United States

Background: Childhood obesity affects 1 in 3 children in the U.S. and is associated with a myriad of comorbidities. Executive functions (EF), including goal-directed behavior and self-management, are hypothesized to be impaired in obesity. Additionally, parental mental health issues such as depression, anxiety, and ADHD have seen a significant increase during the COVID-19 pandemic. The EF of children living with parents suffering from mental illnesses such as depression is likely to be impaired. To what degree parental mental health issues are associated with executive dysfunction (ED) in treatment seeking children with obesity is yet to be explored. The primary objective of this study was to compare the presence of ED in children with parents who have mental health diagnoses to those with parents who do not.

Methods: This was a double-blinded, cross-sectional study of 11-17 year old patients who were recruited from a multidisciplinary pediatric weight management (PWM) clinic. At initial appointments, all parents were asked about a family history of mental health diagnoses. Parents also completed the Behavior Rating Inventory of Executive Function-2 (BRIEF-2) parent form, to assess for ED in their presenting children. The scores that were analyzed from the BRIEF-2 assessments included the patients’ global executive composite (GEC), inhibit, and shift scores, which provide a global summary of all BRIEF-2 clinical scales, insight into impulsive behavior, and shifting attention between tasks, respectively. These scores were compared utilizing t-tests between the children of parents with and without mental health diagnoses.

Results: Of the 39 participants analyzed, 21 (53.8%) had one parent with a mental health diagnosis and 7 (17.9%) had both parents with a mental health diagnosis. Furthermore, 17 (43.5%) of the children had ED, 14 (35.9%) had problematic inhibit scores, and 19 (48.7%) had problematic shift scores. There were no significant differences in GEC, inhibit, and shift scores between children whose parents did and did not have mental health diagnoses, p = 0.07, 0.09, 0.08, respectively.

Conclusion: This study was underpowered to associate child ED with parental mental health diagnoses. Given that this is an interim analysis of an ongoing study, this association may be proven with a larger cohort. Of interest is that over half of our treatment seeking population had at least one parent with a mental health diagnosis, much higher than a global estimate of 15-23%. This suggests that parental mental health illnesses may be concentrated among children seeking PWM, over 70% of whom have severe obesity. Thus, further investigation is needed on how parental mental health illnesses impact patient PWM outcomes.


AMA Research Challenge 2022

Relationship between Executive Dysfunction and Parental Mental Health in a Pediatric Weight Management Clinic

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Charles Lopresto, DO

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poster

Retinopathy of prematurity (ROP) is a leading cause of childhood blindness. Our understanding of underlying risk factors for this disease in very low birth weight (VLBW) infants is still evolving. ROP has also been frequently observed in VLBW infants with patent ductus arteriosus (PDA), however little is known about the factors influencing their co-occurrence. We sought to explore the association of PDA and ROP in VLBW infants and analyze the role of co-morbidities in altering their association. We posit that VLBW infants with severe PDA may be at a higher risk of developing clinically significant ROP.

Severe Patent Ductus Arteriosus as an Independent Risk Factor for Clinically Significant Retinopathy of Prematurity in Very Low Birth Weight Infants

Background: Studies have shown that children with ADHD have higher problematic use of video games, though none have investigated the types of games played. Some of the most popular video games are online multiplayer games, meaning that there is no option to pause the game. This can be especially frustrating for kids with ADHD, who have poor time management skills. The lack of research into types of games played means that there is a gap in information used to tailor anticipatory guidance. Children with ADHD are also at higher risk of addiction. DSM-5 defined criteria for gaming addiction, but there have been no studies on gamers with ADHD using this criteria.

Methods: The study was conducted at an outpatient pediatric subspecialty office using a cross-sectional survey method. The survey was completed by 119 participants and assessed aspects of video game usage and screened for video game addiction using DSM-5 criteria. The most frequently played game was determined to be primarily single player or multiplayer.

