Publications by authors named "Adrian Ong"

93 Publications

Reconstruction of the Mandibular Condyle.

Facial Plast Surg 2021 Apr 20. Epub 2021 Apr 20.

Facial Plastic Surgery Associates, Fort Worth, Texas.

The mandibular condyle is an integral structure in the temporomandibular joint (TMJ) serving not only as the hinge point for mandibular opening, but also facilitating mandibular growth and contributing to facial aesthetics. Significant compromise of the TMJ can be debilitating functionally, psychologically, and aesthetically. Reconstruction of the mandibular condyle is rarely straightforward. Multiple considerations must be accounted for when preparing for condylar reconstruction such as ensuring eradication of all chronically diseased or infected bone, proving clear oncologic margins following tumor resection, or achieving stability of the surrounding architecture in the setting of a traumatic injury. Today, there is not one single gold-standard reconstructive method or material; ongoing investigation and innovation continue to improve and transform condylar reconstruction. Herein, we review methods of condylar reconstruction focusing on autologous and alloplastic materials, surgical techniques, and recent technological advances.
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http://dx.doi.org/10.1055/s-0041-1726444DOI Listing
April 2021

Complications Secondary to Nonsurgical Rhinoplasty: A Systematic Review and Meta-analysis.

Otolaryngol Head Neck Surg 2021 Feb 16:194599820987827. Epub 2021 Feb 16.

Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, New York, USA.

Objective: The popularity of nonsurgical rhinoplasty with injectable fillers continues to rise, and it is important to understand the scope of potential adverse outcomes. The purpose of our study is to determine the prevalence and types of adverse outcomes secondary to nonsurgical rhinoplasty.

Data Sources: PubMed, Cochrane, Embase.

Review Methods: The data sources were explored using the following combination of terms: (("inject*" OR "nonsurgical" OR "augmentation" OR "filler") AND "rhinoplast*") AND ("complication" OR "adverse" OR "embol*"). Studies on human nonsurgical rhinoplasty using injectable fillers were included. A quantitative meta-analysis was performed on articles with low risk of bias.

Results: The search yielded 37 publications for review, with 23 included cohort studies and 14 case reports with 8604 patients undergoing nonsurgical rhinoplasty with reported complications. The overall rate of adverse outcome across all cohort studies was 2.52%. The most commonly reported complications were bruising (1.58%) and hematoma (0.13%). While uncommon, there are several reports of major complications including 30 episodes of vessel occlusion (0.35%), 7 reports of skin necrosis (0.08%), 8 reports of vision loss (0.09%), and 6 reports of infection (0.07%).

Conclusion: Overall, nonsurgical rhinoplasty with injectable fillers is safe with low rates of complications. However, serious complications, such as vision loss, skin necrosis, and vessel occlusion, can occur. Further studies are needed to optimize delivery of injectable fillers in the nose to decrease the rate of adverse outcomes.
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http://dx.doi.org/10.1177/0194599820987827DOI Listing
February 2021

Influence of Social Media on Facial Plastic and Reconstructive Surgeons.

Facial Plast Surg Aesthet Med 2021 Feb 5. Epub 2021 Feb 5.

Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, New York, USA.

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http://dx.doi.org/10.1089/fpsam.2020.0452DOI Listing
February 2021

Maxillofacial trauma in children: Association between age and mandibular fracture site.

Am J Otolaryngol 2021 Mar-Apr;42(2):102874. Epub 2020 Dec 29.

Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, United States; Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, United States. Electronic address:

Purpose: To describe the association between age and location of facial fractures in the pediatric population.

Materials And Methods: A retrospective analysis of the Healthcare Cost and Utilization Project (HCUP) from the 2016 Kids' Inpatient Database (KID) in children aged ≤18 years was conducted. International Statistical Classification of Diseases, 10th Revision (ICD-10) codes were used to extract facial fracture diagnoses. Logistic regression was used to evaluate and compare the contribution of various demographic factors among patients who had different types of facial fractures.

Results: A total of 5568 admitted patients were identified who sustained any type of facial bone fracture. Patients who had facial fractures were significantly more likely to be male (68.2% versus 31.8%; p<0.001) and were older with a mean age of 12.86 years (95% confidence interval [CI]: 12.72-12.99). Approximately one-third of patients with a facial fracture had a concomitant skull base or vault fracture. Maxillary fractures were seen in 30.9% of the cohort while mandibular fractures occurred in 36.9% of patients. The most common mandibular fracture site was the symphysis (N=574, 27.9% of all mandibular fractures). Condylar fractures were more common in younger children while angle fractures were more common in teenagers. Regression analysis found that age was the only significant contributor to the presence of a mandibular fracture (β=0.027, p<0.001) and race was the only significant contributor to maxillary fractures (β=-0.090, p<0.001).

Conclusions: Facial fractures increase in frequency with increasing age in children. The mandible was the most commonly fractured facial bone, with an age-related pattern in fracture location.
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http://dx.doi.org/10.1016/j.amjoto.2020.102874DOI Listing
December 2020

Flap Failure and Salvage in Head and Neck Reconstruction.

Semin Plast Surg 2020 Nov 24;34(4):314-320. Epub 2020 Dec 24.

Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas.

