Purpose Accurate classification of brachial plexus birth injury (BPBI) is critical for predicting outcomes and guiding early intervention. In 1987, Narakas introduced the first widely adopted system. Over time, misquotations and reinterpretations have obscured the work, conflating group definitions, exaggerating recovery rates, and misrepresenting prognosis. Methods This manuscript revisits Narakas’ original classification, traces misquotations, and clarifies their impact on management. We aim to provide the original publication as a reliable reference for contemporary care of BPBI. Results Group 1 involves Sunderland grade 1−2 injuries to C5 and/or C6, with 93% achieving full spontaneous recovery. Group 2 includes Sunderland grade 2−3 injuries to C5−6 and grade 1−2 to C7. Groups 1 and 2 present similarly, with slightly weaker elbow extension in group 2. The key differentiator is slower recovery of the upper trunk, not C7 involvement. Only 22% fully recovered. Group 3 involves Sunderland grades 4−5 for C5−C6, grade 3 for C7, and grades 1−2 for C8−T1. Five percent achieved a full recovery, and 15% had a satisfactory outcome. Group 4 involves Sunderland grade 5 injuries to C5−C7 with avulsion of C8. No patients achieved full or good shoulder recovery, 35% had fair elbow recovery, and hand/wrist recovery was poor. Conclusions BPBI is complex, with extensive sequelae if mismanaged. Narakas’ work provides critical guidance for prognosis and treatment. Misquotations have propagated inaccurate expectations and hindered care. Reprinting and disseminating the original classification and associated group outcomes clarifies prognosis, informs clinical decisions, and supports improved care. Our table and commentary provide an accessible reference to optimize BPBI care. Level of evidence IV.
Background:Pediatric low-grade gliomas (pLGGs) are the most common childhood central nervous system (CNS) tumors. Targeted therapies are effective treatments in patients with pLGGs harboring mutations in the mitogen-activated protein kinase (MAPK)/extracellular signal-regulated kinase 1/2 (ERK) signaling pathway. Understanding the toxicity profile and tolerability of emerging MAPK inhibitors (MAPKi) and how adverse events (AEs) can be managed to avoid treatment discontinuation, interruption, or dose reduction is important for optimizing clinical benefit. Methods:A modified Delphi consensus initiative was conducted to provide recommendations on the monitoring and management of AEs that occur with MAPKi in patients with pLGG. A 9-member steering committee was convened to develop statements based on the findings of a comprehensive literature review of AEs reported with the use of MAPKi in pediatric cancers. Consensus on statements was determined via online surveys completed by a large, global panel of experts in pLGG. Results:Of the 129 statements drafted, consensus (≥75% agreement) among 82 global experts in pLGG was reached for 50 statements, mostly pertaining to the general management of AEs occurring with MAPKi and the management of cutaneous AEs. Consensus statements include guidance on skin care and specific cutaneous conditions. Many AEs were rare with limited evidence or experience to achieve consensus recommendations. Conclusions:The consensus statements developed provide guidance and recommendations for the management of common AEs in patients with pLGG treated with MAPKi. Sharing this knowledge may lead to patients with pLGG achieving optimal benefit from MAPKi while minimizing and effectively managing AEs.
Objectives:Rapid brain MRI (rMRI) provides a radiation-free neuroimaging tool to screen children without sedation. Our objective was to retrospectively analyze clinical rMRI utilization by describing demographics, operational metrics, clinical indications, and temporal trends associated with rMRI utilization in the emergency department (ED).Methods:We conducted a single-center, retrospective, cross-sectional study of children who underwent rMRI in the ED at an urban children's hospital between May 2014 and March 2024. We used descriptive statistics to examine operational metrics and trends in rMRI utilization over the study period. We performed a subgroup analysis of operational metrics by age and clinical indication.Results:We included 2401 patients who underwent rMRI during their ED encounter. rMRI was frequently performed in infants and toddlers younger than 3 years old (n = 604, 25.1%), with a median patient age of 8.0 [interquartile range (IQR): 3.0 to 14.5] years. The median (IQR) time to scan was 3.5 (2.4 to 5.1) hours, and the median (IQR) ED length of stay was 7.5 (5.8 to 9.6) hours. Of the total, 1917 (79.8%) patients were initially triaged as "emergent," and 990 (41.2%) were discharged home from the ED. rMRI was predominantly used to evaluate ventricular shunt function (n = 2069, 86.1%) and traumatic brain injury (n = 214, 9.0%). Annual rMRI utilization increased by 80.8% between 2015 and 2023, with an average utilization rate increase of 46.1 scans annually between the years 2015 and 2019, and relatively static utilization rate from 2020 to 2023.Conclusions:This work supports the feasibility of widespread rMRI in the high-volume ED care setting, including for young children. rMRI utilization increased over time, with the technique most frequently used to evaluate ventricular shunt function and traumatic brain injury.
