Publications by authors named "Joseph A Ricci"

79 Publications

Risk for Venous Thromboembolism in Transgender Patients Undergoing Cross-Sex Hormone Treatment: A Systematic Review.

J Sex Med 2021 07 16;18(7):1280-1291. Epub 2021 Jun 16.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Montefiore Medical Center, Bronx, NY, USA. Electronic address:

Background: Feminizing and masculinizing hormone treatments are established components of management in transgender patients. Exogenous hormones have been associated with hemostatic effects, which are well-studied in cis-gender individuals on hormone replacement therapy (HRT). Unfortunately, comprehensive understanding of their effects on venous thromboembolism (VTE) risk in the transgender population is lacking.

Aim: This manuscript aims to identify the risk of VTE among transgender individuals undergoing cross-sex hormone therapy.

Methods: A Systematic review of the literature was performed in March 2020 for studies reporting VTE rates in transgender patients undergoing hormone treatment and rates in cis-gender patients on HRT. Data regarding demographics, hormone therapy, and VTE incidence were collected and pooled for analysis.

Outcome: The primary outcome of interest was the development of a VTE event in association with concurrent hormone administration.

Results: Overall, 22 studies were included with 11 reporting VTE rates among transgender patients, 6 in cis-female patients, and 5 in cis-male patients. Data from 9,180 transgender patients (6,068 assigned male at birth [AMAB] and 3,112 assigned female at birth [AFAB]) undergoing hormone treatment and 103,713 cis-gender patients (18,748 female and 84,965 male) undergoing HRT were pooled. The incidence of VTE was higher in AMAB patients compared to AFAB patients (42.8 vs 10.8 VTE per 10,000 patient years; P = .02). The rate of VTE incidences in AMAB patients appears similar or higher than the rate demonstrated in cis-females on HRT. VTE incidence in AFAB patients, however, is similar to the published rates in cis-males on HRT.

Clinical Implications: AMAB patients on hormone therapy have higher VTE rates than AFAB patients. AMAB and AFAB patients may have similar VTE incidence to cis-female and cis-male patients on hormone replacement therapy, respectively.

Strengths & Limitations: This is the first study to aggregate and quantify the development of VTE events in association with hormone therapy in transgender patients. It places these values in the context of rates published in more widely studied populations. It is limited by its retrospective data and heterogenic data.

Conclusion: Surgical planning regarding perioperative and postoperative VTE prophylaxis or cessation of hormone therapy should take into account each patient's Caprini risk assessment and the nature of each intervention. Kotamarti VS, Greige N, Heiman AJ, et al. Risk for Venous Thromboembolism in Transgender Patients Undergoing Cross-Sex Hormone Treatment: A Systematic Review. J Sex Med 2021;18:1280-1291.
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http://dx.doi.org/10.1016/j.jsxm.2021.04.006DOI Listing
July 2021

What's in a Name? Implicit Bias Affects Patient Perception of Surgeon Skill.

Plast Reconstr Surg 2021 Jun;147(6):948e-956e

From the Department of Surgery, Division of Plastic Surgery, Albany Medical Center; and the Department of Surgery, Division of Plastic Surgery, Montefiore Medical Center.

Background: Implicit bias is the unconscious associations and beliefs held toward specific demographic groups. Instagram is commonly used by plastic surgeons to market their practice. This study investigates whether a surgeon's name on a social media platform influences perception of their competence and their likelihood of gaining a new patient.

Methods: A mock Instagram post was created using before-and-after photographs of a breast augmentation patient. Eight different ethnicities were selected, and common female and male names were selected based on U.S. Census data for each ethnicity. Surveys using the Instagram post were distributed asking responders to evaluate the competency of the surgeon and how likely they are to become a patient of that plastic surgeon. The surgeon's name was the only variable in the survey.

Results: A total of 2965 survey responses were analyzed. The majority of responders were Caucasian (57 percent); 55 percent were men and 45 percent were women. Overall, competence and recruitment likelihood scores between surgeons of different ethnicities were not significantly different. Caucasian and Latinx responders both assigned higher competence and recruitment likelihood scores to their own respective ethnicities.

Conclusions: Implicit bias plays a role in whether or not a patient is likely to seek care from a surgeon with an ethnically identifiable name. The two most common cosmetic surgery demographic groups, Caucasians and Latinxs, were also the only two ethnic groups to display in-group favoritism. Public education should be directed toward surgeon qualifications and experience in an effort to reduce implicit bias on patient decision-making.
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http://dx.doi.org/10.1097/PRS.0000000000008171DOI Listing
June 2021

Identifying Factors Affecting Outcomes in Scalp Replantation: A Systematic Review of the Literature.

J Reconstr Microsurg 2021 May 19. Epub 2021 May 19.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Montefiore Medical Center, Bronx, New York.

Introduction:  Replantation is the ideal treatment in traumatic scalp defects to provide immediate coverage with restoration of hair-bearing skin. However, data are limited to case reports and small case series. Comprehensive analysis of techniques and outcomes is not available. Our aim was to systematically analyze the available literature to better understand management and postoperative outcomes of patients undergoing scalp replantation.

Methods:  A systematic review of the PubMed, Cochrane, and EBSCO databases was performed in October 2019. Search terms included "replantation," "replant," "revascularized," "revascularization," "avulsion," and "scalp." Only papers reporting microvascular replantation of completely avulsed scalps, including case reports, were included. Review articles, non-English language articles, articles discussing nonreplant coverage, incomplete scalp avulsions, and articles discussing delayed scalp replantation were excluded. Data extracted included demographics, percent of scalp affected, mechanism, operative technique, and postoperative outcomes. Statistical analysis was performed using Mann-Whitney U tests, Kruskal-Wallis, and chi-squared tests.