Results: Among children with ADHD, there was no significant difference in positive screening for gaming addiction between those who primarily played video games with versus without a pause button. However, in children with no ADHD diagnosis, there was a significant difference in positive addiction screening between those who primarily played games with a pause button versus without. A chi-square test of independence was performed to examine the relationship between the criteria for video game addiction being met and whether the most frequently played game has a pause button. The relation between these variables was significant, p = .019. 
When comparing positive addiction screening for children with versus without ADHD, regardless of primary game type played, there was a 9% increase in positive screening for addiction in children with ADHD, though this number was not significant.

Conclusion: Children with ADHD whose most frequently played video game does not have a pause button did not have an increased risk of video game addiction. However, children without ADHD were more at risk for video game addiction when their primary game was multiplayer. This warrants further research into the types of video games children are playing.

Types of Video Games Played and Their Effect on Video Game Addiction in Children With and Without Attention Deficit-Hyperactivity Disorder

Phrenic Nerve Injury: Results of a Northwestern Phrenic Nerve Clinic Registry

Background: Fronto-orbital advancement requires removal of the fronto-orbital bandeau via extra- and intra-cranial osteotomies. During this transitional osteotomy, visualization of the saw blade is lost as it passes through the fronto-orbital-sphenoid junction. This places the dura and parenchyma of the temporal lobe at risk of injury. We aim to provide a three-dimensional analysis of the space surrounding this osteotomy to determine differences amongst different types of craniosynostoses. 

Method: We reconstructed 3D skulls from head CT scans of 30 patients with 6 different types craniosynostosis (4 with Apert sydrome, 3 Crouzon syndrome, 2 Muenke syndrome, 6 metopic, 6 nonsyndromic bicoronal, and 6 unicoronal), and landmarked them with 47 cephalometric points using Mimics 24.0 (Materialise NV, Lueven, Belgium). Statistical analyses were performed to determine differences in the linear and volumetric measurements among the 6 groups.

Results: Multiple significant differences were found amongst groups. The mean distance from the lateral orbital rim to cornea was significantly different among the 6 groups, with Apert syndrome having the largest (16.1± 2.3mm) value. The average distance of the middle cranial fossa from the frontozygomatic suture was significantly different with Apert (10±3.4mm), Muenke (10.4±2.0) and bicoronal (9.5±1.6mm) having the smallest values. The mean cephalocaudal depth of the temporal lobe tip from the edge of the sphenoid was significantly different, with Apert having the largest average depth (38±11.6mm). The thickness of the fronto-orbito-sphenoid junction at the level of the supraorbital rim was significantly different among the groups, with smallest values for the Apert (3.6±3.1mm) and bicoronal (3.7±1.3mm) groups. The mean distance from the cornea to the supraorbital rim, overall orbital depth, and overhang of the lesser sphenoid wing over the middle cranial fossa did not show significant difference among the groups.

Conclusion: Patients with Apert syndrome have the most unfavorable morphology of the anterior and middle cranial fossae. They have the highest corneal overhang beyond the lateral orbit, a large projection of the middle cranial fossa anteriorly, the most vertically deep middle cranial fossa and the thinnest bone at the fronto-orbital-sphenoid junction, all of which make retraction and protection of the temporal lobe more challenging during fronto-orbital advancement.

Alterations in Sphenoid anatomy in Craniosynostosis: Implications for Fronto-orbital Advancement

Background: 
Hourly flap checks are the most common means of assessing the vascular status of flaps during the first 24 hours following autologous breast reconstruction (ABR). This practice often requires ICU admission which is a known driver of healthcare costs and decreased patient satisfaction. This study seeks to address these issues by demonstrating the safety of a longer interval between flap checks during the first 24 hours following ABR. 
Methods:
This is a retrospective review of ABR surgeries performed by multiple surgeons from 2017 to 2020. Two cohorts were present, one which underwent flap checks every hour in the ICU (Q1 cohort) and the other which underwent flap checks every four hours on the hospital floor (Q4 cohort). Our primary outcome measures were length of stay (LOS), flap takebacks, total flap loss, and partial flap loss. 
Results: 
575 total flaps were reviewed. 331 in the Q4 cohort and 244 in the Q1 cohort. There was no significant difference in the rates of flap take back (p=.59), partial flap loss (p=.69) or total flap loss (p=.34) between the two cohorts. The Q4 cohort also had a significantly shorter LOS (p=.01).
Conclusion: 
This study demonstrates the safety of lengthened flap check intervals during the first postoperative day in patients following ABR. Lengthened flap check intervals will decrease the cost of ABR and increase patient satisfaction by avoiding ICU admission. These changes will ultimately make ABR a more accessible means of breast reconstruction for all patients to pursue.

