Craniofacial Surgery

Resection of Septal Adenoid Cystic Carcinoma and Primary Reconstruction of the Surgical Defect via Open Rhinoplasty Adenoid cystic carcinoma is one of the most common minor salivary gland malignancies of the head and neck region. However, adenoid cystic carcinoma of the nasal septum is extremely rare. The authors herein report a case of a septal adenoid cystic carcinoma in a 68-year-old man who complained of nasal bleeding and nasal obstruction for several months. Diagnostic nasal endoscopy revealed a protruding mass arising from the anterosuperior part of the nasal septum. The tumor was removed with a safety margin using the open rhinoplasty approach and primary reconstruction of the surgical defect was performed using septal cartilage. Histopathology indicated an adenoid cystic carcinoma with cribriform pattern. Two years postoperatively, there was no evidence of recurrence, the functional and cosmetic results were good, and the patient was satisfied with the treatment outcome. Address correspondence and reprint requests to Myeong Sang Yu, MD, PhD, Department of Otolaryngology, Asan Medical Centre, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul 05505, Republic of Korea; E-mail: entyums@amc.seoul.kr Received 25 March, 2019 Accepted 19 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Zygomatic Rotation-Advancement: A New Concept for the Correction of Exorbitism in Patients With Syndromic Craniosynostosis Background: The exophthalmos and class III malocclusion seen in Crouzon syndrome can be treated by Le Fort III advancement/distraction. However, reconstructive options for zygomatic retrusion are limited. The authors describe the repair of isolated exorbitism in a patient with Crouzon syndrome, via bilateral zygomatic rotation-advancement. Methods: A 34-year-old woman with Crouzon syndrome complained of exorbitism and malar hypoplasia. Four years prior, she declined Le Fort III advancement and underwent orthodontic/orthognathic correction of malocclusion. Radiographs were used to develop a computerized surgical plan. Bilateral periorbital osteotomy with advancement/rotation of the zygomatic process was performed using custom osteotomy guides and plates. Images obtained immediately postoperative and 3- and 19-month postoperative were compared to assess surgical stability, accuracy, and soft tissue changes. Results: Decreased globe exposure and increased malar prominence have improved facial balance. Superimposed pre- and postoperative radiographs demonstrate bilateral advancement of the zygomatic body and inferior orbital rim. Superimposition of immediate postoperative and 19-month radiographs showed no relapse. Soft tissue histogram showed increased prominence of the malar eminence, lateral orbital rim, and cheek. Conclusions: Zygomatic rotation-advancement proved a safe, effective, stable, and predictable treatment for isolated malar hypoplasia in a patient with Crouzon syndrome. Virtual planning can enhance novel complex craniofacial procedures. Address correspondence and reprint requests to Roberto L. Flores, MD, Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, 222 East 41st St, New York, NY, 10017; E-mail: Roberto.Flores@nyulangone.org Received 2 March, 2018 Accepted 25 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Review of "The Current State of Surgical Ergonomics Education in U.S. Surgical Training-A Survey Study" by Epstein S et al. in Ann Surg 269: 778-784, 2019 No abstract available

