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Abstract Background mHealth holds the potential to educate rural communities in developing countries such as Malawi, on issues which over-burdened and under staffed health centres do not have the facilities to address. Previous research provides support that mHealth could be used as a vehicle for health education campaigns at a community level; however the limited involvement of potential service users in the research process endangers both user engagement and intervention effectiveness. Methods This two stage qualitative study used participatory action research to inform the design and development of an mHealth education intervention. First, secondary analysis of 108 focus groups (representing men, women, leadership, elderly and male and female youth) identified four topics where there was a perceived health education need. Second, 10 subsequent focus groups explored details of this perceived need and the acceptability and feasibility of mHealth implementation in Chikwawa, Malawi. Results Stage 1 and Stage 2 informed the design of the intervention in terms of target population, intervention content, intervention delivery and the frequency and timing of the intervention. This has led to the design of an SMS intervention targeting adolescents with contraceptive education which they will receive three times per week at 4 pm and will be piloted in the next phase of this research. Conclusion This study has used participatory methods to identify a need for contraception education in adolescents and inform intervention design. The focus group discussions informed practical considerations for intervention delivery, which has been significantly influenced by the high proportion of users who share mobile devices and the intervention has been designed to allow for message sharing as much as possible.

Competing Interests: Declarations. Conflict of interest: The authors declare that they have no conflicts of interest to disclose. Ethical Approval: This article does not contain any studies with human participants or animals performed by any of the authors. Informed Consent: For this type of study informed consent is not required..

Emerging evidence indicates periostin (POSTN) is upregulated in patients with OA, and studies have shown that it can induce the activation of inflammatory cytokines and catabolic enzymes, making it a potential therapeutic target. Link N (LN) is a peptide fragment derived from the link protein and has been demonstrated as an anabolic-like factor and anti-catabolic and anti-inflammatory factors both in vitro and in vivo. This study aims to determine if LN can regulate POSTN expression and function in OA cartilage. Articular cartilage was recovered from donors undergoing total knee replacements to isolate chondrocytes and prepare osteochondral explants. Cells and explants were treated with POSTN and LN (1 and 100 μg) and measured for changes in POSTN expression and various matrix proteins, catabolic and proinflammatory factors, and signaling. To determine the effects of POSTN expression in vivo, a rabbit OA model was used. Immunoprecipitation and in silico modeling were used to determine peptide/POSTN interactions. Western blotting, PCR, and immunohistochemistry demonstrated that LN decreased POSTN expression both in vitro and in vivo. LN was also able to directly inhibit POSTN signaling in OA chondrocytes. In silico docking suggested the direct interaction of LN with POSTN at residues responsible for its oligomerization. Immunoprecipitation experiments confirmed the direct interaction of LN with POSTN and the destabilization of its oligomerization. This study demonstrates the ability of a peptide, LN, to suppress the overexpression and function of POSTN in OA cartilage.

Objectives: General practice plays a key role in end-of-life care, yet the extent of this remains largely unknown due to a lack of detailed clinical data. This study aims to describe the care provided by General Practitioners (GPs) for people with cancer in their last year of life., Methods: Retrospective cohort study using linked routine primary care and death certificate data in Victoria, Australia. Patients were included who died from cancer between 2008 and 2017., Results: In total 7025 cancer patients were included, mean age of 74.8 yrs. 95% of patients visited their GP in the last 6 months of life, with a median of 11 general practice contacts in this period. 72% of patients visited their GP in the second-last month prior to death, and 74% in the last month of life. The majority of patients (58%) were prescribed opioids, 19% anticipatory medications, 24% received a home visit, and a small proportion had imaging (6%) in the last month and pathology (6%) in the last fortnight. Patients in regional areas had more contact with general practices in the last year of life compared to metropolitan patients (median metropolitan = 16, inner regional = 25, and outer regional = 23, P < .001). The use of GP services did not differ by cancer type., Conclusions: GP's play a central role in end-of-life care provision for cancer patients, which intensifies in the last months of life. There is room for improvement, with a proportion having little or no engagement, and low rates of home visits and anticipatory medication prescribing., (© The Author(s) 2024. Published by Oxford University Press.)

Complications following mandibular fracture repair (MFR) may carry significant morbidity to patients. The purpose of our study is to determine the risk factors for postoperative complications following MFR. The authors conducted a retrospective cohort study of trauma patients who underwent MFR in 2018 and 2019. Excluded were patients below 18 years old and those with postoperative follow-up <2 weeks. The primary outcome was the incidence of major and minor postoperative complications following MFR. Of n=275 patients included, mean (SD) age was 35 (14) years and median (IQR) follow up was 49 (26-117) days. Most patients [n=208 (76%)] underwent both maxillomandibular/intermaxillary fixation (MMF/IMF) and open reduction and internal fixation (ORIF). The incidence of major postoperative complications was 19% (n=51) including malunion [n=8 (2.9%)], malocclusion [n=21 (7.6%)], and unplanned reoperation [n=26 (9.5%)]. The incidence of minor postoperative complications was 61% (n=167). Alcohol use at the time of surgery and greater MISS score were associated with greater odds of major complications [adjusted odds ratio (aOR) 95% CI: 3.4 (1.2-9.0), 1.09 (1.02-1.160), respectively]. Smoking at the time of surgery and moderately (>2 mm) and severely displaced fractures (>4 mm) were associated with greater odds of minor complications [aOR (95% CI): 2.1 (1.04-4.2), 2.7 (1.2-6.4), 2.7 (1.1-6.6), respectively]. Alcohol use, smoking, greater MISS score, and displaced fractures >2 mm were significant risk factors for postoperative complications following MFR. Our findings can help guide informed decision making and surgical planning in patients with mandibular fractures., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Intervertebral disc degeneration and pain are associated with the nucleotide-binding domain, leucine-rich repeat, and pyrin domain-containing 3 (NLRP3) inflammasome activation and the processing of interleukin-1 beta (IL-1β). Activation of thehm inflammasome is triggered by Toll-like receptor stimulation and requires the cofactor receptor cluster of differentiation 14 (CD14). Short Link N (sLN), a peptide derived from link protein, has been shown to modulate inflammation and pain in discs in vitro and in vivo; however, the underlying mechanisms remain elusive. This study aims to assess whether sLN modulates IL-1β and inflammasome activity through interaction with CD14. Disc cells treated with lipopolysaccharides (LPS) with or without sLN were used to assess changes in Caspase-1, IL-1β, and phosphorylated nuclear factor kappa-light-chain-enhancer of activated B cells (NFκB). Peptide docking of sLN to CD14 and immunoprecipitation were performed to determine their interaction. The results indicated that sLN inhibited LPS-induced NFκB and Caspase-1 activation, reducing IL-1β maturation and secretion in disc cells. A significant decrease in inflammasome markers was observed with sLN treatment. Immunoprecipitation studies revealed a direct interaction between sLN and the LPS-binding pocket of CD14. Our results suggest that sLN could be a potential therapeutic agent for discogenic pain by mitigating IL-1β and inflammasome activity within discs.