Results:  From a total of 704 initial results, 61 studies were included for analysis comprising 149 scalps. Complete survival was achieved in 54.7%, partial survival in 38.9%, and failure in 6.7%. Total ischemia time greater than 12 hours was associated with complete replant failure. Arterial anastomoses appeared to protect against complete loss. The number of venous repairs, proportion of venous-to-arterial repairs, use of vein grafts, thromboprophylaxis, or intraoperative complications did not affect outcomes. Patients required significant volumes of blood products, which was associated with partial success. Salvage rate after unplanned return to the operating room was 60.0%. Normal hair growth was achieved in all surviving native scalp tissue.

Conclusion:  Scalp replantations, while technically challenging, are the ideal treatment for scalp avulsions. Fortunately, these have high rates of success. And as a focal point of a patient's appearance, this is invaluable in restoration of a sense of normalcy.
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http://dx.doi.org/10.1055/s-0041-1729876DOI Listing
May 2021

Expanding the Utilization of Low-Dose Computed Tomography in Plastic and Reconstructive Surgery Based on Validated Practices Among Surgical Specialties.

Ann Plast Surg 2021 Mar 24. Epub 2021 Mar 24.

From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Montefiore Medical Center, Bronx, NY.

Introduction: As computed tomography (CT) usage increases, so have concerns over radiation-induced malignancy. To mitigate these risks, low-dose CT (LDCT) has emerged as a versatile alternative by other specialties, although its use in plastic surgery remains sparse. This study aimed to investigate validated uses of LDCT across surgical specialties and extrapolate these insights to expand its application for plastic surgeons.

Methods: A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using search terms "low dose CT" OR "low dose computed tomography" AND "surgery," where the name of each surgical specialty was substituted for word "surgery" and each specialty term was searched separately in combination with the 2 CT terms. Data on radiation dose, outcomes, and level of evidence were collected. Validated surgical applications were correlated with similar procedures and diagnostic tests performed routinely by plastic surgeons to extrapolate potential applications for plastic surgeons.

Results: A total of 3505 articles were identified across surgical specialties, with 27 ultimately included. Depending on the application, use of LDCT led to a 25% to 97% reduction in radiation dose and all studies reported noninferior image quality and diagnostic capability compared with standard-dose CT. Potential identified uses included the following: evaluation of soft tissue infections, preoperative and postoperative management of facial and hand fractures, flap design, 3D modeling, and surgical planning.

Discussion: Low-dose CT is a valid imaging alternative to standard-dose CT. Expanded utilization in plastic surgery should be considered to minimize the iatrogenic effects of radiation and to promote patient safety without compromising outcomes.
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http://dx.doi.org/10.1097/SAP.0000000000002815DOI Listing
March 2021

A Meta-Analysis of Traumatic Orbital Apex Syndrome and the Effectiveness of Surgical and Clinical Treatments.

J Craniofac Surg 2021 Mar 22. Epub 2021 Mar 22.

Division of Plastic Surgery, Albany Medical Center, Albany Division of Plastic and Reconstructive Surgery, Montefiore Medical Center, Bronx, NY.

Purpose: Traumatic orbital apex syndrome (TOAS) commonly occurs secondary to trauma and irreversible ischemic optic neuropathy occurs as early as 2 hours after injury. Multiple treatment options have been described, however, there is a lack of consensus regarding the optimal treatment of these patients.

Methods: A systematic review of the PubMed Database from 1970 to 2020 was conducted, using the search terms "orbital apex," "syndrome," and "traumatic" with the Boolean operators "AND" or "OR." Papers that did not describe TOAS, describe patient outcomes or treatments, and those without available full English text were excluded. Patients were clustered and compared based on treatment received with the primary outcomes of improvement in vision or ophthalmoplegia.

Results: Three hundred forty-seven papers were identified, of which 22 were included, representing 117 patients with TOAS. A total of 75.9% patients underwent decompressive surgery, 82.6% received steroids, and 72.2% received nerve growth factors. Fewer than 20% of patients were treated with antibiotics, diuretics, hormones, or hyperbaric oxygen. Overall, 51.7% of patients experienced improvement in vision and 85.2% in ophthalmoplegia at 6 months. Patients treated with surgical decompression (66.7% versus 16.7%, P < 0.01) or steroids (60.0% versus 0%; P < 0.01) were more likely to have improvement in vision than those without treatment. Nerve growth factors did not improve vision. Ophthalmoplegia did not improve with any treatment.

Conclusions: Outcomes of TOAS tend to be poor, with overall low recovery of vision, though surgical decompression or steroid treatment did suggest improved visual outcomes. Further standardized patient data is needed to elucidate the comparative effectiveness of these interventions.
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http://dx.doi.org/10.1097/SCS.0000000000007629DOI Listing
March 2021

Curtailing Unnecessary Waste Among Operating Room Personnel: Evaluating the Cost Awareness of Commonly Used Surgical Items.

Am Surg 2021 Feb 17:3134821995079. Epub 2021 Feb 17.

Division of Plastic and Reconstructive Surgery, Department of Surgery, 2013Montefiore Medical Center, Bronx, NY, USA.

Background: Operating rooms (ORs) generate 70% of hospital waste, leading to increased costs for the hospital, patient, and the environment. The lack of cost awareness among physicians has been well documented; however, there is little information on anesthesiologists or ancillary OR staff. This study aimed to evaluate the cost awareness of commonly used items at an academic medical center among OR personnel.

Methods: Anonymous surveys were distributed to OR personnel (nurses, surgical technicians (STs), nurse anesthetists, anesthesiologists, surgeons, and residents), asking for the estimated costs of ten commonly used items. These costs were then compared against actual costs to evaluate the accuracy of participants' estimates. Responders were clustered by job, highest level of education, and years of experience for comparison.

Results: 167 surveys were collected, and overall only 16.4% of estimates were accurate within 50% of actual price. No significant differences in accuracy between groups were identified overall ( = .2), but both surgical and anesthesia attendings had significantly higher rates of correct responses than their respective residents. No difference was seen in accuracy when all attendings (surgeons and anesthesiologists) were compared with either nurses or STs. Linear regression demonstrated no correlation between number of years at current position or years at institution and number of correct responses ( = .0025 and = .005, respectively).

