Pediatric Facial Burn Reconstruction.

Contrary to prior pediatric burn treatment philosophies, we now know that early burn excision and grafting for non life-threatening burns can compromise future reconstruction. Extensive scar excision should be minimized and scar rehabilitation maximized, as secondary iatrogenic deformities can become even more difficult to fix. Scar remodeling with local tissue rearrangement can relieve tension and soften scars over time. The majority of facial burns often only involve skin and can be adequately treated without the need for complex flap reconstruction. Facial burn scars are a different problem than facial burn scar contracture. The former needs scar rehabilitation, whereas the latter needs the addition of skin. Laser therapy has transformed the treatment of burn scars and is an incredibly valuable adjunct to local tissue rearrangement and grafting. The most favorable functional, aesthetic, and psychological outcomes require a long-term multidisciplinary effort and customized protocol utilizing the vast armamentarium of reconstructive tools described below.

Obesity Severity Does Not Associate With Rate, Timing, or Invasiveness of Early Reinterventions After Total Knee Arthroplasty.

BACKGROUND: The use of body mass index (BMI) cutoff values has been suggested for proceeding with total knee arthroplasty (TKA) in obese patients. However, the relationship between obesity severity and early reoperations after TKA is poorly defined. This study evaluated whether increased World Health Organization (WHO) obesity class was associated with risk, severity, and timing of reintervention within one year after TKA. METHODS: There were 8,674 patients from our institution who had a BMI ≥ 30 and underwent unilateral TKA for primary osteoarthritis between 2016 and 2021. Patients were grouped by WHO obesity class: 4,456 class I (51.5%), 2,527 class II (29.2%), and 1,677 class III (19.4%). A chart review was performed to determine patient characteristics and identify patients who underwent any closed or open reintervention requiring anesthesia within the first postoperative year. Regression analyses were performed to identify variables associated with increased odds ratios (ORs) for requiring a reintervention, its timing, and invasiveness. RESULTS: There were 158 patients (1.8%) who required at least one reintervention, and 15 patients (0.2%) required at least 2 reinterventions. Reintervention rates for obesity classes I, II, and III were 1.8% (n = 81), 2.0% (n = 51), and 1.4% (n = 23), respectively. There were 65 closed procedures (41.1%), 47 minor procedures (29.7%), 34 open with or without liner exchange (21.5%), and 12 revisions with component exchange (7.6%). Obesity class was not associated with reintervention rate (P = .3), timing (P = .36), or invasiveness (P = .93). Diabetes (odds ratio [OR] = 2.47; P = .008) was associated with a need for reintervention. Non-Caucasian race (OR = 1.7; P = .01) and Charlson comorbidity index (OR = 2.1; P = .008) were associated with earlier reintervention. No factors were associated with the invasiveness of reintervention. CONCLUSIONS: The WHO obesity class did not associate with rate, timing, or invasiveness of reintervention after TKA in obese patients. These findings suggest that policies that restrict the indication for elective TKA based only on a BMI limit have limited efficacy in reducing early reintervention after TKA in obese patients. LEVEL OF EVIDENCE: III.

To Stage or Not to Stage? Comparison of Patient-Reported Outcomes, Complications, and Discharge Disposition After Staged and Simultaneous Bilateral Posterior Total Hip Arthroplasty.

BACKGROUND: Patients who have bilateral hip arthritis can be treated with bilateral total hip arthroplasty (bTHA) in either a staged or simultaneous fashion. The goal of this study was to determine whether staged and simultaneous posterior bTHA patients differ in regard to (1) patient-reported outcome measures, (2) 90-day complication rates, and (3) discharge dispositions and cumulative lengths of stay. METHODS: Patients who (1) underwent simultaneous bTHA or staged bTHA (within 12 months) using the posterior approach, and (2) completed preoperative and 1-year postoperative Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement surveys were included in the study. A total of 266 patients (87 simultaneous bTHA and 179 staged bTHA) were included. Chart review was performed to collect patient-level variables, postoperative complications, discharge dispositions, and lengths of stay. RESULTS: Staged bTHA patients had higher Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement, Lower Extremity Activity Scale, and Veterans RAND 12-Item Health Survey physical component scores compared to simultaneous bTHA patients at 6 weeks after surgery (P = .019, .006, and .008, respectively), but these differences did not meet the minimal clinically important difference threshold for any questionnaire. Simultaneous bTHA was associated with higher rate of periprosthetic fractures (P = .034) and discharge to a location other than home (P < .001). CONCLUSIONS: There were statistically significant, but likely not clinically meaningful differences in patient-reported outcomes for staged and simultaneous bTHA patients at 6 weeks after surgery. Surgeons should be aware of the higher periprosthetic fracture risk and greater likelihood of discharge to a rehabilitation facility associated with simultaneous bTHA. Further research should aim to understand which patients may benefit most from simultaneous bTHA.

