbidity previously caused by transverse rectus abdominis muscle (TRAM) and muscle-sparing TRAM flaps. However, abdominal wall complications continue to persist after DIEP flap surgery, with bulge rates reported as high as 33%. Methods:. The first 25 patients undergoing DIEP flap surgery with the use of Duramesh (MSI, Chicago, Ill.) by the senior author were identified. A retrospective chart review of patient and surgical details was performed. Charts were reviewed for outcomes, including surgical site infections, surgical site events, incisional hernia formation, and/or bulge. Standard descriptive summary statistics were used for patient characteristics, surgical details, and primary and secondary outcomes. Results:. Twenty-five patients were reviewed. Average follow-up duration was 216 ± 39 days. One patient (4%) developed a surgical site infection, and four patients (16%) developed a surgical site event. One patient developed a bulge, but no patients developed an incisional hernia. Conclusions:. Duramesh mesh suture provides a promising opportunity for DIEP surgeons to minimize both abdominal wall morbidity and mesh-related complications. Mesh suture can be used in a similar fashion as other sutures to perform primary closure of the anterior rectus sheath while also providing force-distribution benefits typically unique to planar mesh. This pilot study suggests that Duramesh is a safe, simple alternative to existing techniques in DIEP flap surgery and can be considered by microsurgeons to reduce fascial dehiscence, bulge, and/or hernia formation.

Background:. Enhanced recovery after surgery protocols have become increasingly adopted for autologous breast reconstruction, demonstrating improved quality of care and reduced hospital stays. Despite this, average length of stay remains over 3 days. We have found, in appropriately selected patients, hospital length of stay can be safely reduced to less than 48 hours. Methods:. Retrospective review was performed of patients who underwent microsurgical breast reconstruction by the senior author (M.H.) from April 2019 to December 2021. Demographics, operative details, length of stay, and postoperative complications are reported to assess for safety of discharge within 48 hours, with the primary outcome measure being flap loss. Results:. In total, 188 flaps were performed on 107 patients. Average age was 51.4 years (SD 10.1 years) with average BMI 26.6 kg/m2 (SD 4.8 kg/m2). Average length of stay was 1.97 days (SD 0.61 days), and 96 patients (89.7%) were discharged within 48 hours. Six flaps (3.2%) required operative takebacks. Five of the six (83.3%) takebacks occurred on postoperative days zero or one, and all five of these flaps were salvaged. There were four breast hematomas (2.1%), four breast seromas (2.1%), eight breast infections (4.3%), 13 breasts (6.9%) with wound dehiscence, four flaps (2.1%) with partial flap loss, and 24 breasts (12.8%) with mastectomy flap necrosis. One hundred fifty flaps (79.8%) had no complications. Overall success rate of flap reconstruction was 99.5%. Conclusion:. Hospital discharge in 24–48 hours is safe in appropriately selected patients undergoing autologous tissue breast reconstruction.

Background:. Over the past 10 years, smartphones have become ubiquitous, and mobile apps serve a seemingly endless number of functions in our everyday lives. These functions have entered the realm of plastic surgery, impacting patient care, education, and delivery of services. This article reviews the current uses of plastic surgery mobile apps, app awareness within the plastic surgery community, and the ethical issues surrounding their use in patient care. Methods:. A scoping review of electronically available literature within PubMed, Embase, and Scopus databases was conducted in two waves in November and May 2022. Publications discussing mobile application use in plastic surgery were screened for inclusion. Results:. Of the 80 nonduplicate publications retrieved, 20 satisfied the inclusion criteria. Articles acquired from the references of these publications were reviewed and summarized when relevant. The average American Society of Plastic Surgeons evidence rating of the publications was 4.2. Applications could be categorized broadly into three categories: patient care and surgical applications, professional development and education, and marketing and practice development. Conclusions:. Mobile apps related to plastic surgery have become an abundant resource for patients, attending surgeons, and trainees. Many help bridge gaps in patient care and surgeon-patient communication, and facilitate marketing and practice development. Others make educational content more accessible to trainees and performance assessment more efficient and equitable. The extent of their impact on patient decision-making and expectations has not been completely elucidated.