Background: For people with limited lifetime expectancy, the benefit of many medications may be outweighed by their potential harms. Despite the relevance of reducing unnecessary medication use, deprescribing is poorly enacted in primary care practice., Aim: This study aims to describe factors, as identified by primary care professionals and patients, that influence deprescribing in the last phase of life., Design: Semi-structured interviews were conducted and analysed using a thematic approach., Setting/participants: This study was performed in primary care settings, including general practices, hospices and community care teams in The Netherlands. Purposefully identified primary care professionals (general practitioners, pharmacists, nurses) and patients with limited lifetime expectancy due to advanced chronic illness or cancer and their caretakers were interviewed., Results: Three themes emerged detailing factors influencing deprescribing in the last phase of life in primary care: (1) non-maleficence, the wish to avoid additional psychological or physical distress; (2) reactive care, the lack of priority and awareness of eligible patients; and (3) discontinuity of care within primary care and between primary care and specialty care., Conclusions: Deprescribing is an incremental process, complicated by the unpredictability of life expectancy and attitudes of patients and health care professionals that associate continued medication use with clinical stability. Opportunities to facilitate the deprescribing process and its acceptance include the routinely systematic identification of patients with limited life expectancy and potentially inappropriate medications, and normalisation of deprescribing as component of regular primary care, occurring for all patients and continuing into end-of-life care., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Traumatic brain injury (TBI) is common in up to 50% of patients with facial fractures. Orbital fractures account for 25% of all facial fractures. The authors sought to determine the prevalence and risk factors for TBI in patients undergoing orbital fracture repair (OFR) and assess the impact of TBI on surgical timing. A retrospective review of trauma patients who underwent OFR at a single trauma center from 2015 to 2020 was conducted. Excluded were patients <18 years old and those with unreported GCS on presentation. TBI was defined as GCS <15 or any neurological symptom on presentation. TBI was categorized into mild (GCS=14-15), moderate (GCS=9-13), and severe TBI (GCS=3-8). Our primary and secondary outcomes were the prevalence of TBI on presentation and duration from injury to surgery, respectively. Of the 200 patients analyzed, 99 (49.5%) had concomitant TBI on presentation. The most common neurological symptom on presentation was loss of consciousness [n=80 (40%)]. Patients with TBI were significantly more likely to have an orbital roof [n=11 (11.1%), n=4 (4.0%), P=0.048] and lateral wall fractures [n=25 (25.3%), n=14 (13.9%), P=0.031] compared with patients without TBI. Patients with severe TBI were more likely to have delayed OFR-a significantly greater proportion of patients who had severe TBI had OFR after 60 days of injury compared with those without TBI or with mild TBI [5 (39%), 12 (12%), 4 (5%), P=0.032]. Craniofacial surgeons must suspect and screen for TBI in patients presenting with facial trauma, especially those with orbital roof and lateral wall fractures., Competing Interests: The authors report no conflicts of interest, (Copyright © 2024 by Mutaz B. Habal, MD.)

Facial buttresses are supportive bony structures of the facial skeleton that form a thick, strong, and protective framework for the face. Surgical fixation may be required to restore morphology and function when damage to these buttresses occurs. We sought to determine if, similar to buttresses of the facial skeleton, buttresses of the internal orbit exist. Hence, we analyzed 10 human cadaver skulls imaged by microcomputed tomography (micro-CT). Image processing and thickness/heat mapping were performed using Avizo and ImageJ softwares. After identifying the orbital buttresses, we reviewed CT scans of patients who had orbital fractures across three years to determine the frequency of fracture of the orbital buttresses. We identified 5 buttresses of the internal orbit: superomedial fronto-ethmoidal strut with the deep orbital buttress, inferomedial strut with the posterior ledge, inferior orbital fissure, sphenoid-frontal superolateral strut, and the sphenoid lip. The average threshold orbital buttress thickness was 1.36 (0.25) mm. A total of 1186 orbits of 593 individuals were analyzed for orbital buttress involvement. Orbital buttresses were spared in 770 (65%) orbits. The inferomedial strut with the posterior ledge was the most commonly fractured buttress in 14.4% of orbits (n=171), followed by the sphenoid strut and lip (66 [5.6%]). To our knowledge, this is the first description of the buttresses of the internal orbit. Orbital reconstruction for fracture repair or oncologic purposes requires the support of orbital buttresses. Understanding the anatomy of orbital buttresses is crucial for successful surgical planning, proper implant positioning, and restoration of function and appearance., Competing Interests: Financial Disclosure Statement: All authors report no potential conflicts of interest, including financial interests, activities, relationships, and affiliations. None of the authors received any funds or has any financial interests to disclose for the research, authorship, and publication of this article., (Copyright © 2024 by the American Society of Plastic Surgeons.)

Objectives: Total hip arthroplasty is a successful procedure for treating advanced osteoarthritis (OA). Metal bearing surfaces remain one of the most widely implanted prosthesis, however approximately 10% of patients develop adverse local tissue reactions (ALTRs), namely lymphocytic predominant soft tissue reaction with or without necrosis and osteolysis resulting in high revision rates. The mechanism(s) for these reactions remains unclear although T lymphocyte mediated type IV hypersensitivity to cobalt (Co) and chromium (Cr) ions have been described. The purpose of this study was to determine the prolonged effects of Co and Cr metal ions on synovial fibroblasts to better understand the impact of the synovial membrane in the development of ALTRs., Methods: Human synovial fibroblast-like cells were isolated from donors undergoing arthroplasty. DNA content and Alamar blue assay were used to determine cellular viability against exposure to Co and Cr. A beta-galactosidase assay was used to determine the development of cellular senescence. Western blotting and RT-qPCR were employed to determine changes in senescent associated secretory factors, signaling and anti-oxidant enzyme expression. A fluorescent assay was used to measure accumulation of hydrogen peroxide., Results: We demonstrate that prolonged cobalt exposure results in a downregulation of the enzyme catalase resulting in cytosolic accumulation of hydrogen peroxide, decreased Akt activity and cellular senescence. Senescent fibroblasts demonstrated upregulation of proinflammatory cytokines IL-1β and TNFα in addition to the neurotrophic factor NGF., Conclusion: Our results provide evidence that metal ions induce a senescent associated secretory phenotype in synovial fibroblasts that could contribute to the development of adverse local tissue reactions., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 Published by Elsevier Ltd on behalf of Osteoarthritis Research Society International (OARSI).)