Discussion: Addressing the knowledge deficit around item costs via global education of all OR personnel (surgeons, anesthesia providers, and ancillary staff) could be a viable pathway to reduce waste, and thus cost, for our healthcare system.
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http://dx.doi.org/10.1177/0003134821995079DOI Listing
February 2021

Pneumosinus Dilatans: A Novel Algorithm for its Classification and Management.

Authors:
Joseph A Ricci

J Craniofac Surg 2021 Jan 7;Publish Ahead of Print. Epub 2021 Jan 7.

The Division of Plastic and Reconstructive Surgery, Montefiore Medical Center, Bronx, NY.

Background: Pneumosinus dilatans (PD) is a rare condition in which one or more paranasal sinuses are pathologically hyperaerated. Patients commonly present with an aesthetic complaint, however it has been associated with several serious conditions. The etiology is largely theoretical and the management remains unstandardized, potentially leading to missed diagnoses. This article aims to establish a presumptive classification scheme and management algorithm based on a comprehensive review of the literature.

Materials And Methods: A systematic review of all available publications on the search term "Pneumosinus dilatans" was conducted in PubMed. Associated conditions were identified and clustered based on the number and anatomic location of the sinuses involved. The resultant data was used to formulate an evidence-based algorithm for the evaluation and management of PD patients.

Results: A total of 145 patients from 103 articles were included. The majority of patients were male (57.2%) with an average age of 32.6 years-old at onset. The frontal sinus was most commonly involved (62.8%) and one pathologic sinus was most common (84.6%). 51% of patients presented with an associated condition; with it least common in frontal sinus PD (29.7% cases) and most common in ethmoid sinus PD (81.5%). To date, no articles to date have proposed a management algorithm for PD based on the number or location of sinus involved.

Conclusions: A standardized evidence-based management algorithm and classification scheme for patients with PD will not only lead to the highest-quality treatment, but will also be instrumental in elucidating an etiology for this rare, and potentially serious, condition.
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http://dx.doi.org/10.1097/SCS.0000000000007432DOI Listing
January 2021

Reply: Can You Trust What You Watch? An Assessment of the Quality of Information in Aesthetic Surgery Videos on YouTube.

Plast Reconstr Surg 2020 12;146(6):824e-825e

Division of Plastic Surgery, Albany Medical Center, Albany, N.Y.

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http://dx.doi.org/10.1097/PRS.0000000000007405DOI Listing
December 2020

A Meta-Analysis of Autologous Microsurgical Breast Reconstruction and Timing of Adjuvant Radiation Therapy.

J Reconstr Microsurg 2021 May 21;37(4):336-345. Epub 2020 Sep 21.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Montefiore Medical Center, Bronx, New York.

Background:  Postmastectomy radiation therapy (PMRT) decreases loco-regional recurrence and improves survival in patients with locally advanced breast cancer. Autologous free flap reconstruction, while more durable in the setting of radiation than alloplastic reconstruction, is still susceptible to radiation-induced fibrosis, contracture, fat necrosis, volume loss, and distortion of breast shape. Options for reconstruction timing (immediate vs. delayed) have been discussed to mitigate these effects, but a clear optimum is not known.

Methods:  A systematic review of the literature was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using search terms "breast reconstruction AND (radiation OR irradiation OR radiotherapy)" were used. Inclusion criteria consisted of studies reporting complications for free flap breast reconstruction in the setting of PMRT. Patients who underwent PMRT were pooled into two groups: those who underwent immediate free flap reconstruction prior to PMRT and those who underwent delayed reconstruction after PMRT.

Results:  Out of the 23 studies, 12 focused on immediate reconstruction, seven focused on delayed reconstruction, and four studies included both groups. Overall, 729 patients underwent immediate reconstruction, while 868 underwent delayed reconstruction. Complete and partial flap loss rates were significantly higher in patients undergoing delayed reconstruction, while infection and wound-healing complication rates were higher in those undergoing immediate reconstructions. Rates of unplanned reoperations, vascular complications, hematoma/seroma, and fat necrosis did not differ significantly between the two groups. However, rates of planned revision surgeries were higher in the delayed reconstruction group.

Conclusion:  Immediate free flap breast reconstruction is associated with superior flap survival compared with delayed reconstruction. Rates of complications are largely comparable, and rates of revision surgeries are equivalent. The differences in long-term aesthetic outcomes are not, however, clearly assessed by the available literature. Even in the face of PMRT, immediate free flap breast reconstruction is an effective approach.
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http://dx.doi.org/10.1055/s-0040-1716846DOI Listing
May 2021

Thrombolytic Salvage of the Frostbitten Upper Extremity: A Systematic Review.

Hand (N Y) 2020 Sep 16:1558944720940065. Epub 2020 Sep 16.

Albany Medical Center, NY, USA.

Background: Vascular thrombosis secondary to frostbite can lead to ischemic tissue damage in severe cases. Threatened extremities may be salvaged with thrombolytics to restore perfusion; however, current data are limited to single institution case series. The authors performed a systematic review to determine the efficacy of thrombolytic therapy in treating upper extremity frostbite.

Methods: PubMed, EBSCO, and Google Scholar were queried using the keywords "thrombolytics," "frostbite," "fibrinolytics," and "tPA." Exclusion criteria were failure to delineate anatomic parts injured, failure to report number of limbs salvaged, animal studies, and non-English language publications. Thrombolytic therapy was defined as intraarterial (IA) or intravenous (IV) administration of tissue plasminogen activator (tPA), alteplase, urokinase, streptokinase, or any tPA derivative.

Results: A total of 42 studies were identified, with 13 satisfying inclusion criteria. Eight studies reported catheter-directed IA thrombolysis, four reported systemic IV administration, and 1 reported both methods. A total of 157 patients received thrombolytics. In all, 73 upper extremity digits were treated by IA route and 136 digits were treated by IV route. Overall upper extremity digit salvage rate was 59%. There was a significantly higher salvage rate in digits treated by the IA route compared to the IV route.