Unexpected Positive Cultures in Hip and Knee Periprosthetic Fractures.

BACKGROUND: The purpose of this study was to determine the prevalence of unexpected positive cultures noted at the time of revision surgery for periprosthetic fracture (PPF) after total hip or knee arthroplasty. Moreover, we evaluated whether this finding should be considered clinically significant and what type of treatment, if any, was required. METHODS: This was a single-center retrospective review of 270 patients undergoing surgery for PPFs from December 2010 to December 2021. Exclusion criteria included: open fractures; history of infection at fractured joint; non-operatively treated patients; and intraoperative fractures. The primary end point was the prevalence of unexpected positive cultures noted at the time of revision surgery. This was defined as one or more positive cultures in a PPF that the surgeon had preoperatively classified as aseptic according to the 2018 International Consensus Meeting. Data collection included patient demographics, medical histories, preoperative investigations, postoperative microbiology, and treatment. RESULTS: During the study period, 159 patients were admitted with PPFs of the hip and 61 with PPFs of the knee. The mean age was 70 years (range, 32 to 93 years). Unexpected positive cultures were diagnosed postoperatively in 15 patients (6.8%; 10 hips, 5 knees). The most prevalent organism was Staphylococcus epidermidis (35.0%). Of those 15 patients, 6 required a surgical revision for infection. None of the patient-related risk factors were found to be associated with an increased risk of unexpected positive cultures. The comparison between infected and noninfected patients showed a significant association between preoperative C-reactive protein >10 mg/mL (P = .04), loose implant (P = .07), and infection. CONCLUSIONS: The prevalence of unexpected positive cultures was 6.8% in our study cohort. Although surgical treatment may be required, the majority of patients seem to require no treatment. Larger series are required to investigate the clinical importance of this rare finding. LEVEL OF EVIDENCE: III.

Early Periprosthetic Femur Fractures After Primary Cementless Total Hip Arthroplasty: High Risk of Periprosthetic Joint Infection and Subsequent Reoperation.

BACKGROUND: Periprosthetic femur fracture (PFF) following total hip arthroplasty (THA) is a leading cause of early reoperation. The objective of this study was to compare rates of periprosthetic joint infection (PJI) and reoperation following PFFs occurring early postoperatively to those that occurred late. METHODS: We retrospectively identified 173 consecutive surgically managed PFFs following primary THA. Cases were categorized as "early" if they occurred within 90 days of THA (n = 117) or "late" if they occurred following the initial 90 days (n = 56). Mean age at time of PFF was 68 years (range, 26 to 96) and 60% were women. Mean body mass index was 29 (range, 16 to 52). Mean follow-up was 2 years (range, 0 to 13). Kaplan-Meier survival analysis estimated cumulative incidences of PJI and reoperation. RESULTS: Early PFFs had higher 2-year cumulative incidence of PJI (11% versus 0%, P < .001) and reoperation (24% versus 13%, P = .110). Following early PFF, 27 patients required reoperation (ie, 13 for PJI, 5 for instability, 2 for re-fracture, 2 for painful hardware, 2 for non-union, 1 for adverse local tissue reaction, 1 for aseptic loosening, and 1 for leg-length discrepancy). Following late PFF, 5 patients required reoperation (ie, 3 for instability, 1 for re-fracture, and 1 for non-union). CONCLUSIONS: There are greater incidences of PJIs and overall reoperations following early PFFs compared to late PFFs after THA. In addition to focusing efforts on prevention of early PFFs, surgeons should consider antiseptic interventions to mitigate the increased risk of PJI after treatment of early PFF.

Defining Patient-relevant Thresholds and Change Scores for the HOOS JR and KOOS JR Anchored on the Patient-acceptable Symptom State Question.