Comparing Flap Monitoring Intervals in the 1st Postoperative Day: A Retrospective Analysis of Major Complications Following Autologous Breast Reconstruction

Background:
YouTube is a video platform for many topics, including plastic surgery. Previous studies have shown poor educational value in YouTube videos of plastic surgery procedures. The purpose of this study was to evaluate the quality and accuracy of YouTube videos concerning gynecomastia surgery.

Methods:
The phrases “gynecomastia surgery” (GS) and “man boobs surgery” (MB) were queried on YouTube. The first 50 videos for each search term were examined. The videos were rated using our novel Gynecomastia Surgery Specific Score (GSSS) to measure gynecomastia-specific information, the Patient Education Materials Assessment Tool (PEMAT) to measure understandability and actionability, and the Global Quality Scale (GQS) to measure general quality. 

Results:
The most common upload source was a board-certified plastic surgeon (35%) and content category was surgery techniques and consultations (51%). Average scores for GQS (x̄ = 2.25), GSSS (x̄ = 3.50), and PEMAT Actionability (x̄ = 44.8%) were low, whereas PEMAT Understandability (x̄ = 77.4%) was moderate to high. There was no difference in all scoring modalities between the GS and MB groups. Internationally uploaded MB videos tended to originate from Asian countries whereas GS videos tended to originate from non-US Western countries. Patient uploaders had higher PEMAT Actionability scores than plastic surgeon uploaders. 

Conclusion:
The quality and amount of gynecomastia-specific information in gynecomastia surgery videos on YouTube is low and contains few practical, take-home points for patients. However, understandability is adequate. Plastic surgeons should caution their patients that YouTube as a source of information for gynecomastia surgery may be unreliable.


Gynecomastia Surgery Patient Education: An Information Quality Assessment of YouTube Videos

Background
Autologous skin grafting is one of the mainstay treatments to wound closure on the reconstructive ladder. However, skin grafts have few well-described inadequacies, such as limited application over avascular structures and graft contracture. Regional or free flaps can be a solution to these challenging defects, but not all patients or situations are amenable to flap reconstruction. In these cases, tissue engineered skin substitutes may provide a reliable solution. Traditional skin substitutes have limitations such as high cost, antigenicity, and susceptibility for infection. NovoSorb™ Biodegradable Temporizing Matrix (BTM), is a novel, synthetic bilayer scaffold made of biodegradable polyurethane matrix covered with a sealing membrane. BTM has displayed promising performance in recent burn literature and may reduce costs compared to competing dermal substitutes on the market. Our study sought to evaluate applications and outcomes of BTM in a cohort of complex reconstructive cases with variable patient presentation characteristics and diverse wound etiologies.

Methods
After IRB approval, a retrospective review was performed from 2018-2022 to identify pediatric and adult patients who underwent reconstruction with BTM, regardless of wound etiology. Patient demographics, wound presentation characteristics, operative details, and reconstructive outcomes were recorded. Comparisons between successful and failed reconstructions were made with Kruskal-Wallis, Mann-Whitney U, and Fisher’s exact tests.

