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To develop an intrauterine infection model for Trueperella pyogenes in postpartum dairy cows and to assess the effect of this infection on the degree of intrauterine inflammation and concentrations of progesterone in serum. The oestrous cycles of 36 healthy, non-pregnant, postpartum dairy cows were synchronised. They were then treated by intrauterine infusion of 0.5 g cephapirin before being blocked by age and randomly assigned to treatment with intrauterine infusion of saline (n = 18), 107 (n = 9) or 109 (n = 9) cfu of T. pyogenes, approximately 4 days after the expected time of ovulation (Day 0). Prior to intrauterine infusion on Day 0 and again on Days 3, 7, 10, and 15, cytobrush samples were collected from the uterus of each cow for microbiology and assessment of the percentage of polymorphonuclear neutrophils (PMN%). Blood samples were collected on the same days for measurement of concentrations of progesterone in serum, and uterine lumen diameter was assessed daily using transrectal ultrasonography. Trueperella pyogenes was isolated from 5/18 (28%), 7/9 (78%) and 8/9 (89%) cows infused with saline, 107 or 109 cfu of T. pyogenes, respectively (p < 0.001). Mean PMN% in the control cows did not change over time (p > 0.05), whereas it was higher on Days 7 and 10 than Day 0 in the 107 cfu group, and higher on Days 3 and 10 than Day 0 in the 109 cfu group (p < 0.05). The percentage of observations with uterine lumen diameters >2 mm was higher in cows infused with 107 (29.3 (95% CI = 14.5–44.2)%) or 109 cfu (19.2 (95% CI = 7.0–31.5)%) than in control cows (3.1 (95% CI = 0.1–6.0)%) (p < 0.001). Mean concentrations of progesterone in serum were higher in cows infused with 107 cfu (2.01 (SE 0.19) ng/mL) than cows infused with 109 cfu (1.01 (SE 0.27) ng/mL), with the control group intermediate (1.41 (SE 0.19) ng/mL) (p = 0.03). Infusion of 107 or 109 cfu of T. pyogenes resulted in the establishment of intrauterine infection in 83% of cows. Infection resulted in increased uterine lumen diameter, and an inflammatory response, i.e. elevated PMN%. This intrauterine infection model may be useful for future research on, for example, the pathogenesis of intrauterine infection in postpartum dairy cows. [ABSTRACT FROM AUTHOR]

Aims: To determine the association of hypotonia and depression in neonates at or near term with metabolic acidemia at birth (umbilical arterial pH<7.0 and base excess <-12 mM). Methods: This case-control study identified 87 infants without chromosomal or congenital abnormalities born at a single university hospital between 7/91 and 10/04 with hypotonia at birth requiring resuscitation and admission to the neonatal intensive care unit that had a cord gas at delivery. Controls were the subsequent delivery with a cord gas matched by gestational age. Results: Cases and controls did not differ in gestational age (38.7+/-1.9, 38.6+/-1.9 weeks) or birth weight (3066+/-664, 3171+/-655 g, P=0.20). Cases were more likely to have a cord pH<7.0 [17 (20%) vs. 1 (1.1%), P=0.0001] and cord pH 7.0-7.1 [13 (14.9%) vs. 2 (2.3%), P=0.003]. Among the hypotonic infants, 31 (35.6%) also were depressed at birth with a 5-min Apgar <7. In the depressed subset of hypotonic neonates 14/31 (45%) had a pH<7.0. Of the 12 hypotonic neonates with seizures, 3 (25%) had pH<7.0. Multivariate analysis showed a significant association between neonatal hypotonia and hypoglycemia, umbilical arterial pH, and nucleated red blood cell count. Conclusions: Although metabolic acidemia is significantly associated with hypotonia at the time of birth, the majority of neonates with hypotonia and depression or seizures do not have objective evidence of asphyxia as measured by a cord gas at the time of delivery. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine if an amniotic fluid index (AFI) < or =5.0 cm within 7 days of delivery in the third trimester is associated with decreasing umbilical arterial pH and base excess. STUDY DESIGN: Cases for this retrospective cohort study were all pregnancies > or =26 weeks with intact membranes and an AFI < or =5.0 cm within 7 days of delivery between 11/99 and 7/02. Multiple gestations, aneuploid, and anomalous fetuses were excluded. Controls with an AFI >5.0 cm within 7 days of delivery were matched to each case within 1 week by gestational age. For a control group with a mean+/-SD umbilical arterial pH of 7.26+/-0.07 and alpha=0.05, a sample size of 100 would have a power of 99% to detect a difference with a study group whose mean was 7.20. Data were compared using paired Student's t-test, Mann-Whitney, Fisher's exact, chi(2) and risk ratios with 95% confidence intervals. RESULTS: In all, 131 neonates with an AFI < or =5.0 cm were matched to 131 controls with an AFI >5 cm. There was no difference in gestational age (37.6+/-3.0, 37.7+/-3.0 weeks) or birth weight (2897+/-810, 2762+/-788 g). There was no difference in umbilical artery pH (7.25+/-0.07, 7.26+/-0.07) or base excess (-3.32+/-2.59, -2.83+/-2.45 mmol/l), even in small for gestational age (SGA) infants in both groups. There was no difference in the number of SGA neonates, 5-minute Apgar <7, respiratory distress syndrome, necrotizing enterocolitis, or neurologic morbidity. Linear regression showed no correlation between AFI and either umbilical arterial pH (r=-0.00047, SE=0.001, p=0.63) or base excess (r=-0.029, SE=0.037, p=0.428). CONCLUSION: An AFI < or =5.0 cm measured within 7 days of delivery in the third trimester is not associated with decreasing umbilical arterial pH and base excess. [ABSTRACT FROM AUTHOR]