Trends of coagulation parameters during long-term treatment with combination antiretroviral therapy (cART) are unclear. We followed 40 male subjects living with human immunodeficiency virus (HIV). Plasma levels of procoagulant parameters, factor VIII, von Willebrand factor and D-dimer, and anticoagulant parameter Protein S (PS), were measured before start and 3 months, 1 year, and 9 years after. Analyses were adjusted for cardiovascular risk factors (age, smoking, and hypertension) at baseline. At baseline, procoagulant parameters were markedly elevated and PS was in the lower range of normal. CD4/CD8-ratio improved during the complete follow-up period. In the first year, procoagulant parameters were decreasing, but at year 9 an increase was observed. After correction for cardiovascular risk factors, this increase was no longer present. PS remained stable during the first year and slightly increased from one to 9 years. This study indicates that decreasing immune activation by cART reverses the procoagulant state in HIV partially during the first year. These parameters increase in the long term despite an on-going decrease in immune activation. This increase might be related to established cardiovascular risk factors.

Background: The gold standard treatment for infected total knee arthroplasty (TKA) is two-stage revision. The first stage involves a temporary antibiotic spacer, which can be static or articulating; it remains unclear which is best. We aimed to compare 5-year outcomes between static and dynamic spacers. Methods: One hundred and seventy-six patients with infected TKA requiring two-stage revision were enrolled. Patients were organized based on the type of spacer used during the first-stage revision. One hundred and four patients received articulating spacers, and 72 received static spacers. At 5 years, postoperative range of motion (ROM), Short Form 12 (SF-12), Knee Society Score (KSS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were recorded. Reinfection and revisions were also tracked. Results: Eradication of infection was similar in both groups, with 83.7% in the articulating group and 86.1% in the nonarticulating spacer group (P = .234). Articulating spacers resulted in significantly improved ROM (111 vs 82 degrees, P < .001), SF-12 physical component score (35.2 vs 31.0, P = .01), KSS (145.2 vs 113.7, P < .001), and WOMAC function scores (60.1 vs 51.1, P = .03) as compared to the static spacer group. Conclusions: Treatment with an articulating spacer as opposed to a static spacer resulted in improved ROM, SF-12 physical component score, KSS, and WOMAC function scores at the final follow-up visit. There was no significant difference in reinfection rates. Patients requiring staged revision for infected TKA may benefit from an articulating spacer.

Purpose: Patients with cervical cancer who are at high risk for para-aortic lymphatic involvement may receive extended-field chemoradiation (EF-CRT), with inclusion of the para-aortic region. Increased radiation to bone marrow (BM) may heighten hematologic toxicity (HT) and affect timely delivery of chemoradiation. Factors associated with HT in this setting have not been well studied. Methods and Materials: This study was a retrospective analysis of women treated with EF-CRT from 2012 to 2018 with platinum-based chemotherapy. Factors including age, body mass index (BMI), race, Charlson Comorbidity Index (CCI), and nadirs for white blood cell count, absolute neutrophil count, hemoglobin, and platelet count were collected. The BM metrics included V5Gy, V10Gy, V15Gy, V20Gy, V25Gy, V30Gy, V35Gy, V40Gy and V45Gy (VxGy was defined as the percentage of BM volume receiving x Gy). Hematologic toxicity was defined as grade ≥2 (Cooperative Group Common Toxicity Criteria) leukopenia, anemia, neutropenia, or thrombocytopenia. Univariate analysis (UVA) and multivariate analysis (MVA) were performed using the χ2 test, the Fisher exact test, and logistic regression. Previously published dosimetric BM constraints were examined as detailed in each respective study. Results: Fifty-two women underwent EF-CRT with cisplatin. UVA showed no association between HT and age, BMI, or CCI. When accounting for race, V5Gy ≥98% was associated with grade ≥2 leukopenia (P = .02) and grade ≥2 HT (P = .05). Most previously described radiation metrics were not reproduced in our cohort, but a similar constraint, V20Gy

