Level Of Evidence Research Articles

Racial Disparities Exist in 90-Day Unplanned Return to the Emergency Department Following Orthopaedic Trauma Surgery.

Racial disparities in healthcare outcomes exist, including in orthopaedic trauma care. The aim of this study was to determine the impact of race, social deprivation, and payor status on 90-day emergency department (ED) revisits among orthopaedic trauma surgery patients at a Level 1 trauma academic medical center. Retrospective chart review analysis. Level 1 trauma academic center in Durham, NC. Adult patients undergoing orthopaedic trauma surgery between 2017 and 2021. The primary outcome of this retrospective cohort study was 90-day return to the ED. Logistic regression analysis was performed for variables of interest [race, social deprivation (measured by the Area Deprivation Index), and payor status] separately and combined, with each model adjusting for distance to the hospital. Results were interpreted as odds ratios (ORs) of 90-day ED revisits comparing levels of the respective variables. Statistical significance was assessed at α = 0.05. A total of 3120 adult patients who underwent orthopaedic trauma surgery between 2017 and 2021 were included in the analysis. Black race (OR = 1.47; 95% confidence interval [CI]: 1.17-1.84, P < 0.001) and Medicaid coverage (OR = 1.63, 95% CI: 1.20-2.21, P = 0.002) were significantly associated with higher odds of return to ED compared with non-Black or non-Medicaid-covered patients. While ethnic minority (Hispanic/Latino or non-White) was statistically significant while adjusting only for distance to the hospital (OR = 1.23, 95% CI: 1.00-1.50, P = 0.047), it was no longer significant after adjusting for the other sociodemographic variables (OR = 1.13, 95% CI: 0.91-1.39, P = 0.27). The weighted Area Deprivation Index was not associated with a difference in odds of return to ED in any adjusted models. The results highlight the presence of racial and socioeconomic disparities in ED utilization, with Black race and Medicaid coverage significantly associated with higher odds of return to the ED. Future research should delve deeper into comprehending the root causes contributing to these racial and socioeconomic utilization disparities and evaluate the effectiveness of targeted interventions to reduce them. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Multicenter, Prospective, Observational Study of Nonoperative Versus Operative Treatment for High-Energy Midshaft Clavicle Fractures.

Evaluate if nonoperative or operative treatment of displaced clavicle fractures delivers reduced rates of nonunion and improved Disability of the Arm, Shoulder, and Hand (DASH) scores. Multicenter, prospective, observational. Seven Level 1 Trauma Centers in the United States. Adults with closed, displaced (100% displacement/shortened >1.5 cm) midshaft clavicle fractures (Orthopaedic Trauma Association 15.2) were treated nonoperatively, with plates and screw fixation, or with intramedullary fixation from 2003 to 2018. DASH scores (2, 6 weeks, 3, 6, 12, and 24 months), reoperation, and nonunion were compared between the nonoperative, plate fixation, and intramedullary fixation groups. Four hundred twelve patients were enrolled, with 203 undergoing plate fixation, 26 receiving intramedullary fixation, and 183 treated nonoperatively. The average age of the nonoperative group was 40.1 (range 18-79) years versus 35.8 (range 18-74) in the plate group and 39.3 (range 19-56) in the intramedullary fixation group (P = 0.06). One hundred forty (76.5%) patients in the nonoperative group were male compared with 154 (75.9%) in the plate group and 18 (69.2%) in the intramedullary fixation group (P = 0.69). All groups showed similar DASH scores at 2 weeks, 12 months, and 24 months (P > 0.05). Plate fixation demonstrated better DASH scores (median = 20.8) than nonoperative (median = 28.3) at 6 weeks (P = 0.04). Intramedullary fixation had poorer DASH scores at 6 weeks, 3 months, and 6 months than plate fixation and worse DASH scores than nonoperative at 6 months (P < 0.05). The nonunion rate for nonoperative treatment (14.6%) was significantly higher than the plate group (0%) (P < 0.001). Operative treatment of displaced clavicle fractures provided lower rates of nonunion than nonoperative treatment. Except at 6 weeks, no difference was observed in DASH scores between plate fixation and nonoperative treatment. Intramedullary fixation resulted in worse DASH scores than plate fixation at 6 weeks, 3 months, and 6 months and worse DASH scores than nonoperative at 6 months. Implant removal was the leading reason for reoperation in the plate and intramedullary fixation groups, whereas surgery for nonunion was the primary reason for surgery in the nonoperative group. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

The Intermalleolar Method for Intraoperative Rotational Assessment of the Tibia-A Prospective Clinical Validation Study.

