bluuebunny/crossref_metadata_2025 huggingface dataset:
Recurrent Surgical Site Infections in the Spine After Treatment With the Vacuum-assisted Closure (VAC) System
Authors: Alcala-Marquez Christopher , Torrealba Rubén , Mehbod Amir A. , Dawson John M. , Dressel Thomas D. , Transfeldt Ensor E.
Published: June 2018

Study Design:

This study retrospectively reviewed recurrences of surgical site infections (SSI) in spinal patients treated with vacuum-assisted closure (VAC) technology.

Objective:

Identify patient and treatment factors associated with recurrence of SSI after VAC treatment.

Summary of Background Data:

Patients treated with VAC can achieve healing of deep spine wound infections; however, some patients develop a recurrent infection. Risk factors associated with a recurrence have not been identified.

Materials and Methods:

One hundred and eleven patients with SSI after spine surgery from 2002 to 2010 were studied. They had been treated with irrigation and debridement, placement of VAC, and IV antibiotics. They subsequently were taken to surgery for primary closure of their wound. Patients with SSI who healed after the initial infection treatment were compared with patients who experienced recurrence. Patient and treatment factors that were studied included smoking status, body mass index, obesity status, diagnosis of diabetes, fusion surgery, methicillin-resistant Staphylococcus aureus, or polybacteria infection, number of irrigation and debridement treatments before closure, duration of IV antibiotic treatment, and duration of treatment time with VAC. Patients with SSI who healed after the initial treatment were compared with patients who experienced recurrence.

Results:

Fourteen patients had at least one recurrence of wound infection. None of the patient or treatment factors was associated with the recurrence of a SSI.

Conclusions:

Among spine surgery patients with a SSI treated with the VAC system, those factors which predispose a patient to develop a recurrent SSI remain unknown.

Level of Study:

Level IV.
What are the Rates, Reasons, and Risk Factors of 90-day Hospital Readmission After Lumbar Discectomy?
Authors: Kohls Morgan R. , Jain Nikhil , Khan Safdar N.
Published: June 2018

Study Design:

This is a retrospective cohort study.

Objective:

To report the rate, reasons, and risk factors for 90-day readmissions after lumbar discectomy at an academic medical center.

Summary of Background Data:

Several studies have reported complications and readmissions after spine surgery; however, only one previous study has focused specifically on lumbar discectomy. As the patient profile and morbidity of various spine procedures is different, focus on procedure-specific complications and readmissions will be beneficial.

Materials and Methods:

Patients who underwent lumbar discectomy for unrelieved symptoms of prolapsed intervertebral disk and had at least 90 days of follow-up at an academic institution (2013–2014) were included. Retrospective review of electronic medical record was performed to record demographic and clinical profile of patients. Details of lumbar discectomy, index hospital stay, discharge disposition, hospital readmission within 90 days, reason for readmission and treatment given have been reported. Risk factors for hospital readmission were analyzed by multivariate logistic regression analysis.

Results:

A total of 356 patients with a mean age of 45.0±13.8 years were included. The 90-day readmission rate was 5.3% (19/360) of which two-third patients were admitted within 30 days giving a 30-day readmission rate of 3.7% (13/356). The top 2 primary reasons for readmission included back and/or leg pain, numbness, or tingling (42.9%), and persistent cerebrospinal fluid leak or seroma (25.0%). On adjusted analysis, risk factors associated with higher risk of readmission included incidental durotomy [odds ratio (OR), 26.2; 95% confidence interval (CI), 5.3–129.9] and discharge to skilled nursing facility/inpatient rehabilitation (OR, 25.2; 95% CI, 2.7–235.2). Increasing age was a negative predictor of readmission (OR, 0.95; 95% CI, 0.91–0.99).

Conclusions:

Incidental durotomy, younger age, and discharge to nursing facility were associated with higher risk of 90-day hospital readmission after lumbar discectomy. As compared with extensive spine procedures, patient comorbidity burden may not be as significant in predicting readmission after this relatively less invasive procedure.
Disparities Predict for Higher Rates of Cut-through Hysterectomies in Locally Advanced Cervical Cancer
Authors: Amini Arya , Robin Tyler P. , Rusthoven Chad G. , Schefter Tracey E. , Akhavan David , Chen Yi-Jen , Glaser Scott M. , Corr Bradley R. , Ashing Kimlin T. , Fisher Christine M.
Published: June 2018

Objectives:

The treatment of choice for locally advanced cervical cancer is definitive chemoradiation (CRT). Hysterectomy is not indicated due to higher-rates of cut-through resections leaving gross disease behind, requiring additional therapy with increasing morbidity and no benefit in overall survival (OS). The objectives of this study were to determine factors associated with cut-through hysterectomies and evaluate OS outcomes.