Purpose: Hippocampal volume (HV) is an established predicting factor for neurocognitive function (NCF) in neurodegenerative disease. Whether the same phenomenon exists with hippocampal-avoidant whole brain radiation therapy is not known; therefore, we assessed the association of baseline HV with NCF among patients enrolled on RTOG 0933. Methods and Materials: Hippocampal volume and total brain volume were calculated from the radiation therapy plan. Hippocampal volume was correlated with baseline and 4-month NCF scores (Hopkins Verbal Learning Test–Revised [HVLT-R] Total Recall [TR], Immediate Recognition, and Delayed Recall [DR]) using Pearson correlation. Deterioration in NCF was defined per the primary endpoint of RTOG 0933(mean 4-month relative decline in HVLT-R DR). Comparisons between patients with deteriorated and nondeteriorated NCF were made using the Wilcoxon test. Results: Forty-two patients were evaluable. The median age was 56.5 years (range, 28-83 years), and 81% had a class II recursive partitioning analysis. The median total, right, and left HVs were 5.4 cm3 (range, 1.9-7.4 cm3), 2.8 cm3 (range, 0.9-4.0 cm3), and 2.7 cm3 (range, 1.0-3.7 cm3), respectively. The median total brain volume was 1343 cm3 (range, 1120.5-1738.8 cm3). For all measures of corrected HV, increasing HV was associated with higher baseline HVLT-R TR and DR scores (ρ: range, 0.35-0.40; P-value range, .009-.024) and 4-month TR and DR scores (ρ: range, 0.29-0.40; P-value range, .009-.04), with the exception of right HV and 4-month DR scores (ρ: 0.29; P = .059). There was no significant association between HV and NCF change between baseline and 4 months. Fourteen patients (33.3%) developed NCF deterioration per the primary endpoint of RTOG 0933. There was no significant difference in HV between patients with deteriorated and nondeteriorated NCF, although in all instances, patients with deteriorated NCF had numerically lower HV. Conclusions: Larger HV was positively associated with improved performance on baseline and 4-month HVLT-R TR and DR scores in patients with brain metastases undergoing hippocampal-avoidant whole brain radiation therapy but was not associated with a change in NCF.

Background:. Lymphovenous anastomosis (LVA) is a microsurgical treatment for lymphedema of the lower extremity (LEL). This study systematically reviews the most recent data on outcomes of various LVA techniques for LEL in diverse patients. Methods:. A comprehensive literature search was conducted in the Ovid MEDLINE, Ovid EMBASE, and Scopus databases to extract articles published through June 2021. Studies reporting data on objective postoperative improvement in lymphedema and/or subjective improvement in quality of life for patients with LEL were included. Extracted data comprised demographics, number of patients and lower limbs, duration of symptoms before LVA, surgical technique, duration of follow-up, and objective and subjective outcomes. Results:. A total of 303 articles were identified and evaluated, of which 74 were ultimately deemed eligible for inclusion in this study, representing 6260 patients and 2554 lower limbs. The average patient age ranged from 22.6 to 76.14 years. The duration of lymphedema before LVA ranged from 12 months to 11.4 years. Objective rates of improvement in lymphedema ranged from 23.3% to 100%, with the greatest degree of improvement seen in patients with early-stage LEL. Conclusions:. LVA is a safe and effective technique for the treatment of LEL of all stages. Several emerging techniques and variations may lead to improved patient outcomes.

Delusions of parasitosis (DOP), which is also called Morgellons disease or delusional infestation, can be one of the most challenging clinical encounters in a dermatologist’s practice. One reason for this is lack of education during dermatology residency and a paucity of resources for the practicing dermatologist such as specialized psychodermatology clinics for these patients. To help close this knowledge gap, an interview was conducted with 3 experts in the field of psychodermatology and their responses were recorded and edited with goal of improving care for patients suffering from DOP by educating the busy, practicing dermatologist. The experts discussed many topics regarding DOP including the difference between primary and secondary DOP, how to build a good rapport with DOP patients, why the condition is seen mostly in older woman, and which medications are effective for treatment. The interview ends with a few high-yield practical treatment tips.