With advanced head and neck ablative surgery comes the challenge to find an ideal reconstructive option that will optimize functional and aesthetic outcomes. Contemporary microvascular reconstructive surgery with free tissue transfer has become the standard for complex head and neck reconstruction. With continued refinements in surgical techniques, larger surgical volumes, and technological advancements, free flap success rates have exceeded 95%. Despite these high success rates, postoperative flap loss is a feared complication requiring the surgeon to be aware of potential options for successful salvage. The purpose of this article is to review free flap failure and ways to optimize surgical salvage in the scenario of flap compromise.
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http://dx.doi.org/10.1055/s-0040-1721766DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759432PMC
November 2020

Characterization of Medical Malpractice Litigation after Rhinoplasty in the United States.

Aesthet Surg J 2020 Dec 17. Epub 2020 Dec 17.

Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States.

Background: Rhinoplasty is one of the most common operations performed with favorable results and high patient satisfaction. However, when complications occur or when the desired outcome is not achieved, patients may seek litigation on the premise that there was a violation in the standard of care. Knowledge of malpractice claims can inform rhinoplasty surgeons on how to minimize risk of future litigation as well as improve patient satisfaction.

Objectives: 1) To identify motives for seeking medical malpractice litigation after rhinoplasty; 2) To examine outcomes of malpractice litigation after rhinoplasty in the United States.

Methods: The Westlaw legal database was reviewed for all available court decisions related to malpractice after rhinoplasty. Data collected and analyzed included plaintiff gender, location, specialty of defendant(s), plaintiff allegation, and adjudicated case outcomes.

Results: Twenty-three cases were identified between 1960 and 2018, located in 12 states in the United States. Plaintiffs were 70% female. Otolaryngologists were cited in 11 cases while 12 cases involved a plastic surgeon. All cases alleged negligence. Cases involved "technical" errors (69.6%), "unsatisfactory" outcomes (39.1%), inadequate follow-up or aftercare (30.4%), issues with the informed consent process (21.7%), unexpectedly extensive surgery (8.7%), improper medication administration (4.3%), and failure to recognize symptoms (4.3%). Twenty of the 23 adjudicated cases (86.9%) were ruled in favor of the surgeon. Contributing factors in cases alleging malpractice included poor aesthetic outcome/disfigurement (60.7%), new (post-surgical) onset/persistent nasal symptoms (30.4%), postoperative pain (21.7%), orbital/ocular injury (17.4%), burns (4%), nerve damage (4%), and issues with sleep (4%).

Conclusions: Malpractice litigation after rhinoplasty favored the surgeon in the majority of the adjudicated cases reviewed. The most common reason for litigating was dissatisfaction with aesthetic outcomes. Rhinoplasty surgeons may mitigate possible litigation by developing a positive doctor-patient relationship, clearly understanding the patient's surgical expectations, obtaining detailed informed consent while maintaining frequent and caring communication with the patient.
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http://dx.doi.org/10.1093/asj/sjaa380DOI Listing
December 2020

Postoperative Management After Tracheostomy and Laryngectomy: Improving Nursing Knowledge With Bedside Posters.

OTO Open 2020 Oct-Dec;4(4):2473974X20971185. Epub 2020 Nov 2.

Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, New York, USA.

This study sought to improve nursing staff understanding regarding the differences in postoperative management between patients who have undergone tracheostomy and laryngectomy. The intervention involved a brief didactic session followed by the placement of an informative poster and anatomic diagram above the bed of tracheostomy and laryngectomy patients over a 6-month period. Data were collected before and after the didactic session and poster implementation. Of the 50 nurses surveyed, 32% believed oral ventilation is appropriate for laryngectomy patients compared to 0% of nurses after the intervention. The percentage of nursing staff reporting self-assessed clear understanding of the patient care differences between laryngectomy and tracheostomy improved after the intervention. The use of informational posters and didactic sessions significantly improves nursing staff understanding of the differences between tracheostomy and laryngectomy patients. : IV.
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http://dx.doi.org/10.1177/2473974X20971185DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7649854PMC
November 2020

Outcome of Hypotensive Trauma Patients by Time and Day of Arrival.

J Surg Res 2021 02 30;258:113-118. Epub 2020 Sep 30.

Department of Surgery, Reading Hospital, Reading, Pennsylvania; Division of Traumatology, Critical Care and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.

Background: Although most studies of trauma patients have not demonstrated a "weekend" or "night" effect on mortality, outcomes of hypotensive (systolic blood pressure <90 mm Hg) patients have not been studied. We sought to evaluate whether outcomes of hypotensive patients were associated with admission time and day.

Methods: We retrospectively analyzed patients from Pennsylvania Level 1 and Level 2 trauma centers with systolic blood pressure of <90 mm Hg over 5 y. Patients were stratified into four groups by arrival day and time: Group 1, weekday days; Group 2, weekday nights; Group 3, weekend days; and Group 4, weekend nights. Patient characteristics and outcomes were compared for the four groups. Adjusted mortality risks for Groups 2, 3, and 4 with Group 1 as the reference were determined using a generalized linear mixed effects model.

Results: After exclusions, 27 trauma centers with a total of 4937 patients were analyzed. Overall mortality was 44%. Compared with patients arriving during the day (Groups 1 and 3), those arriving at night (Groups 2 and 4) were more likely to be younger, to be male, to have lower Glasgow Coma Scale scores and blood pressures, to have penetrating injuries, and to die in the emergency room. Controlled for admission variables, odds ratios (95% confidence intervals) for Groups 2, 3, and 4 were 0.92 (0.72-1.17), 0.89 (0.65-1.23), and 0.76 (0.56-1.02), respectively, for mortality with Group 1 as reference.