Background:To describe the incidence of QRS prolongation, intraventricular conduction delay (IVCD), and presence of ventricular arrhythmias in patients undergoing the Norwood procedure with subsequent superior cavopulmonary anastomosis. Differences between the modified Blalock-Taussig shunt (BTS) and the right ventricle to pulmonary artery shunt (RV-PA) on these variables were investigated. Methods:Eighty-two consecutive patients underwent Norwood palliation with a BTS (n = 41) or a RV-PA (n = 41). Standard 12-lead surface ECGs were retrospectively reviewed at three separate times: (1) prior to the Norwood procedure, (2) immediately post-Norwood procedure, and (3) prior to the superior cavopulmonary anastomosis. Groups were compared at these times for the absolute QRS duration, the change in QRS duration from one time interval to the other, and the number of patients with IVCD. The presence of ventricular rhythm abnormalities requiring treatment at any time was recorded. Results:Immediately after the Norwood procedure, QRS duration was slightly longer and median QRS change slightly larger for the RV-PA than the BTS group (P = 0.04). However, there were no differences in these variables at the time of pre superior cavopulmonary anastomosis. Within both groups, there was a significant increase in median QRS duration over time; from both pre- and post-Norwood to presuperior cavopulmonary anastomosis (P < 0.001). Conclusions:IVCD is common in patients following a Norwood procedure regardless of the type of shunt received. A ventriculotomy had small effects on QRS duration in the short term, but had no effect on the incidence of treatable ventricular rhythm abnormalities. [ABSTRACT FROM AUTHOR]

Introduction: Throughout the COVID-19 pandemic, outpatient hand therapy services were restricted. The use of telehealth was adopted to continue to provide care to patients with hand injuries. This survey aims to investigate patient satisfaction with hand therapy delivered via telehealth in a NSW public tertiary referral metropolitan setting and explore whether this differs for specific hand injury/conditions and treatments offered., Methods: Patients using hand therapy services via telehealth between 28 June 2021 and 27 May 2022 responded to a bespoke electronic survey. Participants were grouped depending on their particular injury/condition and treatment received. Analysis was conducted using MS Excel, and correlations were determined by using Fisher's exact test., Community and Consumer Involvement: No consumers were involved in the study design or analysis., Results: Sixty-eight of 262 patients responded to the survey (26% response rate). Overall results showed high patient satisfaction (n = 55, 81%) with hand therapy delivered via telehealth with most patients agreeing that telehealth should be offered going forward (n = 59, 87%). Benefits reported by patients included convenience, reduced travel time and parking issues, and time saving. Patients receiving therapy for 'finger thumb bony injury with K wires' demonstrated a statistically significant association of lower satisfaction with telehealth (n = 3, 43%, P = 0.02). Patients receiving wound care over telehealth were just as satisfied with their experience (n = 15, 82%) as overall results (n = 55, 81%)., Conclusion: The survey suggests that patients are satisfied with their experience of telehealth for hand therapy. Patients with finger thumb bony injuries with k wires may be less suitable for telehealth. Wound care appears to be well received over telehealth in a hand therapy population., Plain Language Summary: There is little evidence to guide hand therapists in which conditions or injuries patients find can be managed well with telehealth. Patients who answered a survey about their experience with telehealth for their hand therapy management overall reported satisfaction with the experience. Some patients had undergone surgery for broken fingers and thumbs using wires to hold the bone together while it healed. These patients were less likely to find telehealth satisfactory for their hand therapy care. Most patients requiring wound care over telehealth found this satisfactory., (© 2024 Occupational Therapy Australia.)