Cranial Suture Anchor Temporalis Resuspension: A New Technique to Reconstruct Temporal Hollowing After Craniotomy Introduction: Proper temporalis resuspension following craniotomy or craniectomy is necessary to prevent significant temporofacial deformity. Several methods of temporalis reconstruction have been described with varying success; currently there are no reports of suture anchor utilization. Methods: A patient is presented displaying successful temporalis resuspension using suture anchor fixation. An incision was made in the temporal hair-bearing scalp to access and lengthen the retracted temporalis under direct visualization. Stab incisions were then made in the scalp to expose the superior temporal line, where suture anchors were placed for muscle fixation. After confirming appropriate vectors for muscle resuspension, 1 suture arm was passed through a subgaleal tunnel to capture the temporalis and the other was fixated to the temporoparietal skull. The suture anchors were secured and the incisions were closed in layers. Results: A 36-year-old female with history of decompressive craniectomy for hemorrhagic stroke presented with significant temporal hollowing. Her temporalis was retracted with a noticeable defect on frontal view and bulging over the zygomatic arch. The patient underwent temporalis resuspension as described with durable correction resembling her premorbid state. The buried suture anchors were nonpalpable. Conclusion: Temporal hollowing after craniotomy is a difficult contour deformity to correct. In the presented patient, reconstruction with temporalis elevation and suture anchor resuspension was found to be an effective technique with excellent cosmetic outcome. The efficiency of suture anchor placement, postoperative maintenance of muscle tension, and nonpalpable profile of the buried suture anchors suggest comparable efficacy to plate fixation and suture-only techniques. Address correspondence and reprint requests to Oluwaseun A. Adetayo, MD, 43 New Scotland Ave, Albany, NY 12208; E-mail: adetayo@amc.edu Received 11 July, 2018 Accepted 22 February, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Challenges in Microsurgical Reconstruction for Craniofacial Osteomyelitis With Resultant Osteonecrosis Introduction: Chronic osteomyelitis is characterized by compromised blood supply and eventual osteonecrosis. Definitive treatment requires aggressive resection of affected bone. The resultant defect poses a unique challenge to reconstructive surgeons. Much of the literature on craniofacial osteomyelitis focuses on infection eradication, rather than subsequent reconstruction. This article reports representative cases from our experience with free flap reconstruction for defects secondary to chronic osteomyelitis of the craniofacial skeleton. Methods/Results: The authors selected 5 of the most difficult reconstructive cases of craniofacial osteomyelitis from our experience in a single tertiary referral institution with a follow-up of at least 6 months. Three of the 5 cases arose in the setting of previous head and neck cancer treated with resection and radiation therapy. One case had a previous surgical craniotomy complicated by osteomyelitis and multiple failed alloplastic reconstructions. The final case was due to multiple gunshots to the head, with subsequent cerebral and cranial abscess (>1000cc). In each case, the defect was successfully treated with free tissue transfer. Two cases required creation of recipient vessels with an arteriovenous loop. Conclusions: Free tissue transfer provides a versatile and effective tool in the reconstruction of extensive craniofacial osteomyelitis defects. Furthermore, the addition of vascularized tissue can protect against further episodes of osteomyelitis. Finally, arteriovenous loops can be employed successfully when prior radiation and infection of the wound bed precludes the use of local recipient target vessels. Address correspondence and reprint requests to Brian R. Gastman, MD, 9500 Euclid Ave, Desk A60, Cleveland, OH 44195; E-mail: sinclan@ccf.org Received 12 September, 2018 Accepted 20 March, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Fully Automatic Robot-Assisted Surgery for Mandibular Angle Split Osteotomy With the development of computer-assisted surgery, preoperational design is detailed in software. However, it is still a challenge for surgeons to realize the surgical plan in the craniofacial surgery. Robot-assisted surgery has advantages of high accuracy and stability. It is suitable for the high-stress procedures like drilling, milling, and cutting. This study aims to verify the feasibility for automatic drilling without soft tissues in model test based on an industrial robot platform. This study chose the data from digital laboratory in Shanghai 9th People's Hospital. The mandibular was reconstructed in software and surgical plan was also designed. Then, the coordinate data was input to the robot's software and matrix conversion was calculated by 4 marked points. The trajectory generation was calculated by inverse kinematics for target coordinates and robot coordinates. The model was fixed and calibrated for automatic drilling. At last, the accuracy was calculated by optic scanning instrument. The installment and preparation cost 10 minutes, the drilling procedure cost 12 minutes. The outside position error was (1.71 ± 0.16) mm, the inside position error was (1.37 ± 0.28) mm, the orientation error was (3.04 ± 1.02) °. Additionally, a total of 5 beagles were tested, with an accuracy error of (2.78 ± 1.52) mm. No postoperative complications occurred. This is the first study reported for robot-assisted automatic surgery in craniofacial surgery. The result shows it is possible to realize the automatic drilling procedure under the condition of no interference like soft tissues. With the development of artificial intelligence and machine vision, robot-assisted surgery may help surgeons to fulfill more automatic procedures for craniofacial surgery. Address correspondence and reprint requests to Gang Chai, MD, PhD, College of Medical Instruments, Shanghai University of Medicine & Health Sciences, No. 257, Zhouzhu Highway, Pudong District, Shanghai, China; Department of Plastic and Reconstructive Surgery, Maternal and Child Health Care Hospital of Hainan Province, Haikou 570206, China; Department of Plastic and Reconstructive Surgery, Shanghai 9th People's Hospital, School of Medicine, Shanghai Jiao Tong University, 639 Zhi Zao Ju Rd, Shanghai, 200011, China; e-mail: chaig1081@sh9hospital.org Received 16 October, 2018 Accepted 3 March, 2019 MS and YC contributed equally to this study. This work was supported by Shanghai Municipal Education Commission–Gaofeng Clinical Medicine Grant Support (20161420), Science and Technology Department of Hainan Province (ZDYF2018022), the project of science and technology commission of Shanghai municipality (18DZ2201900, 19441912300, 17411952800, 18441904500). The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Chimeric Lateral Arm Free Flap to Treat Pharyngocutaneous Fistula After Total Laryngectomy Pharyngocutaneous fistula is a major complication after total laryngectomy, leading to a severe adverse impact for the patient and social activity. The reported incidence ranges from 9% to 25% in the last decade. In this paper, the authors present our experience using chimeric lateral arm free flap for reconstruction of the pharyngo-esophageal segment. Eight patients with pharyngocutaneous fistula were treated with this technique. The flap has 2 skin islands, each one supplied by a perforator coming from the main pedicle. One skin island is used as a patch for pharynx closure and the other is used for anterior soft tissue coverage. The follow-up period ranged from 8 months to 3 years. All flaps survived. There was 1 small fistula that was sutured. External skin wound dehiscence was present in 1 case and it was secondary closed by itself. All patients were able to eat by mouth and there were no signs of stricture. The authors preferred this type of flap because both defects are simultaneously closed and each skin paddle is supplied by a perforator coming from the main pedicle. It has a better color match than other free flaps. The skin island is thin and remains thin even after the patients gain weight. Address correspondence and reprint requests to Magdalena Chirila MD, PhD, Emergency District Hospital, Ear Nose and Throat Department, 4-6 Clinicilor Str., 400006, Cluj-Napoca, Romania; E-mail: chirila_magda@yahoo.com Received 14 January, 2019 Accepted 1 April, 2019 The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Comparative Analysis of the Healing Effects of the Transplanted Cell Sheets to the Experimentally Injured Maxillary Sinuses Background: In our study, the authors aimed to obtain a live and functional sinus epithelium with mesenchymal stem cells and nasal mucosa epithelial cells from rabbits which are cultured in temperature-responsive culture plates to get a single-layer. Methodology/Principal: Twenty-two female New Zealand rabbits were included in the study. Two of them were used to obtain mesenchymal stem cells. A total of 40 maxillary sinuses were randomly divided into 5 groups: control group which is used to investigate normal rabbit maxillary mucosa,secondary healing group,mesenchymal stem cell graft group,differentiated mesenchymal stem cell group, andnasal mucosal graft group. The animals were sacrificed at the 28th day after the surgery. Scanning electron microscopy, transmission electron microscopy, and immunohistochemical investigations were performed. Results: With these investigations, it was shown that; all graft groups were histologically better than secondary healing group and when the authors compared the graft groups, differentiated mesenchymal stem cell group were the best. Conclusion: Our study results showed that endoscopic sinus surgery and treatment with cell sheets, which were generated in temperature-responsive culture dishes, had more functional respiratory epithelium. Address correspondence and reprint requests to Ahmet Kara, MD, Sakarya University Training and Research Hospital, 54000, Korucuk, Sakarya, Turkey; E-mail: doktor.kbb@hotmail.com Received 19 February, 2019 Accepted 23 April, 2019 This study has been funded by the Turkey Scientific and Technological Research Center (TUBITAK project number: 113S871). The research protocol was approved by the Kocaeli University Animal Ethics Committee (KOU HADYEK3/7 2013). This was presented at 15th Turkish Rhinology, 7th National Otology-Neurology, and National Head and Neck Congress, April 4–7, 2019; Ankara, Turkey. The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Rigid External Le Fort I Distraction Followed by Secondary Bone Grafting for Maxillary Advancements in Patients With Cleft Lip and Palate Introduction: Maxillary hypoplasia after cleft lip and palate (CLP) repair can result in significant functional and aesthetic impairments. Le Fort I osteotomy & advancement and Le Fort I distraction osteogenesis are standard treatment options for individuals with CLP-associated midface retrusion. However, both of these modalities continue to be associated with a high relapse rate. This study describes surgical outcomes of a 2-stage technique utilizing distraction osteogenesis combined with bone grafting and rigid fixation, which may optimize skeletal stability by reducing relapse. Methods: A retrospective review of CLP patients with severe maxillary hypoplasia evaluated by a single surgeon from 2003 to 2014 was performed. Twenty-one subjects were identified that underwent maxillary advancement via a 2-stage technique: (1) Le Fort I external rigid distraction using a HALO device, followed by (2) autologous iliac crest bone graft application and plate-fixation. Post-operative cephalograms were taken on average 1-year following surgery. Results: Twelve subjects met the inclusion/exclusion criteria. A distraction rate of 1 mm/day was achieved with an average of 14 mm of maxillary advancement. Average increase in SNA was +9.03°, with an increase from 71.84° to 80.88° (normal = 82.0°, P value <0.0001), with no significant change in SNB, and a +9.63° change in ANB from −7.76° to 1.88° (normal = 1.6°, P value <0.0001). Conclusions: The described 2-step procedure had similar cephalometric improvements as compared to distraction osteogenesis alone. However, successive bone grafting and rigid fixation as a second procedure may help ameliorate relapse risk and optimize the correction of maxillary hypoplasia in susceptible populations. Address correspondence and reprint requests to Anthony P. Tufaro DDS, MD, University of Oklahoma Health Sciences Center, Department of Surgery, Division of Plastic Surgery, Chief of Plastic Surgery, 800 Stanton L. Young Blvd, Suite 8300, Oklahoma City, OK 73104; E-mail: anthony-tufaro@ouhsc.edu Received 31 July, 2018 Accepted 24 March, 2019 Dr. Mundinger receives research funding from KLS Martin and is on the advisory board for Polarity TE. The other authors have no other conflicts of interest to disclose. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Evaluation of the Effects of Low-Level Laser Therapy on Diabetic Bone Healing The aim of the present study was to evaluate the effects of low-level laser therapy (LLLT) and biphasic alloplastic bone graft material on diabetic bone healing. Induction of diabetes was performed in 14 male Sprague-Dawley rats by intraperitoneal injection of a 50 mg/kg dose of streptozotocin. Two bilaterally symmetrical non-critical-sized bone defects were created in the parietal bones in each rat. Right defects were filled with biphasic alloplastic bone graft. Rats were randomly divided into 2 groups, with 1 group receiving 10 sessions of LLLT (GaAlAs, 78.5 J/cm2, 100mW, 0.028 cm2 beam). The LLLT was started immediately after surgery and once every 3 days during postoperative period. At the end of treatment period, new bone formation and osteoblast density were determined using histomorphometry. Empty (control), graft-filled, LLLT-treated and both graft-filled and LLLT-treated bone defects were compared. New bone formation was higher in the graft treatment samples compared with the control (P = 0.009) and laser samples (P = 0.029). In addition, graft–laser combination treatment samples revealed higher bone formation than control (P = 0.008) and laser (P = 0.026) samples. Osteoblast density was significantly higher in the laser treatment (P <0.001), graft treatment (P = 0.001) and graft–laser combination treatment (P <0.001) samples than control samples. In addition, significantly higher osteoblast density was observed in the graft-laser combination treatment samples compared to the graft treatment samples (P = 0.005). The LLLT was effective to stimulate osteoblastogenesis but failed to increase bone formation. Graft augmentation for treatment of bone defects seems essential for proper bone healing in diabetes, regeneration may be supported by the LLLT to enhance osteoblastogenesis. Address correspondence and reprint requests to Nurettin Diker, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Bezmialem Vakif University, Adnan Menderes Bulvari, Vatan Caddesi, 34093 Fatih, Istanbul, Turkey; E-mail: ndiker@bezmialem.edu.tr, dikernurettin7tp@gmail.com Received 22 January, 2019 Accepted 24 April, 2019 This study was funded by a Baskent University Research Fund (project no. D-DA 13/09). The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Orthodontics and Dentofacial Orthopedics