Immunoglobulin G4-related aortitis (IgG4-RA) is histologically characterized by the infiltration of IgG4 positive plasma cells and fibrosis in systemic organs and the elevation of serum IgG4 levels. The cardiovascular system is commonly involved with various possible presentations such as aortitis, arteritis, periaortitis, periarteritis, and inflammatory aneurysm. We present a case of a 48-year-old male without known previous medical history, admitted for further workup of long-standing chest pain and shortness of breath with suspected aortic dissection on initial assessment. Investigation with computed tomography angiography (CTA) and magnetic resonance angiography (MRA) indicated severe thoracic and abdominal aortoarteritis associated with an ascending thoracic aortic aneurysm, which was confirmed to be IgG4-RA on histopathologic analysis. Thoracic and abdominal IgG4-RA clinical and radiological presentation may simulate other causes of acute aortic syndrome such as aortic dissection, atherosclerotic aneurysm and inflammatory conditions. Accurate recognition of IgG4-RA diagnostic imaging features are essential for early diagnosis and treatment surveillance.

A left ventricle pseudoaneurysm (LV PSA) is defined as a free wall rupture of the left ventricle contained by the adjacent pericardial tissue. This rare complication is most commonly encountered following myocardial infarction, trauma, or infection. Surgery is typically warranted to avoid progression to spontaneous rupture, which may potentially lead to cardiac tamponade and death. Cardiac magnetic resonance imaging is the modality of choice to characterize left ventricle morphology and function. Accurate distinction between a pseudoaneurysm and a true aneurysm is crucial, since management and prognosis are significantly different between these 2 entities. We present a case of a 63-year-old male heart transplant recipient, admitted for suspicion of acute cellular rejection, with an unexpected finding of a LV PSA.

Background:. Plastic surgeons regularly perform injections for both cosmetic and functional purposes. This article examines the most common injections utilized by plastic surgeons under Medicare and how their usage and billing has changed between 2012 and 2019. Methods:. Using the earliest and latest data available on the Centers for Medicare and Medicaid Services’ Provider Utilization and Payment Data File, we first determined Healthcare Common Procedure Coding System injection codes most billed to Medicare in 2012 and 2019. The number of services, amount of Medicare beneficiaries, and reimbursement rates were collected and analyzed for each Healthcare Common Procedure Coding System code from the Provider Utilization and Payment Data File for years 2012 and 2019. We compared the change in reimbursement rate for each injection to the rate of inflation in US dollars over the same period. Results:. The unadjusted Medicare reimbursement rate for eight included injection types increased an average of 31.63% during the study period. This was not significantly different from the rate of inflation during the same period (+11.33%, P = 0.311). When all Medicare reimbursement data were adjusted for inflation to 2019 dollars, the average percentage change in reimbursement for all included injections in this study increased by 17.58% from 2012 to 2019. Conclusions:. The findings from our study suggest that injections administered by plastic surgeons appear to be unique in their general stability in reimbursement rates as compared to rates in other fields. Further research should be performed to better understand the driving factors for usage and reimbursement changes.

Introduction: This study aims to understand patient factors associated with refusal of surgery for nonmetastatic colorectal cancer and the associated cancer-specific mortality. Methods: Patients diagnosed with nonmetastatic colorectal cancer between 2004 and 2015 from the Surveillance, Epidemiology, and End Results Program were included. Results: A total of 152,731 (99.4%) patients underwent surgery, and 983 (0.6%) refused surgery. Independent predictors of refusal included male sex, older age, minority race, single relationship status, being uninsured, more recent date of diagnosis, having an earlier stage of diagnosis, and rectal versus colon cancer. Refusing surgery for nonmetastatic colorectal cancer increased cancer-specific mortality (adjusted hazard ratio 5.10, 95% confidence interval 4.62–5.62). Conclusion: Most patients diagnosed with nonmetastatic colorectal cancer undergo surgery in the United States. However, refusal of surgery is increasing and associated with higher cancer-specific mortality. A better understanding of surgical decision making in colorectal cancer is urgently needed.