Purpose: Web creep and scar contracture are established complications of syndactyly reconstruction; however, few reports characterize risk factors for revision surgery. The purpose of this investigation was to examine the rate and risk factors of reoperation for congenital hand syndactyly., Methods: Patients undergoing syndactyly reconstruction from 2007 to 2021 at a single children's hospital were reviewed. Cases with less than 1 year of follow-up were excluded. Demographic, surgical, and outcomes data were recorded by each web space to account for mixed treatments., Results: In total, 514 web spaces in 231 children were reviewed with a mean follow-up of 6.0 years after primary reconstruction; 66 (12.8%) web spaces in 51 (22.1%) children underwent revision. The most common procedures were web space deepening due to web creep (57.9% of cases) and digital scar contracture release (45.6%); these were augmented in a minority (17.5%) of cases by other aesthetic/functional procedures. Revisions occurred at a median of 1.7 years after primary reconstruction. First web spaces (thumb-index finger) were most frequently reoperated (33.3%). On multivariable analysis, first web space involvement, complete syndactyly, and complications after the primary reconstruction significantly increased odds of revision. Age at primary reconstruction was not a significant predictor. Following revision, 10.5% of cases had recurrent web creep, and 14.0% had recurrent scar contracture. Eight (1.6%) web spaces in seven (3.0%) children required multiple revisions., Conclusions: Approximately 13% of syndactyly reconstructions (22% of patients) require reoperation. Most revisions occur within 4 years of primary reconstruction. Complete syndactyly, complications after the primary reconstruction, and first web space involvement increase the risk of revision; age at primary reconstruction is not a risk factor. Revision outcomes mirror the index procedure, with 10% to 14% of revised web spaces experiencing recurrent web creep or contracture., Type of Study/level of Evidence: Therapeutic IV., Competing Interests: Conflicts of Interest No benefits in any form have been received or will be received related directly to this article., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Metabolic syndrome is linked to an increased risk of incident cardiovascular disease and all-cause mortality. Notable associations exist between hysterectomy with bilateral salpingo-oophorectomy and metabolic syndrome. However, there is emerging evidence that even with ovarian conservation, hysterectomy may be independently associated with long-term cardiovascular disease risk., Objective: To examine the associations between hysterectomy with ovarian preservation and metabolic syndrome risk in a multiethnic cohort., Study Design: We studied 3367 female participants in the Multi-Ethnic Study of Atherosclerosis who had data on self-reported history of hysterectomy, oophorectomy, hystero-oophorectomy, and metabolic syndrome at baseline (2000-2002). We used adjusted logistic regression to assess the cross-sectional associations between hysterectomy and or oophorectomy subgroups and prevalent metabolic syndrome at baseline. Furthermore, we investigated 1355 participants free of baseline metabolic syndrome and used adjusted Cox regression models to evaluate incident metabolic syndrome from examinations 2 (2002-2004) to 6 (2016-2018)., Results: The mean age was 59.0±9.5 years, with 42% White, 27% Black, 19% Hispanic, and 13% Chinese American participants. 29% and 22% had a history of hysterectomy and oophorectomy, respectively. Over a median follow-up of 10.5 (3.01-17.62) years, there were 750 metabolic syndrome events. Hysterectomy (hazard ratio, 1.32 [95% confidence interval, 1.01-1.73]) and hystero-oophorectomy (hazard ratio, 1.40 [95% confidence interval, 1.13-1.74]) were both associated with incident metabolic syndrome compared with having neither hysterectomy nor oophorectomy., Conclusion: Hysterectomy, even with ovarian preservation, may be independently associated with a higher risk of metabolic syndrome. If other studies confirm these findings, screening and preventive strategies focused on females with ovary-sparing hysterectomies and the mechanisms underpinning these associations may be explored., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Despite a rigorous screening process, including cardiac catheterization, a subset of patients with a single right ventricle (SRV) demonstrates suboptimal short-term outcomes after the Fontan operation. The goal of this study was to perform a comprehensive assessment of diastolic function in pre-Fontan patients with an SRV using invasive reference-standard measures and determine their associations with post-Fontan outcomes., Methods and Results: Children aged 2 to 6 years with SRV physiology undergoing pre-Fontan heart catheterization were recruited prospectively. Patients were divided into those who had an optimal or suboptimal outcome. A suboptimal outcome was defined as length of stay ≥14 days or heart transplant/cardiac death in first year after Fontan. Patients underwent pressure-volume loop analysis using reference-standard methods. The measure of ventricular stiffness, β, was obtained via preload reduction. Cardiac magnetic resonance imaging for extracellular volume and serum draws for matrix metalloproteinase activity were performed. Of 19 patients with an SRV, 9 (47%) had a suboptimal outcome. Mean age was 4.2±0.7 years. Patients with suboptimal outcomes had lower ventricular stiffness (0.021 [0.009-0.049] versus 0.090 [0.031-0.118] mL -1 ; P =0.02), lower extracellular volume (25% [28%-32%] versus 31% [28%-33%]; P =0.02), and lower matrix metalloproteinase-2 (90 [79-104] versus 108 [79-128] ng/mL; P =0.01) compared with patients with optimal outcomes. The only invasive measure that had an association with suboptimal outcome was β ( P =0.038)., Conclusions: Patients with an SRV with suboptimal outcome after the Fontan operation had lower ventricular stiffness and evidence of maladaptive extracellular matrix metabolism compared with patients with optimal outcome. This appears to be a novel phenotype that may have important clinical implications and requires further study.

Background: A novel tendon stapler device (TSD) to improve the strength and consistency of primary tendon repairs was recently approved by the U.S. Food and Drug Administration. The authors hypothesized that this TSD would demonstrate faster and superior biomechanical properties compared with a standard suture coaptation. The authors also hypothesized that the TSD biomechanical properties would be consistent across participants with differing tendon repair experiences., Methods: Participants included a novice, intermediate, and expert in tendon repairs. Timed comparisons were performed in flexor zones IV and V and extensor zones VI and VII on human cadaver arms. Suture repairs were performed with a modified Kessler technique with a horizontal mattress. TSD repairs were performed on the matched donor arms. Biomechanical testing included 2-mm gap force, ultimate failure load, and mode of failure., Results: In total, 228 tendon coaptations from 12 donor arms were performed and analyzed. TSD coaptations were 3 times faster and withstood nearly 50% higher forces on 2-mm gap testing and roughly 30% higher forces on ultimate failure testing. These findings did not change when the repair times were analyzed by participant. Suture coaptations failed owing to suture pull-through, suture breakage, or knot failure. TSD coaptation failures only occurred from device pull-through., Conclusions: The TSD produces significantly faster and stronger primary tendon coaptations compared with a standard 4-strand core suture repair in human donor arms. The findings demonstrated minimal variability among participants with differing tendon repair experience. Although further investigation is needed, this device has potential to revolutionize tendon repairs., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: NovoSorb biodegradable temporizing matrix (BTM) is a novel, bilayer, synthetic skin substitute made of biodegradable polyurethane foam covered with a sealing membrane. BTM has demonstrated excellent outcomes in burn literature; however, few studies have been published for hand and extremity soft tissue reconstruction., Methods: All patients who underwent extremity reconstruction with BTM from 2018 to 2023 were reviewed. Demographics, presentations, and clinical outcomes were recorded., Results: A total of 86 cases from 54 patients (53.7% pediatric; age range: 0-81 years) were included. Common indications included trauma (36%), infection (18.6%), and malignancy (11.6%). BTM was placed over exposed tendon (38.4%), bone (19%), joints (12.8%), nerves (8.1%), and/or blood vessels (7%). BTM served as temporary wound coverage in 26 cases. Complications included hematoma (8.1%), infection (4.7%), and spontaneous delamination (4.7%). Wound closure was successfully obtained without flap use in 93.3%. Poor BTM take was associated with peripheral vascular disease, hypertension, immunosuppression, and BTM hematoma and infection (<0.05)., Conclusion: This study contributes to the growing body of evidence favoring BTM use in challenging reconstructive cases. Although prospective comparative studies are forthcoming, BTM likely has broad applications in reconstructive surgery., Competing Interests: Author Shaun D. Mendenhall is an educational consultant for PolyNovo, the manufacturer of NovoSorb BTM. All the other authors have no financial interest to declare in relation to the content of this article., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