Directory: AAO Officers and Organizations Publication date: June 2019 Source: American Journal of Orthodontics and Dentofacial Orthopedics, Volume 155, Issue 6 Author(s):

Craniofacial embryogenetics and development Publication date: June 2019 Source: American Journal of Orthodontics and Dentofacial Orthopedics, Volume 155, Issue 6 Author(s): David S. Carlson

June 2019:155(6) Publication date: June 2019 Source: American Journal of Orthodontics and Dentofacial Orthopedics, Volume 155, Issue 6 Author(s): Dr Allen H. Moffitt

Searching the literature for studies for a systematic review. Part 5: Beyond the standard electronic databases Publication date: June 2019 Source: American Journal of Orthodontics and Dentofacial Orthopedics, Volume 155, Issue 6 Author(s): Anne Littlewood, Dimitrios Kloukos

It's enough to make your hair stand on end Publication date: June 2019 Source: American Journal of Orthodontics and Dentofacial Orthopedics, Volume 155, Issue 6 Author(s): Laurance Jerrold

Comparison of automated grading of digital orthodontic models and hand grading of 3-dimensionally printed models Publication date: June 2019 Source: American Journal of Orthodontics and Dentofacial Orthopedics, Volume 155, Issue 6 Author(s): Jonathan D. Scott, Jeryl D. English, Benjamin E. Cozad, Catharine L. Borders, Lacey M. Harris, Audrey L. Moon, F. Kurtis Kasper Introduction Emerging workflows in orthodontics enable automated analysis of digital models and production of physical study models from digital files for the evaluation of treatment outcomes. The objective of this study was to compare the automated assessment of digital orthodontic models and the hand grading of 3D-printed models with the use of the American Board of Orthodontics cast-radiograph evaluation (ABO CRE) system. Methods Plaster models from 15 cases were scanned with the use of a desktop model scanner to create digital models from which physical models were produced with the use of a stereolithography-based 3D printer. All digital models from each case were graded with the use of an automated software tool (SureSmile), and 3D-printed models were scored by hand with the use of the ABO CRE grading system. All hand-graded models were scored a second time at least 2 weeks later. Results SureSmile gave statistically significantly higher scores to alignment and rotations (P < 0.001), overjet (P < 0.001), occlusal contacts (P < 0.001), and total score (P < 0.001). Hand grading scored higher in buccolingual inclination (P < 0.001). No significant differences were found in marginal ridges, occlusal relationships, and interproximal contacts. Conclusions Scores assessed in an automated manner by SureSmile are generally significantly greater than those assessed by hand grading.

A needle in a haystack: Report of a retained archwire fragment in the pterygomandibular space Publication date: June 2019 Source: American Journal of Orthodontics and Dentofacial Orthopedics, Volume 155, Issue 6 Author(s): Carolyn B. Bradford, Bhavna Shroff, Robert A. Strauss, Daniel M. Laskin This clinical report describes a retained archwire fragment, discovered during a new-patient examination of a young woman seeking orthodontic retreatment. The diagnostic process, care coordination, and patient management decisions are discussed, along with a brief exploration of clinical considerations associated with this incident. A suggested emergency prevention and response protocol is also presented.

A simple approach to correct ectopic eruption of maxillary canines Publication date: June 2019 Source: American Journal of Orthodontics and Dentofacial Orthopedics, Volume 155, Issue 6 Author(s): Jamille Barros Ferreira, Giordani Santos Silveira, José Nelson Mucha This case report describes the orthodontic treatment of a patient with severe crowding; the maxillary right canines were ectopic, positioned far to the buccal side, and superimposed on the lateral incisors in near-transposition. Treatment included extraction of the 4 first premolars. A transpalatal bar was used as an anchorage device, and beta-titanium T-loop springs (0.019 × 0.025″) were used to better control the ideal force applied to retract the maxillary canines. A segmental T-loop spring was used as if it were a modified system of the segmental archwire technique. After the canines were retracted and space created for the anterior teeth, the latter were included in the treatment and the treatment was finished in the usual manner. Excellent results were achieved, both esthetic and functional. The treatment choices and their straightforward approach were appropriate, yielding predictable and stable results in the long term.

A novel approach of torque control for maxillary displaced incisors Publication date: June 2019 Source: American Journal of Orthodontics and Dentofacial Orthopedics, Volume 155, Issue 6 Author(s): Qian Jiang, Ren Yang, Li Mei, Qiaoling Ma, Tuojiang Wu, Huang Li Effective torque control is crucial for the successful treatment of impacted incisors; however, torque control is often a challenge with the use of conventional bracket systems, especially when the adjacent teeth require opposite torque managements. A novel approach of torque control for adjacent anterior teeth is introduced in this case report. A 12-year-old boy had an impacted maxillary right central incisor with the adjacent teeth severely displaced. The treatment plan was to regain space and pull the impacted incisor into the dentition. An upper removable appliance was first used to regain space for the impacted central incisor, followed by a spontaneous eruption of the impacted incisor. Subsequently, fixed appliances were bonded to level and align the dentition. However, the crown of the maxillary right central incisor was found to be tipped lingually, while the maxillary right lateral incisor was tipped labially. Traditional torque control, including torque bend and the use of a Warren spring, were first used for the correction, but they were ineffective due to the overlap of the root apex of the maxillary central incisor and lateral incisor. After the roots were separated with a V-shaped curve, auxiliary brackets were bonded on the gingival one-third areas of the maxillary incisors and canine with nickel-titanium wires used for the torque control. This approach of using the auxiliary brackets and wires was demonstrated to be efficient and effective in the torque control of adjacent anterior teeth with opposite torque control requirements. The final result and the 2-year follow-up records demonstrated the proper torque of anterior teeth and good and stable dental and profile esthetics.

Association of incisal overlaps with /s/ sound and mandibular speech movement characteristics Publication date: June 2019 Source: American Journal of Orthodontics and Dentofacial Orthopedics, Volume 155, Issue 6 Author(s): Ruirui Liu, Anni Hu, Lin Niu, Fang Wang, Yi Lu, Qin Zhou Introduction Modern anterior restorations are intended to achieve esthetic and functional reconstruction and coordination. The positioning of the anterior teeth can affect pronunciation, but the effect of anatomic factors on pronunciation after anterior restoration has not been critically tested. The purpose of this study was to provide possible references for the design of the anterior overlaps in future anterior restorations. Methods Thirty-nine subjects with normal occlusion (NO) participated. They completed questionnaires, were examined clinically, and were recorded pronouncing the /s/ sound. Links between overlaps with spectral features of the /s/ sound and mandibular movements during speech were investigated. Results When NO subjects pronounced the /s/ sound, the average fricative length was 202.54 ± 44.57 ms; the average noise peak was 4052.89 ± 445.80 Hz, which was in the high-frequency region; the center of gravity was 2452.85 ± 623.50 Hz; and the mean intensity was 40.61 ± 4.99 dB. The mandibular speech movements showed a slightly long and narrow backward and downward oblique path. Overbite positively correlated with the /s/ sound's noise peak frequency and negatively correlated with the maximum closing speed. Overjet negatively correlated with the maximum distance in the sagittal plane. Conclusions This is the first attempt to correlate the spectral features of the /s/ sound and speaking movements with incisal overlaps. The results suggest that significant associations exist and that these associations can offer some references for esthetic anterior restoration.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Radiology: Cardiothoracic Imaging

Original Research

Cardiac CT   Prognosis of CT-derived Fractional Flow Reserve in the Prediction of Clinical Outcomes   In this single-center real-world experience of intermediate-term outcomes, it was demonstrated that at a median follow-up of more than 1 year, a positive result at fractional flow reserve (FFR) derived from CT (or FFRCT) analysis was associated with a significantly increased risk of late revascularization and myocardial infarction.  Charis G. McNabney, Stephanie L. Sellers... Jonathan R. Weir-McCall

Commentary   How Well Does CT-derived Fractional Flow Reserve Predict Outcome? Timothy A. Fairbairn, Russell Bull