Results
A total of 59 cases from 39 patients were included. Burns and burn scar contracture releases were the primary indication for reconstructing with BTM (25.4%), followed by trauma (20.3%), and infection (18.6%). BBTM was placed over exposed tendon in 20 cases (33.9%), bone in 11 cases (18.6%), and/or joints in 5 cases (8.5%). 
Wound closure was successfully obtained with BTM reconstruction and subsequent skin grafting in 96.1% of cases. Cases that failed to achieve wound closure had significantly higher rates of peripheral vascular disease, ongoing immunosuppressive therapy, and current tobacco use compared to cases that achieved wound closure (p=0.03, p=0.03, and p=0.004, respectively). 

Conclusion
Our study highlights the versatility of BTM and favors its use in challenging reconstructive cases as an adjunct to definitive wound closure. Although future prospective studies are forthcoming, our findings support the reliability and versatility of BTM as an exciting addition to the field of plastic and reconstructive surgery.

NovoSorbTM Biodegradable Temporizing Matrix – A Novel Dermal Scaffold for Reconstructive Surgery

Abstract Title: 
Patient Shared Decision-Making in DIEP Flap Donor Site Complications: A Patient Centric Classification Validated by BREAST-Q Improves Satisfaction
Background
The body of literature on abdominal donor site complications after DIEP flap breast reconstruction lacks standardization. The aim of this study is to standardize reporting of abdominal donor site complications and report on patient satisfaction based on shared decision-making of treatment outcomes.
Methods
This retrospective study was conducted on patients who underwent DIEP flap breast reconstruction between January 2011 to December 2021 performed by the senior authors. Patients were excluded if they had prior significant abdominal surgeries, post-reconstruction radiation, or if underwent a concomitant autologous flap reconstruction. Primary outcomes included abdominal donor site complications, treatment outcomes, and BREAST-Q questionnaire responses. Categorical outcomes were compared between groups using Chi-squared test or Fisher-exact test, and strength of association using Phi or Cramer’s V when appropriate, while continuous outcomes were compared using independent-samples t-test. A binomial logistic regression was performed to ascertain the effects of covariates on the likelihood complication outcomes.

Results
Five hundred two patients were evaluated. The patient complication rate was 35.3%. Complications were comprised of 68.1% (n = 205) minor complications and 31.9% (n = 96) major complications. A moderately strong association was noted between history of DVT/PE and major complications, φ = 0.174, p < 0.001. There was a near significant association between umbilical preservation and minor complications, φ = 0.086, p = 0.055. In the logistic regression BMI, hypertension, and umbilical preservation were associated with increased minor complications, while BMI, race, hypertension, and history of DVT/PE were associated with increased risk of major complications. Patient cohort reported higher postoperative psychosocial well-being in minor complications (80.49, EMM) while higher postoperative abdominal well-being in no complications (73.50, EMM).
Conclusion
This study standardizes abdominal donor site complications after DIEP flap breast reconstruction which aids in the effort of communicating clearly with patients as a part of shared decision-making, and leads to improved patient satisfaction and understanding.

Patient Shared Decision-Making in Deep Inferior Epigastric Perforator (DIEP) Flap Donor Site Complications: A Patient Centric Classification Validated by BREAST-Q Improves Satisfaction

Private vs. Public Insurance Delays in Gender Affirming Mastectomy Coverage
Elise Hogan, BS, Kiersten Woodyard, BS, Ermina Lee, BS, Douglas Dembinski, MD, Ryan Gobble, MD, FACS

Intro:
Gender affirming care is recognized by every major medical association in the US as medically necessary for the treatment of gender dysphoria1. However, a 2015 national survey of transgender individuals found that 25% of respondents were denied coverage for hormones and 55% were denied coverage for surgical care within that year2. Access to gender affirming care has been associated with improved health outcomes in the transgender population, but there is a paucity of literature characterizing wait time from initial surgical consult to gender-affirming mastectomy. The purpose of this study was to investigate insurer coverage practices for transgender patients seeking gender-affirming mastectomy at the University of Cincinnati Medical Center to better inform surgical providers and their patients.