Conclusions: Thrombolytics, particularly when administered by the intra-arterial route, are emerging as a promising treatment of severe frostbite of the upper extremity, increasing digit salvage rates.
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http://dx.doi.org/10.1177/1558944720940065DOI Listing
September 2020

Analysis of Alternative Metrics of Research Impact: A Correlation Comparison between Altmetric Attention Scores and Traditional Bibliometrics among Plastic Surgery Research.

Plast Reconstr Surg 2020 11;146(5):664e-670e

From Albany Medical College; the Division of Plastic Surgery, Albany Medical Center; and the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center.

Background: Scholarly output has typically been measured by citation-based metrics such as the Hirsch index (h-index). The Altmetric Attention Score has emerged as a substitute to measure digital attention given to a project. This study aims to determine whether there is any correlation between h-index and the Altmetric score in the plastic surgery literature.

Methods: Article metrics (full-text views, abstract views, PDF downloads, times e-mailed, Altmetric Attention Score, times tweeted, and number of citations by posts) were extracted from articles published in Plastic and Reconstructive Surgery over a 2-year period. Author metrics, including h5-index, were also collected. Pairwise correlations were performed using Spearman's rank correlation coefficient (r).

Results: A total of 1668 articles were published, with 971 included. Altmetric Attention Scores showed strong correlation with other article metrics (r = 0.48 to 0.97; p < 0.001) but weak correlation with h5-index (r = 0.14; p < 0.001) and sum of times cited without self-citation (r = 0.14; p < 0.001). It did not correlate with total publications, average citations per item, or sum of times cited. The h5-indexes showed strong positive correlation with other author bibliometrics (r = 0.66 to 0.97; p < 0.001); moderate correlation with times e-mailed (r = 0.41; p < 0.001); weak correlation with number of citations by posts (r = 0.10; p = 0.002); and no correlation with full-text views, abstract views, PDF downloads, and times tweeted.

Conclusion: The Altmetric Attention Score and conventional senior author bibliometrics have weak positive correlation at best and appear to have distinct but complementary roles in measuring scholarly output.
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http://dx.doi.org/10.1097/PRS.0000000000007270DOI Listing
November 2020

Early Discontinuation of Breast Free Flap Monitoring: A Strategy Driven by National Data.

Plast Reconstr Surg 2020 09;146(3):258e-264e

From the Division of Plastic Surgery, Department of Surgery, Albany Medical Center; the Division of Plastic, Maxillofacial, and Oral Surgery, Duke University School of Medicine; the Department of Plastic and Reconstructive Surgery, The Johns Hopkins University; and the Division of Plastic Surgery, Rutgers Robert Wood Johnson Medical Group.

Background: Multiple single-institution studies have revealed that breast free flap compromise usually occurs within the first 48 postoperative hours. However, national studies analyzing the rates and timing of breast free flap compromise are lacking. This study aimed to fill this gap in knowledge to better guide postoperative monitoring.

Methods: All women undergoing breast free flap reconstruction from the American College of Surgeons National Surgical Quality Improvement Program 2012 to 2016 database were analyzed to determine the rates and timing of free flap take-back. Take-backs were stratified by postoperative day through the first month. Multivariable modified Poisson regression analysis was used to determine the independent predictors of free flap take-back.

Results: A total of 6792 breast free flap patients were analyzed. Multivariable analysis revealed that body mass index of 40 kg/m or higher, hypertension, American Society of Anesthesiologists class of 3 or higher, steroid use, and smoking were independent predictors of take-back (p < 0.05). Take-back occurred at the highest rate during postoperative day 1, dropped significantly by postoperative day 2 (p < 0.001), and remained consistently low after postoperative day 2 (<0.6 percent daily). The identified risk factors significantly increased the likelihood of take-back on postoperative day 1 (p < 0.05), with a trend noted on postoperative day 2 (p = 0.06). Fewer than 0.4 percent of patients (n = 27) underwent take-back on postoperative day 2 without having risk factors.

Conclusions: This is the first national study specifically analyzing rates, timing, and independent predictors of breast free flap take-back. The data support discontinuing breast free flap monitoring by the end of postoperative day 1 for patients without risk factors, given the very low rate of take-back for such patients during postoperative day 2 (≤0.4 percent).

Clinical Question/level Of Evidence: Risk, III.
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http://dx.doi.org/10.1097/PRS.0000000000007052DOI Listing
September 2020

Current Trends in Management of Marjolin's Ulcer: A Systematic Review.

J Burn Care Res 2021 Mar;42(2):144-151

Division of Plastic Surgery, Albany Medical Center.

Marjolin's ulcer (MU) is a rare, aggressive entity with frequent delay in diagnosis for a variety of regions. Although well described and classically taught in medical school, aspects of its treatment remain ill-defined and controversial. A systematic review was performed according to PRISMA guidelines to identify studies discussing patients who underwent surgical treatment of MU. A total of 31 papers, reporting on 1016 patients, were included. Burns were the most common etiology of malignant degeneration (68%), followed by trauma. The lower extremity was most affected (51%) and Squamous Cell Carcinoma (SCC) was found in 94% of cases, with the majority being well differentiated. Basal cell carcinoma and melenoma composed a minority of cases. Melanoma occurred more frequently in previously skin grafted wounds and had a higher rate of metastases than SCC. Most patients did not have associated regional or distant metastases present at diagnosis. Wide local excision (71%) was performed in most cases, unless amputation was indicated for severe disease or bone involvement. Lymphadenectomy and sentinel lymph node biopsy were variably reported, with conflicting evidence on the efficacy. Lymphadenectomy was most commonly indicated for known lymph node involvement. In cases of metastatic disease chemotherapy and radiation were used in conjunction with surgical treatment. Despite numerous articles on this topic, controversy remains in the management of MU. Early diagnosis of suspicious chronic wounds and prompt surgical intervention remains imperative to its treatment.
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http://dx.doi.org/10.1093/jbcr/iraa128DOI Listing
March 2021

High-Resolution Maxillofacial Computed Tomography Is Superior to Head Computed Tomography in Determining the Operative Management of Facial Fractures.