BACKGROUND: When evaluating the results of clinical research studies, readers need to know that patients perceive effect sizes, not p values. Knowing the minimum clinically important difference (MCID) and the patient-acceptable symptom state (PASS) threshold for patient-reported outcome measures helps us to ascertain whether our interventions result in improvements that are large enough for patients to care about, and whether our treatments alleviate patient symptoms sufficiently. Prior studies have developed the MCID and PASS threshold for the Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR) and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) anchored on satisfaction with surgery, but to our knowledge, neither the MCID nor the PASS thresholds for these instruments anchored on a single-item PASS question have been described. QUESTIONS/PURPOSES: (1) What are the MCID (defined here as the HOOS/KOOS JR change score associated with achieving PASS) and PASS threshold for the HOOS JR and KOOS JR anchored on patient responses to the single-item PASS instrument? (2) How do patient demographic factors such as age, gender, and BMI correlate with MCID and PASS thresholds using the single-item PASS instrument? METHODS: Between July 2020 and September 2021, a total of 10,970 patients underwent one primary unilateral THA or TKA and completed at least one of the three surveys (preoperative HOOS or KOOS JR, 1-year postoperative HOOS or KOOS JR, and 1-year postoperative single-item anchor) at one large, academic medical center. Of those, only patients with data for all three surveys were eligible, leaving 13% (1465 total; 783 THAs and 682 TKAs) for analysis. Despite this low percentage, the overall sample size was large, and there was little difference between completers and noncompleters in terms of demographics or baseline patient-reported outcome measure scores. Patients undergoing bilateral total joint arthroplasty or revision total joint arthroplasty and those without all three surveys at 1 year of follow-up were excluded. A receiver operating characteristic curve analysis, leveraging a 1-year, single-item PASS (that is, "Do you consider that your current state is satisfactory?" with possible answers of "yes" or "no") as the anchor was then used to establish the MCID and PASS thresholds among the 783 included patients who underwent primary unilateral THA and 682 patients who underwent primary unilateral TKA. We also explored the associations of age at the time of surgery (younger than 65 years or 65 years and older), gender (men or women), BMI (< 30 or ≥ 30 kg/m 2 ), and baseline Patient-Reported Outcome Measure Information System-10 physical and mental component scores (< 50 or ≥ 50) for each of the MCID and PASS thresholds through stratified analyses. RESULTS: For the HOOS JR, the MCID associated with the PASS was 23 (95% CI 18 to 31), with an area under the receiver operating characteristic curve of 0.75, and the PASS threshold was 81 (95% CI 77 to 85), with an area under the receiver operating characteristic curve of 0.81. For the KOOS JR, the MCID was 16 (95% CI 14 to 18), with an area under the receiver operating characteristic curve of 0.75, and the PASS threshold was 71 (95% CI 66 to 73) with an area under the receiver operating characteristic curve of 0.84. Stratified analyses indicated higher change scores and PASS threshold for younger men undergoing THA and higher PASS thresholds for older women undergoing TKA. CONCLUSION: Here, we demonstrated the utility of a single patient-centered anchor question, raising the question as to whether simply collecting a postoperative PASS is an easier way to measure success than collecting preoperative and postoperative patient-reported outcome measures and then calculating MCIDs and the substantial clinical benefit. LEVEL OF EVIDENCE: Level III, therapeutic study.

Cause for concern? Significant cement coverage in retrieved metaphyseal cones after revision total knee arthroplasty.

BACKGROUND: Metaphyseal cones are used to manage bone loss in revision total knee arthroplasty with increasing popularity. Post-operative radiographs and explant procedures suggest that cement may extrude around the cone implant into the cone-bone interface and prevent biologic in- or on-growth. The purpose of this study was to perform a retrieval analysis to describe the pattern of direct cementation onto the porous surface area of metaphyseal cones. METHODS: Eighteen tibial and femoral cones were identified in an institutional implant retrieval registry. Anterior, posterior, medial and lateral quadrants were digitally mapped for direct cementation, bone ongrowth and fibrous ongrowth were calculated as a percentage of the porous surface area. Plain radiographs from prior to cone explant were analyzed for the presence of cement in all four quadrants and compared with results of the retrieval analysis. RESULTS: Mean bone ongrowth was 25%, direct cementation was 24% (31% in tibial cones) and fibrous ongrowth was 29% of the porous surface area of the retrieved cones. There were no significant differences when comparing patterns of bone or fibrous ongrowth or cementation between anterior, posterior medial and lateral porous surfaces for tibia cones, femoral cones or all cones grouped together. Plain radiographs significantly underestimated the amount of cement covering the cone (p = 0.02). CONCLUSION: In this retrieval study, we found significant cement extrusion around the porous surface of metaphyseal cones in revision TKAs. Optimizing the cone-bone interface may reduce the risk of cement extrusion and theoretically reduce the risk of aseptic loosening.

