Tag: pubmed

Ann Plast Surg. 2023 Jun 1;90(6S Suppl 5):S578-S582. doi: 10.1097/SAP.0000000000003501. Epub 2023 Feb 18.

ABSTRACT

PURPOSE: Patients undergoing resection of the external genitalia are often faced with significant deformity and decreased quality of life. Plastic surgeons are tasked with the challenge of reconstructing these defects to minimize morbidity and increase patients’ quality of life. The authors have set out to investigate the efficacy of local fasciocutaneous and pedicled perforator flaps in external genital reconstruction.

METHODS: A retrospective review was conducted of all patients undergoing reconstruction of acquired defects of the external genitalia from 2017 to 2021. In total, 24 patients met inclusion criteria for the study. Patients were allocated into 2 cohorts: patients with defects reconstructed using local fasciocutaneous flaps (FF) versus patients with defects reconstructed using pedicled islandized perforator flaps (PF). Comorbid conditions, ablative procedures, operative times, flap size, and complications were compared across all groups. Fisher exact test was used to analyze differences in comorbidities, while independent t tests were used to analyze age, body mass index, operative time, and flap size. Significance was set at P < 0.05.

RESULTS: Of the 24 patients included in the study, 6 underwent reconstruction with islandized PFs (either profunda artery perforator or anterolateral thigh), and 18 underwent reconstruction with FFs. The most common indication for reconstruction was vulvectomy for vulvar cancer, followed by radical debridement for infection, and lastly penectomy for penile cancer. The PF cohort had a significantly higher percentage of previously irradiated patients (50% vs 11.1%, P = 0.019). Although mean flap size was larger in the PF cohort, this difference did not reach statistical significance (176 vs 143.4 cm2, P = 0.5). Perforator flaps had significantly longer operative times when compared with FFs (237.33 vs 128.99 minutes, P = 0.003). Average length of stay was 6.88 days in FF and 5.33 days in PF (P = 0.624). Complication profile including flap necrosis, wound healing delays, and infection were similar between groups despite a significantly higher rate of prior radiation in the PF cohort.

CONCLUSIONS: Our data suggest that PFs such as profunda artery perforator and anterolateral thigh flaps are associated with longer operative times but may offer a suitable option for reconstruction of acquired defects of the external genital compared with local FFs, especially in the setting of prior radiation.

PMID:37399482 | DOI:10.1097/SAP.0000000000003501

Ann Plast Surg. 2023 Jun 1;90(6S Suppl 5):S543-S546. doi: 10.1097/SAP.0000000000003488. Epub 2023 Feb 18.

ABSTRACT

PURPOSE: Reconstruction of massive incisional hernias (IHs) poses a significant challenge with high rates of recurrence. Preoperative chemodenervation using botulinum toxin (BTX) injections in the abdominal wall is a technique that has been used to facilitate primary fascial closure. However, there is limited data directly comparing primary fascial closure rates and postoperative outcomes after hernia repair between patients who do and do not receive preoperative BTX injections. The objective of our study was to compare the outcomes of patients who did and did not receive BTX injections before abdominal wall reconstruction.

METHODS: This is a retrospective cohort study including adult patients from 2019 to 2021 who underwent IH repair with and without preoperative BTX injections. Propensity score matching was performed based on body mass index, age, and intraoperative defect size. Demographic and clinical data were recorded and compared. The statistical significance level was set at P < 0.05.

RESULTS: Twenty patients underwent IH repair with preoperative BTX injections. Twenty patients who underwent IH repair without preoperative BTX injections were selected to comprise a 1:1 propensity-matched control cohort. The average defect size was 663.9 cm2 in the BTX group and 640.7 cm2 in the non-BTX group (P = 0.816). There was no difference in average age (58.6 vs 59.2 years, P = 0.911) and body mass index (33.0 vs 33.2 kg/m2, P = 0.911). However, there was a greater proportion of male patients in the BTX group (85% vs 55%, P = 0.082).Primary fascial closure was achieved in 95% of BTX patients and 90% of non-BTX patients (P = 1.0). Significantly fewer patients in the BTX group required component separation techniques to achieve primary fascial closure (65% vs 95%, P = 0.044). There was no significant difference in any postoperative surgical and medical outcomes. Hernia recurrence was 10% in the BTX group and 20% in non-BTX group (P = 0.661).