Conclusions: Patients arriving in shock to Pennsylvania Level 1 and Level 2 trauma centers at night or weekends had no increased mortality risk compared with weekday daytime arrivals.
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http://dx.doi.org/10.1016/j.jss.2020.08.048DOI Listing
February 2021

Breast Hematoma: An Under-Recognized and Under-Reported Female-Specific Traumatic Injury and Its Clinical Significance.

Am Surg 2021 Jan 9;87(1):156-158. Epub 2020 Sep 9.

Department of Trauma and Critical Care, Tower Health-Reading Hospital, Reading, PA, USA.

Female-specific traumatic injury patterns have not been well researched and are potentially not well documented. Our aim was to examine the prevalence of breast hematomas (BHs) after blunt chest trauma, and to evaluate if there were risk factors associated with BH requiring intervention. A retrospective review from 2013 to 2018 was performed, identifying female patients ≥18 years sustaining blunt chest trauma. BH was defined as the presence of a collection of blood within the breast parenchyma, and clinically significant breast hematoma (CSBH) as BH requiring blood transfusion, surgical, or interventional radiology intervention. Univariate analysis was performed comparing CSBH with BH in terms of demographics, injury severity, antithrombotic agent use, and body mass index (BMI). Of 871 female patients meeting criteria, 59 (7%) had BH. Of these, 10 (17%) had CSBH (transfusion only, n = 3; angioembolization, n = 4; operation, n = 3). Compared to BH not requiring intervention, CSBH patients were older (mean age, 80 vs 69, = .006), but had similar rates of motor vehicle crashes (90% vs 78%), seatbelt use (70% vs 71%), antiplatelet use (10% vs 12%), and anticoagulant use (10% vs 6%). Median Injury Severity Scores and median BMI (34 vs 34) were similar between the groups.
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http://dx.doi.org/10.1177/0003134820943568DOI Listing
January 2021

Colorectal resection in emergency general surgery: An EAST multicenter trial.

J Trauma Acute Care Surg 2020 12;89(6):1023-1031

From the R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland Medical Center (B.O.A., L.O.M., J.K., B.B.R.), Baltimore, Maryland; Department of Surgery, Mayo Clinic (M.C.H., M.D.Z.), Rochester, Minnesota; Department of Surgery, Southside Hospital, Northwell Health (A.B.R., M.D.G.), Bay Shore, NY; Department of Surgery, UCHealth Memorial Hospital Central Trauma Center (T.J.S., H.H.), Colorado Springs, Colorado; Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital (N.K., H.M.A.K.), Boston, Massachusetts; Department of Surgery, West Virginia University Medicine (A.W., D.G.), Morgantown, West Virginia; Department of Surgery, Robert Wood Johnson University Hospital (M.S., G.P.), New Brunswick, NJ; Department of Surgery, University of Southern California (G.C., K.M.), Los Angeles, California; Department of Surgery, Marshfield Clinic (D.C.C., L.M.C.), Marshfield, Wisconsin; Department of Surgery, Northwestern Memorial Hospital (B.S., J.P.), Chicago, Illinois; Department of Surgery, Loma Linda University Medical Center (U.J.S., R.D.C.), Loma Linda, CA; Dewitt Daughtry Family Department of Surgery, Ryder Trauma Center/Jackson Memorial Hospital (G.V., D.D.Y.), Miami, Florida; Department of Surgery, Methodist Dallas Medical Center (V.A., M.S.T.) Dallas, Texas; Department of Surgery, University of Texas Southwestern Medical Center and Parkland Hospital (M.P., L.D.), Dallas, Texas; Department of Surgery, Reading Hospital (A.M., A.W.O.), West Reading, Pennsylvania; Cooper University Health Care (J.L.S.R., N.B.), Camden, NJ; Department of Surgery, University of Colorado (O.F., C.G.V.), Denver, Colorado; George Washington University (C.H., J.M.E), Washington, District of Columbia; Department of Surgery, University of California, Irvine (S.G., J.N.), Irvine, California; Department of Surgery, Tufts University (K.J., N.B), Boston, Massachusetts; and Department of Surgery, Medical City Plano (V. P., M.M.C.), Plano, Texas.

Objective: Evidence comparing stoma creation (STM) versus anastomosis after urgent or emergent colorectal resection is limited. This study examined outcomes after colorectal resection in emergency general surgery patients.

Methods: This was an Eastern Association for the Surgery of Trauma-sponsored prospective observational multicenter study of patients undergoing urgent/emergent colorectal resection. Twenty-one centers enrolled patients for 11 months. Preoperative, intraoperative, and postoperative variables were recorded. χ, Mann-Whitney U test, and multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication/mortality.

Results: A total of 439 patients were enrolled (ANST, 184; STM, 255). The median (interquartile range) age was 62 (53-71) years, and the median Charlson Comorbidity Index (CCI) was 4 (1-6). The most common indication for surgery was diverticulitis (28%). Stoma group was older (64 vs. 58 years, p < 0.001), had a higher CCI, and were more likely to be immunosuppressed. Preoperatively, STM patients were more likely to be intubated (57 vs. 15, p < 0.001), on vasopressors (61 vs. 13, p < 0.001), have pneumoperitoneum (131 vs. 41, p < 0.001) or fecal contamination (114 vs. 33, p < 0.001), and had a higher incidence of elevated lactate (149 vs. 67, p < 0.001). Overall mortality was 13%, which was higher in STM patients (18% vs. 8%, p = 0.02). Surgical complications were more common in STM patients (35% vs. 25%, p = 0.02). On multivariable analysis, management with an open abdomen, intraoperative blood transfusion, and larger hospital size were associated with development of a surgical complication, while CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion were independently associated with mortality.