A Case Study: Preserved Nipple-Areolar Complex Vascularity in High-Risk Secondary Reduction Mammaplasty Using Single-Stage Suction-Assisted Lipectomy With Dermal Mastopexy.

Repeat surgery is known to increase risk of several surgical complications, including compromise to the blood supply of/surrounding the surgical site. As such, we offer an alternative to the use of a standard breast reduction technique in the case of a re-do reduction, pursued with a goal of maintaining the blood supply to the nipple-areola complex. When compared to traditional reduction mammoplasty, suction-assisted lipectomy with dermal mastopexy has been demonstrated to be a highly effective technique in protecting the vascularity of the nipple-areola complex in repeat breast reductions. We describe a successful utilization of this technique for a high-risk patient with active tobacco use undergoing secondary reduction mammoplasty.

Hyperinsulinemia is a probable trigger for weight gain and hyperphagia in individuals with Prader-Willi syndrome.

Objective: Prader-Willi syndrome (PWS) is the most frequently diagnosed genetic cause of early childhood obesity. Individuals with PWS typically progress through 7 different nutritional phases during their lifetime. The main objective of this study was to assess potential factors, particularly insulin, that may be responsible for the weight gains in sub-phase 2a and their role in the subsequent increase in fat mass and obesity in sub-phase 2b and insatiable appetite in phase 3. Methods: Fasting plasma insulin levels were measured in children with PWS between the ages of 0-12 years and in age-matched non-PWS participants with early-onset major (clinically severe) obesity (EMO) and in healthy-weight sibling controls (SC). Results: Participants with PWS in nutritional phases 1a and 1b had plasma insulin levels comparable to SC. However, the transition from phase 1b up to phase 3 in the PWS group was accompanied by significant increases in insulin, coinciding in weight gains, obesity, and hyperphagia. Only individuals with PWS in phase 3 had comparable insulin levels to the EMO group who were higher than the SC group at any age. Conclusions: Elevated insulin signaling is a probable trigger for weight gain and onset of hyperphagia in children with Prader-Willi syndrome. Regulating insulin levels early in childhood before the onset of the early weight gain may be key in modulating the onset and severity of obesity and hyperphagia in individuals with PWS, as well as in other young children with non-PWS early-onset obesity. Preventing or reversing elevated insulin levels in PWS with pharmacological agents and/or through diet restrictions such as a combined low carbohydrate, low glycemic-load diet may be a viable therapeutic strategy in combating obesity in children with PWS and others with early childhood obesity.

Global Burn Prevention: Ukraine.

Burn injury accounts for a large proportion of surgically treatable disease. It is estimated that over 180 000 flame burn deaths occur annually across the globe, with roughly 95% occurring in low- or middle-income countries (LMIC). Within these countries, children account for a disproportionately high number of burn injuries. As such, the WHO has identified burn prevention as a topic of interest, with an increased need in LMIC. Here, we describe the creation and implementation of a burn prevention program in Ukraine. We instituted a 5-step burn prevention initiative consisting of; data gathering, program design, implementation, outcome evaluation, program maintenance, and expansion. The burn prevention initiative has been adopted nationally leading to policy change. Active education and an information campaign were used to target pediatric scald injuries and improve first-aid care. The authors have successfully implemented a targeted multifaceted, national, burn prevention program within Ukraine. The described approach may be used as a guide and adapted to create similar prevention programs within other countries or regions. At this time, the Russo-Ukrainian War has caused an abrupt hold on our role in the prevention program and left the healthcare system in havoc. Moving forward, our team is prepared to re-evaluate the impact of the war on social life and the medical system and aid in redesigning the prevention program when appropriate.

Does Acetabular Bone Loss Severity Associate With Patient-Reported Outcome Measures and Reoperation Rate in Revision Total Hip Arthroplasty?