Materials and Methods:

The National Cancer Database (NCDB) was queried for patients 18 years and older with clinical Federation of Gynecology and Obstetrics stage IB2 to IVA. All patients underwent upfront hysterectomy and had known margin status. Cut-through hysterectomy was classified as presence of microscopic or macroscopic disease at the margin.

Results:

A total of 11,638 patients were included; 993 (8.5%) had positive margins. In patients with positive margins, 560 (56.4%) received postoperative CRT and 148 (14.9%) underwent postoperative radiation. Five-year OS was worse for those with cut-through resections when compared with those with negative margins, 66.0% versus 86.7%, respectively (hazard ratios, 3.08; P<0.001). Under multiple logistic regression, African American race (odds ratio [OR], 1.45; P=0.001), older age (OR per year increase, 1.03; P<0.001), patients with government insurance (OR, 1.21; P=0.019), and those treated at community practices (OR, 1.31; P=0.001) were more likely to undergo cut-through hysterectomies.

Conclusions:

A review of national patterns of care over the past decade confirms women with positive margins after hysterectomy for cervical cancer have significantly worse OS. Disparities in surgical results for women with cervical cancer exist. In response, further causality evaluation and corrective action are warranted to address these inequalities.
An Improved LC-ESI-MS/MS Method to Quantify Pregabalin in Human Plasma and Dry Plasma Spot for Therapeutic Monitoring and Pharmacokinetic Applications
Authors: Dwivedi Jaya , Namdev Kuldeep K. , Chilkoti Deepak C. , Verma Surajpal , Sharma Swapnil
Published: June 2018

Background:

Therapeutic drug monitoring (TDM) of antiepileptic drugs provides a valid clinical tool in optimization of overall therapy. However, TDM is challenging because of the high biological sample (plasma/blood) storage/shipment costs and the limited availability of laboratories providing TDM services. Sampling in the form of dry plasma spot (DPS) or dry blood spot is a suitable alternative to overcome these issues.

Methods:

An improved, simple, rapid, and stability-indicating method for quantification of pregabalin (PGB) in human plasma and DPS has been developed and validated. Analyses were performed on liquid chromatography–tandem mass spectrometer under positive ionization mode of electrospray interface. PGB-d4 was used as internal standard, and the chromatographic separations were performed on Poroshell 120 EC-C18 column using an isocratic mobile phase flow rate of 1 mL/min. Stability of PGB in DPS was evaluated under simulated real-time conditions. Extraction procedures from plasma and DPS samples were compared using statistical tests. The method was validated considering the Food and Drug Administration method validation guideline.

Results:

The method was linear over the concentration range of 20–16,000 ng/mL and 100–10,000 ng/mL in plasma and DPS, respectively. DPS samples were found stable for only 1 week on storage at room temperature and for at least 4 weeks at freezing temperature (−20 ± 5°C). Method was applied for quantification of PGB in over 600 samples of a clinical study. Statistical analyses revealed that 2 extraction procedures in plasma and DPS samples showed statistically insignificant difference and can be used interchangeably without any bias.

Conclusions:

Proposed method involves simple and rapid steps of sample processing that do not require a precolumn or postcolumn derivatization procedure. The method is suitable for routine pharmacokinetic analysis and therapeutic monitoring of PGB.
The Uptake and Translocation of 99Tc, 133Cs, 237Np, and 238U Into Andropogon Virginicus With Consideration of Plant Life Stage
Authors: Montgomery Dawn A. , Edayilam Nimisha , Tharayil Nishanth , Powell Brian A. , Martinez Nicole E.
Published: June 2018