Conclusion: This study highlights a tendency to perform fecal diversion in patients who are acutely ill at presentation. There is a higher morbidity and mortality rate in STM patients. Independent predictors of mortality include CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion. Following adjustment by clinical factors, method of colon management was not associated with surgical complications or mortality.

Level Of Evidence: Therapeutic study, level IV.
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http://dx.doi.org/10.1097/TA.0000000000002894DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7957828PMC
December 2020

A Rare Case of Total Rectal and Urethral Disruption After Blunt Trauma.

Am Surg 2021 Jan 1;87(1):149-151. Epub 2020 Sep 1.

Department of Trauma and Critical Care, Tower Health-Reading Hospital, Reading, PA, USA.

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http://dx.doi.org/10.1177/0003134820943548DOI Listing
January 2021

Recurrent Bleeding From a Hepatic Artery Pseudoaneurysm After Successful Transarterial Embolization.

Am Surg 2020 Aug 31:3134820943561. Epub 2020 Aug 31.

35355 Division of Acute Care and Trauma Surgery, Department of Surgery, Reading Hospital, Reading, PA, USA.

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http://dx.doi.org/10.1177/0003134820943561DOI Listing
August 2020

Hepatitis C Virus (HCV) Eradication With Interferon-Free Direct-Acting Antiviral-Based Therapy Results in KLRG1+ HCV-Specific Memory Natural Killer Cells.

J Infect Dis 2021 Apr;223(7):1183-1195

Storr Liver Centre, The Westmead Institute for Medical Research, University of Sydney, Westmead, New South Wales, Australia.

Direct acting antiviral therapies rapidly clear chronic hepatitis C virus (HCV) infection and restore natural killer (NK) cell function. We investigated NK-cell memory formation following HCV clearance by examining NK-cell phenotype and responses from control and chronic HCV patients before and after therapy following sustained virologic response at 12 weeks post therapy (SVR12). NK-cell phenotype at SVR12 differed significantly from paired pretreatment samples, with an increase in maturation markers CD16, CD57, and KLRG1. HCV patients possessed stronger cytotoxic responses against HCV-infected cells as compared to healthy controls; a response that further increased following SVR12. The antigen-specific response was mediated by KLRG1+ NK cells, as demonstrated by increased degranulation and proliferation in response to HCV antigen only. Our data suggest that KLRG1+ HCV-specific memory NK cells develop following viral infection, providing insight into their role in HCV clearance and relevance with regard to vaccine design.
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http://dx.doi.org/10.1093/infdis/jiaa492DOI Listing
April 2021

Noncontiguous Spine Injury: Is the Risk Increased in Low-Energy Falls?

Am Surg 2020 Jul 9:3134820934414. Epub 2020 Jul 9.

Division of Trauma and Acute Care Surgery, Department of Surgery, Reading Hospital, Reading, PA, USA.

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http://dx.doi.org/10.1177/0003134820934414DOI Listing
July 2020

External signs of trauma: A poor predictor of injury in found down and ground level falls.

Am J Surg 2020 11 1;220(5):1300-1303. Epub 2020 Jul 1.

Reading Trauma Center, Reading Hospital, Tower Health System, USA.

Background: The significance of external signs (EST) and signs or symptoms of trauma (SS) after ground level falls or found down (GLF/FD) is unclear. We hypothesized that EST and SS were associated with injury.

Methods: Patients with GLF/FD were retrospectively studied. SS was defined as having any EST, tenderness, or subjective complaint. Outcomes were any significant finding (SF) and Injury Severity Score (ISS) > 8. Diagnostic accuracy of EST and SS were assessed with positive and negative likelihood ratios (LR+, LR-).

Results: Of 578 patients, 66% and 95% had EST and SS respectively. For EST, LR+ and LR-were 1.14 and 0.76 (SF), and 1.21 and 0.64 (ISS>8). For SS, LR+ and LR-were 1.07 and 0.19 (SF), and 1.03 and 0.49 (ISS>8).

Conclusion: EST lacked sufficient diagnostic accuracy for SF and ISS>8. Lack of SS was reasonably accurate in ruling out SF but not ISS>8. Triage utilizing EST alone for GLF/FD is not useful.
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http://dx.doi.org/10.1016/j.amjsurg.2020.06.046DOI Listing
November 2020

Outcomes of Dog Bite Avulsion Injury Reconstruction With Urinary Bladder Matrix.

Otolaryngol Head Neck Surg 2020 Dec 9;163(6):1166-1168. Epub 2020 Jun 9.

Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.

Dog bite avulsion injuries of the head and neck are difficult to manage in pediatric patients. This study assesses the outcomes of using porcine urinary bladder extracellular matrix (UBM) for reconstruction of these complete avulsion injuries. Five male pediatric patients underwent reconstruction using UBM. Two (40%) patients underwent reconstruction of the nose; the other 3 patients underwent reconstruction of the forehead, forehead/glabella, and auricle. The average size of the avulsion defect was 7.0 ± 2.4 cm. No patient developed wound dehiscence, graft loss, or wound infection. Four (80%) patients received pulsed dye laser treatment to improve wound cosmesis. Use of UBM is a safe and effective reconstructive option after dog bite avulsion injuries of the head and neck. Given the advantages of convenient availability and avoidance of donor site morbidity, UBM can be considered for reconstruction of posttraumatic avulsion injuries or Mohs defects.
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http://dx.doi.org/10.1177/0194599820932534DOI Listing
December 2020

Impact of an Open Access Nationwide Treatment Model on Hepatitis C Virus Antiviral Drug Resistance.