Cardiac MRI   Free-breathing Cardiorespiratory Synchronized Cine MRI for Assessment of Left and Right Ventricular Volume and Function in Sedated Children and Adolescents with Impaired Breath-holding Capacity   A free-breathing cardiorespiratory synchronized cine sequence acquires the complete cardiac cycle with adequate spatial, contrast, and temporal resolutions for evaluating ventricular morphology, volume, and function with image quality equivalent to that of the standard of reference breath-hold sequence.  Amol S. Pednekar, Siddharth Jadhav, Cory Noel, Prakash

Myocardial Imaging   Stress Myocardial Perfusion PET Provides Incremental Risk Prediction in Patients with and Patients without Diabetes   In this large cohort including nearly 2000 patients with diabetes, myocardial perfusion PET results provide powerful and incremental prognostic information with appropriate reclassification improvement in 39% of patients with diabetes.  Hicham Skali, Marcelo F. Di Carli... Sharmila Dorbala

Pulmonary Imaging   Predicting Outcome in Idiopathic Pulmonary Fibrosis: Addition of Fibrotic Score at Thin-Section CT of the Chest to Gender, Age, and Physiology Score Improves the Prediction Model   Incorporating semiquantitative fibrotic score from thin-section CT to gender, age, and physiology (GAP) score provides an improved prediction model for survival in patients with idiopathic pulmonary fibrosis, especially in early-stage or mild disease.  Anurag Chahal, Roozbeh Sharif... Sushilkumar Sonavane

Commentary   Will Adding Fibrotic Score to the GAP Score Help Predict Patient Survival? Jonathan H. Chung

Vascular Imaging   Two-Minute k-Space and Time–accelerated Aortic Four-dimensional Flow MRI: Dual-Center Study of Feasibility and Impact on Velocity and Wall Shear Stress Quantification   The feasibility of 2-minute aortic four-dimensional flow MRI in 68 healthy volunteers and patients from two centers is shown, providing reproducible velocity and wall shear stress indices sensitive to expected aging- and disease-related aortic hemodynamic alterations. Emilie Bollache, Kristopher D. Knott... Michael Markl

Commentary   Fast and Feasible: Two-Minute k-Space and Time–accelerated Aortic Four-dimensional Flow MRI Christopher J. François

Reviews

Cardiac MRI   Cocaine Abuse: An Attack to the Cardiovascular System—Insights from Cardiovascular MRI   Cardiac MRI has a pivotal role in the diagnostic workflow of cocaine-induced cardiovascular diseases in both acute and chronic settings.   Gianluca De Rubeis, Federica Catapano... Marco Francone

Images in Cardiothoracic Imaging

Pulmonary Imaging   Harlequin Syndrome during Venoarterial Extracorporeal Membrane Oxygenation Chetan Pasrija, Kareem Bedeir, Jean Jeudy, Zachary N. Kon

Clinical Nuclear Medicine

18F-FDG PET/CT in Oral Cuniculatum Carcinoma A 69-year-old woman was referred for initial staging of an oral cavity mass. 18F-FDG PET/CT displayed a homogeneous intense uptake of the 50-mm left hemipalatal mass with local extension to the dental arcade and maxillary sinus. Infracentimetric bilateral cervical nodes with faint uptake were also detected, contrasting with the usual presentation of other head and neck squamous cell carcinoma. Biopsy concluded to a rare head and neck squamous cell carcinoma subtype: oral cuniculatum carcinoma (OCC). After radiotherapy, 18F-FDG PET/CT showed metabolic complete response. Our case describing specifically the metabolic characteristics of OCC and radiotherapy evaluation for this rare tumor. Received for publication February 11, 2019; revision accepted May 1, 2019. Conflicts of interest and sources of funding: none declared. Correspondence to: Sébastien Dejust, MD, Service de Médecine Nucléaire, Institut Jean Godinot, 1 Rue du Général Koenig, 51100 Reims, France. E-mail: sebastien.dejust@reims.unicancer.fr. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Incidental Detection of Ovarian Thecoma by 99mTc-MDP Whole-Body Bone Scan: Contribution of Hybrid SPECT/CT Ovarian thecoma is a benign and rare neoplasm that accounts for 0.5% to 1% of all ovarian tumors. A 55-year-old woman with known breast cancer underwent a metastatic workup before surgery. The 99mTc-MDP whole-body bone scan revealed intense uptake in the left pelvic region. Hybrid SPECT/CT imaging showed that the elevated 99mTc-MDP activity was in a tumor with calcification in the left adnexa. Dynamic enhanced MRI revealed marked enhancement of the tumor. Resection of the tumor was subsequently performed, and pathologic analysis confirmed the diagnosis of an ovarian thecoma. Received for publication February 5, 2019; revision accepted May 5, 2019. L.Z. and Q.H. contributed equally to this work. Conflicts of interest and sources of funding: none declared. Correspondence to: Rusen Zhang, MD, Department of Nuclear Medicine, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, 78 Hengzhigang Road, Guangzhou, Guangdong 510095, China. E-mail: zhangrusen2015@163.com. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

68Ga-PSMA-617 Compared With 68Ga-RM2 and 18F-FCholine PET/CT for the Initial Staging of High-Risk Prostate Cancer 68Ga-labeled prostate-specific membrane antigen inhibitors and 68Ga-labeled gastrin-releasing peptide receptor antagonists showed interesting results for staging biochemically recurrent prostate cancer. In this case, 68Ga–prostate-specific membrane antigen-617 PET/CT, 68Ga-RM2 PET/CT, and 18F-choline PET/CT were performed in a patient (66-year-old man, prostate-specific antigen = 6.7 ng/mL) with biopsy-proven Gleason 9 (5 + 4) prostate cancer, candidate for radical prostatectomy and lymph node dissection. Received for publication January 3, 2019; revision accepted May 3, 2019. Conflict of interest and sources of funding: This study was funded by the University Hospital of Bordeaux under grant AOI 2016 and was achieved within the context of the Laboratory of Excellence TRAIL ANR-10-LABX-57. None declared to all authors. Correspondence to: Clément Morgat, PharmD, PhD, Nuclear Medicine Department, University Hospital of Bordeaux, Place Amélie Raba Léon, 33076 Bordeaux, France. E-mail: clement.morgat@u-bordeaux.fr. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Low 68Ga–PSMA PET/CT Uptake in Chronic Intramuscular Nodular Fasciitis Nodular fasciitis is an uncommon benign mass-forming myofibroblastic proliferation, most frequently found in the upper limbs, with only rare intramuscular cases. We describe herein a case of chronic nodular fasciitis of the left triceps muscle with a low 68Ga-labeled prostate-specific membrane antigen (PSMA) ligand uptake on PET/CT. 68Ga-PSMA ligands bind to PSMA-expressing prostate cancer cells, but uptake has also been demonstrated in other solid neoplasms and various benign lesions. Nodular fasciitis should be included in the differential diagnosis of soft tissue lesions with variable 68Ga-PSMA uptake. Received for publication April 15, 2019; revision accepted May 4, 2019. Conflicts of interest and sources of funding: none declared. Author Contributions: N.P. followed up on the PET/CT, reviewed the patient's medical records, and drafted the manuscript. C.A. acted as an expert consultant for the case and revised the manuscript. I.K. initially reported the PSMA PET/CT and revised the manuscript. P.F. revised the manuscript for important intellectual content. Correspondence to: Nicolas Plouznikoff, MD, PhD, FRCPC, Service de Médecine Nucléaire, Centre Hospitalier de l'Université de Montréal (CHUM), 1051 rue Sanguinet, Montréal, Quebec, Canada H2X 0C1. E-mail: nicolas.plouznikoff@umontreal.ca. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