BACKGROUND: Acetabular bone loss is a challenging clinical problem when performing revision total hip arthroplasty (rTHA). This study aimed to evaluate how acetabular bone loss severity influences (1) clinical outcomes and (2) patient-reported outcome measures (PROMs) in rTHA patients. METHODS: Patients who underwent rTHA with acetabular component revision from January 2016 to February 2022 were included. Treating surgeons determined Paprosky acetabular bone loss classification intraoperatively. Patients were grouped based on numeric classification (PI, PII, or PIII) to categorize severity. Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR.) and Lower Extremity Activity Scale (LEAS) score were collected preoperatively and 1 year postoperatively. There were 197 patients included. Paprosky classification was PI for 47 patients (23.9%), PII for 113 patients (57.4%), and PIII for 37 patients (18.8%). Mean clinical follow-up was 29 months (range, 1 to 69). RESULTS: Reoperation rate was 0% (0 patients), 6.2% (7 patients), and 10.8% (4 patients) for PI, PII and PIII groups respectively (P = .052). Mean preoperative HOOS, JR. and LEAS for PI, PII and PIII groups were significantly different, but 1-year postoperative HOOS, JR. and LEAS did not differ significantly. Rates of HOOS, JR. minimal clinically important difference achievement differed significantly between bone loss groups. CONCLUSION: In this study of rTHA patients, greater acetabular bone loss severity was associated with worse preoperative PROMs and trended toward higher reoperation rate. Postoperative PROMs for bone loss severity groups were statistically similar. Patients who had worse acetabular bone loss were more likely to achieve HOOS, JR. minimal clinically important difference postoperatively. LEVEL OF EVIDENCE: III.

Pediatric Postburn Ear Reconstruction of Significant Cartilage Defects.

The external ear is a vulnerable appendage susceptible to trauma. Repairing and recreating its intricate architecture presents a formidable challenge after burn injury, especially when scar tissue, impaired vasculature, and damage to cartilage all influence reconstructive options. The authors share their institutional experience and provide a guide for reconstruction of significant postburn auricular cartilage defects. A retrospective review was conducted on 54 patients (61 ears) aged 0-21 years old admitted to a specialized pediatric burn hospital between January 2004 and January 2021 for postburn ear cartilage reconstruction. Conchal cartilage grafting was performed in 9 patients (9 ears) with an average age of 14.0 ± 5.1 years, requiring an average of 2.0 ± 1.0 procedures that resulted in one case of infection. A total of 21 patients (24 ears) with an average age of 15.1 ± 4.5 years underwent a conchal transposition flap, requiring an average of 1.8 ± 0.4 procedures that resulted in no major complications. A total of 20 patients (23 ears) with an average age of 12.0 ± 5.3 years underwent porous polyethylene implantation, requiring an average of 3.5 ± 1.5 operations that resulted in 3 complications. Costal cartilage grafting was performed in 4 patients (5 ears) with an average age of 13.2 ± 5.3 years, requiring an average of 3.2 ± 2.2 operations that resulted in one case of infection. Postburn ear cartilage defects necessitate an individualized approach tailored to a patient's reconstructive goals. In addition to defect size and location, factors such as reconstructive course duration, complication potential, and anticipated aesthetic results should be discussed with the patient.

Molecular Classes and Growth Hormone Treatment Effects on Behavior and Emotion in Patients with Prader-Willi Syndrome.

Prader-Willi syndrome (PWS) is a complex genetic disorder with three genetic classes. Patients with PWS are characterized by severe hypotonia, developmental delay, behavioral problems, learning disabilities and morbid obesity in early childhood if untreated. Data were collected through Rare Disease Clinical Research Network (RDCRN) from four study centers which evaluated patients with PWS. The Behavior Assessment System for Children 2nd edition (BASC-2) was chosen to provide behavioral assessment. Data from 330 participants ((64% 15q11-q13 deletion (DEL), 36% maternal disomy 15 (UPD)) were separated into three age groups and analyzed, 68% of whom were still actively receiving recombinant human growth hormone (rhGH) treatment. When comparing the BASC results by molecular subtype, parent-reported aggression was higher for the deletion than for the UPD cohort (p = 0.007). Participants who were on rhGH treatment showed lower scores for parent-reported hyperactivity and aggression (p = 0.04, 0.04, respectively), and a trend for anger control (p = 0.06) and teacher-reported attention problems and aggression (p = 0.01, 0.004, respectively). Additional adjusted analyses were undertaken and significant differences were noted in the GH versus non-GH treated groups for only teacher-reported aggression, which increased in the No GH treated patient group (p = 0.03). This study showed documented differences in PWS behavior by molecular class and rhGH treatment. RhGH therapy may be beneficial for certain behaviors in patients with PWS; however, observed differences need more studies for confirmation in the future.

Management of a Bronchopleural Fistula After Right-Sided Lobectomy Using a Delayed Random Flap Under Guidance of Indocyanine Green (ICG) Angiography: A Case Report.