J Surg Res 2020 12 31;256:381-389. Epub 2020 Jul 31.

Division of Plastic and Reconstructive Surgery, Montefiore Medical Center, Bronx, New York. Electronic address:

Background: Computed tomography of the head (CTH) and maxillofacial bones (CTMF) can be performed concurrently, but CTMF is frequently ordered separately, after facial fractures identified on CTH scans. This study aims to evaluate whether obtaining additional CTMF after CTH changes operative management of patients with facial trauma.

Materials And Methods: A retrospective chart review was performed of all patients with facial trauma who presented to our level 1 trauma center between January 2009 and May 2019. CTH and CTMF were reviewed for each patient. Fracture numbers and patterns were compared to determine if CTMF provided additional information that necessitated change in management, based on predetermined criteria.

Results: A total of 1215 patients were assessed for facial trauma. Of them, 899 patients underwent both CTH and CTMF scans. CTH identified 22.7% less fractures than CTMF (P < 0.001); specifically, more orbital, nasal, naso-orbito-ethmoid, zygoma, midface, and mandible fractures (P < 0.001). Of all patients 9.2% (n = 83) of patients with nonoperative fractures on CTH were reclassified as operative on CTMF; 0.6% (n = 5) with operative patterns on CTH were reclassified as nonoperative on CTMF, and 18.1% (n = 163) experienced a changed in their operative plan though operative fractures were seen on both imaging modalities. Additional findings seen on CTMF delegated change in the operative plan in 27.9% (n = 251) of cases.

Conclusions: CTMF scans are necessary to determine operative intervention. As CTH and CTMF are constructed from the data, physicians should consider ordering both scans simultaneously for all patients with facial trauma to limit radiation exposure, control costs, and avoid delays in care.
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http://dx.doi.org/10.1016/j.jss.2020.06.060DOI Listing
December 2020

Reply: Can You Trust What You Watch? An Assessment of the Quality of Information in Aesthetic Surgery Videos on YouTube.

Plast Reconstr Surg 2020 10;146(4):513e

Division of Plastic Surgery, Albany Medical Center, Albany, N.Y.

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http://dx.doi.org/10.1097/PRS.0000000000007213DOI Listing
October 2020

Estimation of Profunda Artery Perforator Flap Weight Using Preoperative Computed Tomography Angiography.

J Reconstr Microsurg 2020 Nov 24;36(9):645-650. Epub 2020 Jun 24.

Division of Plastic and Reconstructive Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.

Background:  Given the relatively small size of thigh-based flaps and the possible necessity for a multiflap reconstruction, it is imperative to arrive at an accurate estimation of flap weight during preoperative planning. It was our objective to develop a novel technique for the preoperative estimation of profunda artery perforator (PAP) flap weight.

Methods:  All patients that underwent transverse PAP flap breast reconstruction at two institutions were retrospectively reviewed. Subcutaneous tissue thicknesses were measured on axial computed tomography angiography scans at several predetermined points. The distance from the inferior gluteal crease to the PAP was also recorded. Linear regression was used to estimate flap weight.

Results:  A total of 18 patients (32 flaps) were analyzed. The median intraoperative flap weight was 299 g (interquartile range [IQR]: 235-408). The parsimonious model (  = 0.80) estimated flap weight using the Eq. 77.9 + 33.8 + 43.4 - 254.3, where is subcutaneous tissue thickness (cm) at the lateral border of long head of the biceps femoris at a level 4.5 cm caudal to the inferior gluteal fold, is distance (cm) from the inferior gluteal fold to the dominant PAP, and has a value of 1 if the patient was scanned in the supine position or 0 if prone. The aforementioned formula yielded a median estimated flap weight of 305 g (IQR: 234-402) and a median percent error of 10.5% (IQR: 6.1-16.2).

Conclusion:  The authors demonstrate a simple and accurate formula for the preoperative estimation of transverse PAP flap weight for breast reconstruction.
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http://dx.doi.org/10.1055/s-0040-1713599DOI Listing
November 2020

Matched Comparison of Microsurgical Anastomoses Performed with Loupe Magnification versus Operating Microscope in Traumatic Lower Extremity Reconstruction.

Plast Reconstr Surg 2020 09;146(3):382e-383e

Division of Plastic and Reconstructive Surgery, Department of Surgery, Montefiore Medical Center, Bronx, N.Y.

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http://dx.doi.org/10.1097/PRS.0000000000007115DOI Listing
September 2020

Access to Breast Cancer Treatment and Reconstruction in Rural Populations: Do Women Have a Choice?

J Surg Res 2020 10 28;254:223-231. Epub 2020 May 28.

Division of Plastic and Reconstructive Surgery, Montefiore Medical Center, Bronx, New York. Electronic address:

Background: Federal law mandates complete insurance coverage for breast reconstruction and considers it an "essential" aspect of breast cancer treatment, on par with mastectomy and chemotherapy. Unfortunately, a significant proportion of women do not undergo reconstruction. The objective of this study is to assess care gaps in breast cancer treatment and reconstruction in rural populations.

Methods: All hospitals in Upstate New York were surveyed regarding what components of breast cancer care they provide, including breast surgery, medical oncology, radiation oncology, and plastic surgery. Survey results were correlated with population data to determine how many women might be impacted by geographic barriers to care.

Results: Of 135 hospitals, only 56% offered any component of breast cancer treatment, while 30% offer breast surgery, 44% offer radiation oncology, and 42% offer plastic surgery. Microsurgical breast reconstruction was offered at just 14% of hospitals. Only 11% of hospitals were complete cancer care centers, which offer all the essential elements of breast cancer care (breast surgery, reconstructive surgery, medical oncology, and radiation) and all reconstructive options (including microvascular). Based on population data, 21% of Upstate New Yorkers live in counties without access to any form of breast reconstruction, 44% live in counties without microsurgical reconstruction, 30% live in counties without a hospital that staffs all members of the cancer care team, and 47% live in counties without a complete cancer care center.