CONCLUSIONS: In our study, we observed a lower rate of component separations to achieve primary fascial closure among patients with massive hernia defects who received preoperative BTX injections. These results suggest that preoperative BTX injections may “downstage” the complexity of hernia repair with abdominal wall reconstruction in patients with massive hernia defects and reduce the need for component separation.

PMID:37399480 | DOI:10.1097/SAP.0000000000003488

Ann Plast Surg. 2023 Jun 1;90(6S Suppl 5):S457-S461. doi: 10.1097/SAP.0000000000003491.

ABSTRACT

BACKGROUND: Malar augmentation is a key procedure sought out by transfeminine individuals seeking to feminize their facial appearance. Different surgical techniques have been described in the literature including fat transfer to the cheeks and malar implant placement. Because of the paucity of information in the literature, there is no consensus on best practices for this procedure. The objective of our study is to determine the effectiveness and safety of malar implants as compared with fat transfer to the cheeks in transfeminine individuals.

METHODS: We examined all patients with the diagnosis of gender dysphoria that were referred to the senior author seeking consultation for feminizing facial procedures between June 2017 and August 2022. Patients who underwent fat transfer to the cheeks or malar implant placement were included in our study. We reviewed the electronic medical record of each patient, and we retrieved and analyzed data regarding demographics, medical and surgical history, operative dictations, clinic notes, and postoperative follow-up. Univariate analysis was used to assess for differences in postoperative complications between these 2 groups.

RESULTS: We identified 231 patients underwent feminizing facial gender affirming surgery, with 152 patients receiving malar augmentation through malar implants or fat grafting. One hundred twenty-nine patients (84.9%) underwent malar implant placement and 23 (15.1%) underwent fat grafting to the cheeks. The mean follow-up time was 3.6 ± 2.7 months. Patient satisfaction was greater in the malar implant group (126/129, 97.7%) compared with the fat transfer group (20/23, 87%, P < 0.045). Two patients who received implants (1.8%) experienced postoperative complications. No patient undergoing fat transfer experiences similar adverse outcomes. Nevertheless, the difference was not statistically significant (P = 1.00).

CONCLUSIONS: Our findings support the contention that malar implants are a safe alternative for malar augmentation among transfeminine individuals. While autologous fat transfer to the cheek is an indispensable option in patients requiring minor malar enhancement, malar implants offer a more permanent option with a better aesthetic outcome in patients requiring major malar enhancement. To minimize postoperative complications, surgeons should emphasize patient compliance with postoperative directions.

PMID:37399477 | DOI:10.1097/SAP.0000000000003491

JAAPA. 2023 Jul 3;Published Ahead of Print. doi: 10.1097/01.JAA.0000944616.43802.f6. Online ahead of print.

ABSTRACT

Information on the employment of patient-care clinicians is needed for policy planning and human resource management. The 2021 Bureau of Labor Statistics (BLS) employment data were probed for occupational settings of 698,700 physicians and surgeons, 246,690 NPs, and 139,100 physician associates/assistants (PAs). These three healthcare professionals accounted for about 1.1 million medical and surgical clinicians serving a US population of 331.5 million. Clinician demographics differ-in 2021, the median age of physicians was 45 years; NPs, 43 years; and PAs, 39 years. The largest employment location is “office of a physician” (physician, 53%; NP, 47%; PA, 51%), followed by hospitals (physician, 25%; NP, 25%; PA, 23%), and outpatient centers (physician, 4%; NP, 9%; PA, 10%). The 10-year job outlook predicts physician growth at 3%, NPs at 46%, and PAs at 28%. NP and PA employment is growing more than that of physicians because of constrained physician postgraduate education funding. Other factors influencing employment changes include medical practice mergers, the rising value of team-based care, the cost of new medical schools, and task shifting.