18F-FDG PET/CT in Lymphomatoid Papulosis Mimicking Primary Cutaneous Anaplastic Large Cell Lymphoma Lymphomatoid papulosis is a benign self-healing condition, presenting as papulonodular skin eruptions and mimicking malignant cutaneous lymphomas histopathologically. 18F-FDG PET/CT findings in this benign condition have not been described in detail in the literature. We present a case of lymphomatoid papulosis mimicking primary cutaneous anaplastic large cell lymphoma histopathologically and demonstrating intensely FDG-avid cutaneous lesions on 18F-FDG PET/CT, which disappear spontaneously in the follow-up scan. Received for publication March 4, 2019; revision accepted May 4, 2019. Conflicts of interest and sources of funding: none declared. Correspondence to: Raja Senthil, MD, Department of Nuclear Medicine and PET/CT, VPS Lakeshore Hospital, Maradu, Nettoor (PO), Kochi, Kerala 682040, India. E-mail: senthilrajapgi@yahoo.com. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Multiple Solitary Plasmacytomas With Multifocal Bone Involvement Diagnosed With 68Ga–Prostate-Specific Membrane Antigen PET/CT A 63-year-old man with elevated prostate-specific antigen serum levels and enlarged prostate gland underwent ultrasound-guided transrectal biopsy, which did not reveal any evidence of malignancy. In order to help guidance of repeat biopsy, 68Ga–prostate-specific membrane antigen–targeted ligand PET (PSMA PET/CT) was ordered. PET/CT scan showed no abnormal PSMA expression within the prostate gland. There were, however, multiple PSMA-expressing osteolytic lesions throughout the axial skeleton. Bone lesion biopsy obtained for final workup revealed multiple solitary plasmacytomas with multifocal bone involvement. This rare case highlights the utility of PSMA PET/CT in diagnosing nonprostate malignancies. Received for publication April 22, 2019; revision accepted May 11, 2019. Conflicts of interest and sources of funding: none declared. This article has not been published before or is not under consideration for publication anywhere else and has been approved by the author in the title page. Correspondence to: Yazan Z. Alabed, MD, PhD, Department of Nuclear Medicine, PET/CT Unit, Gulf International Cancer Center, PO Box 5882, Abu Dhabi, United Arab Emirates. E-mail: yazan.alabed@gmail.com. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Pearls in the Wrong Pockets: Idiopathic Scrotal Calcinosis Idiopathic scrotal calcinosis, also called dystrophic scrotal calcinosis, is a rare benign condition that causes superficial intradermal scrotal calcifications. We present one such case of a 40-year-old married man who underwent PET/CT scan for staging workup of lymphoma and revealed this rare entity incidentally without any other testicular pathology. Received for publication February 9, 2019; revision accepted May 11, 2019. Conflicts of interest and sources of funding: none declared. Correspondence to: Pir Abdul Ahad Aziz Qureshi, MBBS, FCPS, Department of Radiology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, 7-A Block R-3, M.A. Johar Town, Lahore, Punjab, Pakistan 54770. E-mail: abdulahadaziz@skm.org.pk. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Propionibacterium acnes Pacemaker Endocarditis in a Patient With a Redundant Loop of the Ventricular Lead: PET/CT Findings A 59-year-old man with a pacemaker who was admitted for evaluation of fever was found to have a redundant loop of the ventricular lead and a vegetation attached to it. An FDG PET/CT revealed a focus of FDG uptake at the ventricular lead loop. Surgical extraction of the pacemaker device confirmed a Propionibacterium acnes pacemaker endocarditis. We hypothesize that the redundant loop of the ventricular lead induced a chronic mechanical stress both to the tricuspid valve and to the lead itself, facilitating the bacterial colonization of the lead. Received for publication April 25, 2019; revision accepted May 17, 2019. Conflicts of interest and sources of funding: none declared. This has not been submitted or presented elsewhere in any form. Correspondence to: Luis Gorospe, MD, Department of Radiology, Ramón y Cajal University Hospital, Ctra. de Colmenar Viejo Km 9.100, 28034 Madrid, Spain. E-mail: luisgorospe@yahoo.com. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Diverse Behavior in 18F-Fluorocholine PET/CT of Brain Tumors in Patients With Neurofibromatosis Type 1 Neurofibromatosis type 1 (NF1) is an autosomal dominant disorder that causes CNS tumors in around 20% of patients, being pilocytic astrocytomas (PA), and particularly optic pathway gliomas (OPG), the most common. We present three cases of NF1 patients referred for 18F-fluorocholine PET/CT because of suspected glioma in the setting of ongoing FUMEGA (Functional and Metabolic Glioma Analysis) trial. One case turned out to be a WHO grade I ganglioglioma; the second was a high grade glioma; and the last one (negative in PET) a probable low-grade glioma. Received for publication November 8, 2018; revision accepted April 14, 2019. No disclaimer. All the authors have participated in the writing and revision of this article and take public responsibility for its content. The present publication is approved by all authors and by the responsible authorities where the work was carried out. All the authors confirm the fact that the article is not under consideration for publication elsewhere. Compliance with Ethical Standards. Conflicts of interest and sources of funding: none declared. Research involving Human Participants and/or Animals: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent: Informed consent was obtained from all individual participants included in the study. Correspondence to: Francisco José Pena Pardo, MD, Nuclear Medicine Department, University General Hospital, C/ Obispo Rafael Torija s/n. 13005, Ciudad Real, Spain. E-mail: fjpena@msn.com. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Asymptomatic Bone Marrow Edema Detected by 67Ga Scintigraphy A 46-year-old woman presented with a complaint of fever. CRP was 2.1 mL/L in blood, white blood cell count was 20–29/hpf, and bacterial count was 3418/μL in a urinalysis. 67Ga scan revealed accumulation of 67Ga in the left distal femur, although she had no symptoms around the site. MRI demonstrated diffuse high signal intensity on T2-weighted STIR images. Osteomyelitis was suspected, and biopsy was performed. Bacterial culture of the bone marrow was negative, and histological examination showed no infiltration of inflammatory cells. Two months after the biopsy, disappearance of altered signal intensity of MRI was observed. Received for publication February 15, 2019; revision accepted April 27, 2019. Conflicts of interest and sources of funding: none declared. Correspondence to: Shinji Miwa, MD, PhD, Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan. E-mail: smiwa001@yahoo.co.jp. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Alexandros Sfakianakis
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Pediatric Critical Care Medicine

