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Background: A long philtrum and poor perioral skin quality are stigmata of the aging face. Micro-Coring is a novel technology that allows for scarless skin removal., Objectives: In this study we aimed to determine whether micro-coring can shorten the philtrum and improve perioral skin quality., Methods: A retrospective cohort study was performed on patients who underwent facelift with perioral micro-coring and age- and BMI-matched controls who underwent facelift alone. Preoperative and postoperative 3-dimensional facial imaging was performed. Standard perioral distances and percentage of change were calculated. Perioral skin quality was evaluated by blinded raters with the Scientific Assessment Scale of Skin Quality (SASSQ) and Global Aesthetic Improvement Scale (GAIS)., Results: Thirteen patients and 13 controls were included, with a mean follow-up of 8.9 months (range 3.0-21.5). Patients had significantly shorter mean philtrum length postoperatively compared to preoperatively, with an average decrease of 6.18% (±2.25%; P < .05). Controls did not experience significant changes in philtrum length (P > .05). There were no significant changes in other perioral measurements. Perioral skin elasticity and wrinkles significantly improved in patients compared to controls and patients had significantly greater GAIS scores (P < .05)., Conclusions: Micro-Coring can achieve perioral rejuvenation through measurable shortening of the philtrum and observable improvement in skin quality. Nonsurgical techniques continue to find new ways to achieve aesthetic goals without significant recovery or scarring and offer value to patients and clinicians., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society.)

The ability to perform surgical replantation of individual digits and limbs can provide substantial functional improvement for patients who sustain devastating upper extremity injuries. Defining success in replantation surgery extends beyond the acute period and the binary metrics of survival or loss of the replanted part to include the long-term overall functional outcomes. Functional outcomes include both objective clinical evaluation and patient-reported outcomes. There has been significant variation in the way outcomes following replantation are measured, which inherently leads to heterogeneity in the reported outcome data. Given the variability among outcome measures, we aim to explore the outcomes of replantation surgery, particularly clinical evaluation and patient-reported functional outcomes following replantation., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Hair restoration surgery (HRS) is a commonly performed elective procedure but to date lacks a review of the full scope of complications., Objectives: To provide a comprehensive overview of observed complications associated with follicular unit extraction (FUE) and follicular unit transplantation (FUT)., Eligibility Criteria: Randomized control trials, cohort studies, case series, and case reports published in 1985 or later on adults (age>18). Nontraumatic or autoimmune etiologies of alopecia were excluded as procedure indications., Sources of Evidence: PubMed, EMBASE, Cochrane databases (last search December 31, 2022)., Charting Methods: Data-charting and extraction were independently performed with two reviewers using Covidence., Results: Forty-three publications were included. Two large series reported the overall complication rate to be 1.2 and 4.7%. Common complications included bleeding requiring intervention (up to 8%), persistent numbness (up to 11%), infection (up to 11% with two reports of Kaposi varicelliform eruptions and one of mucormycosis), effluvium at donor and recipient sites (up to 4.1% and 6.5%, respectively). The most common donor-site complication was hypertrophic scarring/keloid formation after FUT (up to 15.1%). Complications at the recipient site, including crusting (up to 54.8%), frontal edema (up to 50%), and sterile folliculitis (up to 53.3%), tended to be poorly defined with a broad range of incidences., Conclusion: Serious complications associated with HRS are rare in the hands of experienced providers. However, comprehensive discussions of risk must be had with prospective patients as any complication in the context of an elective procedure may be significant and psychologically devastating for the individual patient., Level of Evidence V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 ., (© 2024. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.)

Cotton (Gossypium hirsutum L.) is the key renewable fibre crop worldwide, yet its yield and fibre quality show high variability due to genotype-specific traits and complex interactions among cultivars, management practices and environmental factors. Modern breeding practices may limit future yield gains due to a narrow founding gene pool. Precision breeding and biotechnological approaches offer potential solutions, contingent on accurate cultivar-specific data. Here we address this need by generating high-quality reference genomes for three modern cotton cultivars ('UGA230', 'UA48' and 'CSX8308') and updating the 'TM-1' cotton genetic standard reference. Despite hypothesized genetic uniformity, considerable sequence and structural variation was observed among the four genomes, which overlap with ancient and ongoing genomic introgressions from 'Pima' cotton, gene regulatory mechanisms and phenotypic trait divergence. Differentially expressed genes across fibre development correlate with fibre production, potentially contributing to the distinctive fibre quality traits observed in modern cotton cultivars. These genomes and comparative analyses provide a valuable foundation for future genetic endeavours to enhance global cotton yield and sustainability., (© 2024. The Author(s).)

Background: Numeric scales are validated methods to report pain outcomes after targeted muscle reinnervation (TMR) but do not include the assessment of qualitative pain components. This study evaluates the application of pain sketches within a cohort of patients undergoing primary TMR and describes differences in pain progression according to early postoperative sketches., Methods: This study included 30 patients with major limb amputation and primary TMR. Patients' drawings were categorized into four categories of pain distribution [focal pain (FP), radiating pain (RP), diffuse pain (DP), or no pain (NP)] and interrater reliability was calculated. Second, pain outcomes were analyzed for each category. Pain scores were the primary outcome, and Patient-Reported Outcomes Measurement Information System (PROMIS) instruments were the secondary outcome., Results: The interrater reliability for the sketch categories was good (overall kappa coefficient of 0.8). The NP category reported a mean decrease in pain of 4.8 points, followed by the DP (2.5 points) and FP categories (2.0 points). The RP category reported a mean increase in pain of 0.5 points. For PROMIS Pain Interference and Pain Intensity, the DP category reported a mean decrease of 7.2 and 6.5 points, respectively, followed by the FP category (5.3 and 3.6 points). The RP category reported a mean increase of 2.0 points in PROMIS Pain Interference and a mean decrease of 1.4 points in PROMIS Pain Intensity. Secondary outcomes for the NP category were not reported., Conclusion: Pain sketches demonstrated reliability in pain morphology assessment and might be an adjunctive tool for pain interpretation in this setting., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Naturally-colored brown cotton (NBC) fiber is an environmentally friendly raw source of fiber for textile applications. The fiber of some NBC cultivars exhibits flame-retardant properties, which can be used in textiles that require flame resistance. Proanthocyanidins or their derivatives are responsible for the brown pigment in NBC; however, how flame retardancy is related to pigmentation in NBC is poorly understood. To gain insight into brown pigment biosynthesis, we conducted comparative transcripts and metabolites profiling analysis of developing cotton fibers between the brown (MC-BL) and white (MC-WL) cotton near-isogenic lines (NILs), genetically different only in the Lc1 locus. In this study, mass spectrometry was used to detect metabolites in BL and WL developing fibers at 8, 12, 16, 20, 24, 36, and 40 days post anthesis (DPA) and mature fibers. Transcripts analysis was performed at two critical fiber developmental points, 8 DPA (fiber elongation) and 20 DPA (secondary cell wall deposition). We found 5836 (ESI MS positive mode) and 4541 (ESI MS negative mode) metabolites significantly different accumulated between BL and WL. Among them, 142 were known non-redundant metabolites, including organic acids, amino acids, and derivatives of the phenylpropanoid pathway. Transcript analysis determined 1691 (8 DPA) and 5073 (20 DPA) differentially expressed genes (DEGs) between BL and WL, with the majority of DEGs down-regulated at 20 DPA. Organic acids of the citric acid cycle were induced, while most of the detected amino acids were reduced in the MC-BL line. Both cis - and trans -stereoisomers of flavan-3-ols were detected in developing MC-WL and MC-BL fibers; however, the gallocatechin and catechin accumulated multiple times higher. Gas chromatography-mass spectrometry (GC-MS) analysis of fatty acids determined that palmitic acid long-chain alcohols were the main constituents of waxes of mature fibers. Energy-dispersive X-ray spectrometry (EDS) analysis of mature fibers revealed that potassium accumulated three times greater in MC-BL than in MC-WL mature fibers. This study provides novel insights into the biosynthesis of pigments and its association with flame retardancy in NBC fibers., 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. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Hinchliffe, Naoumkina, Thyssen, Nam, Chang, McCarty and Jenkins.)