To determine the accuracy of the intermalleolar method, an intraoperative fluoroscopic method for assessing tibial rotation in patients undergoing intramedullary nail fixation for tibial shaft fractures, by comparing it with the gold standard computed tomography (CT). Prospective cohort study. Academic Level 1 trauma center. Consecutive patients, aged 18 years and older, with unilateral tibial shaft fractures who underwent intramedullary fixation from September 2021 to January 2023. Intraoperatively, tibial rotation measurements were obtained using the intermalleolar method on both the uninjured and injured limbs. Postoperatively, patients underwent bilateral low-dose lower extremity rotational CT scans. CT measurements were made by 4 blinded observers. Mean absolute rotational differences and standard errors were calculated to compare the injured and uninjured limbs. Subgroup analysis was performed assessing accuracy relating to injured versus uninjured limbs, body mass index, OTA/AO fracture pattern, tibial and fibular fracture location, and distal articular fracture extension requiring fixation. Of the 20 tibia fractures, the mean patient age was 43.4 years. The intermalleolar method had a mean absolute rotational difference of 5.1 degrees (standard error 0.6, range 0-13.7) compared with CT. Sixty percent (24/40) of the measurements were within 5 degrees, 90% (36/40) of the measurements were within 10 degrees, and 100% (40/40) were within 15 degrees of the CT. No patients were revised for malrotation postoperatively. The intermalleolar method is accurate and consistently provides intraoperative tibial rotation measurements within 10 degrees of the mean CT measurement for adult patients undergoing intramedullary nail fixation for unilateral tibial shaft fractures. This method may be employed in the operating room to accurately quantify tibial rotation and assist with intraoperative rotational corrections. Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Nonoperative Treatment of Humeral Shaft Fractures With Immediate Functional Bracing Versus Coaptation Splinting and Delayed Functional Bracing: A Retrospective Study.

To compare radiographic and clinical outcomes in nonoperative management of humeral shaft fractures treated initially with coaptation splinting (CS) followed by delayed functional bracing (FB) versus treatment with immediate FB. Retrospective cohort study. Academic Level 1 Trauma Center. Patients with closed humeral shaft fractures managed nonoperatively with initial CS followed by delayed FB or with immediate FB from 2016 to 2022. Patients younger than 18 years and/or with less than 3 months of follow-up were excluded. The primary outcome was coronal and sagittal radiographic alignment assessed at the final follow-up. Secondary outcomes included rate of failure of nonoperative management (defined as surgical conversion and/or fracture nonunion), fracture union, and skin complications secondary to splint/brace wear. Ninety-seven patients were managed nonoperatively with delayed FB (n = 58) or immediate FB (n = 39). Overall, the mean age was 49.9 years (range 18-94 years), and 64 (66%) patients were female. The immediate FB group had less smokers ( P = 0.003) and lower incidence of radial nerve palsy ( P = 0.025), with more proximal third humeral shaft fractures ( P = 0.001). There were no other significant differences in demographic or clinical characteristics ( P > 0.05). There were no significant differences in coronal ( P = 0.144) or sagittal ( P = 0.763) radiographic alignment between the groups. In total, 33 (34.0%) humeral shaft fractures failed nonoperative management, with 11 (28.2%) in the immediate FB group and 22 (37.9%) in the delayed FB group ( P = 0.322). There were no significant differences in fracture union ( P = 0.074) or skin complications ( P = 0.259) between the groups. This study demonstrated that nonoperative treatment of humeral shaft fractures with immediate functional bracing did not result in significantly different radiographic or clinical outcomes compared to treatment with CS followed by delayed functional bracing. Future prospective studies assessing patient-reported outcomes will further guide clinical decision making. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Postoperative Care and Outcomes in Solid-Organ Transplant Patients Undergoing Lower Extremity Fracture Treatment.