The Base Deficit, International Normalized Ratio, and Glasgow Coma Scale (BIG) Score, and Functional Outcome at Hospital Discharge in Children With Traumatic Brain Injury Objectives: To examine the association of the base deficit, international normalized ratio, and Glasgow Coma Scale (BIG) score on emergency department arrival with functional dependence at hospital discharge (Pediatric Cerebral Performance Category ≥ 4) in pediatric multiple trauma patients with traumatic brain injury. Design: A retrospective cohort study of a pediatric trauma database from 2001 to 2018. Setting: Level 1 trauma program at a university-affiliated pediatric institution. Patients: Two to 17 years old children sustaining major blunt trauma including a traumatic brain injury and meeting trauma team activation criteria. Interventions: None. Measurements and Main Results: Two investigators, blinded to the BIG score, determined discharge Pediatric Cerebral Performance Category scores. The BIG score was measured on emergency department arrival. The 609 study patients were 9.7 ± 4.4 years old with a median Injury Severity Score 22 (interquartile range, 12). One-hundred seventy-one of 609 (28%) had Pediatric Cerebral Performance Category greater than or equal to 4 (primary outcome). The BIG constituted a multivariable predictor of Pediatric Cerebral Performance Category greater than or equal to 4 (odds ratio, 2.39; 95% CI, 1.81–3.15) after adjustment for neurosurgery requirement (odds ratio, 2.83; 95% CI, 1.69–4.74), pupils fixed and dilated (odds ratio, 3.1; 95% CI, 1.49–6.38), and intubation at the scene or referral hospital (odds ratio, 2.82; 95% CI, 1.35–5.87) and other postulated predictors of poor outcome. The area under the BIG receiver operating characteristic curve was 0.87 (0.84–0.90). Using an optimal BIG cutoff less than or equal to 8, sensitivity and negative predictive value for functional dependence at discharge were 93% and 96%, respectively, compared with a sensitivity of 79% and negative predictive value of 91% with Glasgow Coma Scale less than or equal to 8. In children with Glasgow Coma Scale 3, the BIG score was associated with brain death (odds ratio, 2.13; 95% CI, 1.58–2.36). The BIG also predicted disposition to inpatient rehabilitation (odds ratio, 2.26; 95% CI, 2.17–2.35). Conclusions: The BIG score is a simple, rapidly obtainable severity of illness score that constitutes an independent predictor of functional dependence at hospital discharge in pediatric trauma patients with traumatic brain injury. The base deficit, international normalized ratio, and Glasgow Coma Scale score may benefit Trauma and Neurocritical care programs in identifying ideal candidates for traumatic brain injury trials within the therapeutic window of treatment. Presented, in part, as oral presentations at the: 1) Trauma Association of Canada meeting, Toronto, ON, Canada, February 23, 2018; and 2) Pediatric Academic Societies meeting, Toronto, ON, Canada, May 6, 2018. Drs. Davis, Hochstadter, and Schuh conceived the study and wrote the protocol. Dr. Davis supervised data collection by Drs. Hochstadter and Daya. Mr. Stephens performed the data analysis. Drs. Davis, Hochstadter, and Schuh drafted the article and Drs. Davis, Hochstadter, Daya, Kulkarni, Wales, and Schuh contributed substantially to its revision. All authors take responsibility for the article as a whole. The authors have disclosed that they do not have any potential conflicts of interest. Address requests for reprints to: Adrienne Davis, MD, MSc, FRCPC, Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada. E-mail: adrienne.davis@sickkids.ca ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Endothelial-Dependent Vasomotor Dysfunction in Infants After Cardiopulmonary Bypass Objectives: Cardiopulmonary bypass–induced endothelial dysfunction has been inferred by changes in pulmonary vascular resistance, alterations in circulating biomarkers, and postoperative capillary leak. Endothelial-dependent vasomotor dysfunction of the systemic vasculature has never been quantified in this setting. The objective of the present study was to quantify acute effects of cardiopulmonary bypass on endothelial vasomotor control and attempt to correlate these effects with postoperative cytokines, tissue edema, and clinical outcomes in infants. Design: Single-center prospective observational cohort pilot study. Setting: Pediatric cardiac ICU at a tertiary children's hospital. Patients: Children less than 1 year old requiring cardiopulmonary bypass for repair of a congenital heart lesion. Intervention: None. Measurements and Main Results: Laser Doppler perfusion monitoring was coupled with local iontophoresis of acetylcholine (endothelium-dependent vasodilator) or sodium nitroprusside (endothelium-independent vasodilator) to quantify endothelial-dependent vasomotor function in the cutaneous microcirculation. Measurements were obtained preoperatively, 2–4 hours, and 24 hours after separation from cardiopulmonary bypass. Fifteen patients completed all laser Doppler perfusion monitor (Perimed, Järfälla, Sweden) measurements. Comparing prebypass with 2–4 hours postbypass responses, there was a decrease in both peak perfusion (p = 0.0006) and area under the dose-response curve (p = 0.005) following acetylcholine, but no change in responses to sodium nitroprusside. Twenty-four hours after bypass responsiveness to acetylcholine improved, but typically remained depressed from baseline. Conserved endothelial function was associated with higher urine output during the first 48 postoperative hours (R2 = 0.43; p = 0.008). Conclusions: Cutaneous endothelial dysfunction is present in infants immediately following cardiopulmonary bypass and recovers significantly in some patients within 24 hours postoperatively. Confirmation of an association between persistent endothelial-dependent vasomotor dysfunction and decreased urine output could have important clinical implications. Ongoing research will explore the pattern of endothelial-dependent vasomotor dysfunction after cardiopulmonary bypass and its relationship with biochemical markers of inflammation and clinical outcomes. The views expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government. Dr. Krispinsky is a military service member. This work was prepared as part of his official duties. Title 17 U.S.C. 105 provides that "Copyright protection under this title is not available for any work of the U.S. Government." Title 17 U.S.C. 101 defines a U.S. Government work as a work prepared by a military service member or employee of the U.S. Government as part of that person's official duties. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). Supported, in part, by grants from Vanderbilt University Medical Center. Dr. Stark is supported by a grant from the National Institute of General Medical Sciences (K08 GM117367). Dr. Krispinsky disclosed government work. Dr. Stark's institution received funding from the National Institutes of Health (NIH), and he received support for article research from the NIH. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: luke.t.krispinsky.mil@mail.mil Address requests for reprints to: Fred S. Lamb, MD, PhD, Pediatric Critical Care, Vanderbilt Children's Hospital, 2200 Children's Way, 5111 Doctors' Office Tower, Nashville, TN 37232. E-mail: fred.s.lamb@vanderbilt.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Current Epidemiology of Vocal Cord Dysfunction After Congenital Heart Surgery in Young Infants Objectives: Surgery of the aortic arch poses risk of recurrent laryngeal nerve injury due to the anatomic proximity and can manifest as vocal cord dysfunction after surgery. We assessed risk factors for vocal cord dysfunction and calculated surgical procedure associated rates in young infants after congenital heart surgery. Design: Cross section analysis. Setting: Forty-four children's hospitals reporting administrative data to Pediatric Health Information System. Participants: Cardiac surgical patients less than or equal to 90 days old and discharged between January 2004 and June 2014. Interventions: None. Measurements and Main Results: Overall, 2,319 of 46,567 subjects (5%) had vocal cord dysfunction, increasing from 4% to 7% over the study period. Of those with vocal cord dysfunction, 75% had unilateral partial paralysis. Vocal cord dysfunction was significantly more common in newborn infants (74%), those with aortic arch procedures (77%) and with greater surgical complexity. Rates of vocal cord dysfunction ranged from 0.7% to 22.4% across surgical procedure groups. Vocal cord dysfunction was significantly associated with greater use of: prolonged mechanical ventilation (53% vs 40%), diaphragmatic plication (3% vs 1%), feeding tube use (32% vs 8%), surgical airways (4% vs 2%), and prolonged length of stay (44 vs 21 d). Vocal cord dysfunction testing increased significantly over the study (6–14 %), and vocal cord dysfunction diagnosis increased almost two-fold (odds ratio, 1.9; 95% CI, 1.7–2.1) comparing the last to first study quarters with the increase in vocal cord dysfunction diagnosis occurring predominately in surgeries to the aortic arch supported by cardiopulmonary bypass. However, aortic procedures without cardiopulmonary bypass and nonaortic arch procedures were common surgeries accounting for 27% and 23% of vocal cord dysfunction cases despite low overall vocal cord dysfunction rates (3.7% and 2.6%). Conclusions: Vocal cord dysfunction complicated all cardiac surgical procedures among infants including those without aortic arch involvement. Increased efforts to determine appropriate indications for prevention, screening and treatment of vocal cord dysfunction among young infants after congenital heart surgery are needed. This work was performed at the University of Utah. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http:/journals.lww.com/pccmjournal). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: Susan.Bratton@hsc.utah.