Background: We assessed factors associated with change in radiographic teardrop angle following volar locking plate (VLP) fixation of volarly displaced intra-articular distal radius fractures with volar ulnar fragments (VUF) within the ICUC database. The primary outcome was change in radiographic alignment on follow-up imaging, defined as a change in teardrop angle from intra-operative fluoroscopy greater than 5°., Methods: Patients with distal radius fractures treated with a VLP within the ICUC database, an international collaborative and publicly available dataset, were identified. The primary outcome was volar rim loss of reduction on follow-up imaging, defined as a change in radiographic alignment from intra-operative fluoroscopy, teardrop angle less than 50°, or loss of normal radiocarpal alignment. Secondary outcomes were final range of motion (ROM) of the affected extremity. Radiographic Soong classification was used to grade plate position. Descriptive statistics were used to assess variables' distributions. A Random Forest supervised machine learning algorithm was used to classify variable importance for predicting the primary outcome. Traditional descriptive statistics were used to compare patient, fracture, and treatment characteristics with volar rim loss of reduction. Volar rim loss of reduction and final ROM in degrees and as compared with contralateral unaffected limb were also assessed., Results: Fifty patients with volarly displaced, intra-articular distal radius fractures treated with a VLP were identified. Six patients were observed to have a volar rim loss of reduction, but none required reoperation. Volar ulnar fragment size, Soong grade 0, and postfixation axial plate position in relation to the sigmoid notch were significantly associated ( P < .05) with volar rim loss of reduction. All cases of volar rim loss of reduction occurred when VUF was 10.8 mm or less., Conclusions: The size of the VUF was the most important variable for predicting volar rim loss of reduction followed by postfixation plate position in an axial position to the sigmoid notch and the number of volar fragments in the Random Forest machine learning algorithm. There were no significant differences in ROM between patients with volar ulnar escape and those without., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: REC, YAJH, CLEL, AG, PR, and JCM have nothing to disclose. ARB is a consultant for Synthes/TriMed. JBJ and AFD are affiliated with the ICUC Library. AFD has a Royalty Agreement with DePuy Synthes. JBJ is a consultant at the AO Foundation and TriMed; they also provide research support to the AO Foundation, Materialize Textbook, and Elsevier.

Background: For transmasculine individuals, double-incision mastectomy with free nipple grafts is the most common procedure for gender-affirming chest masculinization. However, patients report decreased sensation postoperatively. Direct coaptation of intercostal nerves to the nipple-areolar complex (NAC) is an experimental technique that may preserve postoperative sensation, yet whether reimbursements and billing codes incentivize hospital systems and surgeons to offer this procedure lacks clarity., Methods: A retrospective cross-sectional analysis of fiscal year 2023 Medicare physician fee schedule values was performed for neurotization procedures employing Current Procedural Terminology codes specified by prior studies for neurotization of the NAC. Additionally, operative times for gender-affirming mastectomy at a single center were examined to compare efficiency between procedures with and without neurotization included., Results: A total of 29 encounters were included in the study, with 11 (37.9%) receiving neurotization. The mean operating time was 100.3 minutes (95% CI, 89.2-111.5) without neurotization and 154.2 minutes (95% CI, 139.9-168.4) with neurotization. In 2023, the average work relative value units (wRVUs) for neurotization procedures was 13.38. Efficiency for gender-affirming mastectomy was 0.23 wRVUs per minute without neurotization and 0.24 wRVUs per minute with neurotization, yielding a difference of 0.01 wRVUs per minute., Conclusions: Neurotization of the NAC during double-incision mastectomy with free nipple grafts is an experimental technique that may improve patient sensation after surgery. Current reimbursement policy appropriately values the additional operative time associated with neurotization relative to gender-affirming mastectomy alone., Competing Interests: Dr. Valerio is a consultant for Axogen Inc, Checkpoint Surgical Inc, and Integra Lifesciences. 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.)

If untreated, scaphoid nonunions may progress to scaphoid nonunion advanced collapse in a substantial portion of cases and may require salvage procedures. Multiple different techniques have been described to address scaphoid nonunion. Vascularized bone flaps (VBFs) are associated with faster time to union compared with nonvascularized grafts. Because these are local pedicled flaps, they do not require microsurgical anastomoses and should be within the armamentarium of all hand surgeons. Appropriately chosen local VBFs, can achieve union rates up to 90% to 100% in appropriately selected patients., Competing Interests: Disclosures K.R. Eberlin-consultant for AxoGen, Integra, Checkpoint., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The Soong classification grades the prominence of volar locking plates used to treat distal radius fractures in relation to the volar rim. The basis of the classification scheme is that increasing plate prominence over the volar rim and distal radius watershed zone is associated with increased likelihood of flexor tendon irritation and need for plate removal. However, recent studies report mixed results on the predictive value of the Soong classification for these outcomes. We hypothesized that the decreased predictive accuracy of Soong classification is due to misclassification between Soong grades secondary to a suboptimal correlation between the Soong classification on radiographs (XRs) and computed tomography (CT)., Methods: Fifty volarly displaced distal radius fractures treated with a volar locking plate in the international and publicly available ICUC database were reviewed. All cases with a postoperative XR and CT were included. Soong classification of the volar locking plate in relation to the volar ulnar rim was determined on both XR and CT by 2 independent, fellowship-trained hand surgeons using CT imaging as the gold standard. The distribution of Soong grades on XR and CT was compared using Pearson's χ 2 test, and correlation was calculated using the Matthews correlation coefficient (MCC). A multi-class confusion matrix was used to calculate each grade's positive predictive value (PPV)., Results: We found an MCC of 0.65, indicating only moderate correlation between the 2 modalities. Per individual Soong grade, the PPV was the highest for grade 2 (0.96), with lower PPVs for grade 0 (0.63) and grade 1 (0.60)., Conclusions: The distribution of Soong grades was significantly different when using XR versus CT ( P < .001)., Level of Evidence: Oxford Centre for Evidence-Based Medicine, diagnostic, level 2b., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: R.E.C., Y.A.J.H., R.G., and J.C.M. have nothing to disclose. A.R.B. is a consultant for Synthes/TriMed. J.B.J., A.G., and A.F.D. are affiliated with the ICUC Library. A.F.D. has a royal agreement with DePuy Synthes. J.B.J. is a consultant at the Arbeitsgemeinschaft für Osteosynthesefragen (AO) Foundation and TriMed, and he also provides research support to the AO Foundation, Materialize Textbook, and Elsevier.

Background: Facial filler is an effective nonsurgical treatment option for improving facial symmetry in patients with facial paralysis (FP). Objective: To compare the effects of filler among patients with FP that is self-perceived as major or minor asymmetry, by measuring psychosocial distress. Methods: In this prospective cohort study of patients with FP undergoing filler at a tertiary academic center, patients were classified as having minor or major self-perceived asymmetry using a visual analog scale (VAS). FACE-Q Appearance-Related Psychosocial Distress was administered before and after filler. Descriptive statistics and a random-effects generalized linear model assessed the relationship between perceived facial asymmetry and change in psychosocial distress. Results: A total of 28 patients participated. Twenty-five (89%) patients were female with median age of 54 (interquartile range [IQR]: 49-66). Median VAS score was 2 (IQR: 1-3.5, 0 = completely asymmetric, 10 = no asymmetry). Psychosocial distress improved in all patients after filler. In multivariable modeling, patients with major asymmetry experienced 2.45 (confidence interval: 0.46-4.44, p  = 0.016) points more improvement in psychosocial distress than patients with minor asymmetry. Age, gender, and FP duration were not associated with change in psychosocial distress. Conclusion: Facial filler treatment was seen to improve psychosocial distress in patients with FP, especially by those with more self-perceived deficit.