Hepatol Commun 2020 Jun 6;4(6):904-915. Epub 2020 Apr 6.

Storr Liver Centre The Westmead Institute for Medical Research The University of Sydney and Westmead Hospital Sydney Australia.

Direct acting antivirals (DAAs) have revolutionized hepatitis C virus (HCV) treatment, but drug resistance could undermine proposed global elimination targets. Real-world studies are needed to inform the impact of widespread DAA treatment on antiviral resistance in the community. The prevalence and range of posttreatment resistance-associated substitutions (RASs) was determined in Australian patients with open access to DAAs through a wide range of prescribers. NS3, NS5A, and NS5B regions were amplified by polymerase chain reaction and analyzed by population sequencing. Clinically relevant RASs were identified using online databases (ReCALL and Geno2Pheno[hcv]). Of 572 samples, 60% were from genotype 3 and 27% from genotype 1a. Ninety-two percent of people failed a DAA regimen containing an NS5A inhibitor, including 10% with a pangenotype regimen. NS5A RASs were detected in 72% of people with genotype 1 and 80% with genotype 3. For genotype 1, there was a range of RASs across the NS5A region, while for genotype 3, the Y93H RAS predominated (72%). The prevalence of NS3 RASs was higher in people exposed to an NS3 inhibitor (35% vs. 3.9%;  < 0.0001). NS5B resistance was rare, with a single case of sofosbuvir resistance. Multiclass drug resistance was found in 33% of people exposed to both NS3 and NS5A inhibitors. : The high prevalence of NS5A RASs among people failing DAA therapy reinforces the importance of specific retreatment regimens, ideally guided by resistance testing. The impact of multiclass drug resistance on retreatment in people exposed to both NS3 and NS5A inhibitors needs to be assessed in real-world studies. Surveillance for increasing antiviral resistance during treatment scale-up is essential to maintain the efficacy of current DAA regimens.
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http://dx.doi.org/10.1002/hep4.1496DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7262285PMC
June 2020

Success Of An Expedited Emergency Department Triage Evaluation System For Geriatric Trauma Patients Not Meeting Trauma Activation Criteria.

Open Access Emerg Med 2019 29;11:241-247. Epub 2019 Oct 29.

Department of Emergency Medicine, Reading Hospital, Reading, PA, USA.

Background: Geriatric patients are at increased risk of injury following low-energy mechanisms and are less tolerant of injury. Current criteria for trauma team activation (TTA) often miss these injuries. We evaluated a novel triage process for an expedited Emergency Medicine Physician evaluation protocol (T3) for at-risk geriatric sub-populations not meeting trauma team activation (TTA) criteria.

Methods: Retrospective review of injured patients (≥65 years) from a Level II Trauma Center with an Injury Severity Score (ISS < 16), prior to (Pre-T3, Jan 2007-Oct 2009), and after (Post-T3, Jan 2010-Oct 2012), implementation of T3, as well as a contemporary period (CP, Jan 2013-Oct 2015). Demographics, physiologic variables, and timeliness of care were measured. Rates of ICU admission, operative procedures and lengths of stay and in-hospital mortality were compared for all periods. Logistic regression analysis determined variables independently associated with mortality.

Results: Post-T3, 49.2% of geriatric registry patients underwent T3 with a reduction in key time intervals. Median time to evaluation (42.1 mins vs 61.7 min, p<0.001), median time to CT (161.3 mins vs 212.9 mins, p<0.001) and EDLOS (364.6 mins vs 451.5 mins, p=0.023) were all reduced compared to non-expedited evaluations. There was no change in mortality after the implementation of the protocol.

Conclusion: The T3 protocol expedited patient evaluation of at-risk geriatric patients that would not otherwise meet TTA criteria. The new process met the goals of the American College of Surgeons Trauma Quality Improvement Program while conserving resources.
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http://dx.doi.org/10.2147/OAEM.S212617DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6825467PMC
October 2019

Early postoperative small bowel obstruction: A review.

Am J Surg 2020 03 8;219(3):535-539. Epub 2019 Nov 8.

Department of Surgery, Reading Hospital, West Reading, PA, 19611, United States. Electronic address:

Early postoperative small bowel obstruction (ESBO) is a challenging problem. Although it is usually amenable to non-operative management, a significant proportion of patients will require re-operation. Certain causes of ESBO and types of index procedures should prompt consideration for early re-operation. A laparoscopic approach during the index operation, certain barrier agents and closure of mesenteric defects in bariatric surgery may reduce the risk of ESBO. There is no consensus regarding an acceptable length of time for initial non-operative management of ESBO but re-operation beyond two weeks may be associated with increased complications.
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http://dx.doi.org/10.1016/j.amjsurg.2019.11.008DOI Listing
March 2020

Langerhans Cell Histiocytosis of the Skull.

Ear Nose Throat J 2021 May 26;100(4):219-221. Epub 2019 Sep 26.

Department of Otolaryngology, 12291Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA.