Hydroponic uptake studies were conducted to evaluate the uptake and translocation of 99Tc, 133Cs (stable analog for 137Cs), 237Np, and 238U into established and seedling Andropogon virginicus specimens under controlled laboratory conditions. Plant specimens were grown in analyte-spiked Hoagland nutrient solution for 24 h, 3 d, and 5 d. Translocation to shoots was greatest for 99Tc and 133Cs, likely due to their analogous nature to plant nutrients, while 238U (and 237Np to a lesser extent) predominantly partitioned to root tissue with less extensive translocation to the shoots. Plant age contributed significantly to differences in concentration ratios for all nuclides in shoot tissues (p ≤ 0.024), with higher concentration ratios for seedling specimens. Additionally, duration of exposure was associated with significant differences in concentration ratios of 133Cs and 99Tc for seedlings (p = 0.007 and p = 0.030, respectively) while plant part (root or shoot) was associated with significant differences in concentration ratios of established plants (p < 0.001 for both nuclides). Statistically significant increases in radionuclide uptake in seedling specimens relative to established plants under controlled conditions suggests that, in addition to geochemical factors, plant life stage of wild grasses may also be an important factor influencing radionuclide transport in the natural environment.
Orbital Expansion in Cranial Vault After Minimally Invasive Extradural Transorbital Decompression for Thyroid Orbitopathy
Authors: Ramesh Sathyadeepak , Nobori Alexander , Wang Yi , Rootman Daniel , Goldberg Robert Alan
Published: June 2018

Purpose:

To test the hypothesis that the orbit expands in the cranial vault after wide dural exposure after minimally invasive extradural transorbital decompression for thyroid eye disease.

Methods:

A cross-sectional cohort study of 36 patients (60 orbits). Preoperative and postoperative (6 months) orbital CT following extradural transorbital decompression was analyzed. Primary outcome measure was the percentage area of the cranial vault occupied by orbital and brain tissue in a predefined window before and after surgery. Secondary outcome measures were displacement of the anteriormost aspect of the temporal lobe, reduction in clinical proptosis, change in clinical activity score, and change in diplopia.

Results:

The mean percentage of the selected area of the cranial vault preoperatively was 0% orbital and 44% ± 15% brain tissue, compared with 70% ± 16% orbital and 28% ± 14% brain tissue postoperatively (p < 0.001). Posterior movement of the brain was demonstrated in 59 of 60 orbits, with a mean displacement of 2.0 mm ± 1.3 mm (p < 0.001). Mean proptosis reduction was 11.2 mm ± 3.6 mm (p < 0.001). The proportion of patients with clinical activity score <3 compared with clinical activity score ≥3 was not significantly different after surgery (p = 0.163). Improved diplopia was noted in 5 patients (14%), and worsening diplopia was noted in 3 patients (8%), although these changes were not significant (p = 0.772). Intraoperative dural tear with cerebrospinal fluid leak was reported in 2 orbits (3%), which was successfully managed with fibrin glue, with no sequelae. No other complications were noted, including infection, spontaneous orbital pulsations, postoperative hemorrhage (intracranial or intraorbital), or reactivation of disease.

Conclusion:

With wide exposure of the middle cranial fossa dura following extradural transorbital decompression, orbital tissue typically expands in the cranial vault.
Gastrointestinal Stromal Tumor Metastasis to the Orbit
Authors: Roelofs Kelsey A. , Medlicott Shaun , Henning Jan-Willem , Weis Ezekiel
Published: June 2018

A 66-year-old woman was referred to the authors’ service with a 1-week history of blurry vision in her left eye and retro-orbital ache. She had previously undergone a radical distal gastrectomy and omentectomy for gastrointestinal stromal tumor, epithelioid type, 7 years prior. Exophthalmometry confirmed 2 mm of left-sided proptosis. Computed tomography imaging revealed a solid-appearing mass straddling both the intra- and extraconal spaces and involving the superior rectus muscle. An excisional biopsy was performed. Histopathological examination revealed a relatively uniform epithelioid appearance with a high mitotic rate, and immunohistochemical analysis revealed positivity for both KIT (CD117) and CD34. To the best of the authors’ knowledge, this is only the second histopathologically confirmed case of gastrointestinal stromal tumor metastasis to the orbit reported in the literature.
Impacting diabetes self-management in women with gestational diabetes mellitus using short messaging reminders
Authors: Johnson Quinetta B. , Berry Diane C.
Published: June 2018

Background and purpose:

Gestational diabetes mellitus (GDM) has been associated with multiple complications, including increase risk of gestational hypertension, cesarean delivery, macrosomia, stillbirth, and preeclampsia. The purpose of this study was to determine the acceptability of text messaging in women with GDM and further refine intervention materials and study procedures (recruitment, enrollment, intervention, retention, and data collection).