Background: Patients seeking cosmetic abdominoplasty often have umbilical hernias. Optimal management and safety of concomitant umbilical hernia repair with abdominoplasty is not well described., Objectives: The goal of this study was to compare complication rates following abdominoplasty with or without umbilical hernia repair., Methods: A retrospective propensity score matched cohort study of patients who underwent an abdominoplasty at Massachusetts General Hospital was performed. Direct umbilical hernia repair was performed by making a fascial slit inferior or superior to the umbilical stalk. The fascial edges were approximated with up to three 0-Ethibond sutures (Ethicon, Raritan, NJ) from the preperitoneal or peritoneal space. Propensity score matching was used to adjust for confounding variables., Results: The authors identified 231 patients with a mean [standard deviation] age of 46.7 [9.7] years and a mean BMI of 25.9 [4.4] kg/m2. Nine (3.9%) had diabetes, 8 (3.5%) were active smokers, and the median number of previous pregnancies was 2. In total, 223 (96%) had a traditional abdominoplasty, whereas 8 (3.5%) underwent a fleur-de-lys approach. Liposuction was performed on 90%, and 45.4% underwent simultaneous breast or body contouring surgery. The overall complication rate was 6.9%. Propensity scores matched 61 pairs in each group (n = 122) with closely aligned covariates. There was no significant difference in total complication rates between abdominoplasty alone vs abdominoplasty with hernia repair. There were no cases of skin necrosis or umbilical necrosis in either group., Conclusions: Performing umbilical hernia repair with abdominoplasty is safe when utilizing the technique reported in this series., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Meloidogyne enterolobii [the guava root-knot nematode (RKN)] is an emerging plant-parasitic nematode that poses a threat to Upland cotton ( Gossypium hirsutum ) production in the southeastern United States. Like other RKN spp., M. enterolobii has a wide host range and proven ability to overcome resistance sources that have helped protect crops from other Meloidogyne spp., including the southern RKN ( Meloidogyne incognita ). In this study we evaluated the virulence of two North Carolina M. enterolobii isolates on Upland cotton germplasm lines having resistance quantitative trait loci (QTL) to RKN (M240 RNR, MRk-Rn-1) and/or reniform nematode ( Rotylenchulus reniformis ) (M713 Ren1, MRk-Rn-1) in comparison to their susceptible recurrent parents (DPL61, SG747). Multiple assays using eggs or J2 as inoculum demonstrated that both isolates reproduced equally well on all germplasm lines, producing reproductive factor (RF) values ≥ 6 on the otherwise nematode-resistant lines. Measurements of seedling growth in control and inoculated containers suggested that existing nematode-resistance QTL may offer a level of tolerance to M. enterolobii infection that should be further explored in greenhouse and field environments. Meloidogyne enterolobii infection of SG747 and MRk-Rn-1 showed nearly identical stages of symptom and nematode development over a time-course of 24 days. These data demonstrate that existing RKN and RN resistance QTL available in elite cotton varieties to producers are most likely insufficient in preventing yield loss due to M. enterolobii and that future research should focus on (i) understanding the M. enterolobii -cotton interaction at the molecular level, and (ii) screening novel germplasm collections to identify resistance loci., (© 2023 Amanda G. Gaudin et al., published by Sciendo.)

Objective: To determine demographic and socioeconomic variables associated with whether surgery is performed for patients with facial paralysis (FP). Background: Management of FP may include elective surgery dependent on patient goals of care and physician experience. Methods: The 2016 State Inpatient Database and State Ambulatory Surgery Services Database for six states were queried to identify patients with FP. These patients were then stratified based on receiving surgery for FP. Demographic and socioeconomic information was collected. Multivariable logistic regression modeling was used to identify predictors of undergoing FP surgery, as well as the hospital setting in which surgery was performed. Results: Of 20,218 patients with FP, 515 underwent surgery. Black patients were significantly less likely to undergo surgery ( p  < 0.001), as were patients with Medicaid or self-pay insurance ( p  < 0.001). Those living in rural areas were also less likely to receive surgery ( p  = 0.001). Individuals receiving surgery in the inpatient setting were more likely to have private insurance, whereas those in the ambulatory setting were more likely to have Medicare ( p  < 0.001). Conclusion: Several variables are correlated with whether FP is managed surgically, including insurance status, race, and type of residential area.

Textiles made from cotton fibers are flammable and thus often include flame retardant additives for consumer safety. Transgressive segregation in multi-parent populations facilitates new combinations of alleles of genes and can result in traits that are superior to those of any of the parents. A screen of 257 recombinant inbred lines from a multi-parent advanced generation intercross (MAGIC) population for naturally enhance flame retardance (FR) was conducted. All eleven parents, like all conventional white fiber cotton cultivars produce flammable fabric. MAGIC recombinant inbred lines (RILs) that produced fibers with significantly lower heat release capacities (HRC) as measured by microscale combustion calorimetry (MCC) were identified and the stability of the phenotypes of the outliers were confirmed when the RILs were grown at an additional location. Of the textiles fabricated from the five superior RILs, four exhibited the novel characteristic of inherent flame resistance. When exposed to open flame by standard 45° incline flammability testing, these four fabrics self-extinguished. To determine the genetic architecture of this novel trait, linkage, epistatic and multi-locus genome wide association studies (GWAS) were conducted with 473k SNPs identified by whole genome sequencing (WGS). Transcriptomes of developing fiber cells from select RILs were sequenced (RNAseq). Together, these data provide insight into the genetic mechanism of the unexpected emergence of flame-resistant cotton by transgressive segregation in a breeding program. The incorporation of this trait into global cotton germplasm by breeding has the potential to greatly reduce the costs and impacts of flame-retardant chemicals., Competing Interests: The authors have declared that no competing interests exist., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Introgression of superior fiber traits from Pima cotton (Gossypium barbadense, GB) into high yield Upland cotton (G. hirsutum) has been a breeding objective for many years in a few breeding programs in the world. However, progress has been very slow due to introgression barriers resulting from whole genome hybridization between the two species. To minimize such barriers, chromosome substitution lines (CS-B) from Pima cotton 3-79 in an Upland cotton cultivar TM-1 were developed. A multiparent advanced generation inter-cross (MAGIC) population consisting of 180 recombinant inbred lines (RILs) was subsequently made using the 18 CS-B lines and three Upland cotton cultivars as parents. In this research, we sequenced the whole genomes of the 21 parents and 180 RILs to examine the G. barbadense introgression. Of the 18 CS-B lines, 11 contained the target GB chromosome or chromosome segment, two contained more than two GB chromosomes, and five did not have the expected introgression. Residual introgression in non-target chromosomes was prevalent in all CS-B lines. A clear structure existed in the MAGIC population and the 180 RILs were distributed into three groups, i.e., high, moderate, and low GB introgression. Large blocks of GB chromosome introgression were still present in some RILs after five cycles of random-mating, an indication of recombination suppression or other unknown reasons present in the population. Identity by descent analysis revealed that the MAGIC RILs contained less introgression than expected. This research presents an insight on understanding the complex problems of introgression between cotton species., (© 2022. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Objective: To compare the same surgical procedure performed in ambulatory and inpatient settings to determine the demographics associated with this selection, the differences in 30-day revisit rates, and the total 30-day cost of care., Study Design: Retrospective cohort analysis., Setting: Ambulatory and inpatient centers in Florida, New York, and Maryland., Methods: The Healthcare Cost and Utilization Project, the State Ambulatory Surgery and Services Database, and the State Inpatient Database were used to identify patients undergoing commonly performed otolaryngologic procedures in 2016. The State Emergency Department Database and State Inpatient Database were used to identify 30-day revisits., Results: A total of 55,311 patients underwent an otolaryngologic procedure: 51,136 (92.4%) ambulatory and 4175 (7.6%) inpatient. Adjusted odds of receiving care in the ambulatory setting was significantly lower for Black patients (odds ratio, 0.69 [95% CI, 0.55-0.85]; P = .001) and nonspecified other races (odds ratio, 0.71 [95% CI, 0.52-0.95]; P = .001) as compared with White patients. Women had 1.16-higher adjusted odds of undergoing a procedure in the ambulatory setting (95% CI, 1.05-1.29; P = .005). Insurance status and income were associated with location of care in the subcategorization of head and neck surgery. Adjusted inpatient procedure costs were significantly more than ambulatory (median, $59,112 vs $14,899); 30-day adjusted costs were $71,333.07 (95% CI, $56,223.99-$86,42.15; P < .001) more expensive for inpatient procedures vs ambulatory; and the adjusted 30-day odds of revisit were 2.23 times greater (95% CI, 1.44-3.44; P < .001) for ambulatory surgery across all procedures., Conclusions: Disparities exist in the use of ambulatory settings to provide otolaryngologic surgery. Additional research is required to ensure equitable triaging of surgical care setting.