Background: Free flap selection in extremity reconstruction can be challenging. The ideal flap has to be thin and pliable to achieve optimal contour and function. We explore the role of the fascia-only anterolateral thigh (fALT) flap in extremity reconstruction., Methods: We conducted a retrospective review of our experience using fALT-free flap for extremity reconstruction over a 2-year period. Patient demographics, mechanism of injury, flap characteristics, complications- and follow-up were recorded. Descriptive statistics were calculated., Results: Twelve patients were included. The median (interquartile range [IQR]) age was 34 (28-52) years. One fALT flap was used for upper extremity reconstruction, while 11 flaps were used for lower extremity reconstruction (4 for lower third of the leg, 4 for dorsum of foot, and 3 for heel). The median (IQR) flap surface area was 90 (63-120) cm2 and time from injury to reconstruction was 10 (6-16) days. The postoperative course was uneventful for all flaps except for 1 flap failure and 1 delayed healing. The median (IQR) follow-up was 2 (1-4) months. In all cases, durable soft tissue reconstruction was achieved with no need for revisions., Conclusions: The fALT-free flap can be successfully used in extremity reconstruction. The ALT fascia has robust perfusion that allows for the harvest of a large flap that can be surfaced with a split thickness skin graft. Its thin pliable tissue provides excellent contour for the hand, distal leg, and foot that does not require future thinning, optimizing the cosmetic and functional result., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Traumatic optic neuropathy (TON) is a rare but potentially devastating complication of craniofacial trauma. Approximately half of patients with TON sustain permanent vision loss. In this study, we sought to identify the most common fracture patterns associated with TON. We performed a retrospective review of craniomaxillofacial CT scans of trauma patients who presented to the R Adams Cowley Shock Trauma Center from 2015 to 2017. Included were adult patients who had orbital fractures with or without other facial fractures. Patients diagnosed with TON by a formal ophthalmologic examination were analyzed. Craniofacial fracture patterns were identified. Bivariate analysis and multivariate logistic regression were performed to identify craniofacial fracture patterns most commonly associated with TON. A total of 574 patients with orbital fractures who met inclusion criteria [15 (2.6%)] were diagnosed with TON. The median [interquartile range (IQR)] age was 44 (28-59) years. Patients with optic canal fractures and sphenoid sinus fractures had greater odds of TON compared with patients who did not have these fracture types [adjusted odds ratio (aOR) 95% confidence interval (CI) 31.8 (2.6->100), 8.1 (2.7-24.4), respectively]. Patients who sustain optic canal and sphenoid sinus fractures in the setting of blunt facial trauma are at increased odds of having a TON. Surgeons and other physicians involved in the care of these patients should be aware of this association., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Objective: Three-dimensional (3D) modeling technology aids the reconstructive surgeon in designing and tailoring individualized implants for the reconstruction of complex craniofacial fractures. Three-dimensional modeling and printing have traditionally been outsourced to commercial vendors but can now be incorporated into both private and academic craniomaxillofacial practices. The goal of this report is to present a low-cost, standardized office-based workflow for restoring bony orbital volume in traumatic orbital fractures., Methods: Patients with internal orbital fractures requiring open repair were identified. After the virtual 3D models were created by iPlan 3.0 Cranial CMF software (Brainlab), the models were printed using an office-based 3D printer to shape and modify orbital plates to correctly fit the fracture defect. The accuracy of the anatomic reduction and the restored bony orbital volume measurements were determined using postoperative computed tomography images and iPlan software., Results: Nine patients fulfilled the inclusion criteria: 8 patients had unilateral fractures and 1 patient had bilateral fractures. Average image processing and print time were 1.5 hours and 3 hours, respectively. The cost of the 3D printer was $2500 and the average material cost to print a single orbital model was $2. When compared with the uninjured side, the mean preoperative orbital volume increase and percent difference were 2.7 ± 1.3 mL and 10.9 ± 5.3%, respectively. Postoperative absolute volume and percent volume difference between the orbits were -0.2 ± 0.4 mL and -0.8 ± 1.7%, respectively., Conclusions: Office-based 3D printing can be routinely used in the repair of internal orbital fractures in an efficient and cost-effective manner to design the implant with satisfactory patient outcomes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Postoperative diplopia is the most common complication following orbital fracture repair (OFR). Existing evidence on its risk factors is based on single-institution studies and small sample sizes. Our study is the first multi-center study to develop and validate a risk calculator for the prediction of postoperative diplopia following OFR. We reviewed trauma patients who underwent OFR at two high-volume trauma centers (2015-2019). Excluded were patients < 18 years old and those with postoperative follow-up < 2 weeks. Our primary outcome was incidence/persistence of postoperative diplopia at ≥ 2 weeks. A risk model for the prediction of postoperative diplopia was derived using a development dataset (70% of population) and validated using a validation dataset (remaining 30%). The C-statistic and Hosmer-Lemeshow tests were used to assess the risk model accuracy. A total of n = 254 adults were analyzed. The factors that predicted postoperative diplopia were: age at injury, preoperative enophthalmos, fracture size/displacement, surgical timing, globe/soft tissue repair, and medial wall involvement. Our predictive model had excellent discrimination (C-statistic = 80.4%), calibration (P = 0.2), and validation (C-statistic = 80%). Our model rules out postoperative diplopia with a 100% sensitivity and negative predictive value (NPV) for a probability < 8.9%. Our predictive model rules out postoperative diplopia with an 87.9% sensitivity and a 95.8% NPV for a probability < 13.4%. We designed the first validated risk calculator that can be used as a powerful screening tool to rule out postoperative diplopia following OFR in adults., (© 2024. The Author(s).)

Tungsten is widely used in medical, industrial, and military applications. The environmental exposure to tungsten has increased over the past several years, and few studies have addressed its potential toxicity. In this study, we evaluated the effects of chronic oral tungsten exposure (100 ppm) on renal inflammation in male mice. We found that 30- or 90-day tungsten exposure led to the accumulation of LAMP1-positive lysosomes in renal tubular epithelial cells. In addition, the kidneys of mice exposed to tungsten showed interstitial infiltration of leukocytes, myeloid cells, and macrophages together with increased levels of proinflammatory cytokines and p50/p65-NFkB subunits. In proximal tubule epithelial cells (HK-2) in vitro, tungsten induced a similar inflammatory status characterized by increased mRNA levels of CSF1, IL34, CXCL2, and CXCL10 and NFkB activation. Moreover, tungsten exposure reduced HK-2 cell viability and enhanced reactive oxygen species generation. Conditioned media from HK-2 cells treated with tungsten induced an M1-proinflammatory polarization of RAW macrophages as evidenced by increased levels of iNOS and interleukin-6 and decreased levels of the M2-antiinflammatory marker CD206. These effects were not observed when RAW cells were exposed to conditioned media from HK-2 cells treated with tungsten and supplemented with the antioxidant N-acetylcysteine (NAC). Similarly, direct tungsten exposure induced M1-proinflammatory polarization of RAW cells that was prevented by NAC co-treatment. Altogether, our data suggest that prolonged tungsten exposure leads to oxidative injury in the kidney ultimately leading to chronic renal inflammation characterized by a proinflammatory status in kidney tubular epithelial cells and immune cell infiltration., (© 2023. The Author(s), under exclusive licence to Springer Nature B.V.)

The unique anatomy and physiology of the growing craniofacial skeleton predispose children to different fracture patterns as compared to adults. Diagnosis and treatment of pediatric orbital fractures can be challenging. A thorough history and physical examination are essential for the diagnosis of pediatric orbital fractures. Physicians should be aware of symptoms and signs suggestive of trapdoor fractures with soft tissue entrapment including symptomatic diplopia with positive forced ductions, restricted ocular motility (regardless of conjunctival abnormalities), nausea/vomiting, bradycardia, vertical orbital dystopia, enophthalmos, and hypoglobus. Equivocal radiologic evidence of soft tissue entrapment should not withhold surgery. A multidisciplinary approach is recommended for the accurate diagnosis and proper management of pediatric orbital fractures., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Porous tissue-engineered 3D-printed scaffolds are a compelling alternative to autografts for the treatment of large periorbital bone defects. Matching the defect-specific geometry has long been considered an optimal strategy to restore pre-injury anatomy. However, studies in large animal models have revealed that biomaterial-induced bone formation largely occurs around the scaffold periphery. Such ectopic bone formation in the periorbital region can affect vision and cause disfigurement. To enhance anatomic reconstruction, geometric mismatches are introduced in the scaffolds used to treat full thickness zygomatic defects created bilaterally in adult Yucatan minipigs. 3D-printed, anatomically-mirrored scaffolds are used in combination with autologous stromal vascular fraction of cells (SVF) for treatment. An advanced image-registration workflow is developed to quantify the post-surgical geometric mismatch and correlate it with the spatial pattern of the regenerating bone. Osteoconductive bone growth on the dorsal and ventral aspect of the defect enhances scaffold integration with the native bone while medio-lateral bone growth leads to failure of the scaffolds to integrate. A strong positive correlation is found between geometric mismatch and orthotopic bone deposition at the defect site. The data suggest that strategic mismatch >20% could improve bone scaffold design to promote enhanced regeneration, osseointegration, and long-term scaffold survivability., (© 2023 Wiley-VCH GmbH.)