This is a case of a pediatric male who presented with a postauricular mass and pain. Computed tomography and magnetic resonance imaging suggested a diagnosis of Langerhans cell histiocytosis. Characteristic imaging findings and initial workup for Langerhans cell histiocytosis are described.
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http://dx.doi.org/10.1177/0145561319869605DOI Listing
May 2021

Geriatric Patients on Antithrombotic Agents Who Fall: Does Trauma Team Activation Improve Outcomes?

Am Surg 2019 Jul;85(7):721-724

Despite the incorporation of anticoagulant and antiplatelet (ACAP) drugs in our trauma triage criteria, it is unclear whether trauma team activation (TTA) impacts outcomes in geriatric patients on ACAP drugs sustaining falls. We hypothesized that TTA in this cohort was associated with improved outcomes. The hospital electronic database was queried to identify normotensive, awake patients aged ≥65 years on ACAP agent from 2014 to 2018 presenting to the emergency department after falls. The outcome was in-hospital mortality. The association between TTA and mortality was examined using logistic regression analysis and 1:1 propensity score matching analysis. In this study, 4540 patients on ACAP drugs were analyzed, with TTA occurring in 500 (11%). TTA occurred in younger but more severely injured patients with lower Glasgow Coma Score. Logistic regression revealed that TTA was not associated with mortality (odds ratio [95% confidence intervals], 2.04 [0.89-4.25]). The 1:1 propensity score analysis revealed similar mortality for the matched groups (non-TTA, 1.6% TTA, 2.2%, = 0.64). In the elderly patients on ACAP agents, the current triage criteria resulted in the appropriate use of TTA for more severely injured patients. The lack of outcome benefit suggests that ACAP drug use as a criterion for TTA should be re-evaluated.
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July 2019

Anemia at Discharge in Elderly Trauma Patients Is Not Associated with Six-Month Mortality.

Am Surg 2019 Jul;85(7):708-711

Few studies have evaluated outcomes in geriatric trauma patients discharged with anemia. Our hypothesis was that anemia at discharge was not associated with six-month mortality. A 22-month retrospective study of trauma patients ≥ 65 years was conducted from 2015 to 2016. The end point was six-month mortality. The degree of anemia at admission (admission hemoglobin [AHb]) and discharge (discharge hemoglobin [DHb]) was categorized as follows based on hemoglobin (Hb) (g/dL): I (>10), II (>9 and ≤10), III (>8 and ≤9), and IV (≤8). Univariate analysis and multivariate analysis were performed to determine the association of AHb and DHb with the end point. Nine hundred forty-nine patients were analyzed (median age, 82 years). Six-month mortality was 11 per cent. Mortality was associated with AHb by univariate analysis (I: 10% [84/831]; II: 13% [9/67]; III: 22% [7/32]; and IV: 26% [5/19]) ( = 0.003). DHb was not associated with mortality (I: 11% [65/613]; II: 12% [21/183]; III: 10% [12/116]; and IV: 18% [7/39]) ( = 0.37). Logistic regression found that AHb category IV, age, and chronic kidney disease were independently associated with the end point. In geriatric patients, the severity of anemia at admission and not at discharge predicted six-month mortality. Discharging patients with an Hb of ≤8 g/dL was not adversely associated with mortality.
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July 2019

Is clinician assessment accurate or is routine pan-body CT needed in the stable intoxicated trauma patient?

Am J Surg 2019 10 17;218(4):755-759. Epub 2019 Jul 17.

Reading Trauma Center, Reading Hospital, Tower Health System, United States.

Background: We sought to determine if clinician suspicion of injury was useful in predicting injuries found on pan-body computed tomography (PBCT) in clinically intoxicated patients.

Methods: We prospectively enrolled awake, intoxicated patients with low-energy mechanism of injury. For each of four body regions (head/face, neck, thorax and abdomen/pelvis), clinician suspicion for injury was recorded as "low index" or "more than a low index". The reference standard was the presence of any pre-defined significant finding (SF) on CT. Sensitivity, specificity, positive (LR+) and negative (LR-) likelihood ratios were calculated.

Results: Enrollment of 103 patients was completed. Sensitivity, specificity, LR+ and LR-for clinician index of suspicion were: 56%, 68%, 1.75, 0.64 (head/face), 50%, 92%, 6.18, 0.54 (neck), 10%, 96%, 2.60, 0.94 (thorax) and 67%, 93%, 9.56, 0.36 (abdomen/pelvis).

Conclusion: Clinician judgement was most useful to guide need for CT imaging in the neck and abdomen/pelvis. Routine PBCT may not be necessary.

Summary: For awake, stable intoxicated patients after falls and assaults, clinician index of suspicion was most useful to guide the need for CT imaging in the neck and abdomen/pelvis. Our findings support selective use of CT if the index of suspicion is low. Routine PBCT may not be necessary.
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http://dx.doi.org/10.1016/j.amjsurg.2019.07.010DOI Listing
October 2019

Neurotoxins.

Facial Plast Surg 2019 Jun 12;35(3):230-238. Epub 2019 Jun 12.

Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York.