Conclusions: Geographic barriers play a large role in the lack of access to breast cancer care and reconstruction.
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http://dx.doi.org/10.1016/j.jss.2020.04.035DOI Listing
October 2020

Outcomes of Immediate Titanium Cranioplasty Following Post-Craniotomy Infection.

J Craniofac Surg 2020 Jul-Aug;31(5):1404-1407

Division of Plastic Surgery, Albany Medical Center, Albany, NY.

When craniotomy complicated by secondary infection requires debridement and craniectomy, the bony defect is typically not reconstructed immediately. Due to concerns about placing a prosthetic material in an infected field, cranioplasty has traditionally been delayed by weeks or months after craniectomy. However, surgeons have begun performing single-stage cranioplasty after craniectomy in an effort to reduce the morbidity associated with multiple procedures and reduce overall healthcare costs. The purpose of this systematic review is to analyze outcomes of immediate cranioplasty performed after bone flap debridement secondary to infection. A literature review from January 1, 1998 through January 1, 2019 was conducted, examining the data on immediate titanium cranioplasty and its complication and reoperation rates. A meta-analysis of these articles was then performed. Variables studied included incidence of infection post-cranioplasty, wound healing complications, need for unplanned reoperation, and mortality. In total, there were 40 patients who underwent immediate cranioplasty after bone flap debridement. Overall, there was a 5% rate of postoperative infection, a 12.5% rate of unplanned return to the operating room, 7.5% rate of CSF fistula or leak, a 2.5% rate of hematoma, and a 2.5% rate of mortality within the immediate post-op period. Although there are insufficient data in the literature to rigorously compare these immediate cranioplasties in a direct way with the more traditional delayed type; the outcomes of immediate cranioplasty procedures secondary to craniectomy for infection were similar to the outcomes of delayed cranioplasty after craniectomy for any reason. Given these results, immediate titanium cranioplasty should be considered in select patients.
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http://dx.doi.org/10.1097/SCS.0000000000006488DOI Listing
October 2020

Closure of Persistent Tracheocutaneous Fistulas in Pediatric Burn Patients.

J Burn Care Res 2020 Jul;41(4):887-891

Department of Surgery, The Division of Plastic Surgery, Albany Medical Center, Albany, New York.

Tracheocutaneous fistula (TCF) is a common complication that occurs after decannulation of a long-term tracheostomy. Numerous studies have demonstrated the incidence of TCF formation to positively correlate with an increasing duration of cannulation, specifically in children. Treatment of a persistent TCF in a child has been well described in the literature, with good response to local measures such as curettage and silver nitrate. When this fails, fistulectomy followed by primary closure of the skin or secondary intention yields good results. However, there is a lack of knowledge on TCF formation in pediatric burn-injured patients, where a persistent TCF is a particularly challenging problem to correct given the paucity of supple tissue in the neck and potential for contractures after a large burn injury; effectively making the surgical repairs and management algorithms described in the available literature largely not applicable to this patient population. In this manuscript, we describe a series of pediatric burn patients with persistent TCF, successfully treated with a multilayered closure involving local tissue rearrangement in the form of medial mobilization of the strap muscles of the neck.
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http://dx.doi.org/10.1093/jbcr/iraa035DOI Listing
July 2020

Can You Trust What You Watch? An Assessment of the Quality of Information in Aesthetic Surgery Videos on YouTube.

Plast Reconstr Surg 2020 Feb;145(2):329e-336e

From the Division of Plastic Surgery, Albany Medical Center; and the State University of New York, Upstate Medical University.

Background: Videos on YouTube can be posted without regulation or content oversight. Unfortunately, many patients use YouTube as a resource on aesthetic surgery, leading to misinformation. Currently, there are no objective assessments of the quality of information on YouTube about aesthetic surgery.

Methods: YouTube was queried for videos about the 12 most common aesthetic surgical procedures, identified from the 2015 American Society of Plastic Surgeons procedural statistics between May and June of 2016. The top 25 results for each search term were scored using the modified Ensuring Quality Information for Patients criteria based on video structure, content, and author identification. Average Ensuring Quality Information for Patients score, view count, and video duration were compared between authorship groups.

Results: A total of 523 videos were graded after excluding duplicates. The mean modified Ensuring Quality Information for Patients score for all videos was 13.1 (SE, 0.18) of a possible 27. The videos under the search "nose reshaping" had the lowest mean score of 10.24 (SE, 0.74), whereas "breast augmentation" had the highest score of 15.96 (SE, 0.65). Physician authorship accounted for 59 percent of included videos and had a higher mean Ensuring Quality Information for Patients score than those by patients. Only three of the 21 search terms had a mean modified Ensuring Quality Information for Patients score meeting criteria for high-quality videos.

Conclusions: The information contained in aesthetic surgery videos on YouTube is low quality. Patients should be aware that the information has the potential to be inaccurate. Plastic surgeons should be encouraged to develop high-quality videos to educate patients.
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http://dx.doi.org/10.1097/PRS.0000000000006463DOI Listing
February 2020

Postoperative Prophylactic Antibiotics Reduce Surgical Site Infection Rates after Ventral Hernia Repair: A Systematic Review.