PMID:37399472 | DOI:10.1097/01.JAA.0000944616.43802.f6

J Rheumatol. 2023 Jul 1:jrheum.2022-1261. doi: 10.3899/jrheum.2022-1261. Online ahead of print.

ABSTRACT

OBJECTIVE: To analyse the Multidimensional Health Assessment Questionnaire (MDHAQ) in screening for anxiety in patients with rheumatoid arthritis (RA) and psoriatic arthritis (PsA), in comparison to the Hospital Anxiety and Depression Scale (HADS) as the reference standard.

METHODS: Patients with a physician diagnosis of RA or PsA were invited to complete the MDHAQ and HADS at their routine Rheumatology Clinic visit. Sensitivity, specificity, percent agreement and kappa statistics were used to evaluate agreement between two MDHAQ items for anxiety and HADS-anxiety (HADS-A) score of 8 or more. The first is a question asked on a 4-point scale (0-3.3) and the second is a “yes”/”no” (blank) item asked within a 60-symptom checklist (ROS).

RESULTS: The study included 183 participants, of whom 126 (68.9%) had RA and 57 (31.1%) had PsA. The mean age was 57.3 years and 66.7% were female. Positive screen for anxiety according to a HADS-A score of 8 or more was seen in 39.3%. Compared to a HADS-A score of 8 or more, an MDHAQ score of 2.2 or more OR positive on ROS had a sensitivity of 69.9%, specificity of 73.6% and substantial agreement (percent agreement 80.9%, kappa statistic 0.59).

CONCLUSION: The MDHAQ provides information similar to the HADS to screen for anxiety in patients with RA and PsA. The use of this single questionnaire which can also be used to monitor clinical status, screen for fibromyalgia and depression without requiring multiple questionnaires, may present a valuable tool in routine clinical practice.

PMID:37399467 | DOI:10.3899/jrheum.2022-1261

BMJ Open. 2023 Jun 30;13(6):e071688. doi: 10.1136/bmjopen-2023-071688.

ABSTRACT

INTRODUCTION: People who inject drugs (PWID) have remained a contributor to the consistent HIV incidence rates in the US for decades. Pre-exposure prophylaxis (PrEP) is a promising biomedical intervention for HIV prevention among individuals at risk for HIV infection, including PWID. However, PWID report the lowest rates of PrEP uptake and adherence among at-risk groups. Tailored HIV prevention interventions must include strategies that compensate for cognitive dysfunction among PWID.

METHODS AND ANALYSIS: Using the multiphase optimisation strategy, we will be conducting a 16-condition factorial experiment to investigate the effects of four different accommodation strategy components to compensate for cognitive dysfunction among 256 PWID on medication for opioid use disorder. This innovative approach will inform optimisation of a highly effective intervention to enhance PWID’s ability to process and utilise HIV prevention content to improve PrEP adherence and HIV risk reduction in a drug treatment setting.

ETHICS AND DISSEMINATION: The institutional review board at the University of Connecticut approved this protocol (H22-0122) with an institutional reliance agreement with APT Foundation Inc. All participants are required to sign an informed consent form prior to engaging in any study protocols. The results of this study will be disseminated on national and international platforms through presentations at major conferences and journals.

TRIAL REGISTRATION NUMBER: NCT05669534.

PMID:37399447 | DOI:10.1136/bmjopen-2023-071688

BMJ Open. 2023 Jun 30;13(6):e067293. doi: 10.1136/bmjopen-2022-067293.

ABSTRACT

OBJECTIVES: To summarise the effects of various types of aerobic exercise on the global cognitive function of the elderly with mild cognitive impairment (MCI).