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Anemia at Discharge From PICU: A Bicenter Descriptive Study Objective: To determine the prevalence and risk markers of anemia at PICU discharge. Design: Bicenter retrospective cohort study. Setting: Two multidisciplinary French PICUs. Patients: All children admitted during a 5-year period, staying in the PICU for at least 2 days, and for whom a hemoglobin was available at PICU discharge. Interventions: None. Measurements and Main Results: Patient, admission, and PICU stay characteristics were retrospectively collected in the electronic medical records of each participating PICU. Anemia was defined according to the World Health Organization criteria. Among the 3,170 patients included for analysis, 1,868 (58.9%) were anemic at discharge from PICU. The proportion of anemic children differed between age categories, whereas the median hemoglobin level did not exhibit significant variations according to age. After multivariate adjustment, anemia at PICU admission was the strongest predictor of anemia at PICU discharge, and the strength of this association varied according to age (interaction). Children anemic at PICU admission had a reduced risk of anemia at PICU discharge if transfused with RBCs during the PICU stay, if less than 6 months old, or if creatinine level at PICU admission was low. Children not anemic at PICU admission had an increased risk of anemia at PICU discharge if they were thrombocytopenic at PICU admission, if they had higher C-reactive protein levels, and if they received plasma transfusion, inotropic/vasopressor support, or mechanical ventilation during the PICU stay. Conclusions: Anemia is frequent after pediatric critical illness. Anemia status at PICU admission defines different subgroups of critically ill children with specific prevalence and risk markers of anemia at PICU discharge. Further studies are required to confirm our results, to better define anemia during pediatric critical illness, and to highlight the causes of post-PICU stay anemia, its course, and its association with post-PICU outcomes. This work was performed at the Hôpital Universitaire Jeanne de Flandre, Service de Réanimation Pédiatrique 2, Avenue Eugène Avinée, 59037 Lille Cedex, France, and Hôpital Universitaire Femme Mère Enfant, Hospices Civils de Lyon, Service de Réanimation Pédiatrique, 59, Boulevard Pinel, 69677 Lyon-Bron, France. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: pierre.demaret@chc.be ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Epidemiologic Trends of Adoption of Do-Not-Resuscitate Status After Pediatric In-Hospital Cardiac Arrest Objectives: To evaluate the prevalence of do-not-resuscitate status, assess the epidemiologic trends of do-not-resuscitate status, and assess the factors associated with do-not-resuscitate status in children after in-hospital cardiac arrest using large, multi-institutional data. Design: Generalized estimating equations logistic regression model was used to evaluate the trends of do-not-resuscitate status and evaluate the factors associated with do-not-resuscitate status after cardiac arrest. Setting: American Heart Association's Get With the Guidelines-Resuscitation Registry. Patients: Children (< 18 yr old) with an index in-hospital cardiac arrest and greater than or equal to 1 minute of documented chest compressions were included (2006–2015). Patients with no return of spontaneous circulation after cardiac arrest were excluded. Interventions: None. Measurements and Main Results: In total, 8,062 patients qualified for inclusion. Of these, 1,160 patients (14.4%) adopted do-not-resuscitate status after cardiac arrest. We found low rates of survival to hospital discharge among children with do-not-resuscitate status (do-not-resuscitate vs no do-not-resuscitate: 6.0% vs 69.7%). Our study found that rates of do-not-resuscitate status after cardiac arrest are highest in children with Hispanic ethnicity (16.4%), white race (15.0%), and treatment at institutions with larger PICUs (> 50 PICU beds: 17.8%) and at institutions located in North Central (17.6%) and South Atlantic/Puerto Rico (17.1%) regions of the United States. Do-not-resuscitate status was more common among patients with more preexisting conditions, longer duration of cardiac arrest, greater than 1 cardiac arrest, and among patients requiring extracorporeal cardiopulmonary resuscitation. We also found that trends of do-not-resuscitate status after cardiac arrest in children are decreasing in recent years (2013–2015: 13.8%), compared with previous years (2006–2009: 16.0%). Conclusions: Patient-, hospital-, and regional-level factors are associated with do-not-resuscitate status after pediatric cardiac arrest. As cardiac arrest might be a signal of terminal chronic illness, a timely discussion of do-not-resuscitate status after cardiac arrest might help families prioritize quality of end-of-life care. The group authors contributing for the American Heart Association's Get With The Guidelines-Resuscitation Investigators are: Anne-Marie Guerguerian, Elizabeth Foglia, Ericka Fink, Javier J. Lasa, Michael Gaies, Monica Kleinman, Robert Sutton, Taylor L. Sawyer. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). Dr. Parshuram disclosed that he is the named inventor of the Bedside Paediatric Early Warning System. The patent is owned by his institution, the Hospital for Sick Children. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: punkaj_gupta@hotmail.com ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Risk Factors for Mortality in Critically Ill Children Requiring Renal Replacement Therapy Objectives: There is an increased mortality risk in critically ill children who require renal replacement therapy for acute kidney injury and fluid overload. Nevertheless, renal replacement therapy is essential in managing these patients. The objective of this study was to identify risk factors for mortality in critically ill children requiring renal replacement therapy. Design: Single-center, retrospective cohort analysis. Setting: Tertiary care children's hospital. Patients: All patients admitted to an ICU at Boston Children's Hospital from January 2009 to December 2017 who required any form of renal replacement therapy. Interventions: None. Measurements and Main Results: Four-hundred sixty-three patients required inpatient renal replacement therapy over the study period. Of these, there were 98 patients who had 99 unique encounters for renal replacement therapy that met eligibility criteria for analysis. The most common diagnoses were respiratory failure, stem cell transplant, and sepsis. The overall mortality was 55.6%. Nonsurvivors had a lower ICU admission weight compared with survivors (30.0 kg vs 44.0 kg; p = 0.037) and a higher degree of fluid accumulation at the time of renal replacement therapy initiation (17.1% vs 8.1%; p = 0.021). In multivariable logistic regression analysis, invasive mechanical ventilation (odds ratio, 7.22; 95% CI, 1.88–27.7), a longer duration of stage 3 acute kidney injury (odds ratio, 1.08; 95% CI, 1.02–1.15), and higher fluid balance in the 72 hours after initiating renal replacement therapy (odds ratio, 1.12; 95% CI, 1.05–1.20) were associated with an increased odds of mortality. Conclusions: Earlier renal replacement therapy initiation with respect to the development of severe acute kidney injury was associated with lower mortality in this cohort of critically ill children. Additionally, invasive mechanical ventilation at the time of renal replacement therapy initiation and a higher degree of fluid accumulation after initiating renal replacement therapy were associated with increased mortality. We confirm that this article has not been published elsewhere and is not under consideration by another journal. All authors have approved the final version of this article and agree with submission to Pediatric Critical Care Medicine. The authors have disclosed that they do not have any potential conflicts of interest. This study was performed at Boston Children's Hospital, Boston, MA. For information regarding this article, E-mail: Daniel.hames@childrens.harvard.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Rapid Whole Genome Sequencing Has Clinical Utility in Children in the PICU Objectives: Genetic disorders are a leading contributor to mortality in the neonatal ICU and PICU in the United States. Although individually rare, there are over 6,200 single-gene diseases, which may preclude a genetic diagnosis prior to ICU admission. Rapid whole genome sequencing is an emerging method of diagnosing genetic conditions in time to affect ICU management of neonates; however, its clinical utility has yet to be adequately demonstrated in critically ill children. This study evaluates next-generation sequencing in pediatric critical care. Design: Retrospective cohort study. Setting: Single-center PICU in a tertiary children's hospital. Patients: Children 4 months to 18 years admitted to the PICU who were nominated between July 2016 and May 2018. Interventions: Rapid whole genome sequencing with targeted phenotype-driven analysis was performed on patients and their parents, when parental samples were available. Measurements and Main Results: A molecular diagnosis was made by rapid whole genome sequencing in 17 of 38 children (45%). In four of the 17 patients (24%), the genetic diagnoses led to a change in management while in the PICU, including genome-informed changes in pharmacotherapy and transition to palliative care. Nine of the 17 diagnosed children (53%) had no dysmorphic features or developmental delay. Eighty-two percent of diagnoses affected the clinical management of the patient and/or family after PICU discharge, including avoidance of biopsy, administration of factor replacement, and surveillance for disorder-related sequelae. Conclusions: This study demonstrates a retrospective evaluation for undiagnosed genetic disease in the PICU and clinical utility of rapid whole genome sequencing in a portion of critically ill children. Further studies are needed to identify PICU patients who will benefit from rapid whole genome sequencing early in PICU admission when the underlying etiology is unclear. The views expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). Supported, in part, by grant U19HD077693 from National Institute of Child Health and Human Development and National Human Genome Research Institute. Drs. Sanford's, Briggs's, Watkins's, and Dimmock's institution received funding from Grant U19HD077693 from National Institute of Child Health and Human Development and National Human Genome Research Institute (NHGRI). Drs. Sanford, Clark, Farnaes, Bainbridge, Watkins, Chowdhury, Dimmock, and Kingsmore received support for article research from the National Institutes of Health (NIH). Dr. Sanford also received support for article research from NHGRI. Dr. Briggs disclosed that he is employed by the U.S. Navy. Drs. Bainbridge's and Kingsmore's institutions received funding from the NIH. Dr. Bainbridge disclosed that he is a founder of Codified Genomics LLC. Dr. Dimmock received funding from Biomarin (consultant for Pegvaliase trials), Audentes Therapeutics (Scientific Advisory Board), and Ichorion Therapeutics (consultant for mitochondrial disease drugs). The remaining authors have disclosed that they do not have any potential conflicts of interest. The RCIGM investigators are: Sergey Batalov, Sara Caylor, Katarzyna Ellsworth, Jennifer Friedman, Lisa Salz, Mari Tokita, Kristen Wigby, and Terence Wong. For information regarding this article, E-mail: ncoufal@ucsd.