Study Design: Retrospective chart review of revisional orbital surgery outcomes in patients with diplopia from prior operative treatment of orbital trauma., Objective: Our study seeks to review our experience with management of persistent post-traumatic diplopia in patients with previous orbital reconstruction and present a novel patient stratification algorithm predictive of improved outcomes., Methods: A retrospective chart review was performed on adult patients at Wilmer Eye Institute at Johns Hopkins Hospital and at the University of Maryland Medical Center who underwent revisional orbital surgery for correction of diplopia for the years 2005-2020. Restrictive strabismus was determined by Lancaster red-green testing coupled with computed tomography and/or forced duction. Globe position was assessed by computed tomography. Seventeen patients requiring operative intervention according to study criteria were identified., Results: Globe malposition affected fourteen patients and restrictive strabismus affected eleven patients. In this select group, improvement in diplopia occurred in 85.7% of cases with globe malposition and in 90.1% of cases with restrictive strabismus. One patient underwent additional strabismus surgery subsequent to orbital repair., Conclusions: Post-traumatic diplopia in patients with prior orbital reconstruction can be successfully managed in appropriate patients with a high degree of success. Indications for surgical management include (1) globe malposition and (2) restrictive strabismus. High resolution computer tomography and Lancaster red-green testing discriminate these from other causes that are unlikely to benefit from orbital surgery., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Objectives: To document local health department (LHD) COVID-19 prevention or mitigation activities at workplaces in the United States and identify facilitators for and barriers to these efforts., Methods: We conducted a web-based, cross-sectional national probability survey of United States LHDs ( n = 181 unweighted; n = 2,284 weighted) from January to March 2022, collecting information about worker complaints, surveillance, investigations, relationships and interactions with employers/businesses, and LHD capacity., Results: Overall, 94% LHD respondents reported investigating workplace-linked COVID-19 cases; however, 47% reported insufficient capacity to effectively receive, investigate and respond to COVID-19-related workplace safety complaints. Prior relationships with jurisdiction employers and LHD personnel with formal occupational health and safety (OHS) training were predictors of proactive outreach to prevent COVID-19 spread in workplaces ( p < 0.01 and p < 0.001). LHD size predicted OHS personnel and sufficient financial resources to support workplace investigation and mitigation activities ( p < 0.001)., Conclusions: Differences in LHD capacity to effectively respond to communicable disease spread in workplaces may exacerbate health disparities, especially between rural and urban settings. Improving LHD OHS capacity, especially in smaller jurisdictions, could facilitate effective prevention and mitigation of workplace communicable disease spread., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Bonney and Grant.)

The Coronavirus disease 2019 (COVID-19) outbreak impacted health care. We investigated its impact on the time to referral and diagnosis for symptomatic cancer patients in The Netherlands. We performed a national retrospective cohort study utilizing primary care records linked to The Netherlands Cancer Registry. For patients with symptomatic colorectal, lung, breast, or melanoma cancer, we manually explored free and coded texts to determine the durations of the primary care (IPC) and secondary care (ISC) diagnostic intervals during the first COVID-19 wave and pre-COVID-19. We found that the median IPC duration increased for colorectal cancer from 5 days (Interquartile Range (IQR) 1-29 days) pre-COVID-19 to 44 days (IQR 6-230, p < 0.01) during the first COVID-19 wave, and for lung cancer, the duration increased from 15 days (IQR) 3-47) to 41 days (IQR 7-102, p < 0.01). For breast cancer and melanoma, the change in IPC duration was negligible. The median ISC duration only increased for breast cancer, from 3 (IQR 2-7) to 6 days (IQR 3-9, p < 0.01). For colorectal cancer, lung cancer, and melanoma, the median ISC durations were 17.5 (IQR (9-52), 18 (IQR 7-40), and 9 (IQR 3-44) days, respectively, similar to pre-COVID-19 results. In conclusion, for colorectal and lung cancer, the time to primary care referral was substantially prolonged during the first COVID-19 wave. In such crises, targeted primary care support is needed to maintain effective cancer diagnosis.

Introduction: The 2021 interview cycle for craniofacial fellowship applicants was the first to be held virtually due to the coronavirus disease 2019 pandemic. Here, we detail the craniofacial fellowship applicant perceptions and experience on the virtual interview process., Materials and Methods: An institutional review board-approved 35-question survey study on the perception of the virtual interview process among craniofacial fellowship applicants was conducted. Surveys were distributed to individuals who had applied through the match, overseen by the American Society of Craniofacial Surgeons (ASCFS)., Results: Ten surveys were fully completed with a corresponding response rate of 48%. The average number of interviews completed was 12.7±7.7 and 50% of applicants interviewed at >1 program in a single day. Overall, 90% of respondents preferred in-person interviews before the interview season, however, only 10% preferred the in-person format afterwards. Preference for a virtual-only format increased from 10% to 70%. Applicants cited cost (100%), ease of scheduling (90%), and ability to participate in more interviews (70%) as the primary strengths of the virtual platform; none reported difficulties with self-advocacy. After the interview cycle, 90% stated they would recommend virtual interviews., Conclusions: The greatest strengths of virtual interviews were the ability to participate in more interviews, the ease of scheduling, and the cost benefits. Most applicants reported the same or increased ability for self-advocacy with virtual interviews. Following the index interview cycle for 2021, the majority of fellowship applicants now appear to prefer a virtual-only or hybrid format and would recommend virtual interviews in the future., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Purpose: The 2020-2021 interview cycle for integrated plastic surgery applicants was the first to be held virtually because of the COVID-19 pandemic. Here, we detail the largest study on integrated plastic surgery applicant perceptions after the virtual interview cycle., Methods: A 35-question institutional review board-approved survey was distributed to medical students who had applied to the Johns Hopkins/University of Maryland or University of California San Diego integrated residency programs during the 2020-2021 interview cycle. Survey questions assessed the structure, strengths, and weaknesses of the exclusively virtual interview process. Survey administration and data collection were performed using the Qualtrics platform., Results: Of 318 distributed surveys, 94 were completed. In addition, 91.5% of respondents preferred in-person interviews before the interview season, whereas 54.3% preferred in-person interviews afterward. Applicants who favored virtual interviews did not view being unable to physically meet with program staff as a detriment (P = .001) and felt they could effectively advocate for themselves (P = .002). Overall, the most cited strengths were the ability to complete more interviews (P = .01) and cost benefits (P = .02). Criticisms were directed at the impersonal nature of the exchange (86.2%), lack of physical tour (56.4%), and difficulties at self-advocacy (52.1%)., Conclusion: Preference for virtual interviews increased from 7.5% to 34.0% after the virtual interview cycle. For several students, the ideal interview structure permits both in-person and virtual interviews to maximize flexibility. Augmenting with virtual city tours and one-on-one interviews may mitigate the impersonal nature of virtual interviews as perceived by some applicants., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: In the Netherlands, the onset of the coronavirus pandemic saw shifts in primary health service provision away from physical consultations, cancer-screening programs were temporarily halted, and government messaging focused on remaining at home. In March and April 2020, weekly cancer diagnoses decreased to 73% of their pre-COVID levels, and 39% for skin cancer. This study aims to explore the effect of the COVID pandemic on patient presentations for cancer-related symptoms in primary care in The Netherlands. Methods: Retrospective cohort study using routine clinical primary care data. Monthly incidences of patient presentations for cancer-related symptoms in five clinical databases in The Netherlands were analysed from March 2018 to February 2021. Results: Data demonstrated reductions in the incidence of cancer-related symptom presentations to primary care during the first COVID wave (March-June 2020) of -34% (95% CI: -43 to -23%) for all symptoms combined. In the second wave (October 2020-February 2021) there was no change in incidence observed (-8%, 95% CI -20% to 6%). Alarm-symptoms demonstrated decreases in incidence in the first wave with subsequent incidences that continued to rise in the second wave, such as: first wave: breast lump -17% (95% CI: -27 to -6%) and haematuria -15% (95% CI -24% to -6%); and second wave: rectal bleeding +14% (95% CI: 0 to 30%) and breast lump +14% (95% CI: 2 to 27%). Presentations of common non-alarm symptom such as tiredness and naevus demonstrated decreased in-cidences in the first wave of 45% (95% CI: -55% to -33%) and 37% (95% CI -47% to -25%). In the second wave, tiredness incidence was reduced by 20% (95% CI: -33% to -3%). Subgroup analy-sis did not demonstrate difference in incidence according to sex, age groups, comorbidity status, or previous history of cancer. Conclusions: These data describe large-scale primary care avoidance that did not increase until the end of the first COVID year for many cancer-related symptoms, suggestive that substantial numbers of patients delayed presenting to primary care. For those patients who had underlying cancer, this may have had impacted the cancer stage at diagnosis, treatment, and mortality.