Methods:

Nineteen women diagnosed with GDM completed a baseline demographic questionnaire followed by 4 weeks of daily text messages that included either a direct reminder to test their blood glucose levels and keep up with their treatment plan or an educational message. A postintervention survey was administered to assess the satisfaction with the messaging program.

Conclusion:

The use of daily text messages in the treatment plan of patients diagnosed with GDM seems to be acceptable shown by an overall satisfaction with the messages and a willingness to use the messages in future pregnancies. Half of the participants also felt that the messages helped them to eat healthier.

Implications for practice:

This study demonstrated a real opportunity for a low-cost intervention in the management plan of GDM.
Surgical Impact of Coupling an Active Middle Ear Implant to Short Incus Process
Authors: Schraven Sebastian P. , Rak Kristen , Cebulla Mario , Radeloff Andreas , Grossmann Wilma , Hagen Rudolf , Mlynski Robert
Published: June 2018

Introduction:

Since 1996 the active middle-ear implant Vibrant Soundbridge (VSB) is used to treat mild-to-severe sensorineural hearing losses. The former standard surgical approach for incus vibroplasty included a mastoidectomy and a posterior tympanotomy, crimping the Floating-Mass Transducer (FMT) to the long incus process. The introduction of the short process (SP) coupler allows the attachment of the FMT to the incus body making the procedure of a posterior tympanotomy unnecessary. The aim of this study was to evaluate the duration of surgery (surgical case length) and to compare the audiological results of SP coupling with the former standard surgical approach to the long incus process.

Materials and Methods:

Patients undergoing an incus vibroplasty between October 2009 and February 2016 were included in this cohort study. The patients received an incus vibroplasty with crimping the FMT to the long incus process (former standard application) (n = 25) and with the SP coupler (n = 17) respectively. The surgical case length as well as the functional audiological outcome was assessed 12 months postoperatively using pure-tone audiometry and speech audiometry.

Results:

The surgical case length was significantly shorter in the SP coupler group compared to the standard application incus vibroplasty (85 ± 29 min vs. 114 ± 50 min). Additionally, patients receiving the SP coupler had an increased speech perception if compared to the standard application (Freiburger monosyllables at 65 dB SPL: 76.1 ± 16.1% vs. 66.2 ± 23.5%).

Conclusion:

The SP coupler leads to a shortened time of surgery and by the less invasive surgery to reduced risks for facial nerve and chorda tympani. Speech perception is significantly improved by SP coupling compared to classic long incus coupling.
Epidemiology of Clinically Significant Tinnitus: A 10-Year Trend From Nationwide Health Claims Data in South Korea
Authors: Lee Hyun Min , Han Kyung do , Kong Soo Keun , Nam Eui Cheol , Park Shi Nae , Shim Hyun Joon , Byun Jae Yong , Park Hong Ju , Im Gi Jung , Lee Il-Woo
Published: June 2018

Objectives:

Prevalence of tinnitus has been reported to vary according to the target population and definition of tinnitus. To improve the understanding of tinnitus, authors used the nation-wide health claim data to study the tinnitus in the entire population of South Korea.

Study Design:

Retrospective big data review.

Setting:

Analysis of big data from the National Health Information Database.

Patients:

Patients diagnosed with tinnitus according to International Classification of Diseases code 10th edition (ICD-10) and requested to receive National Health Insurance claim at least once from January 2006 to December 2015.

Intervention:

None.

Main Outcome Measure:

Epidemiologic data, association of tinnitus with the otologic and systemic diseases.

Results:

The number of patients who received medical care because of tinnitus was 1.44% (0.78 million per 51 million) in 2015. There was a higher prevalence of tinnitus in women, and the overall prevalence increased with increasing age of patients and peaked at patients in their 70s (4.43%). The prevalence of tinnitus among patients aged 10 to 30 years, showed a tendency to increase during study period. In the regional analysis, highest prevalence was observed in Gwangju (2.02%). In comparison with the control group, the patients with tinnitus showed a higher frequency in otologic and systemic disease. Especially, noise induced hearing loss (adjusted odds ratio [AOR] = 82.1, 95% confidence interval [95% CI] = 74.8–90.2) and sudden sensorineueal hearing loss (AOR = 49.7, 95% CI = 48.4–51.0) showed high frequency in tinnitus patient group.