Key Message: A major QTL conferring resistance to Fusarium wilt race 4 in a narrow region of chromosome D02 was identified in a MAGIC population of 550 RILs of Upland cotton. Numerous studies have been conducted to investigate the genetic basis of Fusarium wilt (FW, caused by Fusarium oxysporum f. sp. vasinfectum, FOV) resistance using bi-parental and association mapping populations in cotton. In this study, a multi-parent advanced generation inter-cross (MAGIC) population of 550 recombinant inbred lines (RILs), together with their 11 Upland cotton (Gossypium hirsutum) parents, was used to identify QTLs for FOV race 4 (FOV4) resistance. Among the parents, Acala Ultima, M-240 RNR, and Stoneville 474 were the most resistant, while Deltapine Acala 90, Coker 315, and Stoneville 825 were the most susceptible. Twenty-two MAGIC lines were consistently resistant to FOV4. Through a genome-wide association study (GWAS) based on 473,516 polymorphic SNPs, a major FOV4 resistance QTL within a narrow region on chromosomes D02 was detected, allowing identification of 14 candidate genes. Additionally, a meta-analysis of 133 published FW resistance QTLs showed a D subgenome and individual chromosome bias and no correlation between homeologous chromosome pairs. This study represents the first GWAS study using a largest genetic population and the most comprehensive meta-analysis for FW resistance in cotton. The results illustrated that 550 lines were not enough for high resolution mapping to pinpoint a candidate gene, and experimental errors in phenotyping cotton for FW resistance further compromised the accuracy and precision in QTL localization and identification of candidate genes. This study identified FOV4-resistant parents and MAGIC lines, and the first major QTL for FOV4 resistance in Upland cotton, providing useful information for developing FOV4-resistant cultivars and further genomic studies towards identification of causal genes for FOV4 resistance in cotton., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Factor V Leiden (FVL) is the most common inherited thrombophilia in White people. Thrombotic complications resulting from free flap breast reconstruction in FVL patients have been studied to a limited degree. We evaluated whether patients heterozygous for a FVL mutation undergoing deep inferior epigastric perforator flap reconstruction had increased risk of micro- or macrovascular thrombotic complications compared with patients without a diagnosed thrombophilia., Methods: We performed a retrospective cohort study of deep inferior epigastric perforator flap reconstructions at Brigham and Women's Hospital (1/2015-12/2020) comparing patients diagnosed as FVL heterozygotes compared with matched controls without a diagnosed thrombophilia. Patients were matched using coarsened exact matching algorithm based on clinical characteristics. The primary outcomes were micro- (return to OR for flap compromise, flap loss) and macrovascular (venous thromboembolism) complications., Results: A total of 506 patients (812 flaps) were included in this study. Eleven patients (17 flaps) were FVL heterozygotes. After matching, 10 patients (16 flaps) with FVL were matched to 55 patients (94 flaps). The return to OR for flap compromise was 0% in the FVL cohort compared with 5% (n = 5/94, 3/94 flaps lost, P = 1.00) in the matched controls (1.9%, n = 15/795 in unmatched controls, 0.6%, n = 5/795 loss rate). There were zero venous thromboembolism events among FVL patients compared with 2% of controls (n = 1/55)., Conclusions: FVL heterozygosity did not increase the risk of micro- or macrovascular complications in patients undergoing deep inferior epigastric perforator flap breast reconstruction. This study supports the safety of microvascular reconstruction in this group of patients when appropriate venous thromboembolism prophylaxis is given., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Objectives/hypothesis: Dermal filler (DF) is a widely used nonsurgical option for facial rejuvenation with a rapidly expanding market. Physician payments by DF industry leaders have yet to be characterized. We sought to investigate trends in physician-industry payments by DF companies over 6 years. Differences in payments based on physician specialty and time were characterized., Study Design: Database review., Methods: The Open Payments Database was queried from 2013 to 2018. Payments made by the three largest DF companies by market share to otolaryngologists, plastic surgeons, and dermatologists were analyzed. Total dollars paid, number of payments made, type of payments made, and total number of specialists paid were recorded. One-way ANOVA was used for statistical analysis., Results: Otolaryngologists, plastic surgeons, and dermatologists received average annual payments of $0.36 million, $6.3 million, and $6.6 million respectively (P < .001). An average of 330 otolaryngologists, 2,128 plastic surgeons, and 5,980 dermatologists were paid annually (P < .001). Accredited speaking arrangements, consulting fees, and royalty/licensing fees comprised the majority of dollars paid to physicians., Conclusions: Average physician payment by DF companies exceeds $12 million annually, with otolaryngologists receiving significantly less compared to plastic surgeons and dermatologists., Level of Evidence: NA Laryngoscope, 132:301-306, 2022., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Cotton (Gossypium hirsutum L.) fiber is the most important resource of natural and renewable fiber for the textile industry. However, the understanding of genetic components and their genome-wide interactions controlling fiber quality remains fragmentary. Here, we sequenced a multiple-parent advanced-generation inter-cross (MAGIC) population, consisting of 550 individuals created by inter-crossing 11 founders, and established a mosaic genome map through tracing the origin of haplotypes that share identity-by-descent (IBD). We performed two complementary GWAS methods-SNP-based GWAS (sGWAS) and IBD-based haplotype GWAS (hGWAS). A total of 25 sQTLs and 14 hQTLs related to cotton fiber quality were identified, of which 26 were novel QTLs. Two major QTLs detected by both GWAS methods were responsible for fiber strength and length. The gene Ghir&#95;D11G020400 (GhZF14) encoding the MATE efflux family protein was identified as a novel candidate gene for fiber length. Beyond the additive QTLs, we detected prevalent epistatic interactions that contributed to the genetics of fiber quality, pinpointing another layer for trait variance. This study provides new targets for future molecular design breeding of superior fiber quality., (© 2022. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Objective: Assess outcomes in survivors of firearm injuries after 6 to 12 months and compared them with a similarly injured trauma population., Background: For every individual in the United States who died of a firearm injury in 2017, three survived, living with the burden of their injury. Current firearm research largely focuses on mortality and short-term health outcomes, while neglecting the long-term consequences., Methods: We contacted adult patients with a moderate-to-severe injury from a firearm or motor vehicle crash (MVC) treated at 3 level I trauma centers in Boston between 2015 and 2018. Patients were contacted 6 to 12 months postinjury to measure: presence of daily pain; screening for post-traumatic stress disorder (PTSD); new functional limitations; return to work; and physical and mental health-related quality of life. We matched each firearm injury patient to MVC patients using Coarsened Exact Matching. Adjusted Generalized Linear Models were used to compare matched patients., Results: Of 177 eligible firearm injury survivors, 100 were successfully contacted and 63 completed the study. Among them, 67.7% reported daily pain, 53.2% screened positive for PTSD, 38.7% reported a new functional limitation in an activity of daily living, and 59.1% have not returned to work. Compared with population norms, overall physical and mental health-related quality of life was significantly reduced among firearm injury survivors. Compared with matched MVC survivors (n = 255), firearm injury survivors were significantly more likely to have daily pain [adjusted odds ratio (OR) 2.30, 95% confidence interval (CI) 1.08-4.87], to screen positive for PTSD (adjusted OR 3.06, 95% CI 1.42-6.58), and had significantly worse physical and mental health-related quality of life., Conclusions: This study highlights the need for targeted long-term follow-up care, physical rehabilitation, mental health screening, and interventions for survivors of firearm violence., Competing Interests: Disclosure: The authors have no conflicts of interest to disclose,, (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To evaluate opioid prescribing patterns among American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) members in the Medicare population. Methods: Retrospective cohort study of AAFPRS members in the Medicare Part D Prescriber dataset. Results: From 2014 to 2016, there was a significant decrease in the number of days of opioids supplied per beneficiary (5.9 vs. 4.9 days, p  < 0.005), as well as the opioid prescription cost per beneficiary ($14.52 vs. $11.79, p  = 0.005). The highest prescription rate was found in the Midwest (20.5%) and lowest in the Northeast (14.0%), however, the difference between geographic regions was not significant ( p  = 0.11). There was a significant decrease in the number of total opioid days supplied per beneficiary in the South ( p  = 0.001), Midwest ( p  = 0.05), and West regions ( p  < 0.001). There was no significant difference in opioid prescription rate ( p  = 0.89) or total opioid days supplied per beneficiary ( p  = 0.26) when states were stratified by age-adjusted opioid-specific death rate. Conclusion: This study demonstrates a national trend toward fewer opioid days supplied and less opioid cost per Medicare beneficiary among AAFPRS members between 2014 and 2016.