Objectives: Hospice care in the Netherlands is provided in three different types of hospice facilities: volunteer-driven hospices (VDH), stand-alone hospices (SAHs) and hospice unit nursing homes (HU). The organisational structures range from care directed by trained volunteers in VDH to care provided by multiprofessional teams in SAH and HU units.This study aims to characterise the patient populations who access Dutch hospices and describe the patient profiles in different hospice types., Methods: A retrospective cohort study using clinical records of adult hospice inpatients in 2017-2018 from a random national sample of hospices., Results: In total 803 patients were included from 51 hospices, mean age 76.1 (SD 12.4). 78% of patients had a primary diagnosis of cancer, 3% identified as non-Dutch cultural background and 17% were disorientated on admission. At admission, all patients were perceived to have physical needs. Psychological needs were reported in 37%, 36% and 34%, social needs by 53%, 52% and 62%, and existential needs by 23%, 30% and 18% of patients in VDH, SAH, HU units, respectively. 24%, 29% and 27% of patients from VDHs, SAHs and HUs had care needs in three dimensions, and 4%, 6% and 3% in all four dimensions., Conclusions: People who access Dutch hospices predominantly have cancer, and have a range of physical, psychological, social and existential needs, without substantial differences between hospice types. Patients with non-malignant disease and non-Dutch cultural backgrounds are less likely to access hospice care, and future policy would ideally focus on facilitating their involvement., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Although blunt cerebrovascular injury (BCVI) is recognized as a risk factor for trauma morbidity and mortality, little is described regarding similar cerebrovascular injury (CVI) in patients with penetrating wounds. The authors aim to characterize these injuries in the craniofacial self-inflicted gunshot wound (SIGSW) population., Methods: An institutional review board (IRB)-approved retrospective nstudy was conducted on patients presenting to the R Adams Cowley Shock Trauma Center with SIGSWs between 2007 and 2016. All CVIs were categorized by location, type, and associated neurologic deficits. Demographic data, patient characteristics, additional studies, and long-term outcomes were collected. A multivariate analysis determining independent predictors of CVI in the SIGSW population was performed., Results: Of the 73 patients with SIGSWs, 5 (6.8%) had CVIs separate from the bullet/cavitation tract (distant CVIs) and 9 had CVIs along the bullet/cavitation tract (in-tract CVIs). A total of 55.6% of in-tract and 40% of distant injuries were missed on initial radiology read. One distant CVI patient suffered a stroke during admission. The anterior to posterior gunshot wound trajectory was positively associated with distant CVIs when compared with no CVIs ( P  = 0.01). Vessel dissection was more prevalent in patients with distant CVIs, when compared against patients with in-tract CVIs ( P  = 0.02)., Conclusions: Nearly 20% of craniofacial SIGSW patients have CVIs and 6.8% have BCVI-like injuries, which is 2-to-6-fold times higher than traditional BCVIs. Craniofacial SIGSWs serve as an independent screening criterion with comparable screening yields; the authors recommend radiographic screening for these patients with particular scrutiny for CVIs as they are frequently missed on initial radiographic interpretations., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Introduction: Achieving anatomic reduction and re-establishing premorbid occlusion in patients with complex maxillomandibular fractures is challenging even for seasoned surgeons. Historically, surgeons have utilized occlusal splints to help establish occlusal relationships before fracture reduction and fixation. These acrylic splints are fabricated from dental impressions and require manual repositioning of tooth bearing segments along the fracture line to reapproximate premorbid occlusion. The process is laborious, requires a dental lab, and is less efficacious in edentulous patients or those with significantly comminuted fractures; as such it has largely fallen out of practice. Recently, with advances in virtual 3D modeling and printing, we demonstrate that occlusal splints can be designed from computed tomography scans, manipulated virtually, and printed without obtaining impressions from the patient., Methods/results: In our series of 3 patients with complex maxillomandibular fractures, occlusal splints were created by 1) obtaining maxillofacial computed tomography scans, 2) reducing the fractures virtually, and 3) using orthognathic virtual surgery software to create the splint. The time between planning and delivery of the splint was 4 to 7 days. These splints were successfully utilized to help establish premorbid occlusion in conjunction with maxillomandibular fixation and aided in expeditious intraoperative fracture reduction and fixation., Conclusions: In the treatment of complex facial fractures, occlusal splints can be a useful adjunct in the operative reduction and fixation of fractures. With the advent of virtual preoperative surgical planning via 3D modeling and 3D printing, these occlusal splints can be created of a sufficient fidelity to avoid the strict need for dental impressions., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Critical-sized midfacial bone defects present a unique clinical challenge due to their complex three-dimensional shapes and intimate associations with sensory organs. To address this challenge, a point-of-care treatment strategy for functional, long-term regeneration of 2 cm full-thickness segmental defects in the zygomatic arches of Yucatan minipigs is evaluated. A digital workflow is used to 3D-print anatomically precise, porous, biodegradable scaffolds from clinical-grade poly-ε-caprolactone and decellularized bone composites. The autologous stromal vascular fraction of cells (SVF) is isolated from adipose tissue extracts and infused into the scaffolds that are implanted into the zygomatic ostectomies. Bone regeneration is assessed up to 52 weeks post-operatively in acellular (AC) and SVF groups (BV/DV = 0.64 ± 0.10 and 0.65 ± 0.10 respectively). In both treated groups, bone grows from the adjacent tissues and restores the native anatomy. Significantly higher torque is required to fracture the bone-scaffold interface in the SVF (7.11 ± 2.31 N m) compared to AC groups (2.83 ± 0.23 N m). Three-dimensional microcomputed tomography analysis reveals two distinct regenerative patterns: osteoconduction along the periphery of scaffolds to form dense lamellar bone and small islands of woven bone deposits growing along the struts in the scaffold interior. Overall, this study validates the efficacy of using 3D-printed bioactive scaffolds with autologous SVF to restore geometrically complex midfacial bone defects of clinically relevant sizes while also highlighting remaining challenges to be addressed prior to clinical translation., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Ethnography has been used to address a broad range of research questions in health care. With ethnographic research methods it is possible to gain access to the complex realities of health care practice as it occurs, through interpreting the nuances of individual and team behaviours, the roles and dynamics of care provision, and the social impacts and influences of illness. The provision of clinical palliative care is complex, involving multidisciplinary collaboration across different health systems, and is subject to a multitude of personal, cultural and environmental influences. This complexity demands creative methodological approaches to research in palliative care, of which ethnography plays an important, if infrequently utilised, role. Aim: This article aims to explore potential opportunities of ethnographic methods for palliative care research. Findings: Ethnographic methods focuses on behaviour in the 'natural' setting of participants, to create theoretical descriptions of events, cultures, interactions and experiences. In palliative care these methods may provide nuanced understandings of illness, relationships and teams, communication, medical education, complex care provision, and novel or changing health practices. Of particular importance is the potential of these methods to understand complex practices and processes, and engage with under-represented population groups who may be excluded from interview research. Conclusion: Ethnography offers important opportunities for future research in palliative care and should be considered as part of the 'research toolbox' to improve understanding of the complex nature of care provision and the experiences of illness and loss.