To determine the postoperative outcomes in solid-organ transplant (SOT) patients undergoing operative treatment of lower extremity fractures. Retrospective comparative study. Academic Level 1 trauma center. Patients who underwent SOT and operative treatment of lower extremity fracture from 2013 to 2021 were identified, excluding pathologic fractures. Postoperative complications, length of stay, time to death, 90-day and 1-year readmission rates, readmission causes, discharge location, and immunosuppressive regiments. Sixty-one patients with an average age of 67 years (range 29-88) were included. The mortality rate was 37.7%. The average follow-up was 15.2 months (range of 2 weeks-10 years). The majority of patients (32.8%) had received a liver transplant, and femoral neck fractures constituted the largest fracture group. The average length of stay was 10 days, with the shortest being 1 day and the longest being 126 days (SD 18). The majority of patients (57.3%) were not discharged home. Only 2 suffered from a postoperative complication requiring another procedure: hardware removal and liner exchange for periprosthetic joint infection, respectively. There was a 27.9% 90-day readmission rate with 2 deaths within that period with the most common being altered mental status (29.4%), genitourinary infections (17.6%), repeat falls (11.8%), and low hemoglobin requiring transfusion (11.8%). The longest average time to death analyzed by transplant type was found among lung transplant patients (1076 days, 62.5% mortality), followed by liver transplant patients (949 days, 35.0% mortality), and then kidney transplant patients (834 days, 38.9% mortality). The shortest time to death was 71 days from index procedure. Family members of SOT patients undergoing operative treatment of lower extremity fractures should be made aware of the high risk for 90-day readmission postoperatively (27.9%) and overall mortality (12.5%). Providers should be aware of the need for multidisciplinary involvement for inpatient care, monitoring postoperative complications, and facilitating discharge planning. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Subtrochanteric Femur Fractures: The Association Between Obesity and Perioperative, Clinical, and Radiographic Outcomes.

To evaluate the association between obesity and treatment approaches, perioperative factors, and clinical and radiographic outcomes following subtrochanteric fracture fixation. Retrospective Cohort. Academic Medical Center. Patients operatively treated for an AO/OTA 32Axa, 32Bxa, or 32Cxa subtrochanteric femur fracture. Injury characteristics, perioperative parameters, fixation information, postoperative complications, and clinical and radiographic outcomes. Univariate analyses were conducted between the obese (BMI ≥30 kg/m2) and the nonobese (BMI <30 kg/m2) cohorts. Regression analyses were performed to assess BMI as a continuous variable. Of 230 operatively treated subtrochanteric fracture patients identified, 49 (21%) were obese and 181 (79%) were nonobese. The average age of the obese cohort was 69.6 ± 17.2 years, with 16 (33%) male and 33 (77%) female. The average age of the nonobese cohort was 71.8 ± 19.2 years, with 60 (33%) male and 121 (77%) female. Aside from BMI, there were no significant differences in demographics between the obese and nonobese (age [P = 0.465], sex [P = 0.948], American Society of Anesthesiology Score [P = 0.739]). Both cohorts demonstrated similar injury characteristics including mechanism of injury, atypical fracture type, and AO/OTA fracture pattern (32A, 32B, 32C). Obese patients underwent more open reduction procedures (59% open obese, 11% open nonobese, P < 0.001), a finding further quantified by a 24% increased likelihood of open reduction for every 1 unit increase in BMI (OR: 1.2, 95% CI, 1.2-1.3, P < 0.001). There was no difference in average nail diameter, 1 versus 2-screw nail design, or number of locking screws placed. The obese cohort was operated more frequently on a fracture table (P < 0.001) when compared with the nonobese cohort that was operated more frequently on a flat table (P < 0.001). There were no significant differences (P > 0.050) in postoperative complications, mortality/readmission rates, hospital quality measures, fixation failure, or time to bone healing. The treatment of subtrochanteric fractures in obese patients is associated with a higher likelihood of surgeons opting for open fracture reduction and the use of different operating room table types, but no difference was observed in postoperative complications, mortality or readmission rates, or healing timeline when compared with nonobese patients. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Nonoperative Versus Operative Treatment of Z-Type Comminuted Clavicle Fractures in Adolescents: A Prospective Substratified Cohort Analysis.