Botulinum toxin is integral to the practice of facial plastic surgery. Since it was approved by the U.S. Food and Drug Administration for the temporary improvement of glabellar rhytids in 2002, botulinum toxin has achieved a growing number of off-label clinical applications. These include the management of facial rhytids, brow ptosis, excessive gingival display, masseteric hypertrophy, platysmal banding, facial nerve paralysis, hypertrophic scars, and keloids. Many forms of botulinum toxin have been developed, and their safety and efficacy have been thoroughly established. This article will review the aesthetic and functional uses of botulinum toxin as it relates to the field of facial plastic and reconstructive surgery. In addition, the authors will discuss the suggested quantity of units per injection site based on onabotulinumtoxinA.
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http://dx.doi.org/10.1055/s-0039-1688844DOI Listing
June 2019

Fall downs should not fall out: Blunt cerebrovascular injury in geriatric patients after low-energy trauma is common.

J Trauma Acute Care Surg 2019 06;86(6):1010-1014

From the Department of Surgery (E.F.), Philadelphia College of Osteopathic Medicine, Philadelphia; Department of Surgery (A.W.O., A.M., A.S., S.W., J.Z., A.M., L.C., S.C.B., R.R., S.L., F.B.F.), Division of Neurocritical Care, (W.C.M.), and the Department of Radiology (M.R.), Reading Hospital, Tower Health System, Reading, Pennsylvania.

Background: There are limited data examining the impact of screening for blunt cerebrovascular injury (BCVI) in the geriatric population sustaining falls. We hypothesize that BCVI screening in this cohort would rarely identify injuries that would change management.

Methods: A retrospective study (2012-2016) identified patients 65 years or older with Abbreviated Injury Scores for the head and neck region or face region of 1 or greater after falls of 5 ft or less. Patients who met the expanded Denver criteria for BCVI screening were included for analysis. Outcomes were change in management (defined as the initiation of medical, surgical or endovascular therapy for BCVI), stroke attributable to BCVI, in-hospital mortality and acute kidney injury. Univariate analysis was performed where appropriate. A p value less than 0.05 was considered significant.

Results: Of 997 patients, 257 (26%) met criteria for BCVI screening after exclusions. The BCVI screening occurred in 100 (39%), using computed tomographic angiography for screening in 85% of patients. Patients who were not screened (n = 157) were more likely to be on preinjury antithrombotic drugs and to have worse renal function compared with the screened group. There were 23 (23%) BCVIs diagnosed in the screened group while one (0.7%) in the nonscreened group had a delayed diagnosis of BCVI. Of the 24 patients with BCVI, 15 (63%) had a change in management, consisting of the initiation of antiplatelet therapy. Comparing the screened to the nonscreened groups, 14% versus 0.7% (p < 0.0001) had a change in management. The screened group had a higher 30-day stroke rate (7% vs. 1%, p = 0.03) but there were no differences in the stroke rate attributable to BCVI (1% vs. 0.7%, p = 0.99), mortality (6% vs. 8%, p = 0.31) or acute kidney injury (5% vs. 6%, p = 0.40).

Conclusion: In geriatric patients with low-energy falls meeting criteria for BCVI screening, BCVIs were commonly diagnosed when screened, and the majority of those with BCVI had a change in management. These findings support BCVI screening in this geriatric cohort.

Level Of Evidence: Therapeutic/care management, level IV.
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http://dx.doi.org/10.1097/TA.0000000000002241DOI Listing
June 2019

Pre-treatment antiviral resistance in Australians with chronic hepatitis C: prevalence of NS3 and NS5A resistance data in the state of New South Wales.

Antivir Ther 2019 ;24(4):281-290

Storr Liver Centre, The Westmead Institute for Medical Research, The University of Sydney and Westmead Hospital, Sydney, Australia.

Background: Direct-acting antivirals (DAAs) have revolutionized HCV treatment, but the impact of antiviral resistance at a population level is still not clear. The majority of patients who fail DAA therapy develop resistance-associated substitutions (RASs), which can impact re-treatment. There is potential for resistance prevalence to rise in the community with treatment scale up, due to transmission of resistant virus. Monitoring for increasing antiviral resistance requires a reliable baseline, yet there are few published data on the prevalence of HCV resistance in Australia. The aim of this study was to determine the prevalence of RASs among untreated Australians with HCV genotype-1a infection, to inform ongoing surveillance.

Methods: A cross-sectional study was performed at a single large university hospital pathology laboratory in Australia. Archived blood samples referred for HCV genotype testing were analysed. All patients were naive to DAAs. The prevalence of RASs in the HCV NS3 and NS5A regions was determined using Sanger based population sequencing.

Results: Of 379 samples tested, 34% contained DAA-resistant virus: 24% had resistance to NS3 protease inhibitors, 12% had NS5A inhibitor resistance and 4% of patients had resistance to both drug classes. Clinically relevant RASs conferring resistance against NS5A inhibitors ledipasvir, daclatasvir and elbasvir were detected in 5.8% of samples.

Conclusions: This is the largest study of HCV antiviral drug resistance in Australia, which differs from resistance prevalence in the USA. The results provide valuable data on the baseline prevalence of HCV resistance, which can be used in the future to monitor for increasing antiviral resistance.
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http://dx.doi.org/10.3851/IMP3317DOI Listing
June 2020

Photobiomodulation Therapy for Wound Care: A Potent, Noninvasive, Photoceutical Approach.