This study evaluated how Apert hand syndactyly presentations and reconstructive techniques influence reconstruction outcomes. All cases at a major paediatric hospital between 2007 and 2022 were analysed, including 98 web space reconstructions in 17 patients. Overall, 62% of hands developed complications and 15% required revision surgery. Upton hand type was significantly associated with postoperative complication incidence, specifically including range-of-motion deficits, flexion contracture, web creep and revision surgery. More severe syndactylies may benefit from additional measures to reduce complications. Rectangular commissural flaps showed 1.9 times greater complication risk than interdigitating triangular flaps, including 11.2 times greater risk of web creep. Zigzag volar finger flaps showed 1.8 times greater complication risk than straight-line incisions, including 3.8 times greater risk of web creep. Our study showed that interdigitating triangular commissural flaps and straight-line volar finger incisions are preferable to rectangular commissural and zigzag finger flaps in most cases of Apert hand syndactyly to minimize complications., Level of Evidence: III., Competing Interests: Declaration of conflicting interestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: SDM is an educational consultant for PolyNovo, which does not relate to the content of this article. The other authors have no conflicts of interest to disclose.

Introduction: The glass ceiling in academic medicine has resulted in lower pay and fewer career advancement opportunities for women. Creating change relies on preparing early-career women for positions of leadership, but most leadership programs focus on faculty, not trainees. The present exploratory qualitative study investigates how to prepare women medical students to be leaders in academic medicine., Methods: Focus groups with medical students and faculty who identify as women were conducted at an academic medical center in the West. A total of 25 individuals (10 students and 15 faculty) participated. Recordings of focus groups were transcribed and coded using thematic analysis until saturation of themes was achieved., Findings: Codes were organized into three themes: obstacles, support systems, and self-presentation. Obstacles identified included the subthemes microaggressions, macroaggressions, a lack of female role models in leadership, and personal characteristics such as the ability to self-promote and remain resilient. Support systems included sponsorship, allyship, mentorship, networking, and gender-specific role modeling subthemes. Self-presentation involved learning behaviors for demonstrating leadership and exuding confidence, being strategic about career moves, resiliency, and navigating social norms., Conclusions: The key themes of obstacles, support systems, and self-presentation are targets for systemic and individualistic improvement in leadership development., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Chow et al.)

Introduction: Vascular malformations (VMs) typically appear at birth and grow commensurately with patients. They can vary broadly in vessel type and tissue involvement, and upper extremity (UE) VMs can pose unique functional and aesthetic challenges in children. Given the advent of operative and nonoperative technologies like sclerotherapy and medications, a contemporary review of the surgical management of UE VMs is warranted., Methods: We performed a retrospective review of all patients who had surgical management of VMs from 2010 to 2021 at The Children's Hospital of Philadelphia. Demographics, lesion characteristics, treatment (including preceding nonsurgical therapies), complications, and final outcomes were recorded. Operative notes were reviewed for date of operation, depth of excision, type of closure, and current procedural terminology code., Results: Sixty-seven patients with 88 procedures were studied. Average patient age was 5.8 years, with 64% White and 67% male. Venous (34%) and lymphatic (19%) malformations were most common, and anatomic locations were most frequently on the hand (33%) and forearm (25%). The average lesion diameter was 4.2 cm, although this varied by location (eg, 2.9 cm, hand; 11.1 cm, chest wall). Fifty-eight patients (87%) underwent surgical excision as their index procedure, and 9 had sclerotherapy before surgery. Thirty-nine patients (60%) had subcutaneous excisions, and the remainder required subfascial or intramuscular excisions. Nearly all excisions were closed primarily (97%). Of the 53 patients with documented follow-up, 32 patients (60%) had complete resolution of their lesion as of their final visit. Thirty of these 32 patients with no clinical evidence of residual VM had only 1 surgery for excision., Conclusion: Upper extremity VMs were composed of diverse conditions with varying vessel types, size, depth, and anatomic sites. Surgical excision of VMs of the UE was safe and effective. A majority of VMs were fully excised after 1 procedure and frequently closed primarily with relatively low complication rates. Future work should investigate decision-making and outcomes of all treatment options of VMs of the UE for optimal functionality and aesthetics., Competing Interests: Conflicts of interest and source of funding: The authors have no conflicts of interest to declare. This research received no specific grant from any funding agency., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Breast implant safety issues have resulted in the need for global product recalls and medical device tracing. Conventional methods of breast implant tracing, have to date proven to be unsuccessful. This study aims to evaluate the effectiveness of high-resolution ultrasound (HRUS) screening in identifying implanted breast devices., Methods: Data from 113 female patients undergoing preoperative ultrasound screening for secondary breast surgery between 2019 and 2022 was prospectively reviewed to evaluate the effectiveness of HRUS imaging with the aid of a sonographic surface catalog to identify the surface and brand type of implanted breast devices. To corroborate the findings and assess the reproducibility of the approach, further evaluations were replicated in New Zealand white rabbits and compared with the results found in humans., Results: In the human recipients, implant surface and brand types were correctly identified by ultrasound imaging in 99% (112 of 113) and 96% (69 of 72) of the cases, either consultation-only or revision, respectively. This constituted an overall success rate of 98% (181 of 185). Furthermore, in a corroborating New Zealand white rabbit model where full-scale commercial implants were introduced and monitored over many months, from the total 28 analyzed, the surface was accurately identified in a total of 27 cases (the one failure being before generation of a sonograph surface catalogue), demonstrating an overall success rate of 96.4%., Conclusion: HRUS is, therefore, a valid and first-hand tool for breast implant imaging that can correctly evaluate both surface type and brand type alongside other variables such as implant placement, positioning, flipping, or rupture., Clinical Relevance Statement: HRUS is a valid and first-hand tool for the identification and traceability of breast implants that evaluates surface type and brand type. This low-cost, accessible, and reproducible practice provides patients with peace of mind and surgeons with a promising diagnostic tool., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Objective: Volatile organic compounds (VOCs) are used in the sterilization and manufacture of medical equipment. These compounds have high vapor pressures with low water solubility and are emitted as gases from solids or liquids. They can be mutagenic, neurotoxic, genotoxic, and/or carcinogenic. Safe limits of exposure are not known for neonates. This study examined determinants of exposure in newborns undergoing cardiac surgery., Methods: Twenty metabolites of 16 VOCs (eg, xylene, cyanide, acrolein, acrylonitrile, N, N-dimethylformamide, 1,3-butadiene, styrene, and benzene) were measured as metabolites in daily urine samples collected from 10 neonates undergoing cardiac operations (n = 150 samples). Metabolites were quantified using reversed-phase ultra-high performance liquid chromatography and electrospray ionization tandem mass spectrometry. Repeated measures analysis of covariance was performed for each metabolite to examine associations with use of medical devices., Results: At least 3 metabolites were detected in every sample. The median number of metabolites detected in each sample was 14 (range, 3-15). In a model controlling for other factors, the use of extracorporeal membrane oxygenation was associated with significantly (P ≤ .05) greater metabolite levels of acrolein, acrylonitrile, ethylene oxide, propylene oxide, styrene, and ethylbenzene. Patients breathing ambient air had greater levels of metabolites of acrolein, xylene, N,N-dimethylformamide, methyl isocyanate, cyanide, 1,3-butadiene (all P ≤ .05)., Conclusions: Exposure to volatile organic compounds is pervasive in newborns undergoing cardiac surgery. Sources of exposure likely include medical devices and inhalation from the air in the intensive care unit. The contribution of VOC exposure during cardiac surgery in newborns to adverse outcomes warrants further evaluation., (Copyright © 2024. Published by Elsevier Inc.)