DESIGN: A meta-analysis of randomised controlled trials (RCTs).

DATA SOURCES: PubMed, EMBASE and the Cochrane Library were searched for clinical RCTs from the earliest available records to March 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included RCTs of subjects older than 60 years with MCI. The outcome indicators of cognitive function of interest were the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA).

DATA EXTRACTION AND SYNTHESIS: Two researchers independently screened the literature, extracted data and evaluated the quality of the included studies, with disagreements resolved by a third researcher. The Cochrane Handbook for Systematic Reviews of Interventions was used to assess the risk of bias. Meta-analysis was performed by Review Manager V.5.3 software. Random-effect models were used for meta-analysis.

RESULTS: A total of 1680 patients who participated in 20 RCTs were included in this study. Based on outcomes of MMSE analysis, the aerobic exercise, which was beneficial for global cognitive function in MCI patients, included multicomponent aerobic exercise (MD=1.79, 95% CI (1.41 to 2.17), p<0.01) and mind-body exercise (MD=1.28, 95% CI (0.83 to 1.74), p<0.01). The results of the meta-analysis of conventional aerobic exercise (MD=0.51, 95% CI (0.09 to 0.93), p=0.02) turned out to be statistically insignificant after sensitivity analysis (MD=0.14, 95% CI (-0.47 to 0.75), p=0.65). With the evaluation of MoCA, multicomponent aerobic exercise (MD=5.74, 95% CI (5.02 to 6.46), p<0.01), mind-body exercise (MD=1.29, 95% CI (0.67 to 1.90), p<0.01) and conventional aerobic exercise (MD=2.06, 95% CI (1.46 to 2.65), p<0.01) were showed significant beneficial effects for the patient. However, there was a high degree of heterogeneity between the results of multicomponent aerobic exercise (MMSE) and conventional aerobic exercise (MoCA), which was analysed and explored.

CONCLUSIONS: In general, multicomponent aerobic exercise and mind-body exercise were beneficial in improving global cognitive function in the elderly with MCI. Nevertheless, the improvement effect of mind-body exercise is more reliable compared with multicomponent aerobic exercise and conventional aerobic exercise.

PROSPERO REGISTRATION NUMBER: CRD42022327386.

PMID:37399446 | DOI:10.1136/bmjopen-2022-067293

J Clin Neurophysiol. 2023 Jul 1;40(5):434-442. doi: 10.1097/WNP.0000000000000897. Epub 2021 Sep 27.

ABSTRACT

PURPOSE: Lateralized rhythmic delta activity (LRDA) is highly associated with seizures but generalized rhythmic delta activity (GRDA; symmetric by definition) has no known seizure association. A subset of LRDA includes patterns that are “bilateral asymmetric LRDA” (LRDA-ba), falling between purely unilateral LRDA and GRDA. The significance of this finding has not been previously addressed.

METHODS: Clinical, EEG, and imaging findings were reviewed in all patients with >6 hours of continuous EEG and LRDA-ba between 2014 and 2019. They were compared with a control group of patients with GRDA, matched 1:1 for prevalence, duration, and frequency of the predominant rhythmic pattern.

RESULTS: Two hundred fifty-eight patients with LRDA-ba and 258 matched controls with GRDA were identified. Statistically significant findings included that patients with LRDA-ba were more likely to have presented with an ischemic stroke (LRDA-ba 12.4% vs. GRDA 3.9%) or subdural hemorrhage (8.9% vs. 4.3%); those with GRDA were more likely to have a metabolic encephalopathy (GRDA 10.5% vs. LRDA-ba 3.5%) or “altered mental state” without clear etiology (12.5% vs. 4.3%). Patients with LRDA-ba were significantly more likely to have a background EEG asymmetry (LRDA-ba 62.0% vs. GRDA 25.6%) or focal (arrhythmic) slowing (40.3% vs. 15.5%), and acute (65.5% vs. 46.1%) or focal (49.6% vs. 28.3%) abnormalities on computed tomography scan. Patients with LRDA-ba were more likely to have focal sporadic epileptiform discharges (95.4% vs. 37.9%), lateralized periodic discharges (32.2% vs. 5.0%), and focal electrographic seizures (33.3% vs. 11.2%); however, patients with LRDA-ba alone (i.e., without sporadic epileptiform discharges or PDs) showed only a trend toward increased seizures (17.3%) compared with a matched group of patients with GRDA alone (9.9%, P = 0.08).