To compare the clinical, radiographic, and patient-reported outcomes of nonoperative and operative treatment of adolescents with comminuted "Z-type" midshaft clavicle fractures. Prospective observational cohort. Eight tertiary care pediatric centers. Patients aged 10-18 years who were treated either operatively or nonoperatively for a diaphyseal clavicle fracture between 2013 and 2017 were screened/enrolled at the time of injury. The current subcohort analysis was derived from a larger adolescent clavicle study population of 907 patients. Complications and validated patient-reported outcome measures (PROs):(ASES, QuickDASH, Marx Shoulder Activity Score, EQ-5D, EQ-VAS, and patient satisfaction score) were compared between operative and nonoperative cohorts. Eighty-one patients (69 male [85.2%], 12 female; average age 15 years [11.1-18.7]; 78 with sports participation [96.2%]) were followed through bony healing and return to sports, while 59 patients (73%) completed 2-year follow-up with PROs, 26 of whom were treated nonoperatively and 33 treated operatively. All demographic and fracture characteristics were similar (P > 0.05) between the 2-year follow-up cohorts except for fracture shortening, which was greater in the operative cohort (23 vs. 29 mm, P = 0.01). After controlling for this potential confounder through both regression and propensity matched subgroup analysis, nonoperative versus operative cohorts showed no difference in rates of nonunion (0%), delayed union (0% vs. 2.3%, P = 1.0), symptomatic malunion (2.7% vs. 0%, P = 0.4), refracture (2.7% vs. 2.2%, P = 1.0), unexpected subsequent surgery (5.4% vs. 11.4%, P = 0.45), or clinically significant complications (5.4% vs. 16%, P = 0.17). There were no differences in any PROs between cohorts, both before and after controlling for the difference in fracture shortening (all P-values >0.05). In this prospective comparison of complications and 2-year PROs in adolescents with comminuted Z-type clavicle fractures, nonoperative and operative treatment yielded similar outcomes. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

The top 100 most-cited articles in dentistry by authors with Italian affiliation.

Analyzing highly-cited articles can provide a retrospective assessment of research evolution and predict future developments. The aim of this study was to carry out a bibliometric analysis of the 100 most-cited articles in dentistry by authors with an Italian affiliation. All the articles published in journals indexed under the Scopus category "Dentistry" and with at least one author affiliated to any Italian institution were searched in September 2022. The 100 most-cited articles were selected and relevant data were extracted and summarized. The analysis of co-authorship at country level and co-occurrence of keywords was carried out. The 100 most-cited articles were published between 1976 and 2020. The number of citations ranged from 235 to 1683, with a mean of 361. The series included 25 citation classics (>400 citations). The majority of articles were classified as expert opinion/narrative reviews (N.=47). Almost half of the articles refer to three predominant disciplines which were implantology, periodontology and restorative dentistry. Only two articles were single-authored. In 30 articles, all the authors had an Italian affiliation and the US was the most frequent country for non-Italian authors. Only one article was published in journals owned by a non-Italian publisher. The present series of highly-cited articles confirms the important role of Italy in dental research. We found an absence of correlation between the level of evidence and the number of citations and a non-homogeneous distribution of highly-cited papers in the different dental disciplines. The majority of articles included in the series shared international co-authorship and were published in high-impact journals.

Life expectancy and long-term survival after traumatic spinal cord injury: a systematic review.

Spinal cord injuries have a considerable impact on healthcare in terms of mortality and morbidity. To address the difficulties faced by people affected by this condition and to raise awareness among stakeholders and policymakers, it is crucial to understand factors impacting survival. The purpose of this study is to systematically review the literature on life expectancy in people with traumatic spinal cord injury (tSCI), identifying key factors influencing mortality and survival. We conducted a systematic review, searching the literature for articles published up to July 2023 in PubMed, Web of Science, Cochrane Library, Google Scholar, and PEDro. Study outcomes had to be one of survival rate, life expectancy, standardized mortality ratio, or mortality rate. Only original research articles published in English were included. The quality of evidence was evaluated with the MINORS scale. The level of evidence was categorized according to the OCEBM model. A comprehensive literature search yielded 102 articles, after the selection process 20 studies were included in our review. The main factors negatively influencing survival and life expectancy included higher neurological level of injury (NLI), completeness of the lesion, need for mechanical ventilation, increasing age, and male gender. The development of SCI-related comorbidities also negatively impacted survival as well as the lack of specialized care, especially in low-income countries. Additionally, pre-injury health status and personal income may affect survival. Current literature shows that people affected by tSCI have a shorter life expectancy compared to the general population, highlighting some factors as possible predictors. It is difficult to compare available evidence due to the methodological heterogeneity across studies, which makes it challenging to draw generalizable conclusions on life expectancy in people with tSCI. Further studies are required to address these issues and accurately estimate life expectancy accounting for gaps in the management of people affected by tSCI to improve their care.