Background: Registry-based trials have the potential to reduce randomized clinical trial (RCT) costs. However, observed cost differences also may be achieved through pragmatic trial designs. A systematic comparison of trial costs across different designs has not been previously performed., Methods: We conducted a study to compare the current Steroids to Reduce Systemic inflammation after infant heart surgery (STRESS) registry-based RCT vs. two established designs: pragmatic RCT and explanatory RCT. The primary outcome was total RCT design costs. Secondary outcomes included: RCT duration and personnel hours. Costs were estimated using the Duke Clinical Research Institute's pricing model., Results: The Registry-Based RCT estimated duration was 31.9 weeks greater than the other designs (259.5 vs. 227.6 weeks). This delay was caused by the Registry-Based design's periodic data harvesting that delayed site closing and statistical reporting. Total personnel hours were greatest for the Explanatory design followed by the Pragmatic design and the Registry-Based design (52,488 vs 29,763 vs. 24,480 h, respectively). Total costs were greatest for the Explanatory design followed by the Pragmatic design and the Registry-Based design ($10,140,263 vs. $4,164,863 vs. $3,268,504, respectively). Thus, Registry-Based total costs were 32 % of the Explanatory and 78 % of the Pragmatic design., Conclusion: Total costs for the STRESS RCT with a registry-based design were less than those for a pragmatic design and much less than an explanatory design. Cost savings reflect design elements and leveraging of registry resources to improve cost efficiency, but delays to trial completion should be considered., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Eric L. Eisenstein: Nothing to disclose. Kevin D. Hill, MD, MSCI: Nothing to disclose. Nancy Wood, BS: Nothing to disclose. Jerry L. Kirchner, BS: Nothing to disclose. Kevin J. Anstrom, PhD, MS: Merck, Bayer, the National Institutes of Health, and the. Patient-Centered Outcomes Research Institute. Christopher B. Granger, MD: Consulting fees for the following companies: Abbvie, Abiomed, Alnylam Pharmaceuticals, Anthos, Bayer Corporation, Boehringer Ingelheim, Boston Scientific Corporation, Bristol Myers Squibb, Cardionomics, CeleCor Therapeutics, Cadrenal, Janssen Pharmaceutical, Medscape, LLC, Medtronic, Inc., Merck, Nation Institutes of Health, Novo Nordisk, Novartis Pharmaceutical Company, Pfizer, Philips, REATA, NephroSynergy. He also has salary funded by Duke grants sponsored by: Boehinger Ingelheim, Bristol Myers Squibb, Food and Drug Administration, Janssen Pharmaceuticals, Lilly Pharmaceutical, Novartis Pharmaceutical Company, Pfizer, and Philips. He has Equity in Tenac. io. Sunil V. Rao, MD: Grants from National Heart, Lung, and Blood Institute, American College of Cardiology. H. Scott Baldwin, MD: Nothing to disclose. Jeffrey P. Jacobs, MD: Consultant to American Academy of Dermatology. Marshall L. Jacobs, MD: Nothing to disclose. Prince J. Kannankeril, MD, MSCI: Nothing to disclose. Eric M. Graham, MD: Multiple NIH grants to perform research involving congenital heart disease. Sean M. O'Brien, PhD: Nothing to disclose. Jennifer S. Li, MD MHS: Nothing to disclose., (© 2024 The Authors. Published by Elsevier Inc.)