CONCLUSIONS: Patients with LRDA-ba had a higher proportion of acute focal abnormalities compared with a matched group of patients with GRDA. The LRDA-ba was associated with additional evidence of focal cortical excitability on EEG (sporadic epileptiform discharges and lateralized periodic discharges) and seizures but with only a trend toward increased seizures when other signs of focal excitability were absent.

PMID:37399042 | DOI:10.1097/WNP.0000000000000897

JAMA Intern Med. 2023 Jul 3. doi: 10.1001/jamainternmed.2023.2509. Online ahead of print.

ABSTRACT

IMPORTANCE: Although deaths due to external causes are a leading cause of mortality in the US, trends over time by intent and demographic characteristics remain poorly understood.

OBJECTIVE: To examine national trends in mortality rates due to external causes from 1999 to 2020 by intent (homicide, suicide, unintentional, and undetermined) and demographic characteristics. External causes were defined as poisonings (eg, drug overdose), firearms, and all other injuries, including motor vehicle injuries and falls. Given the repercussions of the COVID-19 pandemic, US death rates for 2019 and 2020 were also compared.

DESIGN, SETTING, AND PARTICIPANTS: Serial cross-sectional study using national death certificate data obtained from the National Center for Health Statistics and including all external causes of 3 813 894 deaths among individuals aged 20 years or older from January 1, 1999, to December 31, 2020. Data analysis was conducted from January 20, 2022, to February 5, 2023.

EXPOSURES: Age, sex, and race and ethnicity.

MAIN OUTCOMES AND MEASURES: Trends in age-standardized mortality rates and average annual percentage change (AAPC) in rates calculated by intent (suicide, homicide, unintentional, and undetermined), age, sex, and race and ethnicity for each external cause.

RESULTS: Between 1999 and 2020, there were 3 813 894 deaths due to external causes in the US. From 1999 to 2020, poisoning death rates increased annually (AAPC, 7.0%; 95% CI, 5.4%-8.7%). From 2014 to 2020, poisoning death rates increased the most among men (APC, 10.8%; 95% CI, 7.7%-14.0%). During the study period, poisoning death rates increased in all the racial and ethnic groups examined; the most rapid increase was among American Indian and Alaska Native individuals (AAPC, 9.2%; 95% CI, 7.4%-10.9%). During the study period, death rates for unintentional poisoning had the most rapid rate of increase (AAPC, 8.1%; 95% CI, 7.4%-8.9%). From 1999 to 2020, firearm death rates increased (AAPC, 1.1%; 95% CI, 0.7%-1.5%). From 2013 to 2020, firearm mortality increased by an average of 4.7% annually (95% CI, 2.9%-6.5%) among individuals aged 20 to 39 years. From 2014 to 2020, mortality from firearm homicides increased by an average of 6.9% annually (95% CI, 3.5%-10.4%). From 2019 to 2020, mortality rates from external causes accelerated further, largely from increases in unintentional poisoning, and homicide due to firearms and all other injuries.

CONCLUSIONS AND RELEVANCE: Results of this cross-sectional study suggest that from 1999 to 2020, death rates due to poisonings, firearms, and all other injuries increased substantially in the US. The rapid increase in deaths due to unintentional poisonings and firearm homicides is a national emergency that requires urgent public health interventions at the local and national levels.