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Factors Impacting Physician Recommendation for Tracheostomy Placement in Pediatric Prolonged Mechanical Ventilation: A Cross-Sectional Survey on Stated Practice Objectives: To characterize the stated practices of qualified Canadian physicians toward tracheostomy for pediatric prolonged mechanical ventilation and whether subspecialty and comorbid conditions impact attitudes toward tracheostomy. Design: Cross sectional web-based survey. Subjects: Pediatric intensivists, neonatologists, respirologists, and otolaryngology-head and neck surgeons practicing at 16 tertiary academic Canadian pediatric hospitals. Interventions: Respondents answered a survey based on three cases (Case 1: neonate with bronchopulmonary dysplasia; Cases 2 and 3: children 1 and 10 years old with pediatric acute respiratory distress syndrome, respectively) including a series of alterations in relevant clinical variables. Measurements and Main Results: We compared respondents' likelihood of recommending tracheostomy at 3 weeks of mechanical ventilation and evaluated the effects of various clinical changes on physician willingness to recommend tracheostomy and their impact on preferred timing (≤ 3 wk or > 3 wk of mechanical ventilation). Response rate was 165 of 396 (42%). Of those respondents who indicated they had the expertise, 47 of 121 (38.8%), 23 of 93 (24.7%), and 40 of 87 (46.0%) would recommend tracheostomy at less than or equal to 3 weeks of mechanical ventilation for cases 1, 2, and 3, respectively (p < 0.05 Case 2 vs 3). Upper airway obstruction was associated with increased willingness to recommend earlier tracheostomy. Life-limiting condition, severe neurologic injury, unrepaired congenital heart disease, multiple organ system failure, and noninvasive ventilation were associated with a decreased willingness to recommend tracheostomy. Conclusion: This survey provides insight in to the stated practice patterns of Canadian physicians who care for children requiring prolonged mechanical ventilation. Physicians remain reluctant to recommend tracheostomy for children requiring prolonged mechanical ventilation due to lung disease alone at 3 weeks of mechanical ventilation. Prospective studies characterizing actual physician practice toward tracheostomy for pediatric prolonged mechanical ventilation and evaluating the impact of tracheostomy timing on clinically important outcomes are needed as the next step toward harmonizing care delivery for such patients. This work was performed at Children's Hospital of Eastern Ontario/University of Ottawa. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). Supported, in part, by a Children's Hospital of Eastern Ontario Research Institute resident research grant. Value: $1,500. Drs. Meyer-Macaulay institution received funding from Children's Hospital of Eastern Ontario Research Institute. Dr. Katz's institution received funding from Canadian Institutes of Health Research, Ontario Thoracic Society, Jesse's Journey, and Muscular Dystrophy Canada, and she received funding from Biogen (speaker's bureau) and Connect Experts (medical expert opinion). Dr. Jouvet's institution received funding from Air Liquide Sante, and he disclosed that Philips and Hamilton Medical lent medical devices. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: cmeyermacaulay@gmail.com ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Acquired von Willebrand Syndrome in Pediatric Extracorporeal Membrane Oxygenation Patients: A Single Institution's Experience Objectives: 1) Describe the prevalence of acquired von Willebrand syndrome in pediatric patients undergoing extracorporeal membrane oxygenation deemed to be at increased risk for the disease in our institution, 2) discuss the challenges of testing for acquired von Willebrand syndrome diagnosis, 3) describe the characteristics of the patient population found to have acquired von Willebrand syndrome and their outcomes, and 4) discuss the potential implications of acquired von Willebrand syndrome on bleeding complications. Design: Retrospective chart review. Setting: PICU and cardiovascular ICU in a single institution. Patients: All PICU and cardiovascular ICU extracorporeal membrane oxygenation patients 0–18 years old who underwent screening for acquired von Willebrand syndrome between January 2014 and December 2016. Interventions: Humate P administration to a small subset of acquired von Willebrand syndrome positive subjects. Measurements and Main Results: Laboratory data of identified patients were analyzed. The diagnosis of acquired von Willebrand syndrome was made based on decreased ristocetin cofactor activity to von Willebrand factor antigen ratio and/or abnormal multimer analysis. Clinical data were extracted from the chart and through the Pediatric Extracorporeal Membrane Oxygenation Outcome Registry to describe the demographics, comorbidities, and outcomes of this patient population. In the 2 years, 29 patients had laboratory testing performed for surveillance and in cases of clinical bleeding. Of these, 23 (79%) were positive by criteria. No significant difference in mortality rate was found between patients with acquired von Willebrand syndrome versus without. We also did not find a significant difference in the blood product utilization or bleeding complications between patients with acquired von Willebrand syndrome versus without. Humate P was administered in 39% of patients (9/23) who were positive for acquired von Willebrand syndrome, but no significant difference was seen in blood product utilization or bleeding complications between acquired von Willebrand syndrome patients receiving Humate P versus those who did not. Conclusions: Acquired von Willebrand syndrome is a common but under recognized disorder in pediatric extracorporeal membrane oxygenation patients. The clinical implications of this disorder on bleeding and its potential treatments are still unclear. Supported, in part, by grant from the Division of Pediatric Critical Care of Baylor College of Medicine. Dr. Teruya received funding from STAGO, Evaheart, and Octapharma. The remaining authors have disclosed that they do not have any potential conflicts of interest. This work was performed at the Texas Children's Hospital. The article falls under nonhuman subject category and was approved by the Baylor College of Medicine Institutional Review Board. For information regarding this article, E-mail: axruth@texaschildrens.org ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Specific Viral Etiologies Are Associated With Outcomes in Pediatric Acute Respiratory Distress Syndrome Objectives: Infectious pneumonia is the most common cause of acute respiratory distress syndrome, with viruses frequently implicated as causative. However, the significance of viruses in pediatric acute respiratory distress syndrome is unknown. We aimed to characterize the epidemiology of viral pneumonia in pediatric acute respiratory distress syndrome and compare characteristics and outcomes between pneumonia subjects with and without viruses. Secondarily, we examined the association between specific viruses and outcomes. Design: We performed a secondary analysis of a prospectively enrolled pediatric acute respiratory distress syndrome cohort. Subjects with pneumonia acute respiratory distress syndrome underwent testing of respiratory secretions for viruses and culture for bacteria and fungi and were stratified according to presence or absence of a virus. Setting: Tertiary care children's hospital. Patients: Children with acute respiratory distress syndrome. Interventions: None. Measurements and Main Results: Of 544 children with acute respiratory distress syndrome, 282 (52%) had pneumonia as their inciting etiology, of whom 212 were virus-positive. In 141 of 282 (50%) pneumonia acute respiratory distress syndrome cases, a virus was the sole pathogen identified. Virus-positive pneumonia had fewer organ failures but worse oxygenation, relative to virus-negative pneumonia, with no differences in antibiotic use, ventilator duration, or mortality. Subjects with respiratory syncytial virus-associated acute respiratory distress syndrome had lower mortality (0%), and subjects with influenza-associated acute respiratory distress syndrome had shorter ventilator duration, relative to other viral acute respiratory distress syndrome. Nonadeno herpesviruses, tested for exclusively in immunocompromised subjects, had greater than 80% mortality. Conclusions: Pneumonia was the most common cause of pediatric acute respiratory distress syndrome, and viruses were commonly isolated as the sole pathogen. Respiratory syncytial virus and influenza were associated with better outcomes relative to other viral etiologies. Viral pneumonias in immunocompromised subjects, particularly nonadeno herpesviruses, drove the mortality rate for pneumonia acute respiratory distress syndrome. Specific viral etiologies are associated with differential outcomes in pediatric acute respiratory distress syndrome and should be accounted for in future studies. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/pccmjournal). Dr. Thomas's institution received funding from Gene Fluidics, and he received funding from Therabron and CareFusion. Dr. Yehya's institution received funding from the National Institutes of Health (NIH) (K23-HL136688)/National Heart, Lung, and Blood Institute, and he received support for article research from the NIH. The remaining authors have disclosed that they do not have any potential conflicts of interest. This work was performed at Children's Hospital of Philadelphia. For information regarding this article, E-mail: yehyan@email.chop.edu ©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Alexandros Sfakianakis
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