Background: Facial trauma can have long-lasting consequences on an individual's physical, mental, and social well-being. The authors sought to assess the long-term outcomes of patients with facial injuries., Methods: This is a prospective multicenter cohort study of patients with face abbreviated injury scores ≥1 within the Functional Outcomes and Recovery after Trauma Emergencies registry. The Functional Outcomes and Recovery after Trauma Emergencies registry collects patient-reported outcomes data for patients with moderate-severe trauma 6 to 12 months after injury. Outcomes variables included general and trauma-specific quality of life, functional limitations, screening for post-traumatic stress disorder, and postdischarge healthcare utilization., Results: A total of 188 patients with facial trauma were included: 69.1% had an isolated face and/or head injury and 30.9% had a face and/or head injuries as a part of polytrauma injury. After discharge, 11.7% of patients visited the emergency room, and 13.3% were re-admitted to the hospital. Additionally, 36% of patients suffered from functional limitations and 17% of patients developed post-traumatic stress disorder. A total of 34.3% patients reported that their injury scars bothered them, and 49.4% reported that their injuries were hard to deal with emotionally., Conclusions: Patients who sustain facial trauma suffer significant long-term health-related quality of life consequences stemming from their injuries., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Objective: Sleep medicine is a multidisciplinary field that includes otolaryngology. After 2011, sleep medicine board eligibility required completion of a dedicated sleep medicine fellowship. The objective of our study is to describe the characteristics and geographic distribution of the dual board-certified sleep otolaryngology workforce and to assess the impact of the 2011 change., Methods: A cross-sectional analysis of sleep-certified otolaryngologists registered with the American Board of Otolaryngology-Head and Neck Surgery in 2019 was performed to characterize the sleep otolaryngology workforce. County and regional analysis of provider density was conducted by comparing provider characteristics with county-level data from the United States Census Bureau., Results: There were 275 active dual board-certified sleep otolaryngologists, or approximately 1 for every 1.12 million Americans. 77.8% were in private practice and 2.9% had American Society of Pediatric Otolaryngology membership. Eighty-eight percent were male, with females more likely than males to be in an academic setting (36.4% for females compared to 20.2% for males; P = .045). The South Atlantic and South Central regions had the highest number of sleep board-certified otolaryngologists per capita. Before 2011, an average of 75.7 otolaryngologists took the sleep board exam per 2-year cycle, compared to 14.3 otolaryngologists after 2011 (P = .029)., Conclusion: There are few dual board-certified sleep otolaryngologists across the country, which may affect care for patients with sleep-disordered breathing. Increased resident exposure and otolaryngology training in sleep medicine can strengthen the otolaryngology contribution to the multidisciplinary care of these patients., Level of Evidence: 4 Laryngoscope, 131:E2712-E2717, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Large disparities in access to neurosurgical care are known, but there are limited data on whether geographic distribution of the neurosurgery workforce potentially plays a role in these disparities. The goal of this study was to identify the geographic distribution of neurosurgeons in the United States and to study the association of the per capita workforce distribution with socioeconomic characteristics of the population., Methods: The number of practicing neurosurgeons in the United States in 2016 was obtained from the 2017-2018 American Medical Association Masterfile contained within the Area Health Resource File. The association of the number of neurosurgeons per 100,000 population with socioeconomic characteristics was assessed through linear regression analysis at Hospital Referral Region (HRR) level., Results: The median number of neurosurgeons per capita across all HRRs was 1.47 neurosurgeons per 100,000 population (interquartile range, 1.02-2.27). Bivariable analysis showed that greater supply of neurosurgeons was positively associated with regional levels of college education, median income, and median age. The number of neurosurgeons per capita at the HRR level was negatively associated with unemployment, poverty, and percent uninsured., Conclusions: Regions characterized by low socioeconomic status have fewer neurosurgeons per capita in the United States. Low income, low number of college graduates, and high unemployment rate are associated with fewer numbers of neurosurgeons per capita. Further research is needed to determine if these geographic workforce disparities contribute to poor access to quality neurosurgical care., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Gender-affirming surgery may be pursued by individuals experiencing gender dysphoria. Although genital and chest procedures are classified as medically necessary, facial feminization surgeries (FFSs) are often considered cosmetic. Insurance companies may limit coverage of these procedures, especially in states less supportive of transgender individuals. Objectives: To determine insurance coverage and ease of finding policy information for FFSs, and to analyze differences based on state advocacy. Methods: Insurance policies for the top three commercial health plans per state were reviewed. Coverage status was determined by web-based search and telephone interviews. Ease of gathering policy information was assessed using a post-task questionnaire graded on a 7-point Likert scale, with higher numbers (e.g., 7) representing relative ease. State advocacy was determined by the number of state laws and policies affecting the transgender community. Results: Of the 150 insurance policies, only 27 (18%) held favorable policies for FFS. Most favorable companies covered chondrolaryngoplasty, with 78% ( n  = 21) offering preauthorization. Mean ease of use was rated 6, with 12 companies requiring a telephone interview. Insurance policies in states with laws driving transgender equity covered more FFS procedures ( p  = 0.043), whereas those in restrictive states offered less overall coverage ( p  = 0.023). Conclusions: FFS is rarely covered by commercial insurance companies, especially in states with less legal support for transgender individuals. Policy information remains difficult to obtain, with variable coverage by employer and no standardized medical necessity criteria. Limited coverage, lack of easily accessible information, and absence of universal criteria may act as barriers to FFS.

Nutrients, including macronutrients such as Ca, P, K, and Mg, are essential for crop production and seed quality, and for human and animal nutrition and health. Macronutrient deficiencies in soil lead to poor crop nutritional qualities and a low level of macronutrients in cottonseed meal-based products, leading to malnutrition. Therefore, the discovery of novel germplasm with a high level of macronutrients or significant variability in the macronutrient content of crop seeds is critical. To our knowledge, there is no information available on the effects of chromosome or chromosome arm substitution on cottonseed macronutrient content. The objective of this study was to evaluate the effects of chromosome or chromosome arm substitution on the variability and content of the cottonseed macronutrients Ca, K, Mg, N, P, and S in chromosome substitution lines (CS). Nine chromosome substitution lines were grown in two-field experiments at two locations in 2013 in South Carolina, USA, and in 2014 in Mississippi, USA. The controls used were TM-1, the recurrent parent of the CS line, and the cultivar AM UA48. The results showed major variability in macronutrients among CS lines and between CS lines and controls. For example, in South Carolina, the mean values showed that five CS lines (CS-T02, CS-T04, CS-T08sh, CS-B02, and CS-B04) had higher Ca level in seed than controls. Ca levels in these CS lines varied from 1.88 to 2.63 g kg -1 compared with 1.81 and 1.72 g kg -1 for TM-1 and AMUA48, respectively, with CS-T04 having the highest Ca concentration. CS-M08sh exhibited the highest K concentration (14.50 g kg -1 ), an increase of 29% and 49% over TM-1 and AM UA48, respectively. Other CS lines had higher Mg, P, and S than the controls. A similar trend was found at the MS location. This research demonstrated that chromosome substitution resulted in higher seed macronutrients in some CS lines, and these CS lines with a higher content of macronutrients can be used as a genetic tool towards the identification of desired seed nutrition traits. Also, the CS lines with higher desired macronutrients can be used as parents to breed for improved nutritional quality in Upland cotton, Gossypium hirsutum L., through improvement by the interspecific introgression of desired seed nutrient traits such as Ca, K, P, S, and N. The positive and significant ( p ≤ 0.0001) correlation of P with Ca, P with Mg, S with P, and S with N will aid in understanding the relationships between nutrients to improve the fertilizer management program and maintain higher cottonseed nutrient content.

Background: Intestinal ostomy creation after trauma is selectively indicated for destructive colon and rectal injuries. However, the nationwide rates of creation of ostomies for trauma and their reversal are not known. The objective of this study was to ascertain national estimates of trauma ostomy creation and reversal., Methods: Weighted analysis of Healthcare Cost and Utilization Project Nationwide Readmissions Database 2014 to 2015 was performed. Adult trauma patients (≥16 years) with a hollow viscus injury were included. Patients with preexisting ostomies and permanent ostomies and those who died within 48 hours of admission were excluded. Rates of ostomy creation and same admission ostomy reversal were calculated. Rates of postdischarge ostomy reversal were calculated using the Kaplan-Meier estimator. Multivariable Cox proportional hazards model was used to determine factors associated with postdischarge trauma ostomy reversal., Results: A total of 22,542 patients sustained a hollow viscus injury resulting in the creation of 2,145 ostomies (9.6%). The rate of same-admission ostomy reversal was 0.7% (n = 16). At 1, 3, 6, and 9 months, the cumulative stoma reversal rates were 0%, 7.6%, 31.0%, and 43.1%, respectively. The mean ± SD time from ostomy creation to reversal was 123 ± 6.7 days for those undergoing reversal. Injury Severity Score greater than 9 was significantly associated with ostomy nonreversal after discharge (hazard ratio, 0.41; 95% confidence interval, 0.26-0.66). Age, sex, insurance status, penetrating injury, Charlson Comorbidity Index, and hospital teaching status were not significantly associated with ostomy reversal., Conclusion: The nationwide rate of ostomy creation after trauma is nearly 10%. At 6 months postinjury, only one third of patients had undergone ostomy reversal. Future study is needed to understand patient and provider-level factors associated with trauma ostomy reversal., Level of Evidence: Epidemiology, level III., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Pediatric tonsillectomy is one of the most common surgical procedures performed in the United States. The safety of ibuprofen use after surgery is debated given concern for increased bleeding. The primary objective of this study was to compare the rate of post-tonsillectomy hemorrhage requiring operative management in patients who received ibuprofen perioperatively vs. patients who did not., Methods: Retrospective cohort study of patients 0-18 years old who underwent tonsillectomy with or without adenoidectomy (T&A) with recorded inpatient medication administration data at a single tertiary care institution from 1/2005-1/2019. The association between perioperative medication administration and return to operating room (OR) for control was evaluated using multivariable logistic regression adjusted for patient demographics and operative indication. Secondary outcomes evaluated included the time to operative bleed when it occurred., Results: A total of 4098 patients with a median age of 6 years old (IQR 4-10) underwent T&A over the study period. The overall rate of post-tonsillectomy hemorrhage requiring OR was 3.37% (n = 138/4098). After adjustment for confounders, the odds of bleeding requiring OR did not differ significantly between the ibuprofen (OR 1.16, 95% CI (0.76, 1.74), 3.55%, n = 41/1,156, p = 0.47) and non-ibuprofen groups (3.30%, n = 97/2942). The median time to bleeding requiring OR was postoperative day 6.5 (IQR6-8) in the ibuprofen group and day 6 (IQR 3-8) in the non-ibuprofen group., Conclusions: No difference in post-tonsillectomy hemorrhage requiring OR was observed between patients receiving perioperative ibuprofen versus those patients not receiving this medication. Additional research is required to definitively determine a safe dose and interval for ibuprofen administration following tonsillectomy., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Identifying and linking barriers to access to head and neck cancer care, specifically provider density, to stage of diagnosis and survival outcomes is important to serve as a foundation for policy interventions., Methods: Retrospective cohort study using patients with head and neck squamous cell (HNSCC) in the Surveillance, Epidemiology, and End Results (SEER) database from 2007 to 2016 and Area Resource File. Primary outcomes included stage of presentation and cancer-specific 5-year survival and relation to provider density., Results: The initial cohort consisted of 18 342 patients with oral cavity, 21 809 oropharyngeal, 15 860 laryngeal, and 2887 patients with hypopharyngeal malignancy. Non-Hispanic Black race and being uninsured increased the odds of presenting with advanced stage HNSCC and increased hazard of death. There was no significant and consistent association identified between Health Service Areas provider density and advanced stage at diagnosis or cancer-specific 5-year mortality., Conclusions: Provider density of otolaryngologists and primary care physicians and dentists was not significantly associated with stage of presentation or cancer-specific survival for HNSCC while race and insurance status remained independent predictors for worse outcomes., (© 2020 Wiley Periodicals LLC.)

