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Importance: The United States Preventive Services Task Force (USPSTF) has considered the topic of prevention of child maltreatment multiple times over its nearly 40-year history, each time reaching the conclusion that the evidence is insufficient to recommend for or against interventions aimed at preventing this important health problem with significant negative sequelae before it occurs. In the most recent evidence review, which was conducted from August 2021 to November 2023 and published in March 2024, the USPSTF considered contextual questions on the evidence for bias in reporting and diagnosis of maltreatment in addition to key questions regarding effectiveness of interventions to prevent child maltreatment. Observations: A comprehensive literature review found evidence of inaccuracies in risk assessment and racial and ethnic bias in the reporting of child maltreatment and in the evaluation of injuries concerning for maltreatment, such as skull fractures. When children are incorrectly identified as being maltreated, harms, such as unnecessary family separation, may occur. Conversely, when children who are being maltreated are missed, harms, such as ongoing injury to the child, continue. Interventions focusing primarily on preventing child maltreatment did not demonstrate consistent benefit or information was insufficient. Additionally, the interventions may expose children to the risk of harm as a result of these inaccuracies and biases in reporting and evaluation. These inaccuracies and biases also complicate assessment of the evidence for making clinical prevention guidelines. Conclusions and Relevance: There are several potential strategies for consideration in future efforts to evaluate interventions aimed at the prevention of child maltreatment while minimizing the risk of exposing children to known biases in reporting and diagnosis. Promising strategies to explore might include a broader array of outcome measures for addressing child well-being, using population-level metrics for child maltreatment, and assessments of policy-level interventions aimed at improving child and family well-being. These future considerations for research in addressing child maltreatment complement the USPSTF's research considerations on this topic. Both can serve as guides to researchers seeking to study the ways in which we can help all children thrive.

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OBJECTIVE: The ankle-brachial index (ABI) is a well-established measure of distal perfusion in lower extremity ischemia; however, the ABI is of limited value in patients with noncompressible lower extremity arteries. We sought to demonstrate whether duplex ultrasound-determined tibial artery velocities can be used as an alternative to ABI as an objective performance measure after endovascular treatment of above-knee arterial stenosis. METHODS: Thirty-six patients undergoing above-knee endovascular intervention had preprocedure and postprocedure duplex ultrasound examination within 6 months of intervention. Preprocedure vs postprocedure changes in tibial artery mean peak systolic velocity (PSV; mean of proximal, mid, and distal velocities) were compared with changes in ABI and a reference (control) cohort of 68 patients without peripheral vascular disease. RESULTS: Thirty-six patients (41 limbs) had an above-knee endovascular intervention and had preprocedure and postprocedure duplex ultrasound examinations of the ipsilateral extremity including the tibial arteries. Before the procedure, mean tibial artery PSVs in the 36 patients undergoing intervention were outside (below) the 95% confidence intervals for the control patients. In comparing preprocedure and postprocedure PSVs, the mean anterior tibial (P < .01), mean peroneal (P < .01), and mean posterior tibial (P < .01) PSVs all increased and correlated with an increase in ABI (P < .01). After endovascular intervention, duplex ultrasound-derived mean PSVs fell within or near established reference ranges for patients without peripheral arterial disease. Mean tibial artery PSV increases were similar in patients with and without noncompressible vessels. CONCLUSIONS: Tibial artery PSVs increase, correlate with an increase in ABI, and fall within or near confidence intervals for normal controls after above-knee endovascular interventions. After endovascular intervention, tibial artery PSVs can supplement ABI as an objective performance measure in patients with and in particular without compressible tibial arteries.