Purpose: Recurrent intracranial metastases after whole-brain irradiation pose a clinical challenge owing to the escalating morbidity associated with their treatment. Although stereotactic radiosurgery is increasingly being used, there are still situations in which whole-brain reirradiation (ReRT) continues to be appropriate. Here, we report our experience using whole-brain pulsed reduced dose rate radiation therapy (PRDR), a method that delivers radiation at a slower rate of 0.067 Gy/min to potentially increase sublethal damage repair and decrease toxicity. Methods and Materials: Patients undergoing whole-brain ReRT with PRDR from January 1, 2001 to March 2019 were analyzed. The median PRDR ReRT dose was 26 Gy in 2 Gy fractions, resulting in a median total whole-brain dose of 59.5 Gy. Cox regression analysis was used for multivariate analysis. The Kaplan-Meier method was used for overall survival, progression free survival, and to evaluate the ReRT score. Binary logistic regression was employed to evaluate variables associated with rapid death. Results: Seventy-five patients were treated with whole-brain PRDR radiation therapy. The median age was 54 (range, 26-72), the median Karnofsky performance status (KPS) was 80, and 86.7% had recursive partitioning analysis scores of 2. Thirty-two patients had over 10 metastases and 11 had leptomeningeal disease. The median overall survival was 4.1 months (range, 0.29-59.5 months) with a 1 year overall survival of 10.4%. Age, KPS, dexamethasone usage, and intracranial disease volume were significantly correlated with overall survival on multivariate analysis. A KPS ≤70 was associated with rapid death after radiation. The prognostic value of the ReRT score was validated. The most common acute toxicities were fatigue (23.1%) and headache (16.9%). Conclusions: In this large cohort of patients with advanced intracranial metastases, PRDR achieves acceptable survival and may decrease toxicity associated with ReRT. PRDR is an easily implemented technique and is a viable treatment option for ReRT of brain metastases.

Vascular Ehlers-Danlos syndrome (vEDS), also known as type IV Ehlers-Danlos syndrome, is a rare inherited connective tissue disease that affects 1 in 50,000 to 250,000 individuals. It is characterized by catastrophic vascular complications and hollow viscus rupture; 80% of patients with vEDS experience a vascular complication by the age of 40 years, and median life expectancy is 40 to 50 years. The central vasculature and visceral vasculature are most commonly affected; peripheral involvement is much less common. We describe the case of a 40-year-old woman with vEDS previously complicated by ruptured splenic and posterior tibial artery aneurysms who presented with a ruptured left ulnar artery aneurysm resulting in compartment syndrome. Keywords: Connective tissue disorder, Ehlers-Danlos syndrome, Peripheral aneurysm

Purpose: Patients with cervical cancer are at high risk for opioid use. This study aimed to characterize opioid prescribing patterns at 2 urban hospitals. Methods and Materials: Data from patients with cervical cancer treated with curative intent from 2011 to 2018 were retrospectively collected. Women with unrelated chronic opioid use before diagnosis, persistent/recurrent disease at 3 months after initiation of treatment, or initiation of opioids >6 months after treatment were excluded. Demographics, disease characteristics, treatment, and outpatient prescription practices were collected. Endpoints included duration of opioid use ≥6 and ≥12 months. Results: There were 106 women included, of whom 83% received definitive radiation. Most patients (n = 91, 85.8%) received outpatient opioids. Most common timing of prescriptions were before cancer therapy (35.9%), postprocedure (26.4%), and during radiation therapy (17.0%). Median duration was 3 (interquartile range, 1-11) months; 35.2% of these patients received opioids ≥6 months and 22% received opioids ≥12 months. Greater International Federation of Gynaecology and Obstetrics (FIGO) stage, recurrent/residual disease, initiation of opioids before treatment, history of depression or anxiety, and use of gabapentin or steroids were associated with long-term opioid use. Conclusions: Most patients were prescribed outpatient opioids, many of whom used opioids for 12 months. Improvement in provider communication and education, increased posttreatment monitoring, and further evaluation of nonopioid therapies are needed in this patient population to reduce long-term opioid use.

Objective Determine risk factors for failure to receive surgical treatment among patients with obstructive sleep apnea. Study Design Population-based observational longitudinal cohort study. Setting Population-based database. Methods Multivariate analysis of 500,792 individuals with obstructive sleep apnea from Optum’s deidentified Clinformatics Data Mart database (2004-2018). Results Black race, increased age, diabetes, atrial fibrillation, obesity, and congestive heart failure were independently associated with a decreased rate of surgery for obstructive sleep apnea. Asian race, hypertension, arrhythmias other than atrial fibrillation, pulmonary disease, and liver disease were independently associated with an increased rate of surgery for obstructive sleep apnea. Conclusion Racial disparities in health outcomes related to health care access and in economic resources have an enormous impact on public health and social equity. We found differences in rates of surgery for obstructive sleep apnea based on race. These data are consistent with others demonstrating disparities in medical treatment of sleep apnea with positive pressure and underline a need for a change in awareness and treatment in these populations.