Cotton is grown in arid and semi-arid regions where abiotic stresses such as drought and salt are prevalent. There is a lack of studies that simultaneously address the genetic and genomic basis of tolerance to drought and salt stress. In this study, a multi-parent advanced generation inter-cross (MAGIC) population of 550 recombinant inbred lines (RILs) together with their 11 Upland cotton parents with a total of 473,516 polymorphic SNP markers was used to identify quantitative trait loci (QTL) for drought tolerance (DT) and salt tolerance (ST) at the seedling stage based on two replicated greenhouse tests. Transgressive segregation occurred in the MAGIC-RILs, indicating that tolerant and sensitive alleles recombined for tolerance to the abiotic stress during the intermating process for the population development. A total of 20 QTL were detected for DT including 13 and 7 QTL based on plant height (PH) and dry shoot weight (DSW), respectively; and 23 QTL were detected for ST including 12 and 11 QTL for PH and DSW, respectively. There were several chromosomes with QTL clusters for abiotic stress tolerance including four QTL on chromosome A13 and three QTL on A01 for DT, and four QTL on D08 and three QTL on A11 for ST. Nine QTL (21% of the 43 QTL) detected were in common between DT and ST, indicating a common genetic basis for DT and ST. The narrow chromosomal regions for most of the QTL detected in this study allowed identification of 53 candidate genes associated with responses to salt and drought stress and abiotic stimulus. The QTL identified for both DT and ST have significantly augmented the repertoire of QTL for abiotic stress tolerance that can be used for marker-assisted selection to develop cultivars with resilience to drought and/or salt and further genomic studies towards the identification of drought and salt tolerance genes in cotton.

Micronutrients are essential for plant growth and development, and important for human health nutrition and livestock feed. Therefore, the discovery of novel germplasm with significant variability or higher micronutrients content in crop seeds is critical. Currently, there is no information available on the effects of chromosome or chromosome arm substitution in cotton on cottonseed micronutrients. Thus, the objective of this study was to evaluate the effects of chromosome or chromosome arm substitution on the variability and levels of micronutrients B, Fe, Cu, Zn, Mn, and Ni in cottonseed from chromosome substitution (CS) cotton lines. Our hypothesis was that interspecific chromosome substitution in cotton can affect cottonseed micronutrients content, resulting in significant differences and variabilities of these nutrients among CS lines and between CS lines and the controls. Nine CS lines were grown in two-field experiments at two locations (in 2013 in South Carolina, USA; and in 2014 in Mississippi, USA). TM-1 (the recurrent parent of the CS line) and AM UA48 (cultivar) were used as control. The results showed significant variability among CS lines compared to the controls AM UA48 and TM-1. For example, in South Carolina (SC), B concentration in cottonseed ranged from 10.35 mg kg -1 in CS-M02 to 13.67 mg kg -1 in CS-T04. The concentration of Cu ranged from 4.81 mg kg -1 in CS-B08sh to 7.65 mg kg -1 in CS-T02, and CS-T02 was higher than both controls. The concentration of Fe ranged from 36.09 mg kg -1 to 56.69 mg kg -1 (an increase up to 57%), and six CS lines (CS-B02, CS-B08sh, CS-M02, CS-M04, CS-T02, and CS-T04) had higher concentration than both controls in 2013. In 2014 at the Mississippi location (MS), similar observation was found with CS lines for micronutrients content. The CS lines with higher concentrations of these micronutrients can be used as a genetic tool toward QTL identification for desired seed traits because these lines are genetically similar with TM-1, except the substituted chromosome or chromosome segment pairs from the alien species. Chromosome substitution provides an effective means for upland cotton improvement by targeted interspecific introgression, yielding CS lines that facilitate trait discovery, such as seed micronutritional qualities, due to increased isogenicity and markedly reduced complexity from epistatic interactions with non-target alien chromosomes. The positive correlation between B, Cu, and Fe at both locations, between Ni and Mn, between Zn and Cu, and between Zn and Ni at both locations signify the importance of a good agricultural and fertilizer management of these nutrients to maintain higher cottonseed nutrient content.

Importance: The Merit-Based Incentive Payment System (MIPS) for Medicare is the largest pay-for-performance program in the history of health care. Although the Centers for Medicare & Medicaid Services (CMS) launched the MIPS in 2017, the participation and performance of otolaryngologists in this program remain unclear., Objective: To characterize otolaryngologist participation and performance in the MIPS in 2017., Design, Setting, and Participants: Retrospective cross-sectional analysis of otolaryngologist participation and performance in the MIPS from January 1 through December 31, 2017, using the publicly available CMS Physician Compare 2017 eligible clinician public reporting database., Main Outcomes and Measures: The number and proportion of active otolaryngologists who participated in the MIPS in 2017 were determined. Overall 2017 MIPS payment adjustments received by participants were determined and stratified by reporting affiliation (individual, group, or alternative payment model [APM]). Payment adjustments were categorized based on overall MIPS performance scores in accordance with CMS methodology: penalty (<3 points), no payment adjustment (3 points), positive adjustment (between 3 and 70 points), or bonus for exceptional performance (≥70 points)., Results: In 2017, CMS required 6512 of 9526 (68.4%) of active otolaryngologists to participate in the MIPS. Among these otolaryngologists, 5840 (89.7%) participated; 672 (10.3%) abstained and thus incurred penalties (-4% payment adjustment). The 6512 participating otolaryngologists reported MIPS data as individuals (1990 [30.6%]), as groups (3033 [46.6%]), and through CMS-designated APMs (964 [14.8%]). The majority (4470 of 5840 [76.5%]) received bonuses (maximum payment adjustment, +1.9%) for exceptional performance, while a minority received only a positive payment adjustment (1006 of 5840 [17.2%]) or did not receive an adjustment (364 of 5840 [6.2%]). Whereas nearly all otolaryngologists reporting data via APMs (936 of 964 [97.1%]) earned bonuses for exceptional performance, fewer than 70% of otolaryngologists reporting data as individuals (1124 of 1990 [56.5%]) or groups (2050 of 3033 [67.6%]) earned such bonuses. Of note, nearly all otolaryngologists incurring penalties (658 of 672 [97.9%]) were affiliated with groups., Conclusions and Relevance: Most otolaryngologists participating in the 2017 MIPS received performance bonuses, although variation exists within the field. As CMS continues to reform the MIPS and raise performance thresholds, otolaryngologists should consider adopting measures to succeed in the era of value-based care.