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OBJECTIVE: Interhospital transfers (IHTs) to tertiary care centers are linked to lower operative mortality in vascular surgery patients. However, IHT incurs great health care costs, and some transfers may be unnecessary or futile. In this study, we characterize the patterns of IHT at a tertiary care center to examine appropriateness of transfer for vascular surgery care. METHODS: A retrospective review was performed of all IHT requests made to our institution from July 2014 to October 2015. Interhospital physician communication and reasons for not accepting transfers were reviewed. Diagnosis, intervention, referring hospital size, and mortality were examined. Follow-up for all patients was reviewed. RESULTS: We reviewed 235 IHT requests for vascular surgical care involving 210 patients during 15 months; 33% of requested transfers did not occur, most commonly after communication with the physician resulting in reassurance (35%), clinic referral (30%), or further local workup obviating need for transfer (11%); 67% of requests were accepted. Accepted transfers generally carried life- or limb-threatening diagnoses (70%). Next most common transfer reasons were infection or nonhealing wounds (7%) and nonurgent postoperative complications (7%). Of accepted transfers, 72% resulted in operative or endovascular intervention; 20% were performed <8 hours of arrival, 12% <24 hours of arrival, and 68% during hospital admission (average of 3 days); 28% of accepted patients received no intervention. Small hospitals (<100 beds) were more likely than large hospitals (>300 beds) to transfer patients not requiring intervention (47% vs 18%; P = .005) and for infection or nonhealing wounds (30% vs 10%; P = .013). Based on referring hospital size, there was no difference in IHTs requiring emergent, urgent, or nonurgent operations. There was also no difference in transport time, time from consultation to arrival, or death of patients according to hospital size. Overall patient mortality was 12%. CONCLUSIONS: Expectedly, most vascular surgery IHTs are for life- or limb-threatening diagnoses, and most of these patients receive an operation. Transfer efficiency and surgical case urgency are similar across hospital sizes. Nonoperative IHTs are sent more often by small hospitals and may represent a resource disparity that would benefit from regionalizing nonurgent vascular care.

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BACKGROUND: Hospital-associated UTI rates in surgery patients have not improved despite recommendations for reducing indwelling catheter days. METHODS: We performed a retrospective review of institutional NSQIP general surgery patient data, 2006-2015. During this time, a UTI-reduction policy was implemented. Demographics, HA-UTI incidence, CA-UTI incidence, indwelling catheter days, straight catheterization rates, and mortality were examined. RESULTS: Females had significantly higher risk of HA-UTI. There was no significant change in HA-UTI (X12 = 0.02, p = .878) or indwelling catheter days (5.18 ±â€¯1.12 days v 3.73 ±â€¯0.39 days, p = .23). Straight catheterizations among those with HA-UTI increased (0.04 ±â€¯0.04 v 0.32 ±â€¯0.12, p = .029). There was no change in CA-UTI (1.38 v 1.11 CAUTI/1000 patient hospital-days P = .555) or in initial indwelling catheter days of patients with CA-UTI (7.2 SD 8.89 v 47.0 SD 7.04 days P = .961) after policy implementation. CONCLUSIONS: The reduction policy increased the number of straight catheterizations for patients developing HA-UTI, but did not reduce the number of initial indwelling catheter days, HA-UTI rates, or CA-UTI rates.

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BACKGROUND: Left ventricular assist devices (LVADs) have been shown to cause changes in carotid artery duplex-derived flow velocity waveforms; however, possible effects on lower extremity arterial duplex (LEAD) findings have not been characterized. We sought to characterize LEAD findings in patients with LVADs to establish a basis for vascular laboratory interpretation of LEAD in patients with LVADs. METHODS: Retrospective single institution review of all patients with LEAD performed after LVAD implantation from 2003 to 2014. Peak systolic velocity (PSVs) of common femoral (CFA), superficial femoral (SFA), popliteal, and posterior tibial arteries (PTA) in asymptomatic extremities in patients with LVADs were compared to a control group of patients at our institution without LVADs who underwent LEAD for nonischemic indications. Arterial brachial index (ABIs) and CFA waveform acceleration times (ATs) and end diastolic velocity (EDV) were also measured. RESULTS: There were 248 LVAD patients, 29 had LEAD of at least 1 lower extremity (34 extremities, 22 asymptomatic, and 12 symptomatic) during the study period and 136 control limbs. Mean PSVs (cm/s) in the control CFA, mid SFA, popliteal, and PTA were 137 ± 4.8, 104.2 ± 4.5, 65.2 ± 2.8, and 64.6 ±3.2. Mean PSVs were significantly decreased in the LVAD patients: 49.5 ± 4.9, 40.6 ± 3.7, 27.2 ± 2.2, and 25.5 ± 2.3, P < 0.001 for each comparison. Average ABI for control limbs was 0.91 ± 0.05 compared to 1.17 ± 0.35 in LVAD extremities (P < 0.001). Mean CFA AT was 97 ms in the controls and 207 ms in LVAD patients, P < 0.001. Mean CFA EDV was 14.7 cm/s in the controls and 18.6 cm/s in the LVAD patients, P = 0.011. CONCLUSIONS: This is the first study characterizing LEAD in lower extremity arteries in LVAD patients. PSV is significantly decreased throughout lower extremity vessels, and common femoral artery acceleration time increased. Results can serve as a basis for identifying normal LEAD findings in LVAD patients.