Checks and balances: a meta-analysis on the known-groups validity of functional postural control tests in children.

Pediatric physical therapists commonly treat children with postural control deficits. Ideally, pediatric functional postural control tests should therefore be able to identify postural control deficits in children with various disorders. Despite a plethora of available tests, evidence for their validity - especially known-groups - remains scarce. This review aims to determine the known-group validity of available functional postural control tests to differentiate various pediatric pathological groups of different ages from their typically developing (TD) peers. PubMed, Web of Science and Scopus were systematically searched (last update: February 2023; PROSPERO: CRD42023408982). Forty case-control studies with a pathological pediatric sample (N.=1331) and TD peers (N.=1889) were included and selected for data-extraction and -analysis. Risk of bias was assessed using the SIGN checklist and level of evidence was scored using GRADE. Random-effect meta-analyses were performed to estimate pooled standardized mean differences (SMD) for the various test types and subclassified based on pathology and/or age. When compared with TD peers, children with underlying pathologies performed significantly worse on pediatric functional postural control test batteries (SMD=-2.21), the Timed Up and Go Test and variants (SMD=2.30), the One Leg Stance test and variants (SMD=-2.14), while the Reach tests showed a smaller difference (SMD=-1.19). Subclassification within the meta-analyses showed that pathology was an influencing factor for the test batteries and the one leg stance test and variants. Age was an influencing factor for the reach tests. None of the included functional postural control tests exceeded a low level of evidence. Pediatric functional postural control tests that assess multiple aspects of postural control (such as test batteries) seem to offer higher known-groups validity than single-task tests (e.g. reach tests). The underlying pathology has a larger impact on the validity of these tests than age. There remains an overall low level of evidence for the known-groups validity of pediatric functional postural control tests indicating the need for research with more homogenous groups and norm reference data.

Gastrointestinal stromal tumour (GIST): British Sarcoma Group clinical practice guidelines.

British Sarcoma Group guidelines for the management of GIST were initially informed by those published by the European Society of Clinical Oncology. This update was written by a group of experts to includes a discussion of the highlight improvements in our knowledge of the disease and recent treatment developments. The guidelines include sections on Incidence, Aetiology, Diagnosis, including risk assessment, Treatment and Follow-up. A careful review of the literature was performed to ensure that wherever possible recommendations are supported by the results of clinical trials or substantive retrospective reports. Areas of uncertainty are indicated appropriately. Guidelines represent a consensus view of current best clinical practice. Where appropriate, key recommendations are given and the levels of evidence and strength of recommendation gradings are those used by the European Society for Medical Oncology (ESMO).

Multi-Center Two-Year Patency Outcomes of Endovascular Arteriovenous Fistulas (endoAVF) Created with a 4 French System.

To assess multicenter two-year patency outcomes of endovascular arteriovenous fistulas (endoAVF) created with the WavelinQ device. Patients who had fistulas created at three centers from January 2018 to December 2020 were included in this retrospective study. In total, 112 patients underwent endoAVF creation [40 females, 72 males; mean age 60years (range 18-88)]. Data collected included patient demographics, location of fistula creation, interventions performed, and brachial artery flows pre- and post-creation. Two-year cumulative patency, functional patency, and primary patency were assessed with Kaplan-Meier methodology. Factors affecting patency and maturation were examined using the Cox proportional hazards model. Technical success defined as angiographically successful endoAVF creation was 97.3% (109/112). In 11 patients the fistula did not mature for dialysis use. For 98 patients (87%) with endoAVF maturation, 12- and 24-month cumulative patency was 94.3% and 91.7%. Functional patency (two-needle cannulation) at 12 and 24months was 95.7% and 92.7%, respectively. Median maturation time is 95days (IQR 51-231days). Male gender and brachial vein coiling at the time of endoAVF creation were predictive of maturation. There were 34 censored events (four patients undergoing renal transplantation; 30 patients deceased). Number of reinterventions per patient year was 0.73 where 43 were maturation procedures and 101 were maintenance procedures. One Grade 3 complication occurred of arterial access puncture site pseudoaneurysm. A high two-year functional and cumulative patency following endoAVF creation with the WavelinQ device was observed in this multicenter real-world experience Level of Evidence: 3 Level of Evidence III.