Background and Aims: Current guidelines recommend consideration of endoscopic therapy (ET) when treating select stage I esophageal cancers. The proportion of esophageal cancers treated with ET compared with esophagectomy has increased over time. Overall and cancer-specific survival have not been shown to be superior with ET in prior population-based studies. We thus evaluated cancer-specific survival comparing patients treated with ET and esophagectomy., Methods: We performed a retrospective cohort study using the Surveillance, Epidemiology, and End Results database from 2004 to 2015 of patients with node-negative, superficial (T1a/T1b), esophageal cancer treated with ET or esophagectomy. Competing-risks models were used to compare cancer-specific survival. Cox proportional hazards models were used to assess overall survival. Subgroup analysis was performed comparing time periods 2004 to 2009 and 2010 to 2015., Results: Of 2133 included individuals, 772 (36.2%) underwent ET and 1361 (63.8%) underwent esophagectomy. Unadjusted 5-year survival for cancer-specific death was 87.7% (95% confidence interval [CI], 84.2-90.5) for ET and 82.4% (95% CI, 80.0- 84.5) for esophagectomy (P = .002). Within the adjusted competing-risk model, cancer-specific survival was superior in patients treated with ET compared with esophagectomy (subdistribution hazard ratio [SHR], 1.92; 95% CI, 1.35-2.74; P < .001). From 2004 to 2009, the SHR for esophagectomy was 1.68 (95% CI, 1.07-2.66; P = .024); whereas from 2010 to 2015, the SHR for esophagectomy was 2.02 (95% CI, 1.08-3.76; P = .027)., Conclusions: ET was associated with improved cancer-specific survival compared with esophagectomy in stage I esophageal cancer. This advantage was more pronounced for patients treated after 2009, potentially because of increasing clinician expertise in performing ET and patient selection., (Copyright © 2020 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: Diagnosis of traumatic brain injury (TBI), and specifically mild TBI (mTBI), is a diagnostic challenge which can delay diagnosis preventing early intervention and follow-up care. Facial fractures represent an objective surrogate marker for potential force transmission to the neural cavity. The authors' objective was to characterize the prevalence of TBI in trauma patients with isolated facial fractures stratified by injury severity., Methods: The authors performed a retrospective cross-sectional study of the National Trauma Databank (NTDB) from 2007 to 2014 assessing a total of 1,867,761 participants identified as having a TBI and 306,785(60.2%) had an isolated facial fracture using ICD-9 codes. TBI severity was subdivided using Glasgow Coma Scale into mTBI and moderate-to-severe TBI. Logistic regression assessed odds of mTBI and moderate-to-severe TBI with different isolated facial fractures adjusted for injury severity., Results: Trauma patients with isolated facial fractures of the nasal bone, mandible, malar region and maxilla, orbital floor, and alveolar and palate had a concomitant prevalence of mTBI ranging from 21.3% to 46.0% and moderate-to-severe TBI ranging from 7.3% to 18.4%. Mandibular fractures had the lowest odds of mTBI and moderate to severe TBI while alveolar and palate fractures had the highest odds of mTBI [OR3.20,95%CI (3.11-3.30)] and moderate to severe TBI [OR3.83,95%CI (3.65-4.01)]., Conclusions: Isolated facial fractures have a high prevalence of mTBI at all injury severity levels. Clinicians can use the presence of facial fractures in trauma patients to serve as clinical markers for TBI, without distracting from already existing trauma protocols and their focus on treatment of immediate life-threatening injuries raising both awareness and potential for early intervention.

Background: Surgical resection is a mainstay of colorectal cancer treatment, and prior studies have shown improved outcomes in patients undergoing surgery for colorectal cancer by colorectal surgical specialists compared with nonspecialized surgeons. Here, we examine the geographic distribution of colorectal surgeons in the United States and its relationship with sociodemographic characteristics of the served population., Methods: The Area Health Resource File from 2017 to 2018 was used to identify the number and location of colorectal surgeons practicing throughout the United States and sociodemographic characteristics at the county and hospital referral region (HRR) level. The main outcomes of interest were the density of colorectal surgeons per 100,000 population and associations with sociodemographic characteristics at the county and HRR level based on multivariable linear regression., Results: In multivariable analysis, regions with higher proportion of nonwhite individuals and college-educated individuals had significantly more colorectal surgeons per 100,000 population, whereas regions with higher proportions of uninsured individuals had significantly fewer colorectal surgeons per 100,000 population at both the county and HRR levels., Conclusions: Geographic and sociodemographic variability exists in the distribution of colorectal surgeons in the United States. Such variability may be contributing to disparities in access to specialized colorectal care., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To examine the current geographic distribution of otolaryngologists in the United States and the disparities in socioeconomic demographics at the county and hospital referral region (HRR) level., Study Design: Cross-sectional study., Setting: National cohort analysis including all otolaryngologists in the United States., Subjects and Methods: All otolaryngologists board certified by the American Board of Otolaryngology-Head and Neck Surgery in the United States in 2018 were compared with overlaid demographic data from the 2010 United States Census Bureau by county and HRR. Associations between the density of otolaryngologists per population and socioeconomic characteristics were assessed and stratified by region., Results: The average number of otolaryngologists was 3.6 (SD 9.6) per 100,000. On multivariable regression analysis, the density of otolaryngologists was positively associated with counties with the highest quartile of college education (1.8 providers per 100,000 [95% confidence interval [CI] 0.89, 2.90], P < .001) and income (2.1 providers per 100,000 [95% CI 1.03, 3.07], P = .01). Significant regional variation existed in access to otolaryngology care., Conclusion: There are significant areas with disparate densities of otolaryngologists in the United States. Lower socioeconomic status, more severe poverty, and a lower number of college graduates in a county correlated with reduced density of otolaryngologists.

Background: Understanding the multidimensional postoperative patient experience after rhinoplasty is critical for preoperative counseling and postoperative management. Methods: A prospective clinical study was conducted from June to December 2019 for 60 patients undergoing cosmetic and/or functional rhinoplasty by two facial plastic surgeons. All patients were administered the brief pain inventory, a clinically validated pain instrument, including multiple quality of life (QOL) domains, survey at postoperative days (PODs) 1, 2, 3, and 8. Nasal Obstruction Symptom Evaluation (NOSE) scores were used to predict patients having greatest QOL disturbance. Primary outcomes were postoperative QOL domains, pain scores, and oxycodone usage. Statistical analysis was performed using STATA 14.0 (STATA Corp., College Station, TX). Preoperative NOSE and postoperative Euro Quality of Life 5-Dimension scores were also recorded. Results: Patients showed greatest disruption to QOL in the first 3 PODs and essentially returned to normal levels by POD8, which mirrored trends in pain and opioid usage. All tested QOL domains (general activity, sleep, work, mood, enjoyment, and relationships) were strongly correlated with overall pain. NOSE scores were not significantly associated with pain or QOL impairment. Conclusions: This is the first study to prospectively evaluate the rhinoplasty patient's postoperative experience using a pain instrument, including multiple QOL domains. Utilizing a validated clinical instrument allows for standardized comparison of postrhinoplasty pain and QOL disruption with other surgical procedures and disease processes. These data may help guide preoperative counseling and set accurate patient expectations for the postoperative period.

Cotton ( Gossypium hirsutum ) resistance to root-knot nematode (RKN) ( Meloidogyne incognita ) is controlled by quantitative trait loci (QTLs) on chromosomes 11 (CHR11) and 14 (CHR14). The individual contributions of these QTLs to resistance are not completely understood. We developed near isogenic lines susceptible at both loci (null), having CHR11 or CHR14 alone, and having both QTLs (CHR11/CHR14). RKN reproduction, postinfection development, egg mass formation, and adult female fecundity were evaluated. Total RKN reproduction was reduced more in CHR14 versus CHR11 but not as greatly as in CHR11/CHR14. Second-stage juvenile (J2) development to the J3 and J4 (J3+J4) life stages was delayed in CHR11, whereas the J2 transition to J3+J4 in CHR14 followed a similar track as in null plants. Development of J3+J4 nematodes to adult females was inhibited in CHR14 at 21 days after inoculation (DAI). Adult female numbers were decreased in CHR11 and CHR14 at 21 and 28 DAI, with CHR11/CHR14 showing an even greater reduction by 28 DAI. The number of egg masses per gram of root at 21, 28, and 35 DAI formed on CHR11 and CHR14 followed a similar track as numbers of adult females. RKN adult female fecundity (eggs/egg mass) was reduced for CHR11 and CHR14 compared with the null at 21 DAI; however, CHR11 eggs/egg mass was only slightly reduced versus the null by 28 DAI. In contrast, CHR14 eggs/egg mass was like CHR11/CHR14, showing a 4-fold decrease compared with CHR11 and the null.