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Importance: There is limited literature reporting circumstances surrounding end-of-life care in vascular surgery patients. Objective: To identify factors driving end-of-life decisions in vascular surgery patients. Design, Setting, and Participants: In this cohort study, medical records were reviewed for all vascular surgery patients at a tertiary care university hospital who died during their hospitalization from 2005 to 2014. Main Outcomes and Measures: Patient, family, and hospitalization variables potentially important to influencing end-of-life decisions. Results: Of 111 patients included (67 [60%] male; median age, 75 [range, 24-94] years), 81 (73%) were emergent vs 30 (27%) elective admissions. Only 15 (14%) had an advance directive. Of the 81 (73%) patients placed on comfort care, 31 (38%) had care withheld or withdrawn despite available medical options, 15 (19%) had an advance directive, and 28 (25%) had a palliative care consultation. The median time from palliative care consultation to death was 10 hours (interquartile range, 3.36-66 hours). Comparing the 31 patients placed on comfort care despite available medical options with an admission diagnosis-matched cohort, we found that more than 5 days admitted to the intensive care unit (odds ratio [OR], 4.11; 95% CI, 1.59-10.68; P < .001), more than 5 days requiring ventilator support (OR, 9.45; 95% CI, 3.41-26.18; P < .001), new renal failure necessitating dialysis (OR, 14.48; 95% CI, 3.69-56.86; P < .001), and new respiratory failure necessitating tracheostomy (OR, 23.92; 95% CI, 2.80-204; P < .001) correlated with transition to comfort care. Conclusions and Relevance: Palliative care consultations may be underused at the end of life. A large percentage of patients were transitioned to comfort measures despite available treatment, yet few presented with advance directives. In high-risk patients, discussions regarding extended stays in the intensive care unit, prolonged ventilator management, and possible dialysis and tracheostomy should be communicated with patients and families at time of hospitalization and advance directives solicited.

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BACKGROUND: Statins are recommended for use in patients with peripheral arterial disease (PAD) to reduce cardiovascular events and mortality. However, much of the data regarding benefits of statins stem from the cardiovascular literature. Here, we review the literature regarding statin use specifically in patients with PAD regarding its effects on cardiovascular events and mortality, limb-related outcomes, statin use after endovascular interventions, statin dosing, and concerns about statins. METHODS: We performed a literature review using PubMed for literature after the year 2000. Search terms included "statins," "peripheral arterial disease," "peripheral vascular disease," "lipid-lowering medication," and "cardiovascular disease." RESULTS: There is good evidence of statins lowering cardiovascular events and cardiovascular-related mortality in patients with PAD. Though revascularization rates were reduced with statins, amputation rates and amputation-free survival did not improve. Small randomized controlled trials show that patients taking statins can slightly improve pain-free walking distance or pain-free walking time, although the extent of the effect on quality of life is unclear. Statin use for patients undergoing endovascular interventions is recommended because of the reduction of postoperative cardiovascular events. Not enough data exist to support local effects of systemic statin therapy, such as prevention of restenosis. For statin dosing, there is little increased benefit to intense therapy compared with the adverse effects, whereas moderate-dose therapy has significant benefits with very few adverse effects. Adverse effects of moderate-dose statin therapy are rare and mild and are greatly outweighed by the cardiovascular benefits. CONCLUSIONS: There is strong evidence to support use of statins in patients with PAD to reduce cardiovascular events and mortality. Use in patients undergoing open and endovascular interventions is also recommended. Statin use may reduce the need for revascularization, but reductions in amputation have not been shown. Moderate-dose statin therapy is safe, and the minor risks are greatly outweighed by benefits.