Background: Spatial information about the location and suitability of areas for native plant and animal species under different climate futures is an important input to land use and conservation planning and management. Australia, renowned for its abundant species diversity and endemism, often relies on modeled data to assess species distributions due to the country's vast size and the challenges associated with conducting on-ground surveys on such a large scale. The objective of this article is to develop habitat suitability maps for Australian flora and fauna under different climate futures., Results: Using MaxEnt, we produced Australia-wide habitat suitability maps under RCP2.6-SSP1, RCP4.5-SSP2, RCP7.0-SSP3, and RCP8.5-SSP5 climate futures for 1,382 terrestrial vertebrates and 9,251 vascular plants vascular plants at 5 km2 for open access. This represents 60% of all Australian mammal species, 77% of amphibian species, 50% of reptile species, 71% of bird species, and 44% of vascular plant species. We also include tabular data, which include summaries of total quality-weighted habitat area of species under different climate scenarios and time periods., Conclusions: The spatial data supplied can help identify important and sensitive locations for species under various climate futures. Additionally, the supplied tabular data can provide insights into the impacts of climate change on biodiversity in Australia. These habitat suitability maps can be used as input data for landscape and conservation planning or species management, particularly under different climate change scenarios in Australia., (© The Author(s) 2024. Published by Oxford University Press GigaScience.)

Neonatal hypoxic-ischemic encephalopathy (HIE) is the leading cause of acquired neonatal brain injury with the risk of developing serious neurological sequelae and death. An accurate and robust prediction of short- and long-term outcomes may provide clinicians and families with fundamental evidence for their decision-making, the design of treatment strategies, and the discussion of developmental intervention plans after discharge. Diffusion tensor imaging (DTI) is one of the most powerful neuroimaging tools with which to predict the prognosis of neonatal HIE by providing microscopic features that cannot be assessed by conventional magnetic resonance imaging (MRI). DTI provides various scalar measures that represent the properties of the tissue, such as fractional anisotropy (FA) and mean diffusivity (MD). Since the characteristics of the diffusion of water molecules represented by these measures are affected by the microscopic cellular and extracellular environment, such as the orientation of structural components and cell density, they are often used to study the normal developmental trajectory of the brain and as indicators of various tissue damage, including HIE-related pathologies, such as cytotoxic edema, vascular edema, inflammation, cell death, and Wallerian degeneration. Previous studies have demonstrated widespread alteration in DTI measurements in severe cases of HIE and more localized changes in neonates with mild-to-moderate HIE. In an attempt to establish cutoff values to predict the occurrence of neurological sequelae, MD and FA measurements in the corpus callosum, thalamus, basal ganglia, corticospinal tract, and frontal white matter have proven to have an excellent ability to predict severe neurological outcomes. In addition, a recent study has suggested that a data-driven, unbiased approach using machine learning techniques on features obtained from whole-brain image quantification may accurately predict the prognosis of HIE, including for mild-to-moderate cases. Further efforts are needed to overcome current challenges, such as MRI infrastructure, diffusion modeling methods, and data harmonization for clinical application. In addition, external validation of predictive models is essential for clinical application of DTI to prognostication., (© 2023 The Author(s). Published by S. Karger AG, Basel.)

Children with postpericardiotomy syndrome may develop hemodynamically significant pericardial effusions warranting drainage by surgical pericardial window or pericardiocentesis. The optimal approach is unknown. We performed a retrospective observational study at two pediatric cardiac centers. We included 42 children aged <18 years who developed postpericardiotomy syndrome following cardiac surgery between 2014 and 2021. Thirty-two patients underwent pericardial window and 10 underwent pericardiocentesis. Patients in the pericardial window group presented with postpericardiotomy syndrome sooner than those who underwent pericardiocentesis (median 7.5 days vs. 14.5 days, P = 0.03) and tended to undergo earlier intervention (median 8 days vs. 16 days, P = 0.16). No patient required subsequent drainage. There were no differences between groups in days of pericardial tube duration (median 4 days), complications, and subsequent days of intensive care or hospitalization. For children with postpericardiotomy syndrome with a pericardial effusion warranting drainage, these data suggest that pericardial window and pericardiocentesis have similar efficacy, safety, and resource utilization., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Annals of Pediatric Cardiology.)