Bronchopleural fistula (BPF) following lung resection and thoracic surgery is associated with high rates of morbidity and mortality. Various methods are available for the closure of BPF and thoracic dead space, including flap procedures and thoracoplasty. While delayed random flaps have been used for the treatment of BPF and closure of thoracic dead space, no previous reports have described the concurrent use of laser-assisted indocyanine green angiography (ICG-A). We report a case of successful BPF closure with a random delayed fasciocutaneous flap using laser-assisted ICG-A guidance for flap delay.

Resumption of Short-term Burn Reconstruction Missions to Ukraine in Light of COVID-19: A Paradigm Shift.

The COVID-19 pandemic has disrupted the lives of billions of people globally. Some medical systems continue to be overburdened due to the viral illness leading to incredible public health challenges domestically as well as abroad. However, with vaccination distribution increasing globally, many are pushing for a return to some form of normalcy. In the medical community, some are weighing the risks of returning to global health missions and considering protective strategies to minimize risk of viral spread. Here, we describe our experience in returning to an annual burn reconstruction mission in a low- and middle-income country. We have successfully carried out a return surgical mission trip. Our team of 10 individuals was able to perform over 75 procedures on 25 pediatric patients in 4 operative days. We applied a variety of protective strategies and altered mission protocol to limit exposure and transmission risk while focusing heavily on education and training. Additionally, we increased the use of telemedicine and eliminated typical in-person clinic visits. We increased operative complexity to increase impact while limiting patient exposure. Rigorous perioperative safety and follow-up protocols were implemented. The increased use of telemedicine, reduction of in-person visits, emphasis on education, and implementation of safety and follow-up protocols have led to an improvement in efficiency, safety, and accountability. Our adaptations have provided guidance on responsibly resuming surgical outreach missions, with changes that are likely to endure beyond the COVID-19 pandemic.

Critical review of bariatric surgical outcomes in patients with Prader-Willi syndrome and other hyperphagic disorders.

OBJECTIVE: The aim of this study was to review bariatric procedure outcomes among patients with Prader-Willi syndrome (PWS), melanocortin 4 receptor (MC4R) mutations, Bardet-Biedl syndrome, and hypothalamic obesity. METHODS: Systematic published literature review used the following search terms: "Prader-Willi syndrome," "Bardet-Biedl syndrome," "hyperphagia," "bariatric surgery," "MC4R"/"melanocortin 4 receptor", "hypothalamic obesity," and "bariatric procedure." Information collected included demographics, genetics, anthropometry, procedure type, outcomes, and complications, with inclusion of case series and clinical reports given the rarity of the disorders. For PWS, postoperative weight-change percentage and BMI up to 14 years following surgery were analyzed using general linear mixed models, with descriptive outcomes for other conditions. RESULTS: A total of 54 publications were identified, with variable follow-up periods for 202 patients (114 with PWS, 43 with MC4R mutations, 7 with Bardet-Biedl syndrome, and 38 with hypothalamic obesity) among bariatric procedures. Weight loss of patients with PWS was greatest within 1 year of surgery, with weight-change percentage not significantly different from 0 at 5 years. Long-term results in other conditions were variable and featured suboptimal weight loss and increased reoperation risk. CONCLUSIONS: Bariatric procedures among hyperphagic individuals, including those with PWS, report variable results and outcomes. Benefits of bariatric surgery may be less durable in hyperphagic disorders in comparison with other patients with severe obesity.

Demographic implications of lead poisoning for eagles across North America.

Lead poisoning occurs worldwide in populations of predatory birds, but exposure rates and population impacts are known only from regional studies. We evaluated the lead exposure of 1210 bald and golden eagles from 38 US states across North America, including 620 live eagles. We detected unexpectedly high frequencies of lead poisoning of eagles, both chronic (46 to 47% of bald and golden eagles, as measured in bone) and acute (27 to 33% of bald eagles and 7 to 35% of golden eagles, as measured in liver, blood, and feathers). Frequency of lead poisoning was influenced by age and, for bald eagles, by region and season. Continent-wide demographic modeling suggests that poisoning at this level suppresses population growth rates for bald eagles by 3.8% (95% confidence interval: 2.5%, 5.4%) and for golden eagles by 0.8% (0.7%, 0.9%). Lead poisoning is an underappreciated but important constraint on continent-wide populations of these iconic protected species.