Adv Skin Wound Care 2019 Apr;32(4):157-167

Rodrigo Crespo Mosca, PhD, DDS, MSc • Postdoctoral Associate • Oral Biology & Biomedical Engineering • School of Dental Medicine, Engineering & Applied Sciences • University of Buffalo • Buffalo, New York Adrian A. Ong, MD • Resident Physician • Department of Otolaryngology • University of Buffalo • Buffalo, New York Omar Albasha • Dental Student • Oral Biology & Biomedical Engineering • University of Buffalo • Buffalo, New York Kathryn Bass, MD, MBA • Attending Pediatric Surgeon • Pediatric Surgery • Oshei Children's Hospital • University of Buffalo • Buffalo, New York Praveen Arany, PhD, BDS, MDS, MMSc • Assistant Professor • Oral Biology & Biomedical Engineering • School of Dental Medicine, Engineering & Applied Sciences • University of Buffalo • Buffalo, New York.

General Purpose: To provide background and examine evidence for the therapeutic application of light energy treatments for wound healing.

Target Audience: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

Learning Objectives/outcomes: After completing this continuing education activity, you should be better able to:1. Explain the basics of lasers, light-emitting diodes, and light-tissue interactions as they apply to photobiomodulation therapy.2. Summarize the results of the authors' literature review of the evidence regarding the therapeutic applications of photobiomodulation treatments for wound healing.

Abstract: To provide background and examine evidence for the therapeutic applications of light energy treatments for wound healing.A search was performed in PubMed for peer-reviewed scientific articles published in the last 5 years using the search terms "photobiomodulation therapy" and "low-level laser therapy," and these terms combined with "wound," using a "human species" filter. This search yielded 218 articles on photobiomodulation therapy or low-level laser therapy and wounds. Of these, only articles on in vivo wound care using light treatments were specifically included in this review (n = 11).The wound healing effects of low-dose laser treatments were first described over 50 years ago. Various doses ranging from 0.1 to 10 J/cm and wavelengths ranging from 405 to 1,000 nm appear to provide therapeutic benefits for a broad range of chronic wounds. A range of light energy sources from LEDs to lasers have been used and have specific advantages and limitations. There is a lack of consensus on standardized treatment parameters such as wavelengths, dose, and therapeutic outcomes in the reviewed studies, preventing direct comparison and clinical protocol recommendation. An expert opinion based on ongoing research studies and reported literature is offered.Noninvasive, economical, and multipurpose light devices are an attractive tool for wound management. However, there is an urgent need in the wound care community to develop optimal clinical protocols for use based on well-designed, rigorous clinical research studies.
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http://dx.doi.org/10.1097/01.ASW.0000553600.97572.d2DOI Listing
April 2019

Being Narrow Minded Is Not Always Bad: Focusing on Emergent Interventions in Undertriage Initiatives Improves Mortality Prediction.

Am Surg 2018 Aug;84(8):1277-1283

The American College of Surgeons Committee on Trauma defines undertriage (UT) as any major trauma patient (injury severity score ≥ 16) not undergoing treatment at the highest level of trauma team activation. This methodology does not account for many important factors that may impact outcome. We performed a retrospective review of the Pennsylvania State Trauma Registry to determine the impact of treatment interventions on mortality. Patients were stratified by triage category as follows: UT, appropriate triage, and overtriage. Multiple prehospital (PH) and ED interventions were assessed. Increased mortality was observed in all triage groups in patients requiring intervention. A logistic regression analysis was performed to assess the independent effect of individual interventions on mortality for patients triaged to partial activation or consult. PH CPR (OR 66.13 [47.07-92.93]), ED CPR (OR 16.87 [8.82-32.27]), PH or ED intubation (OR 16.68 [13.90-20.03]), PH or ED packed red blood cell transfusion (OR 1.89 [1.54-2.33]), emergent operative intervention (OR 3.58 [3.07-4.19]), ED central venous access (OR 5.04 [2.31-10.97]) were all associated with worsening mortality. The American College of Surgeons Committee on Trauma methodology overestimates mortality risk when emergent interventions are not required and underestimates risk where such interventions are necessary. Future methodologies for assessing UT should include these interventions.
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August 2018

Does Antithrombotic Drug Use Mandate Trauma Team Activation in Awake Geriatric Patients with Intracranial Hemorrhage?

Am Surg 2018 Jul;84(7):1180-1184

Antithrombotic (anticoagulant [AC] and antiplatelet [AP]) drugs have been associated with mortality in geriatric patients with intracranial hemorrhage (ICH). It is unclear whether trauma team activation (TTA) in this cohort impacts outcome. Patients ≥65 years with a Glasgow Coma Scale of ≥13 and ICH over four years were included and were divided into three groups according to type of drug: group 1, AC with or without AP; group 2, AP only and; group 3, no AC or AP. The Rotterdam score was used to characterize the severity of CT findings. The primary outcome was inhospital mortality or transition to comfort measures. The secondary outcome was need for neurosurgical intervention within 48 hours. Logistic regression analysis was performed to evaluate for predictors of each outcome. Of 419 patients, 20.5, 50.4, and 29.1 per cent belonged to groups 1, 2, and 3, respectively, with TTA occurring in 39.5, 18.0, and 32.0 per cent of the respective groups. Within each group, there were no differences for the primary and secondary outcomes whether or not TTA was triggered. TTA patients had shorter times to CT (median, 20 minutes versus 80 minutes, P < 0.0001) and to administration of reversal agents (median, 105 minutes versus 255 minutes, P < 0.0001). Age, head-Abbreviated Injury Score, and the Rotterdam score were predictors for both outcomes by multivariable analysis, whereas antithrombotic drug use and TTA were not. In awake elderly patients on antithrombotic drugs found to have ICH, TTA expedited evaluation and treatment but was not associated with mortality benefit.
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July 2018