Chronic lateral ankle instability (CLAI) is a condition that is characterized by persistent disability and recurrent ankle sprains while encompassing both functional and mechanical (laxity) instability. Failure of conservative treatment for CLAI often necessitates operative intervention to restore the stability of the ankle joint. The traditional or modified Broström techniques have been the gold standard operative approaches to address CLAI with satisfactory results; however, patients with generalized ligament laxity (GLL), prior unsuccessful repair, high body mass index, or high-demand athletes may experience suboptimal outcomes. Synthetic ligament constructs have been tested as an adjunct to orthopedic procedures to reinforce repaired or reconstructed ligaments or tendons with the hope of early mobilization, faster rehabilitation, and long-term prevention of instability. Suture tape augmentation is useful to address CLAI. Multiple operative techniques have been described. Because of the heterogeneity among the reported techniques and variability in postoperative rehabilitation protocols, it is difficult to evaluate whether the use of suture tape augmentation provides true clinical benefit in patients with CLAI. This review aims to provide a comprehensive outline of all the current techniques using suture tape augmentation for treatment of CLAI as well as present recent research aimed at guiding evidence-based protocols.

Background:. A better understanding of early pain trajectories (patterns) following scoliosis surgery and how they relate to baseline patient characteristics and functional outcomes may allow for the development of mitigating strategies to improve patient outcomes. Methods:. This was a prospective cohort study. Adolescents with idiopathic scoliosis were recruited across multiple centers. Latent growth mixture modeling techniques were used to determine pain trajectories over the first postoperative year. Results:. The median numerical rating scale for pain in the hospital following surgery for adolescent idiopathic scoliosis was 5.0. It improved to 1.0 by 6 weeks, and was maintained at

Objectives:. The main objective of this study was to evaluate trends in set tidal volumes across all adult ICUs at a large academic medical center over 6 years, with a focus on adherence to lung-protective ventilation (≤ 8-cc/kg ideal body weight). A secondary objective was to survey providers on their perceptions of lung-protective ventilation and barriers to its implementation. Design:. Retrospective observational analysis (primary objective) and cross-sectional survey study (secondary objective), both at a single center. Participants:. Mechanically ventilated adult patients with a set tidal volume (primary objective) and providers rotating through the Medical and Neurosciences ICUs (secondary objective). Interventions:. None. Measurements and Main results:. From 2013 to 2018, the average initial set tidal volume (cc/kg ideal body weight) decreased from 8.99 ± 2.19 to 7.45±1.34 (p < 0.001). The cardiothoracic ICU had the largest change in tidal volume from 11.09 ± 1.96 in 2013 to 7.97 ± 1.03 in 2018 (p < 0.001). Although the majority of tidal volumes across all ICUs were between 6.58 and 8.01 (interquartile range) in 2018, 27% of patients were still being ventilated at volumes greater than 8-cc/kg ideal body weight. Most surveyed respondents felt there was benefit to lung-protective ventilation, though many did not routinely calculate the set tidal volume in cc/kg ideal body weight, and most did not feel it was easily calculable with the current electronic medical record system. Conclusions:. Despite a trend toward lower tidal volumes over the years, in 2018, over a quarter of mechanically ventilated adult patients were being ventilated with tidal volumes greater than 8 cc/kg. Survey data indicate that despite respondents acknowledging the benefits of lung-protective ventilation, there are barriers to its optimal implementation. Future modifications of the electronic medical record, including a calculator to set tidal volume in cc/kg and the use of default set tidal volumes, may help facilitate the delivery of and adherence to lung-protective ventilation.