PET-MRI Applications and Future Prospects in Psychiatry.

This article reviews the synergistic application of positron emission tomography-magnetic resonance imaging (PET-MRI) in neuroscience with relevance for psychiatry, particularly examining neurotransmission, epigenetics, and dynamic imaging methodologies. We begin by discussing the complementary insights that PET and MRI modalities provide into neuroreceptor systems, with a focus on dopamine, opioids, and serotonin receptors, and their implications for understanding and treating psychiatric disorders. We further highlight recent PET-MRI studies using a radioligand that enables the quantification of epigenetic enzymes, specifically histone deacetylases, in the brain in vivo. Imaging epigenetics is used to exemplify the impact the quantification of novel molecular targets may have, including new treatment approaches for psychiatric disorders. Finally, we discuss innovative designs involving functional PET using [18F]FDG (fPET-FDG), which provides detailed information regarding dynamic changes in glucose metabolism. Concurrent acquisitions of fPET-FDG and functional MRI provide a time-resolved approach to studying brain function, yielding simultaneous metabolic and hemodynamic information and thereby opening new avenues for psychiatric research. Collectively, the review underscores the potential of a multimodal PET-MRI approach to advance our understanding of brain structure and function in health and disease, which could improve clinical care based on objective neurobiological features and treatment response monitoring. EVIDENCE LEVEL: 1 TECHNICAL EFFICACY: Stage 1.

Implant-Based Gluteal Augmentation:Comparing Complications Between Single- and Double-Incision Techniques.

Gluteal implants are gaining popularity as an alternative to fat grafting for gluteal augmentation. This study aims to compare complication rates between single- and double-incision techniques for implant placement in gluteal augmentation from a single surgeon's experience. Retrospective analysis of a single surgeon's implant-based gluteal augmentations was conducted between October 2018 and August 2022. Consecutive patient cases were reviewed at the beginning and end of the designated period to compare both incision techniques after switching from the single- to double-incision technique in September 2020. Demographics and postoperative complications were compared. Statistical comparisons were made using the independent sample t-test for quantitative variables and the Fisher's exact test for categorical variables. The study included 134 single-incision patients (247 implants) and 47 double-incision patients (91 implants). Baseline demographic and clinical characteristics between the two groups were similar. Overall complication rate per implant was higher in the single-incision group (16.6% vs. 6.6%, p = 0.02). The most common complication per implant was delayed wound healing (single incision: 9.7%, double incision: 5.5%). The odds ratio of developing at least one complication in the double compared to the single-incision group was 0.44 (95% CI: 0.19, 0.92). The double incision techniquedemonstrates a lower complication rate than the single-incision technique for implant-based gluteal augmentation. The most common complication in both groups was delayed wound healing which responded in most patients to conservative wound care. These results support using the double-incision technique for implant-based gluteal augmentation. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Evaluation of the Effect of Botulinum Toxin A on the Lymphatic Endothelial Cells.

Botulinum toxin A (BoTA) is a neurotoxin formed by Clostridium botulinum, with a broad medical application spectrum. While the primary effect of BoTA is on the muscles, the effects of BoTA in other systems including the blood vasculature have already been examined, revealing unexpected actions. However, no studies exist to the best of our knowledge regarding the potential effects of BoTA on the lymphatic vascular system, possessing a critical role in health and disease. Isolated human lymphatic endothelial cells (LECs) were cultured in dedicated in vitro culture systems. The analysis including imaging and cell culture approaches as well as molecular biology techniques is performed to examine the LEC alterations occurring upon exposure to different concentrations of BoTA. Human LECs were cultured and expanded on collagen-coated petri dishes using endothelial basal medium and the commercial product Botox from Allergan as used for all our experiments. Harvested cells were used in various in vitro functional tests to assess the morphologic and functional properties of the BoTA-treated LECs. Gene expression analysis was performed to assess the most important lymphatic system-related genes and pathways. Concentrations of 1, 5 or 10 U of BoTA did not demonstrate a significant effect regarding the proliferation and migration capacity of the LECs versus untreated controls. Interestingly, even the smallest BoTA dose was found to significantly decrease the cord-like-structure formation capacity of the seeded LECs. Gene expression analysis was used to underpin possible molecular alterations, suggesting no significant effect of BoTA in the modification of gene expression versus the starvation medium control. LECs appear largely unaffected to BoTA treatment, with an isolated effect on the cord-like-structure formation capacity. Further work needs to assess the effect of BoTA on the smooth-muscle-cell-covered collecting lymphatic vessels and the possible aesthetic implications of such an effect, due to edema formation. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Generational Exploration on Aesthetic Medicine Products: Influence of Social Media, Reviews, and Brand Identity-GEMS Bond Survey.