Background: Rates of mutilating hand injuries are increasing from accidents caused by all-terrain vehicles (ATVs) and the recently popularized side-by-side utility terrain vehicles (UTVs). Increasing surgeon familiarity with upper extremity (UE) injury patterns, severity, and outcomes following ATV and UTV accidents may improve patient care and advocacy., Methods: Retrospective comparisons of UE injury patterns, severity, hospital and intensive care unit (ICU) admission lengths, and number of operations were made between ATVs and UTVs. Findings were analyzed with Fisher exact tests, multivariate analysis of variance, analyses of variance with post hoc analyses, and multiple linear regressions., Results: A total of 154 cases were identified for inclusion (ATV, n = 87; UTV, n = 67). Patient ages ranged from 4 to 89 years. The UTV group contained significantly more hand and finger injuries, and more of the fractures were open ( P = 0.005, P < 0.001, and P < 0.001, respectively). Riders of UTVs had nearly three times as many mutilating hand injuries and a nearly ninefold increase in amputations compared with ATV riders ( P < 0.001 and P < 0.001, respectively). On average, the UTV group spent 2.5 additional days in the hospital, 0.91 additional days in an ICU, and had 1.3 additional operations ( P = 0.001, P = 0.007, and P < 0.001, respectively). Vehicle type was the only variable significantly correlated with days in the hospital, ICU, and number of UE operations ( P = 0.002, P = 0.008, and P < 0.001, respectively)., Conclusions: Hand surgeons are in a unique position to serve as forerunners for increasing public awareness of off-road vehicle risks and promoting rider safety. Collaborating with manufacturers and emergency care providers and directing teaching initiatives may improve patient outcomes., Clinical Question/level of Evidence: Risk, II., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Purpose: Partial hand amputations are devastating injuries that often negatively affect individuals and communities. Partial hand prostheses can mitigate the burdens of living with an amputation, especially when reconstruction alone cannot restore form or function. However, hand surgeons may be unfamiliar with these newer devices because the prosthetic field is rapidly progressing., Methods: An electronic survey was distributed to hand surgeon members of the American Association for Hand Surgery with the intent of assessing surgeons' familiarity with partial hand prosthetic devices and their clinical applications. Survey items used Likert 5-point scales, rank order, multiple-choice, and yes/no question formats. Responses were compared by training background (orthopedic or plastic surgery) and by years of experience (≤10 years in practice or >10 years in practice)., Results: Overall, hand surgeons are unfamiliar with modern partial hand prosthetic devices. Most of the cohort denied working within a multidisciplinary hand team (76.2%) or consulting with a prosthetist prior to revisional surgeries (71.4%). Restoring gross motor function and reducing pain were important outcomes to the cohort (4.42 and 4.17, respectively). Plastic trained hand surgeons were more likely to list toe-to-hand transfers as treatment options for multilevel digital amputations ( P = .03) and transmetacarpal amputations ( P = .02). Senior hand surgeons were more likely to suggest no treatment for partial thumb amputations ( P = .02)., Conclusions: Expanding surgeon knowledge and encouraging collaboration within a multidisciplinary team may enhance amputee 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.

Background: Previous failed reduction and certain radiographic indicators historically have been used to differentiate simple and complex metacarpophalangeal joint (MPJ) dislocations in children, the latter of which warrants open reduction. This investigation aimed to determine the necessity for open reduction with these indicators and establish a new treatment algorithm and educational focus for these rare injuries., Methods: A 12-year retrospective study was conducted on all children with MPJ dislocations at a single pediatric hospital. The rates of successful closed reduction, number of reduction attempts, and radiographic findings were detailed. Operative details and postoperative outcomes were also gathered., Results: Thirty-three patients with a mean age of 11.1 years were included. Most were male [ n = 27 (82%)] and had undergone two or more previous reduction attempts at an outside facility. Stable closed reduction was then achieved outside of the operating room in five patients and in the operating room under general anesthesia in another 14, for a total of 19 of 33 patients (57.6%). The thumb was injured most often [ n = 19 (57.6%)] and more likely to undergo successful closed reduction ( P = 0.04). There was no relationship between number of previous reduction attempts and ability to achieve closed reduction ( P = 0.72). Neither joint-space widening nor proximal phalanx bayonetting was correlated radiographically with failure of closed reduction ( P = 0.22 and P = 1, respectively)., Conclusions: This study supports closed reduction of pediatric MPJ dislocations in the operating room under general anesthesia before conversion to open reduction, regardless of injury characteristics or previous reduction attempts. This strategy is likely to limit unnecessary open surgery and related risks., Clinical Question/level of Evidence: Risk, IV., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Recent large-scale sequencing efforts have shed light on the genetic contribution to the etiology of congenital heart defects (CHD); however, the relative impact of genetics on clinical outcomes remains less understood. Outcomes analyses using genetics are complicated by the intrinsic severity of the CHD lesion and interactions with conditionally dependent clinical variables., Methods: Bayesian Networks were applied to describe the intertwined relationships between clinical variables, demography, and genetics in a cohort of children with single ventricle CHD., Results: As isolated variables, a damaging genetic variant in a gene related to abnormal heart morphology and prolonged ventilator support following stage I palliative surgery increase the probability of having a low Mental Developmental Index (MDI) score at 14 months of age by 1.9- and 5.8-fold, respectively. However, in combination, these variables act synergistically to further increase the probability of a low MDI score by 10-fold. The absence of a damaging variant in a known syndromic CHD gene and a shorter post-operative ventilator support increase the probability of a normal MDI score 1.7- and 2.4-fold, respectively, but in combination increase the probability of a good outcome by 59-fold., Conclusions: Our analyses suggest a modest genetic contribution to neurodevelopmental outcomes as isolated variables, similar to known clinical predictors. By contrast, genetic, demographic, and clinical variables interact synergistically to markedly impact clinical outcomes. These findings underscore the importance of capturing and quantifying the impact of damaging genomic variants in the context of multiple, conditionally dependent variables, such as pre- and post-operative factors, and demography., (© 2023. Springer Nature Limited.)