Tungsten is a naturally occurring transition element used in a broad range of applications. As a result of its extensive use, we are increasingly exposed to tungsten from our environment, including potable water, since tungsten can become bioaccessible in ground sources. The kidneys are particularly susceptible to tungsten exposure as this is the main site for tungsten excretion. In this study, we investigated the prolonged effects of tungsten on the kidneys and how this may impact injury and function. When mice were exposed to tungsten in their drinking water for 1 mo, kidney function had not significantly changed. Following 3-mo exposure, mice were presented with deterioration in kidney function as determined by serum and urine creatinine levels. During 3 mo of tungsten exposure, murine kidneys demonstrated significant increases in the myofibroblast marker α-smooth muscle actin (αSMA) and extracellular matrix products: fibronectin, collagen, and matricellular proteins. In addition, Masson's trichrome and hematoxylin-eosin (H&E) staining revealed an increase in fibrotic tissue and vacuolization of tubular epithelial cells, respectively, from kidneys of tungsten-treated mice, indicative of renal injury. In vitro treatment of kidney fibroblasts with tungsten led to increased proliferation and upregulation of transforming growth factor β1 (TGFβ1), which was consistent with the appearance of fibroblast-to-myofibroblast transition (FMT) markers. Our data suggest that continuous exposure to tungsten impairs kidney function that may lead to the development of chronic kidney disease (CKD).

Background: There is increasing awareness of the potential hazards of surgical plumes. The plume associated with laser tattoo removal remains uncharacterized., Objective: To determine the gaseous, particulate, and microbiological content of the laser tattoo removal plume., Materials and Methods: Air sampling was performed during laser tattoo removal from pig skin and from patients. Measurement of metals, volatile organic compounds (VOCs), carbon monoxide (CO), hydrogen sulfide (HS), and ultrafine particulates (UPs) as well as bacterial 16S ribosomal DNA sequencing were performed., Results: Metals were identified in the plume from both pig and human skin. Volatile organic compounds were found at similar levels within and outside the treatment room. Several bacterial phyla were detected in the treatment room, but not outside. High levels of UPs were measured throughout the treatment room during tattoo removal from pig skin. Ultrafine particulates were detected at low levels in the room periphery during tattoo removal from human skin, but at higher levels in the immediate treatment zone. HS and CO were not detected., Conclusion: Metals, VOCs, HS, and CO were found at levels below applicable occupational exposure limits. The presence of bacteria is of uncertain significance, but may be hazardous. High levels of UPs require further investigation., (Copyright © 2021 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Tungsten is a naturally occurring metal that is increasingly used in industry and medical devices, and is labeled as an emerging environmental contaminant. Like many metals, tungsten accumulates in bone. Our previous data indicate that tungsten decreases differentiation of osteoblasts, bone-forming cells. Herein, we explored the impact of tungsten on osteoclast differentiation, which function in bone resorption. We observed significantly elevated osteoclast numbers in the trabecular bone of femurs following oral exposure to tungsten in male, but not female mice. In order to explore the mechanism(s) by which tungsten increases osteoclast number, we utilized in vitro murine primary and cell line pre-osteoclast models. Although tungsten did not alter the adhesion of osteoclasts to the extracellular matrix protein, vitronectin, we did observe that tungsten enhanced RANKL-induced differentiation into tartrate-resistant acid phosphatase (TRAP)-positive mononucleated osteoclasts. Importantly, tungsten alone had no effect on differentiation or on the number of multinucleated TRAP-positive osteoclasts. Enhanced RANKL-induced differentiation correlated with increased gene expression of differentiated osteoclast markers Nfatc1, Acp5, and Ctsk. Although tungsten did not alter the RANK surface receptor expression, it did modulate its downstream signaling. Co-exposure of tungsten and RANKL resulted in sustained positive p38 signaling. These findings demonstrate that tungsten enhances sex-specific osteoclast differentiation, and together with previous findings of decreased osteoblastogenesis, implicate tungsten as a modulator of bone homeostasis., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Society of Toxicology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Fractures of the orbital roof require high-energy trauma and have been linked to high rates of neurologic and ocular complications. However, there is a paucity of literature exploring the association between injury, management, and visual prognosis., Methods: The authors performed a 3-year retrospective review of orbital roof fracture admissions to a Level I trauma center. Fracture displacement, comminution, and frontobasal type were ascertained from computed tomographic images. Pretreatment characteristics of operative orbital roof fractures were compared to those of nonoperative fractures. Risk factors for ophthalmologic complications were assessed using univariable/multivariable regression analyses., Results: In total, 225 patients fulfilled the inclusion criteria. Fractures were most commonly nondisplaced [n = 118 (52.4 percent)] and/or of type II frontobasal pattern (linear vault involving) [n = 100 (48.5 percent)]. Eight patients underwent open reduction and internal fixation of their orbital roof fractures (14.0 percent of displaced fractures). All repairs took place within 10 days from injury. Traumatic optic neuropathy [n = 19 (12.3 percent)] and retrobulbar hematoma [n = 11 (7.1 percent)] were the most common ophthalmologic complications, and led to long-term visual impairment in 51.6 percent of cases., Conclusions: Most orbital roof fractures can be managed conservatively, with no patients in this cohort incurring long-term fracture-related complications or returning for secondary treatment. Early fracture treatment is safe and may be beneficial in patients with vertical dysmotility, globe malposition, and/or a defect surface area larger than 4 cm2. Ophthalmologic prognosis is generally favorable; however, traumatic optic neuropathy is major cause of worse visual outcome in this population., Clinical Question/level of Evidence: Risk, III., (Copyright © 2020 by the American Society of Plastic Surgeons.)