The study investigates the impact of social media reviews and brand identity on consumer preferences in the non-surgical aesthetics products across different generations. It highlights the evolving landscape of aesthetic medicine and surgery, driven by technological advancements and a cultural shift towards individual well-being. The research aims to explore the interplay between generational preferences, the influence of social media, and the role of brand identity in shaping consumer decisions. A cross-sectional study design was employed, with a sample size of > 5000 participants stratified across various generational cohorts. The study utilized an online questionnaire to capture both quantitative and qualitative insights into consumer behaviour, with statistical analysis performed to identify patterns and relationships. Analysis of 5850 responses revealed distinct generational preferences and behaviours. Social media engagement varied significantly across generations, with younger cohorts placing a higher emphasis on online reviews. The study also found that brand identity's influence is diminishing in decision-making processes, with consumers increasingly relying on peer reviews and social media content. The findings highlight a pivotal shift in the non-surgical aesthetics consumer market, emphasizing the growing importance of social media and peer reviews over traditional brand identities. Importantly, the study underscores the critical need for integrating patient safety and evidence-based practice within marketing strategies. As consumer preferences evolve towards valuing transparency and authenticity, non-surgical aesthetics providers must prioritize these elements, ensuring that their services are not only appealing but also grounded in safety and scientific validity. "This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 ."

Evaluation of the Reproducibility of Auricular Subunit Markers Based on Three-Dimensional Computed Tomography.

As a facial feature, the auricle plays an important role in the integrity and aesthetics of the whole face. Auricular subunits are associated with patient satisfaction in auricular reconstruction, but there are few studies on auricular subunits. We want to evaluate the reproducibility of auricular subunits by measuring the coordinates of the marker points of auricular subunits, accordingly provide a reference for the improvement of auricular reconstruction and the aesthetics of auricular injection. Mimics 19.0 was used to carry out three-dimensional (3D) reconstruction of the computed tomography (CT) scan data of patients' brains; measure the three-dimensional coordinates of the 13 auricular subunit markers, the morphological auricle length and width, and the physiological auricle length and width; and analyze the reproducibility as well as the differences between group. Reproducibility of auricle subunit markers: There are 1124 (58.82%) high reproducibility, 580 (30.35%) moderate reproducibility, and 207 (10.83%) low reproducibility. The superior tragus notch, tragus, and antitragus had the highest reproducibility. There was no significant difference between the groups in the marking points on the helix, and there were no statistically significant differences in the measurement values of the auricles on the two sides. The physiological ear length and width and the morphological ear length of males were larger than those of females. These showed significant differences between the age groups. Most auricular subunit markers have high reproducibility. The subunits with higher reproducibility are the structures that need to be optimized during auricle reconstruction surgery or auricle injection in the future. This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Double Reinforcing Strategy with Perpendicular Plate of Ethmoid in Asian Secondary Unilateral Cleft Rhinoplasty: A Finite Element Analysis.