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OBJECTIVE: Wound occurrence (WO) after major lower extremity amputation (MLEA) can be due to wound infection or sterile dehiscence. We sought to determine the association of nasal methicillin-resistant Staphylococcus aureus (MRSA) colonization and other patient factors with overall WO, WO due to wound infection, and WO due to sterile dehiscence. METHODS: The medical records of all patients undergoing MLEA from August 1, 2011, to November 1, 2013, were reviewed. Demographic data, hemoglobin A1c level, albumin concentration, dialysis dependence, peripheral vascular disease (PVD), nasal MRSA colonization, and diabetes mellitus (DM) were examined as variables. The overall WO rate was determined, and the cause of WO was categorized as either a sterile dehiscence or a wound infection. RESULTS: Eighty-three patients underwent 96 MLEAs during a 27-month period. The rates of overall WO, WO due to infection, and WO due to sterile dehiscence were 39%, 19%, and 19%, respectively (1% developed a traumatic wound). On univariate analysis, PVD, MRSA colonization, DM, and dialysis dependence were all associated with higher rates of overall WO (P < .05). On multivariate analysis, MRSA colonization was associated with higher rates of overall WO (P = .03) and WO due to wound infection (11% vs 45%; P < .01). DM and PVD were associated with higher rates of overall WO and WO due to sterile dehiscence on both univariate and multivariate analysis (P < .05). CONCLUSIONS: Nasal MRSA colonization is associated with higher rates of overall WO and WO due to wound infection. DM and PVD are associated with higher rates of overall WO and WO due to sterile dehiscence but are not associated with WO due to wound infection. Further studies addressing the effect of nasal MRSA eradication on postoperative wound outcomes after MLEA are warranted.

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INTRODUCTION AND HYPOTHESIS: We assessed the incidence of and risk factors for developing urinary tract infection (UTI) after uterosacral ligament suspension (USLS). METHODS: Retrospective analysis of patients undergoing USLS in 2008-2009 was performed. Postoperative UTI was defined as a positive urine culture within 1 month following surgery. Factors analyzed were patient age, body mass index, parity, history of UTI before surgery, passing voiding trial, discharge with Foley catheter or intermittent self-catheterization, antibiotics at discharge, history of diabetes or renal disease, and surgeon. RESULTS: Surgical records from 169 patients were reviewed. Twenty-three patients (14%) developed UTI. There were no differences in preoperative factors between patients who developed UTI and those who did not. Subgroup analysis revealed those patients who went home with a Foley catheter and did not receive antibiotics had the highest proportion of UTI. CONCLUSION: Patients requiring Foley catheter at discharge following vaginal prolapse repair are at highest risk for UTI and require prophylactic antibiotics.

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An accurate determination of sex is essential in the identification of human remains in a forensic context. Measurements of some of the tarsals have been shown to be sexually dimorphic by previous researchers. The purpose of the present study is to determine which dimensions of the seven tarsals demonstrate the greatest sexual dimorphism and therefore have the most potential for accurate sex determination. Eighteen measurements of length, width, and height were obtained from the tarsals of 160 European-American males and females from the William M. Bass Donated Skeletal Collection. These measurements were made using a mini-osteometric board. Logistic regression analyses were performed to create equations for sex discrimination. All measurements showed significant sexual dimorphism, with the talus, cuboid, and cuneiform I producing allocation accuracies of between 88 and 92%. Combinations of measurements provided better accuracy (88.1-93.6%) than individual measurements (80.0-88.0%).

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The Johns Hopkins University Center for Craniofacial Development and Disorders estimates that 1 in 3,000 children born in the United States is diagnosed with a rare form of craniosynostosis. Although the medical literature has documented numerous descriptions of craniofacial disorders from an anthropometric or genetic perspective, considerably fewer reports of these anomalies have been documented in the context of forensic anthropology. Similar genetic origins of many craniofacial anomalies generate ranges of phenotypic variation between and even within documented cases, producing difficulties in acquiring correct diagnoses. Identical physical characteristics manifested in different disorders create further complications in identifying a craniofacial syndrome in skeletal remains. Reported here is an unusual case of a possibly undiagnosed craniofacial abnormality in a set of identified skeletal remains from a North Carolina homicide case. Traditional metric and geometric morphometric approaches were utilized to further investigate morphological shape differences between the case study and a reference sample. Results show significant differences suggesting a nonsyndromic form of craniosynostosis.

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