Numerous effective techniques for primary tendon coaptations exist. However, these techniques are complex and require a substantial amount of training to become proficient. Recently, a novel tendon stapler device (TSD) was developed that could potentially diminish the discrepancies among surgeons of varying levels of training. We hypothesized that the TSD would be easier to learn and would demonstrate improved learning curve efficiencies across participants of differing tendon repair experience compared with traditional suture methods. Participants included a novice, intermediate, and expert in tendon repairs. Comparisons were performed on wrist-level flexors and extensors from human donor arms. The suture repairs were performed with a modified Kessler with a horizontal mattress and were performed in one session on two donor arms by each participant. In a second session, each participant performed the TSD repairs on the matched, contralateral donor arms. Scatterplots fitted with Loess curves, one-way analysis of variance, Tukey pairwise comparisons, two-sided independent samples t test, and Fisher exact test were used to analyze findings. Results of our study showed that TSD repair times did not vary significantly by experience level. Suture repairs reached a stable "learned" level around repair #30, whereas the TSD repairs showed a more efficient curve that stabilized around repair #23. The TSD required less educational time, demonstrated a more efficient learning curve, and showed less variability across participants and repair order. Overall, the TSD is easy to adopt and may carry positive implications for surgeons and patients., Competing Interests: Author Shaun D. Mendenhall is an educational consultant for PolyNovo, which is unrelated to this study. The other authors have no financial interest to declare in relation to the content of this article., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Introduction: Synpolydactyly is a rare congenital anomaly characterized by syndactyly and polydactyly in the central hand. Limited treatment guidelines exist for this complex condition., Methods: A retrospective review of synpolydactyly patients was conducted at a large, tertiary pediatric referral center to describe our surgical experience and evolution of management. The Wall classification system was used to categorize cases., Results: Eleven patients (21 hands) with synpolydactyly were identified. Most of the patients were White and had at least one first-degree relative who also had synpolydactyly. The Wall classification yielded the following results: 7 type 1A hands, 4 type 2B hands, 6 type 3 hands, and 4 uncategorizable hands. Each patient had an average of 2.6 surgeries and an average follow-up time of 5.2 years. The rates of postoperative angulation and flexion deformities were 24% and 38%, respectively, with many of these cases also demonstrating preoperative alignment abnormalities. These cases often required additional surgeries including osteotomies, capsulectomies, and/or soft tissue releases. The rate of web creep was 14% with 2 of these patients requiring revision surgery. Despite these findings, at the time of final follow-up, most patients had favorable functional outcomes, were able to engage in bimanual tasks, and were able to perform activities of daily living independently., Conclusions: Synpolydactyly is a rare congenital hand anomaly with a significant degree of variability in clinical presentation. The rates of angulation and flexion deformities as well as web creep are not insignificant. We have learned to prioritize correcting contractures, angulation deformities, and skin fusion, over simply trying to delete the "extra" number of bones as this may destabilize the digit(s)., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

To examine the association between three perioperative urine biomarker concentrations (urine cystatin C [uCysC], urine neutrophil gelatinase-associated lipocalin [uNGAL], and urine kidney injury molecule 1 [uKIM-1]), and cardiac surgery-associated acute kidney injury (CS-AKI) and fluid overload (FO) in infants with congenital heart disease undergoing surgery on cardiopulmonary bypass. To explore how urine biomarkers are associated with distinct CS-AKI phenotypes based on FO status., Design: Ancillary prospective cohort study., Setting: Single U.S. pediatric cardiac ICU., Patients: Infants less than 1 year old enrolled in the Steroids to Reduce Systemic Inflammation after Infant Heart Surgery trial (NCT03229538) who underwent heart surgery from June 2019 to May 2020 and opted into biomarker collection at a single center. Infants with preoperative CS-AKI were excluded., Interventions: None., Measurements and Main Results: Forty infants met inclusion criteria. Median (interquartile) age at surgery was 103 days (5.5-161 d). Modified Kidney Disease Improving Global Outcomes-defined CS-AKI was diagnosed in 22 (55%) infants and 21 (53%) developed FO. UCysC and uNGAL peaked in the early postoperative period and uKIM-1 peaked later. In unadjusted analysis, bypass time was longer, and Vasoactive-Inotropic Score at 24 hours was higher in infants with CS-AKI. On multivariable analysis, higher uCysC (odds ratio [OR], 1.023; 95% CI, 1.004-1.042) and uNGAL (OR, 1.019; 95% CI, 1.004-1.035) at 0-8 hours post-bypass were associated with FO. UCysC, uNGAL, and uKIM-1 did not significantly correlate with CS-AKI. In exploratory analyses of CS-AKI phenotypes, uCysC and uNGAL were highest in CS-AKI+/FO+ infants., Conclusions: In this study, uCysC and uNGAL in the early postoperative period were associated with FO at 48 hours. UCysC, uNGAL, and uKIM-1 were not associated with CS-AKI. Further studies should focus on defining expected concentrations of these biomarkers, exploring CS-AKI phenotypes and outcomes, and establishing clinically meaningful endpoints for infants post-cardiac surgery., Competing Interests: Dr. Thompson was supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award Number T32HD104576. Dr. Hill reports support from the National Centers for Advancing Translational Sciences (U01TR-001803-01). The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Background: The Pulvertaft weave technique (PT) is frequently used during tendon repairs and transfers. However, this technique is associated with limitations. In this systematic review and meta-analysis, quantitative and qualitative analyses were performed on in vitro, biomechanical studies that compared the PT with alternative techniques., Methods: Articles included for qualitative and/or qualitative analysis were identified following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies included in the meta-analysis were analyzed either as continuous data with inverse variance and random effects or as dichotomous data using a Mantel-Haenszel analysis assuming random effects to calculate an odds ratio., Results: A comprehensive electronic search yielded 8 studies meeting inclusion criteria for meta-analysis. Two studies with a total of 65 tendon coaptations demonstrated no significant difference in strength between the PT and traditional side-to-side (STS) techniques ( P = .92). Two studies with a total of 43 tendon coaptations showed that the STS with 1 weave has a higher yield strength than the PT ( P = .03). Two studies with a total of 62 tendon repairs demonstrated no significant difference in strength between the PT and the step-cut (SC) techniques ( P = .70). The final 2 studies included 46 tendon repairs and demonstrated that the wrap around (WA) technique has a higher yield strength than the PT ( P < .001)., Conclusions: The STS, SC, and WA techniques are preferred for improving tendon form. The STS and WA techniques have superior yield strengths than the PT, and the SC technique withstands similar stress to failure as the PT.