Am Surg 2019 Nov;85(11):1228-1233

SSIs after ventral hernia repair (VHR) represent a significant complication. The impact of postoperative prophylactic antibiotics on the SSI rates after VHRs is unclear. A systematic review of PubMed and Web of Science databases from inception through March 2016 investigating the effect of postoperative prophylactic antibiotics after VHRs was performed. Strict inclusion and exclusion criteria were implemented, and the methodological quality of the included studies was assessed. After systematic independent assessment of 216 citations, four studies, involving 344 patients, met the inclusion criteria. Among the included studies, 164 patients received >24 hours of postoperative prophylactic antibiotics, whereas 180 patients were controls. The overall incidence of SSI among patients receiving postoperative antibiotics was 14.6 per cent (95% confidence interval [CI], 9.9 to 20.9) which compares favorably with the control group: 35.5 per cent (95% CI, 28.9 to 42.7) (odds ratio: 0.3, 95% CI: 0.2 to 0.5, < 0.01). Among patient's receiving postoperative antibiotics, the pooled average duration of postoperative antibiotic treatment was 6.2 ± 0.4 days. Based on the available evidence, the use of postoperative prophylactic antibiotics seems to be associated with lower SSI rates after VHRs. Future prospective randomized controlled trials should be conducted to further confirm the efficacy of this prophylactic intervention.
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November 2019

Does Anticoagulation Improve Flap Outcomes in Hypercoagulable Patients? A Systematic Review.

J Reconstr Microsurg 2020 Mar 25;36(3):204-212. Epub 2019 Nov 25.

The Division of Plastic and Reconstructive Surgery, Albany Medical Center, Albany, New York.

Background:  Despite improvements in microsurgical techniques, hypercoagulable patients remain a reconstructive challenge. Thrombophilias are a relatively common problem with potentially catastrophic results including free flap loss. The aim of this study was to assess the available literature on free tissue transfer in patients with known hypercoagulability to develop recommendations for management.

Methods:  A systematic review of the PubMed, EBSCO, and Cochrane databases was performed in June 2018. Inclusion criteria were assessment of outcomes of free tissue transfer in patients with established hypercoagulability. Exclusion criteria were review articles, case reports, and studies lacking detailed discussion of anticoagulation regimens and surgical outcomes. Data collected included the number of hypercoagulable patients, anticoagulation regimens, thrombotic complications, flap success, and bleeding complications. Statistical analysis was performed using independent samples -tests.

Results:  Of 147 total results, four articles were included for analysis. One relevant article published after search completion was included. In total, 185 free tissue transfers were performed in 155 thrombophilic patients. Anticoagulation regimens varied widely but often included intraoperative continuous heparin, with or without additional bolus, followed by postoperative and outpatient anticoagulation. Hypercoagulable patients often developed late postoperative thromboses. Of the intraoperative thromboses, 36.4% were successfully salvaged. No flaps with postoperative thrombosis were salvaged. Preemptive therapeutic anticoagulation improved outcomes but increased the bleeding risk.

Conclusion:  Free tissue transfer may be successful in hypercoagulable patients. High-risk patients identified preoperatively should receive therapeutic anticoagulation initiated intraoperatively unless contraindicated. Salvage after postoperative thrombosis is poor. Ultimately, the benefits of free tissue transfer must be considered with the potential morbidity of bleeding complications on a case-by-case basis when developing a reconstructive plan. Initiating anticoagulation based on the presence of intraoperative risk factors may prevent unnecessary intervention.
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http://dx.doi.org/10.1055/s-0039-3400531DOI Listing
March 2020

Using Google Trends to analyze patient search interest in implant-based and autologous breast reconstruction.

Breast J 2020 05 29;26(5):1093-1095. Epub 2019 Oct 29.

Division of Plastic Surgery, Albany Medical Center, Albany, NY, USA.

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http://dx.doi.org/10.1111/tbj.13675DOI Listing
May 2020

Reconstruction of Gustilo Type IIIC Injuries of the Lower Extremity.

Plast Reconstr Surg 2019 10;144(4):982-987

From the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center.

Background: Gustilo type IIIC open tibia fractures are characterized by an ischemic limb requiring immediate arterial repair. In this patient population, the decision between primary amputation and limb salvage can be challenging. This study aims to evaluate the reconstructive outcomes of patients with Gustilo type IIIC injuries.

Methods: A single-center retrospective review of 806 lower extremity free flaps from 1976 to 2016 was performed. Flap loss and salvage rates for patients with Gustilo type IIIC injuries were determined. To determine the utility of performing salvage in this group, outcomes of the IIIC reconstructions were compared to those of similar patients with Gustilo I type IIB injuries with only a single patent vessel.

Results: A total of 32 patients with Gustilo type IIIC injuries underwent reconstruction after traumatic injury. Ten patients (31.3 percent) experienced a perioperative complication, including seven unplanned returns to the operating room (21.9 percent), three partial flap losses (9.4 percent), and five complete flap losses (15.6 percent). When type IIIC injuries were compared with single-vessel Gustilo type IIIB injuries, no statistically significant differences were noted with respect to major perioperative complications (p = 0.527), unplanned return to the operating room (p = 0.06), partial flap loss (p = 0.209), complete flap loss (p = 0.596), or salvage rate (p = 0.368). Although this result was not statistically significant, Gustilo type IIIC injuries trended toward lower take-back rates and higher salvage rates compared with single-vessel Gustilo type IIIB injuries.

Conclusion: Patients with Gustilo type IIIC open tibia fractures should be considered candidates for limb salvage, as flap loss and reconstruction of these injuries are comparable to those of the routinely reconstructed single-vessel runoff type IIIB injuries.

Clinical Question/level Of Evidence: Therapeutic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000006063DOI Listing
October 2019

Diagnosis and Treatment of Scalp Arteriovenous Malformations With Intracranial Extension.

J Craniofac Surg 2019 Nov-Dec;30(8):2429-2431

Division of Plastic Surgery, Albany Medical Center, Albany, NY.