PMID:37399025 | DOI:10.1001/jamainternmed.2023.2509

JAMA Netw Open. 2023 Jul 3;6(7):e2321554. doi: 10.1001/jamanetworkopen.2023.21554.

ABSTRACT

IMPORTANCE: Blood-based measurements of total tau (T-tau) are commonly used to examine neuronal injury in patients with traumatic brain injury (TBI), but current assays do not differentiate between brain-derived tau (BD-tau) and tau produced in peripheral tissues. A novel assay for BD-tau has recently been reported that selectively quantifies nonphosphorylated tau of central nervous system origin in blood samples.

OBJECTIVES: To examine the association of serum BD-tau with clinical outcomes in patients with severe TBI (sTBI) and its longitudinal changes over 1 year.

DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study was conducted at the neurointensive unit at the Sahlgrenska University Hospital, Gothenburg, Sweden, between September 1, 2006, and July 1, 2015. The study included 39 patients with sTBI followed up for up to 1 year. Statistical analysis was performed between October and November 2021.

EXPOSURES: Serum BD-tau, T-tau, phosphorylated tau231 (p-tau231), and neurofilament light chain (NfL) measured on days 0, 7, and 365 after injury.

MAIN OUTCOMES AND MEASURES: Associations of serum biomarkers with clinical outcome and longitudinal change in sTBI. Severity of sTBI was evaluated using the Glasgow Coma Scale at hospital admission, while clinical outcome was assessed with the Glasgow Outcome Scale (GOS) at 1-year follow-up. Participants were classified as having a favorable outcome (GOS score, 4-5) or unfavorable outcome (GOS score, 1-3).

RESULTS: Among the 39 patients (median age at admission, 36 years [IQR, 22-54 years]; 26 men [66.7%]) in the study on day 0, the mean (SD) serum BD-tau level was higher among patients with unfavorable outcomes vs those with favorable outcomes (191.4 [190.8] pg/mL vs 75.6 [60.3] pg/mL; mean difference, 115.9 pg/mL [95% CI, 25.7-206.1 pg/mL]), while the other markers had smaller between-group mean differences (serum T-tau, 60.3 pg/mL [95% CI, -22.0 to 142.7 pg/mL]; serum p-tau231, 8.3 pg/mL [95% CI, -6.4 to 23.0 pg/mL]; serum NfL, -5.4 pg/mL [95% CI, -99.0 to 88.3 pg/mL]). Similar results were recorded on day 7. Longitudinally, baseline serum BD-tau concentrations showed slower decreases in the whole cohort (42.2% on day 7 [from 138.6 to 80.1 pg/mL] and 93.0% on day 365 [from 138.6 to 9.7 pg/mL]) compared with serum T-tau (81.5% on day 7 [from 57.3 to 10.6 pg/mL] and 99.0% on day 365 [from 57.3 to 0.6 pg/mL]) and p-tau231 (92.5% on day 7 [from 20.1 to 1.5 pg/mL] and 95.0% on day 365 [from 20.1 to 1.0 pg/mL]). These results did not change when considering clinical outcome, where T-tau decreased twice as fast as BD-tau in both groups. Similar results were obtained for p-tau231. Furthermore, the biomarker levels on day 365 were lower, compared with day 7, for BD-tau but not T-tau or p-tau231. Serum NfL had a different trajectory to the tau biomarkers, with levels increasing by 255.9% on day 7 compared with day 0 (from 86.8 to 308.9 pg/mL) but decreasing by 97.0% by day 365 vs day 7 (from 308.9 to 9.2 pg/mL).

CONCLUSIONS AND RELEVANCE: This study suggests that serum BD-tau, T-tau, and p-tau231 have differential associations with clinical outcome and 1-year longitudinal change in patients with sTBI. Serum BD-tau demonstrated utility as a biomarker to monitor outcomes in sTBI and can provide valuable information regarding acute neuronal damage.

PMID:37399012 | DOI:10.1001/jamanetworkopen.2023.21554