Objective(s): To characterize procedural trends in facial plastic and reconstructive surgery procedures in relation to the United States economy., Methods: Retrospective cohort study examining annual procedure rates were determined from the American Society of Plastic Surgeons (ASPS) National Clearinghouse of Plastic Surgery Procedural Statistics from January 1 2007 to December 30, 2017. Procedures were compared to economic activity of the United States as measured by gross domestic product (GDP) were compared using Kolmogorov-Smirnov goodness of fit testing and piecewise multivariate regression modeling., Results: Annual trends in procedural rates showed an overall decrease in the rates of rhinoplasty (284,960 to 218,924), blepharoplasty (240,660 to 209,571), and otoplasty (28,571 to 23,433) from 2007 to 2017. Total cosmetic surgery remained fairly stable, while minimally invasive cosmetic surgery increased in frequency over the study period. On piecewise regression analysis, rhinoplasty (P = .02), rhytidectomy (P = .007), invasive cosmetic surgery (P < .001) were significantly associated with GDP, whereas otoplasty (P = .98) and reconstructive surgery (P = .11) were not associated with GDP., Conclusion: Cosmetic plastic surgery procedures show a greater correlation to GDP than reconstructive procedures. Trends in plastic surgery cases over the last decade show a decreasing number of rhinoplasty, otoplasty, and blepharoplasty, with stabilization in the last few years. An increasing number of reconstructive cases are found., Level of Evidence: 4 Laryngoscope, 130:632-636, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

The use of genomic selection (GS) has stimulated a new way to utilize molecular markers in breeding for complex traits in the absence of phenotypic data. GS can potentially decrease breeding cycle by selecting the progeny in the early stages. The objective of this study was to experimentally evaluate the potential value of genomic selection in Upland cotton breeding. Six fiber quality traits were obtained in 3 years of replicated field trials in Starkville, MS. Genotyping-by-sequencing-based genotyping was performed using 550 recombinant inbred lines of the multi-parent advanced generation inter-cross population, and 6292 molecular markers were used for the GS analysis. Several methods were compared including genomic BLUP (GBLUP), ridge regression BLUP (rrBLUP), BayesB, Bayesian LASSO, and reproducing kernel hilbert spaces (RKHS). The average heritability (h 2 ) ranged from 0.38 to 0.88 for all tested traits across the 3 years evaluated. BayesB predicted the highest accuracies among the five GS methods tested. The prediction ability (PA) and prediction accuracy (PACC) varied widely across 3 years for all tested traits and the highest PA and PACC were 0.65, and 0.69, respectively, in 2010 for fiber elongation. Marker density and training population size appeared to be very important factors for PA and PACC in GS. Results indicated that BayesB-based GS method could predict genomic estimated breeding value efficiently in Upland cotton fiber quality attributes and has great potential utility in breeding by reducing cost and time.

Purpose: Alcohol withdrawal syndrome (AWS) is commonly treated in medical ICUs and typically requires high resource utilization. Dexmedetomidine for AWS has not been extensively investigated, and guidelines regarding its use are lacking. We evaluated the association between dexmedetomidine use in AWS and ICU length of stay (LOS)., Methods: We performed a multi-institutional retrospective cohort study of patients in the ICU with the primary diagnosis of AWS. ICU LOS of those treated with benzodiazepines alone vs. benzodiazepines plus dexmedetomidine was compared. Negative binomial regression was performed to test whether dexmedetomidine use was associated with increased ICU LOS after adjustment for age, gender, body mass index, and the time between hospital and ICU admission., Results: Four hundred thirty-eight patients from eight institutions were included. Patients treated with benzodiazepines plus dexmedetomidine had higher Clinical Institute Withdrawal Assessment for Alcohol scores at ICU admission, spent longer on the medical wards prior to ICU admission, and had longer unadjusted ICU LOS ( p  < 0.0001). After covariate adjustment, dexmedetomidine remained associated with longer ICU LOS (relative mean to non-dexmedetomidine group 2.14, 95% CI 1.78-2.57, p  < 0.0001)., Conclusions: Compared to benzodiazepines alone, dexmedetomidine for the treatment of AWS was associated with increased ICU LOS. These results provide evidence that dexmedetomidine may increase resource utilization., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s). 2019.)

Importance: Vessel-sealant devices (VSDs) have been popularized for use in thyroid operations; however, the association of their use with postoperative neck hematoma, a rare but potentially fatal complication, has not been well studied., Objective: To examine the association of VSDs vs conventional hemostasis (CH) in thyroid operations with the development of neck hematoma., Design, Setting, and Participants: This retrospective cohort study evaluated 10 903 patients in the Thyroid Procedure-Targeted Database of the National Surgical Quality Improvement Program from January 1, 2016, to December 31, 2017. One-to-one nearest-neighbor propensity score matching was conducted to adjust for differences in baseline covariates, including demographics, comorbidities, indications for thyroid procedure (goiter, Graves disease, malignant and benign thyroid nodule), and several other thyroid-specific characteristics, between the VSD and CH groups., Main Outcomes and Measures: The primary outcome was postoperative hematoma requiring intervention with open evacuation, return to the operating room, tracheostomy, additional observation, or extended length of stay. Secondary outcomes include recurrent laryngeal nerve injury, operative duration, and hospital length of stay., Results: One-to-one propensity score matching yielded 6522 patients (mean [SD] age, 52 [15] years; 8544 [78.4%] female) with 3261 in each exposure group such that distribution of observed baseline covariates was not different between groups of the same propensity score. Within the matched cohort, CH was associated with higher odds of neck hematoma compared with VSD (odds ratio, 2.33; 95% CI, 1.55-3.49; P < .001), with 34 (1.0%) hematomas in the VSD group and 78 (2.4%) in the CH group. On the basis of this analysis, the number needed to treat with a VSD to prevent 1 postoperative hematoma was 74. Secondary outcomes included longer length of hospital stay (incidence rate ratio, 1.29; 95% CI, 1.23-1.36; P < .001]) in the CH group compared with the VSD group but no difference in the odds of recurrent laryngeal nerve injury (odds ratio, 0.90; 95% CI, 0.73-1.11; P = .32) or operative duration (incidence rate ratio, 0.99; 95% CI, 0.96-1.01; P = .24)., Conclusions and Relevance: Use of VSDs during thyroid operations was associated with reduced odds of neck hematoma compared with CH techniques without increasing odds of nerve injury. The results suggest that postoperative neck hematoma rates after thyroid surgery may differ based on the hemostasis technique and that these differences should be considered when developing strategies for quality improvement of postoperative outcomes.

Importance: More than 500 000 laypeople in the United States have been trained in hemorrhage control, including tourniquet application, under the Stop the Bleed campaign. However, it is unclear whether after hemorrhage control training participants become proficient in a specific type of tourniquet or can also use other tourniquets effectively., Objective: To assess whether participants completing the American College of Surgeons Bleeding Control Basic (B-Con) training with Combat Application Tourniquets (CATs) can effectively apply bleeding control principles using other tourniquet types (commercial and improvised)., Design, Setting, and Participants: This nonblinded, crossover, sequential randomized clinical trial with internal control assessed a volunteer sample of laypeople who attended a B-Con course at Gillette Stadium and the Longwood Medical Area in Boston, Massachusetts, for correct application of each of 5 different tourniquet types immediately after B-Con training from April 4, 2018, to October 9, 2018. The order of application varied for each participant using randomly generated permutated blocks., Interventions: Full B-Con course, including cognitive and skill sessions, that taught bleeding care, wound pressure and packing, and CAT application., Main Outcomes and Measures: Correct tourniquet application (applied pressure of ≥250 mm Hg with a 2-minute time cap) in a simulated scenario for 3 commercial tourniquets (Special Operation Forces Tactical Tourniquet, Stretch-Wrap-and-Tuck Tourniquet, and Rapid Application Tourniquet System) and improvised tourniquet compared with correct CAT application as an internal control using 4 pairwise Bonferroni-corrected comparisons with the McNemar test., Results: A total of 102 participants (50 [49.0%] male; median [interquartile range] age, 37.5 [27.0-53.0] years) were included in the study. Participants correctly applied the CAT at a significantly higher rate (92.2%) than all other commercial tourniquet types (Special Operation Forces Tactical Tourniquet, 68.6%; Stretch-Wrap-and-Tuck Tourniquet, 11.8%; Rapid Application Tourniquet System, 11.8%) and the improvised tourniquet (32.4%) (P < .001 for each pairwise comparison). When comparing tourniquets applied correctly, all tourniquet types had higher estimated blood loss, had longer application time, and applied less pressure than the CAT., Conclusions and Relevance: The B-Con principles for correct CAT application are not fully translatable to other commercial or improvised tourniquet types. This study demonstrates a disconnect between the B-Con course and tourniquet designs available for bystander first aid, potentially stemming from the lack of consensus guidelines. These results suggest that current B-Con trainees may not be prepared to care for bleeding patients as tourniquet design evolves., Trial Registration: ClinicalTrials.gov identifier: NCT03538379.