Deviation and asymmetry relapse after secondary unilateral cleft rhinoplasty with septal extension graft is a common yet serious problem especially among Asian patients. Therefore, finding an effective approach to reduce deformity relapse remains a great challenge to plastic surgeons. In this study, authors established finite element models to simulate different nasal cartilage-corrected options and different reinforcing strategies in secondary unilateral cleft rhinoplasty. A load of 0.01N was given to the nasal tip to simulate the soft tissue pressure, while two loads of 0.5N were separately given to the anterior and posterior part of the septal extension graft to simulate the rhinoplasty condition. Maximum deformations were evaluated to make stability judgments. The maximum deformation of different cartilage correction models in ascending order was: UCL deformity with septum correction, normal nasal cartilage, UCL nasal deformity, and UCL nasal deformity with lower lateral cartilage correction. When applied L-strut reinforcement graft was harvested from the perpendicular plate of the ethmoid bone, the maximum deformation of the models decreased significantly, and strong fixation of the septum could further enhance this decreasing effect. Correcting the septum and lower lateral cartilage together could improve the structural stability and symmetry in secondary unilateral cleft rhinoplasty. To keep the corrected septum stable and thus reduce deformity relapse, reinforcing the L-strut with perpendicular plate of ethmoid graft while strongly anchoring the septal cartilage to the anterior nasal spine was proved to be effective in both finite element analysis and clinical observation. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Hybrid Dorsal Preservation Rhinoplasty: Reediting an Aesthetic Dorsum.

The prerequisite of a well-shaped dorsum with proper dorsal aesthetic lines that needs no modifications in its width and symmetry is key to letdown and push-down techniques as classically described. The common current concept is that total preservation of the middle vault is obligatory. This, however, obviously limits the indications, since nasal dorsum with natural aesthetic dorsal lines per se is relatively few. The recent, impressive, revival of letdown and push-down procedures has progressively generated numerous technical variations, but all those essentially still left the middle vault unmodified. The concept of splitting the middle vault and modifying its width and symmetry, while leaving the crucial dorsal (central) and lateral Keystone area intact, represents a new hybrid approach to the nasal dorsum. The structural benefits of classical component separation are combined with the major advantage of preserving the flexible chondro-osseous joint at the keystone junction. Osteotomies and/or osteoplasty can be done as necessary to modify the bony dorsum and at the same time any type of septal deformity can be addressed according to the time-tested L-strut principle, a Cottle septoplasty included. This hybrid approach expands indications beyond those of the conventional push-down/letdown technique, including moderate asymmetries of the bony and cartilaginous dorsum. Although splitting the middle vault along the septal T will also facilitate middle vault reshaping in cases where a full letdown procedure is indicated, this paper will clarity address only those instances where no circumferential osteotomy is done. The dorsal bony nasal pyramid is always addressed first by rhinosculpture (osteoplasty) with piezoelectric inserts and/or burrs, in combination with different types of osteotomies as needed. This will allow narrowing of the bridge and correction of bony asymmetries. The osseous-cartilaginous connection of the central dorsal keystone area (DKA) is totally preserved. At this point, three main variations are possible: Type 1) preservation of the septal T and push-down by a high-middle septal strip resection, two different variations (1A and 1B) are possible here, Type 2) reduction in width of the septal T-segment and middle vault restoration by spreader flaps without any push-down of the septal T and Type 3) preservation of the septal T and letdown by low strip resection. Hybrid Dorsal Preservation involves concepts of Structure and Preservation Rhinoplasty. Dorsal and lateral keystone area are preserved, and the middle vault could be modified splitting the septal T in the anatomical plane, expanding patient indications and improve outcomes. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Cup and Cage Reconstruction for Metastatic Acetabular Lesions Provides Functional Improvement and Cost-efficiency

Objective: Pathologic acetabular lesions have multiple surgical options proposed and no clearly defined optimal solution at this time. In this study, we present our cage and cup reconstruction method and analyze postoperative outcomes against previously published studies. Patients and Methods: Twenty-four patients from 2014 to 2020 with acetabular pathologic lesions treated with an antiprotrusio cage and cup reconstruction were identified. Patient charts were reviewed for operative time, blood loss, Musculoskeletal Tumor Society functional scores, follow-up, and complications. Results: The average blood loss was 727 mL, and the average postoperative Musculoskeletal Tumor Society score was 70.3, with an average improvement of 35.2 points from preoperative scores. The average cost of our construct per year was $1177 for patients surviving &gt;1 year after surgery. Eleven (45%) patients had died of disease at an average survival time of 14.2 months. Conclusion: Our study compares well with historic reconstruction strategies for metastatic acetabular disease, showing that this cup/cage reconstruction provides a durable and perioperatively safe approach that provides functional improvement while remaining cost-efficient. Level of Evidence: Level IV.