Objective: To assess the relationship between bone marrow (BM) biopsy operator experience and both specimen quality and ancillary testing utilization. Patients and Methods: We evaluated all referred and in-house (IH) BM biopsy specimens obtained over a contiguous 6-week period from April 3, 2017, to May 19, 2017. The BM specimens were assessed for the length of interpretable marrow, and aspirates were assessed for the presence of spicules. Subgroup comparisons included IH BM obtained by a trained team of nurses within our institution, patients clinically referred (CR) to our institution with outside-obtained BM specimens, and outside pathologist-referred (PR) consultation cases. Ancillary study usage was compared between the first 100 cases of each group. Results: A total of 1191 BM specimens were analyzed, including 600 IH, 288 CR, and 303 PR cases with biopsies and/or aspirates. The average interpretable biopsy lengths of IH, CR, and PR cases were 16.0 mm, 10.0 mm, and 7.0 mm, respectively (P

Background: This study provides an example for evaluating learning curve when introducing a new knee system. Methods: Thirty-five investigators across 22 sites prospectively implanted 843 subjects with currently available products (group A). Seventy-seven investigators across 48 sites prospectively implanted 2330 subjects with the ATTUNE Knee System; in which the first 10 subjects for each surgeon were the learning curve cases (group B, N = 611), and the later subjects were designated as group C (N = 1719). Surgical time, rates of intraoperative and early postoperative complications, and patient-reported outcome measures (PROMs) at a minimum of 1 year were compared. Results: Mean (standard deviation) surgical time was 72.0 (21.6) minutes for group A, 83.0 (24.2) for group B, and 72.1 (24.1) for group C (P < .001 for group B vs group C; P = .955 for group C vs group A). Intraoperative, early (

Summary: Apelin agonism causes systemic vasodilatation and increased cardiac contractility in humans, and improves pulmonary arterial hypertension (PAH) in animal models. Here, the authors examined the short-term pulmonary hemodynamic effects of systemic apelin infusion in patients with PAH. In a double-blind randomized crossover study, 19 patients with PAH received intravenous (Pyr1)apelin-13 and matched saline placebo during invasive right heart catheterization. (Pyr1)apelin-13 infusion caused a reduction in pulmonary vascular resistance and increased cardiac output. This effect was accentuated in the subgroup of patients receiving concomitant phosphodiesterase type 5 inhibition. Apelin agonism is a novel potential therapeutic target for PAH. (Effects of Apelin on the Lung Circulation in Pulmonary Hypertension; NCT01457170) Key Words: apelin, APJ, human, pulmonary arterial hypertension

The Centers for Disease Control and Prevention (CDC) estimate that influenza causes 36,000 deaths in the United States every year, and results in direct medical care costs of over $4.6 billion annually. Influenza and pneumonia are responsible for 8,800 deaths per year in California alone, making it the sixth leading cause of death among adults in the state, yet the illnesses are largely preventable by immunization.The California Adult Immunization Coalition (CAIC) is comprised of more than 20 organizations across California who are working together to increase immunization rates for influenza and pneumonia in adults. The CAIC analyzed influenza vaccination rates in California using data from the 2001 California Health Interview Survey (CHIS), and compared the results to the national Healthy People 2010 goals for adult immunization. The national goals specify that 90% of older adults (age 65 and over) should be immunized against influenza annually by the year 2010 (i.e., less than 10% should remain unimmunized).To deepen our understanding of this important public health issue, the CAIC has added several specific questions concerning adult immunizations to the 2003 CHIS survey. Results of this most recent survey will be available next year. Increasing California’s adult immunization rates to reach the national goal requires the persistent efforts of multiple sectors including vaccine suppliers, health departments, and individual health clinics and health providers’ offices.Key findings are:• 32.6% of older adults (age 65 and over) in California for whom annual flu shots are recommended did not get immunized in 2001. • Immunization rates among older adults varied by region; rates were found to be lowest in the Los Angeles region (63.9%) and highest in the Sacramento region (77.0%). However, no regions in California came close to meeting the national goal that 90% of older adults be immunized against influenza. • Although there was a strong age-related trend for the elderly to get an influenza immunization, 27% remained unimmunized even among people aged 75 years and over. • Among the state’s racial and ethnic groups, Latinos (46%) and African Americans (47%) over the age of 65 were almost twice as likely to go unimmunized when compared with Asians (27%) and Whites (28%) in the same age group. • Persons with a "medical home" (a regular place to get medical care) were more than twice as likely to get immunized compared to those who did not have a usual source of care. • The more often an individual saw the doctor, the more likely he or she was to get a flu shot, however, large numbers of people with regular access to care were still unimmunized. • Patients covered by Medicare were immunized more often than those who were not covered; in the Medicare-covered group 32.7% were not immunized. • There were no differences found in immunization rates between women and men.