Scalp arteriovenous malformations (AVMs) are rare entities that may present as large, tortuous vascular lesions with resultant craniofacial deformity. Radiologic findings include feeding arteries and veins associated with dilated tortuous vessels. Intracranial extension is rare. A 5-year-old African American male presented with an occipital mass presumed to be a dermoid cyst on referral. Further workup revealed the presence of a scalp AVM that demonstrated extension into the left sigmoid sinus. Radiologic and intraoperative images are presented. Literature search revealed only 4 patients with scalp AVM extending intracranially into the sagittal sinus, 2 of which were managed with coagulation and division of the feeding vessels and the other 2 underwent preoperative embolization. Our patient is the 1st to be reported to have sigmoid sinus extension. Scalp AVMs with intracranial extension are rare, and require further preoperative workup. Following ultrasound evaluation, computed tomography angiography, magnetic resonance angiography, magnetic resonance imaging, or cerebral angiography can be considered. Treatment entails resection, but preoperative embolization is increasingly used, mirroring patients without intracranial extension. Further studies are needed to evaluate the efficacy and risk profile of these treatments.
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http://dx.doi.org/10.1097/SCS.0000000000005774DOI Listing
January 2020

Thrombolytic Salvage of Threatened Frostbitten Extremities and Digits: A Systematic Review.

J Burn Care Res 2019 08;40(5):541-549

Division of Plastic Surgery, Albany Medical Center, New York.

Frostbite is a cold injury that results in soft tissue loss and can lead to amputation. Vascular thrombosis following injury causes ischemic tissue damage. Despite understanding the pathology, its treatment has remained largely unchanged for over 30 years. Threatened extremities may be salvaged with thrombolytics to restore perfusion. The authors performed a systematic review to determine whether thrombolytic therapy is effective and to identify patients who may benefit from this treatment. The Pubmed, EBSCO, and Google Scholar databases were queried using the key words "thrombolytics," "frostbite," "fibrinolytics," and "tPA." Studies written after 1990 in English met inclusion criteria. Exclusion criteria were failure to delineate anatomic parts injured, failure to report number of limbs salvaged, animal studies, and non-English language publications. Thrombolytic therapy was defined as administration of tPA, alteplase, urokinase, or streptokinase. Forty-two studies were identified and 17 included. Included were 1 randomized trial, 10 retrospective studies, 2 case series, and 4 case reports. One thousand eight hundred and forty-four limbs and digits in 325 patients were studied and 216 patients treated with thrombolytics and 346 amputations performed. The most common means of thrombolysis was intra-arterial tPA. The most common duration of therapy was 48 hours. Limb salvage rates ranged from 0% to 100% with a weighted average of 78.7%. Thrombolytics are a safe and effective treatment of severe frostbite. They represent the first significant advancement in frostbite treatment by preventing otherwise inevitable amputations warranting both greater utilization and further research to clarify the ideal thrombolytic protocol.
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http://dx.doi.org/10.1093/jbcr/irz097DOI Listing
August 2019

Comparing Reconstructive Outcomes in Patients with Gustilo Type IIIB Fractures and Concomitant Arterial Injuries.

Plast Reconstr Surg 2019 05;143(5):1522-1529

From the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center.

Background: The Gustilo classification serves as a proxy for injury severity, but recent data suggest rising complications with decreasing arterial runoff. This study aims to compare different microsurgical anastomosis options based on the number of patent vessels in the lower extremity.

Methods: A single-center retrospective review of 806 lower extremity free flaps performed from 1976 to 2016 was performed. Patients with Gustilo type IIIB injuries were grouped based on the number of patent vessels in the leg (three, two, or one). Patients were compared based on the type of anastomosis performed, evaluating for perioperative complications and flap failures.

Results: Perioperative complications occurred in 111 flaps (27 percent): 71 take-backs (17 percent), 45 partial losses (11 percent), and 37 complete losses (9 percent). Among patients with three-vessel runoff (61.8 percent), there was no difference in take-backs or flap loss between those with end-to-end versus end-to-side anastomoses. In 68 patients (18.7 percent) with two-vessel runoff, no difference between take-backs or flap loss was noted when comparing any anastomosis (i.e., end-to-end into an injured vessel, end-to-end into an uninjured vessel, or end-to-side into an uninjured vessel), although vein grafts were required more often in the end-to-side groups (p < 0.01). Finally, in 39 patients (10.7 percent) with single-vessel runoff, no difference was seen between end-to-end anastomosis into an injured vessel or end-to-side anastomosis into an uninjured vessel in terms of take-backs or flap loss.

Conclusion: Higher rates of flap failure correlated with decreasing numbers of patent vessels in the leg, but neither type of microvascular anastomosis nor vessel selection demonstrated any impact on reconstructive outcomes.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000005552DOI Listing
May 2019

The impact of major league baseball on the incidence of operative hand and facial trauma at a level 1 trauma center.

Arch Plast Surg 2019 May 4;46(3):198-203. Epub 2019 Apr 4.

Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

Background: Professional affiliation between medical centers and professional sports teams can be mutually beneficial in the provision of healthcare and marketing strategy. Anecdotal evidence suggests a link between trauma volume and sporting events; however, there is limited data. This study aims to characterize the incidence of operative hand and facial trauma during professional baseball home games.

Methods: A retrospective review of surgical cases for traumatic hand or facial injuries at a level 1 center between 1999 and 2012 was performed. Demographic information including date of injury, admission status, and operative repair were collected. Patients were grouped based on whether their trauma occurred on the date of a home game.

Results: Operative hand and facial trauma occurred at a rate of 33.4 injuries per 100 days with home games, compared to 22.2 injuries per 100 days (incidence rate ratios, 1.50; 95% confidence interval, 1.34-1.69). When home games were played, patients were more likely to present as a result of motorcycle accidents (3.1% vs. 1.5%; P=0.04) or bicycle accidents (5.0% vs. 2.6%; P=0.01). Other mechanisms of trauma were not statistically different. There was an increase incidence of injuries during home games in August; weekly variability showed an increased incidence during the weekends.

Conclusions: There was an increased rate of operative hand and facial injuries on dates with professional home games. The incidence of injuries during home games was higher in the late summer and on the weekends. Further analysis may allow improved resource allocation and strategies for injury prevention and treatment.
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http://dx.doi.org/10.5999/aps.2018.00276DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6536876PMC
May 2019
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