Introduction: Orbital floor fractures occur commonly as a result of blunt trauma to the face and periorbital region. Orbital floor fractures with a "trapdoor" component allow both herniation and incarceration of contents through a bone defect into the maxillary sinus as the bone rebounds faster than the soft tissue, trapping muscle, fat, and fascia in the fracture site. In children, the fractured floor, which is often hinged on one side, tends to return toward its original anatomical position due to the incomplete nature of the fracture and elasticity of the bone. The entrapment of the inferior rectus muscle itself is considered a true surgical emergency-prolonged entrapment frequently leads to muscle ischemia and necrosis leading to permanent limitation of extraocular motility and difficult to correct diplopia. For this reason, prompt surgical intervention is recommended by most surgeons. In adults, true entrapment of the muscle itself is not as common because the orbital floor is not as elastic and fractures are more complete., Methods: We present an adult patient with an isolated orbital floor fracture with clinical and radiologic evidence of true entrapment of the inferior rectus muscle itself., Results: Despite the delayed surgical repair (4 days after the injury), the patient's inferior rectus muscle function returned to near normal with mild upward gaze diplopia., Conclusions: Inferior rectus entrapment in adults may more likely be associated with immobilization of the muscle without total vascular compression/incarceration significant enough to lead to complete ischemic necrosis., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2020.)

Background: Blood-borne pathogen infections (BPIs), caused by the human immunodeficiency virus, hepatitis C and hepatitis B viruses pose an occupational hazard to healthcare workers. Facial trauma reconstruction surgeons may be at elevated risk because of routine use of sharps, and a higher than average incidence of BPIs in the trauma patient population., Methods: The authors retrospectively reviewed health records of patients admitted to a level 1 trauma center with a facial fracture between January 2010 and December 2015. Patient demographics, medical history, mechanism of injury, type of fracture, and procedures performed were documented. The authors detemined the frequency of human immunodeficiency virus, hepatitis B, and hepatitis C diagnosis and utilized univariable/multivariable analyses to identify risk factors associated with infection in this population., Results: In total, 4608 consecutive patients were included. Infections were found in 4.8% (n = 219) of patients (human immunodeficiency virus 1.6%, hepatitis C 3.3%, hepatitis B 0.8%). 76.3% of BPI patients in this cohort were identified by medical history, while 23.7% were diagnosed by serology following initiation of care. 39.0% of all patients received surgical treatment during initial hospitalization, of whom 4.3% had a diagnosed BPI. History of intravenous drug use (odds ratio [OR] 6.79, P < 0.001), assault-related injury (OR 1.61, P = 0.003), positive toxicology screen (OR 1.56, P = 0.004), and male gender (OR 1.53, P = 0.037) were significantly associated with a BPI diagnosis., Conclusion: Patients presenting with facial fractures commonly harbor a BPI. The benefit of early diagnosis and risk to surgical staff may justify routine screening for BPI in high risk facial trauma patients (male, assault-related injury, and history of intravenous drug use).

On March 24, 2020, the South Dakota Department of Health (SDDOH) was notified of a case of coronavirus disease 2019 (COVID-19) in an employee at a meat processing facility (facility A) and initiated an investigation to isolate the employee and identify and quarantine contacts. On April 2, when 19 cases had been confirmed among facility A employees, enhanced testing for SARS-CoV-2, the virus that causes COVID-19, was implemented, so that any employee with a COVID-19-compatible sign or symptom (e.g., fever, cough, or shortness of breath) could receive a test from a local health care facility. By April 11, 369 COVID-19 cases had been confirmed among facility A employees; on April 12, facility A began a phased closure* and did not reopen during the period of investigation (March 16-April 25, 2020). At the request of SDDOH, a CDC team arrived on April 15 to assist with the investigation. During March 16-April 25, a total of 929 (25.6%) laboratory-confirmed COVID-19 cases were diagnosed among 3,635 facility A employees. At the outbreak's peak, an average of 67 cases per day occurred. An additional 210 (8.7%) cases were identified among 2,403 contacts of employees with diagnosed COVID-19. Overall, 48 COVID-19 patients were hospitalized, including 39 employees and nine contacts. Two employees died; no contacts died. Attack rates were highest among department-groups where employees tended to work in proximity (i.e., <6 feet [2 meters]) to one another on the production line. Cases among employees and their contacts declined to approximately 10 per day within 7 days of facility closure. SARS-CoV-2 can spread rapidly in meat processing facilities because of the close proximity of workstations and prolonged contact between employees (1,2). Facilities can reduce this risk by implementing a robust mitigation program, including engineering and administrative controls, consistent with published guidelines (1)., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Computed tomographic scans are frequently obtained following craniomaxillofacial fracture reconstruction. The additive radiation from such scans is not trivial; cumulative radiation exposure poses stochastic health risks. In this article, the authors postulate that a low-dose computed tomography protocol provides adequate image quality for postoperative evaluation of reconstructed craniomaxillofacial fractures. This study included patients for whom a computed tomographic scan was indicated following craniomaxillofacial fracture repair at a Level I trauma center. Postoperative craniomaxillofacial computed tomography was performed using a low-dose protocol, rather than standard protocols. A craniomaxillofacial surgeon and a radiologist interpreted the images to determine whether they were of sufficient quality. It was decided a priori that any inadequate low-dose computed tomography would require repeated scanning using standard protocols. The primary endpoint was the need for repeated computed tomography. In addition, the clarity of clinically significant anatomical landmarks on the images was graded on a five-point Likert scale. Twenty patients were scanned postoperatively using the low-dose protocol. Mean radiation dose (total dose-length product) from the low-dose protocol was 71 mGy · cm versus 532 mGy · cm for the preoperative computed tomographic scans that were obtained using conventional protocols (p < 0.001). All 20 low-dose computed tomographic scans were determined to provide satisfactory image quality. No patients required repeated computed tomography secondary to poor image quality. Low-dose computed tomography received high image-quality scores. A low-dose computed tomography protocol that delivers approximately 7.5-fold less radiation than the standard protocols was found to be adequate for postoperative evaluation of craniomaxillofacial fractures. Larger prospective studies may be warranted. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Background: The purpose of this study was to characterize differences in facial fracture injury patterns among pediatric patients at highest risk of abusive head trauma/nonaccidental trauma (age ≤ 5 years)., Methods: Using the National Trauma Databank from 2007 to 2015, patients (age ≤ 5 years) suffering facial fractures were included. Demographics and injury characteristics were compared between those sustaining accidental versus nonaccidental trauma (NAT)., Results: Over 9 years 9741 patients were included with 193 patients (2.0%) suffering NAT. Nonaccidental trauma patients were younger (median [interquartile range]; 0 [0, 2] versus 3 [1, 4], P < 0.001), and more frequently were insured by Medicaid (76.7% versus 41.9%, P < 0.001). NAT patients were more likely to sustain mandible fractures (38.9% versus 21.1%, P < 0.001), but less likely to sustain maxilla (9.8% versus 18.3%, P = 0.003), or orbital fractures (31.1% versus 53.4%, P < 0.001). Nonaccidental trauma patients had fewer instances of multiple facial fracture sites (8.9% versus 22.6%, P < 0.001). Among those sustaining mandible fractures, NAT patients were more likely to sustain condylar fractures (75.8% versus 48.4%, P < 0.001), but less likely to sustain subcondylar fractures (0% versus 13.2%, P = 0.002), or angle fractures (1.6 versus 8.7%, P = 0.048)., Conclusions: Differences exist in facial fracture patterns in accidental versus nonaccidental trauma within the pediatric population at highest risk for abusive head trauma. Specifically, NAT is associated with fractures of the mandibular condyle and involve fewer facial fracture sites. In the appropriate context, presence of these fractures/patterns should increase suspicion for NAT.