Methods:
A retrospective review of patients presenting to our institution interested in gender-affirming mastectomies from July 2014 to January 2022 was conducted. Patients were sub-stratified into those with public insurance and private insurance providers. Patient demographic data was collected, including insurance type, race, ethnicity, age, BMI, and smoking status, with additional information such as time on hormone replacement therapy (HRT) and prior psychiatric involvement. Categorical variables were analyzed with t-tests, and continuous variables were examined via linear regression. 

Results:
90 patients were interested in gender-affirming mastectomies that presented to our institution; 67 were insured by public providers and 23 by private insurers. 51 patients went on to have surgery (56.67%); 38 patients with public insurance (74.51% of surgical patients; 56.72% of publicly insured) and 12 patients with private insurance (23.53% of surgical patients; 52.17% of privately insured). 77 of the original 90 new patient consults (85.56%) had previously documented psychiatric involvement; 49 of 51 surgical patients (96.08%) had documented psychiatric involvement. Surgical patients with public insurance were on HRT for an average of 21 months compared to 30 months for private insurance. Average time from initial consultation to surgery was significantly longer for public insurers, with an average of 280 days, compared to private insurers, with an average of 186 days. For both public and private insurance, there was no association between months on HRT and time to surgery. 

Conclusion: There is a delay in time to surgery associated with patients who have public insurance when compared to private insurance that is unassociated with time on hormone replacement therapy. Awareness of a patient’s insurance status allows providers to provide realistic surgical timelines more accurately for patients interested in gender affirming mastectomy. 





References
1. Baker, K. E. (2017). The Future of Transgender Coverage. The New England Journal of
Medicine, 376(19), 1801-1804. https://doi.org/10.1056/NEJMp1702427 
2. James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The Report
of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender 
Equality. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf


Private vs. Public Insurance Delays in Gender Affirming Mastectomy Coverage

Background: One of surgical indications for orbital fracture repair is enophthalmos. Predicting late enophthalmos during initial work-up is a clinical challenge due to periorbital edema, and objective guidelines to direct surgical management in these cases remain ambiguous. We systematically reviewed the existing data on objectively predicting late enophthalmos using CT findings during initial trauma work-up.

Methods: Embase and PubMed were used as databases to identify articles of interest. Included articles were English-language prospective and retrospective studies that utilized CT findings to predict enophthalmos in asymptomatic patients. The Quality in Prognosis Studies (QUIPS) tool was used to identify potential risks of bias. A random effects model meta-analysis of orbital volume change was completed. A regression analysis of 224 data points from 8 orbital volume change studies was performed to determine a pooled threshold for 2mm (clinically significant) enophthalmos.

Results: Initial search delivered 2236 abstracts. 96 articles were selected for full-text review, and 36 met inclusion criteria. 30 retrospective studies evaluated a total of 2851 patients and 6 prospective studies evaluated 211 patients. All 36 articles had predominantly low risk of bias in six assessed domains. 5 articles on fracture location in 969 patients showed that inferior, medial, and medial-inferior orbital fractures were predictive of enophthalmos. 6 articles on inferior rectus muscle displacement in 323 patients showed that CT-notable displacement of IRM, height-to-width ratio more than 1.0, and increased IRM swelling by 60% served as predictors. 12 articles on fracture area in 861 patients offered values ranging from 1.5 go 3.38cm2. 21 study on orbital volume change in 835 patients offered values ranging from 0.688 to 4.26cm3. Five of those articles offered orbital volume ratios of 105.0% to 114.0%. Meta-analysis showed an effect size of 1.5, confirming the validity of orbital volume change as enophthalmos predictor (p<0.001, CI 0.952-2.067). Regression analysis revealed that 3.33cm3 of orbital volume change was a predictor of 2mm enophthalmos. Egger regression (p=0.095) and funnel plot revealed low risk of publication bias.

Conclusions: Simple measurements accessible on two-dimensional CT scans can be used as predictive values for late enophthalmos. Orbital volume change is the most researched predictor.

Next from AMA Research Challenge 2022

Severe Patent Ductus Arteriosus as an Independent Risk Factor for Clinically Significant Retinopathy of Prematurity in Very Low Birth Weight Infants

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