Background: Applicability of the BREAST-Q survey to the flat closure experience after mastectomy is unknown, as it was primarily designed to assess patients who undergo breast reconstruction. Thus, we aimed to investigate the guiding values and quality-of-life outcomes of patients who choose flat closure and assess if the BREAST-Q adequately captures these experiences. Methods: Between February and May 2024, we performed 18 1-hour semi-structured interviews with flat closure patients, identified through institution chart review and purposive sampling on social media, to explore their perioperative experiences and applicability of the BREAST-Q survey. A standardized interview template was developed with input from a plastic surgeon specialized in breast reconstruction, patient feedback, and current literature. Recruitment was complete once thematic saturation was achieved. Transcripts were coded on Dedoose Online Software and analyzed using a Grounded Theory-informed approach. Phenomenological interpretations of excerpts are presented. Results: Analysis of flat closure patients' perioperative experiences revealed 11 themes relating to: experiences with surgeons, experiences with other providers, education, community support, advocacy, motivating factors, financial and insurance considerations, body image and aesthetics, prosthetics use, physical impacts, and sexual impacts. Of note, we identified that most patients reported never being presented with flat closure as an option following mastectomy. Further, we found that online flat closure communities were critical to patients as they provided information, connection, and empowerment. Overall, participants noted that the BREAST-Q generally lacks an assessment of patient ability to fulfill familial duties, community support, pre-operative relationship to breasts, sources of reconstructive information, or prosthetic use. Specific to the flat closure community, participants remarked that the repeated language of "women" and "breasts" throughout the BREAST-Q is not inclusive and many questions were not applicable to their experience. Conclusions: Primary results reveal that community is the cornerstone of perioperative experiences for individuals opting for flat closure after mastectomy. Community provided most resources that guided decision-making, suggesting a potential gap in information provided by surgeons. Further, the sense of judgement participants occasionally felt in their decision highlights potential surgeon bias and the influence of societal beauty standards, necessitating patients to self-educate and then self-advocate, often against physicians pushing for reconstruction. Analysis revealed modules within the BREAST-Q use exclusive language, and many do not adequately capture the full range of experiences they are designed to measure. Overall, these results reveal a need for increased edification on the merits of flat closure and allow providers to understand that certain factors may be of higher value to different patients.
Background: Health professionals experience distress when unable to provide patient care in alignment with personal values and professional commitments. Most recently, Executive Orders (EO) in the USA have resulted in institutions adjusting practice on factors not based on scientific evidence, clinical recommendations, or the best interests of patients. This study describes how an institution's response to EO was felt by healthcare professionals. Methods: An anonymous and voluntary mixed-methods survey was distributed within a single institution. Survey topics included demographics, personal values, professional fulfillment, and feelings about external political pressures and institutional response. Qualitative data were reviewed, analyzed, coded, and clustered into themes through an iterative process. Results: A total of 164 participants responded to the survey, the majority nurses (38.4%) and physicians (15.7%). Participants expressed concern that external political pressures would impact the care of vulnerable patients and had already affected their own professional fulfillment. Nearly all participants felt it was important that their institution share their values and described these as providing quality health care for all (n=88, 53.7%), compassionate care (n=28, 17.1%), and ethical care (n=13, 7.9%). When responding to future external political pressures, healthcare professionals would like open discussion, greater communication, and transparency. Conclusions: Participants in this study described their work as motivated by values of equity and compassion and see the institution as the conduit through which they provide this care. Participants asked that the institution advocate in alignment with expressed values. When decisions are made that do not align with these values, participants asked the institution for greater opportunities for communication and transparency in decision-making.