Congregate work and residential locations are at increased risk for infectious disease transmission including respiratory illness outbreaks. SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is primarily spread person to person through respiratory droplets. Nationwide, the meat and poultry processing industry, an essential component of the U.S. food infrastructure, employs approximately 500,000 persons, many of whom work in proximity to other workers (1). Because of reports of initial cases of COVID-19, in some meat processing facilities, states were asked to provide aggregated data concerning the number of meat and poultry processing facilities affected by COVID-19 and the number of workers with COVID-19 in these facilities, including COVID-19-related deaths. Qualitative data gathered by CDC during on-site and remote assessments were analyzed and summarized. During April 9-27, aggregate data on COVID-19 cases among 115 meat or poultry processing facilities in 19 states were reported to CDC. Among these facilities, COVID-19 was diagnosed in 4,913 (approximately 3%) workers, and 20 COVID-19-related deaths were reported. Facility barriers to effective prevention and control of COVID-19 included difficulty distancing workers at least 6 feet (2 meters) from one another (2) and in implementing COVID-19-specific disinfection guidelines.* Among workers, socioeconomic challenges might contribute to working while feeling ill, particularly if there are management practices such as bonuses that incentivize attendance. Methods to decrease transmission within the facility include worker symptom screening programs, policies to discourage working while experiencing symptoms compatible with COVID-19, and social distancing by workers. Source control measures (e.g., the use of cloth face covers) as well as increased disinfection of high-touch surfaces are also important means of preventing SARS-CoV-2 exposure. Mitigation efforts to reduce transmission in the community should also be considered. Many of these measures might also reduce asymptomatic and presymptomatic transmission (3). Implementation of these public health strategies will help protect workers from COVID-19 in this industry and assist in preserving the critical meat and poultry production infrastructure (4)., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Background: The purpose of this study was to assess the incidence, cause, characteristics, presentation, and management of pediatric frontal bone fractures., Methods: A retrospective cohort review was performed on all patients younger than 15 years with frontal fractures that presented to a single institution from 1998 to 2010. Charts and computed tomographic images were reviewed, and frontal bone fractures were classified into three types based on anatomical fracture characteristics. Fracture cause, patient demographics, management, concomitant injuries, and complications were recorded. Primary outcomes were defined by fracture type and predictors of operative management and length of stay., Results: A total of 174 patients with frontal bone fractures met the authors' inclusion criteria. The mean age of the patient sample was 7.19 ± 4.27 years. Among these patients, 52, 47, and 75 patients were classified as having type I, II, and III fractures, respectively. A total of 14, 9, and 24 patients with type I, II, and III fractures underwent operative management, respectively. All children with evidence of nasofrontal outflow tract involvement and obstruction underwent cranialization (n = 11)., Conclusions: The authors recommend that type I fractures be managed according to the usual neurosurgical guidelines. Type II fractures can be managed operatively according to the usual pediatric orbital roof and frontal sinus fracture indications (e.g., significantly displaced posterior table fractures with associated neurologic indications). Lastly, type III fractures can be managed operatively as for type I and II indications and for evidence of nasofrontal outflow tract involvement. The authors recommend cranialization in children with nasofrontal outflow tract involvement., Clinical Question/level of Evidence: Risk, II.

Purpose: Self-inflicted facial gunshots (SIGSWs) typically result in a spectrum of severe injuries to facial structures, including the orbit and globe. Roughly three-quarters of those who arrive to the hospital will survive their injuries, and recidivism is typically low. Therefore, effective management is paramount to preserve vision, and long-term quality of life. The objective of this study is to characterize the common injuries to the orbit, globe, and periocular structures following SIGSWs, their management, and their eventual visual and reconstructive outcomes., Methods: Retrospective review of trauma registry records at a Level 1 trauma center for patients who presented alive following SIGSWs involving the globe and/or orbit from 2007 to 2016., Results: Of the 47 patients who presented with SIGSWs to the orbit, 33 (70%) were discharged alive from the hospital. Management strategies for these patients fell into 3 groups, based on the involved structures: i) Open globe injuries (Type I: n = 12, 34%) ii) Orbital fractures with preserved globe and optic nerve (Type II: n = 15, 43%), and iii) Optic nerve injuries with preserved globe (Type III: n = 8, 23%). Compared with Type II and III injuries, patients who had Type I injuries were more likely to die prior to hospital discharge (46% vs. 20% vs. 12%, p = 0.04), undergo ophthalmologic intervention (73% vs. 6% vs. 11%, p = 0.01), and more surgery (6 vs. 3 vs. 0.5 mean surgeries, p < 0.001). Type II injuries most frequently underwent debridement and reconstruction of the bony orbit. Type III and Type I injuries were associated with worse initial and final visual acuity, with the majority (100% and 75%, respectively) having No Light Perception (NLP) on initial exam, and no visual recovery during the follow-up period (median follow up= 25 months)., Conclusions: Management and visual outcomes of orbital injuries from SIGSWs is determined by whether the globe and optic nerve are preserved. Open globe injury by itself is associated with higher mortality and significant permanent vision loss.

Purpose: Ventral hernia repair with concurrent panniculectomy (VHR-PAN) is associated with high wound complication rates despite reported increased patient satisfaction. Some surgeons believe negative-pressure therapy after primary closure of the surgical incision (ciNPT) may lower wound complications in high-risk abdominal wounds. This study aims to evaluate if ciNPT improves outcomes in patients undergoing VHR-PAN., Methods: An 8-year retrospective cohort study was performed on patients who underwent VHR-PAN. Patients were divided into two groups: those who received closed-incision negative-pressure therapy ("ciNPT") and those who received standard sterile dressings ("SSD"). The primary outcome of interest was the rate of postoperative complications between these groups. Complications were subdivided into surgical site occurrences (which included surgical site occurrences that required an intervention), return to the operating room, and hernia recurrence., Results: A total of 104 patients were analyzed: 62 in the ciNPT group and 42 in the SSD group. Median follow-up duration was similar between both groups (182 days vs 195 days, p = 0.624). Patients in the ciNPT group had fewer total complications (57% vs. 83%, p = 0.004) and fewer SSO (47% vs. 69%, p = 0.025). However, no differences were noted when comparing individual complications (SSI, wound dehiscence, skin necrosis, chronic wound, seroma, and hematoma). There was no difference in return to the operating room (27% vs. 26%, p = 0.890) or hernia recurrence (21% vs 19%, p = 0.811). Multivariate analysis showed that ciNPT decreased the risk of SSOPI nearly fourfold (odds ratio 0.28, 95% CI = 0.09-0.87, p = 0.027)., Conclusions: This study showed that closed-incision negative-pressure therapy in ventral hernia repair with concurrent panniculectomy may decrease the rate of wound complications in this high-risk population.