Conclusions:

The prevalence and incidence of tinnitus in this study for entire nation were lower than previously reported studies. These results have limitation because the study only covered patient using the medical service for tinnitus and missed tinnitus sufferers not seeking medical service. However, this study is meaningful in that it was targeting entire nation, reflected the characteristics of clinically significant tinnitus patient enough to visit medical service
Less or more hemodynamic monitoring in critically ill patients
Authors: Jozwiak Mathieu , Monnet Xavier , Teboul Jean-Louis
Published: June 2018

Purpose of review

Hemodynamic investigations are required in patients with shock to identify the type of shock, to select the most appropriate treatments and to assess the patient's response to the selected therapy. We discuss how to select the most appropriate hemodynamic monitoring techniques in patients with shock as well as the future of hemodynamic monitoring.

Recent findings

Over the last decades, the hemodynamic monitoring techniques have evolved from intermittent toward continuous and real-time measurements and from invasive toward less-invasive approaches. In patients with shock, current guidelines recommend the echocardiography as the preferred modality for the initial hemodynamic evaluation. In patients with shock nonresponsive to initial therapy and/or in the most complex patients, it is recommended to monitor the cardiac output and to use advanced hemodynamic monitoring techniques. They also provide other useful variables that are useful for managing the most complex cases. Uncalibrated and noninvasive cardiac output monitors are not reliable enough in the intensive care setting.

The use of echocardiography should be initially encouraged in patients with shock to identify the type of shock and to select the most appropriate therapy. The use of more invasive hemodynamic monitoring techniques should be discussed on an individualized basis.
Dermatologic considerations in pediatric transplant recipients
Authors: Bhat Trisha , Coughlin Carrie C.
Published: June 2018

Purpose of review

The pediatric transplant patient population is growing as the number of solid organ transplants and indications for hematopoietic stem cell transplant increase. Understanding cutaneous sequelae of pediatric transplant and treatment strategies to manage these outcomes is vital to the care of these patients.

Recent findings

Important work in the past year enhances our understanding of the cutaneous implications of pediatric transplantation, including further work in areas of malignancy, infection, and graft versus host disease as well as newly reported risks.

This review highlights recent developments in the recognition and management of dermatological complications of pediatric transplant that will be useful for the practicing pediatrician or dermatologist.
Does galvanic vestibular stimulation decrease spasticity in clinically complete spinal cord injury?
Authors: Čobeljić Radoje D. , Ribarič-Jankes Ksenija , Aleksić Antonina , Popović-Maneski Lana Z. , Schwirtlich Laszlo B. , Popović Dejan B.
Published: June 2018

The aim of this study was to determine changes in clinical and biomechanical measures of spasticity after administering galvanic vestibular stimulation in patients with a complete spinal cord injury (SCI). The spasticity in the lower limbs was assessed using the Modified Ashworth Scale and the pendulum test in seven SCI patients (grade A on the ASIA Impairment Scale) before (0−), immediately after (0+), and at 5 and 30 min after the real versus sham galvanic vestibular stimulation (15 s each, anode over the right mastoid). Overall, the changes in spasticity were not significantly different between the real and sham galvanic vestibular stimulation. However, the Modified Ashworth Scale and the pendulum test indicated a reduction in spasticity in two out of seven patients. The results suggest that galvanic vestibular stimulation may modify spasticity in some patients with complete SCI, presumably through the residual vestibulospinal influences. Future studies should determine clinical and neurophysiological profiles of responders versus nonresponders and optimize parameters of galvanic vestibular stimulation.
Incidence and Factors Associated With Attentional Fatigue in Working Long-term Breast Cancer Survivors
Authors: Crouch Adele , Von Ah Diane
Published: June 2018

Purpose:

The purpose of this study was to examine the incidence of attentional fatigue and the relationship between sleep disturbance and attentional fatigue in working long-term breast cancer survivors (BCS).

Methods:

A descriptive, correlation design was used. The data for this study were drawn from a larger descriptive study designed to understand the impact of cognitive dysfunction on work-related outcomes. Breast cancer survivors completed questionnaires regarding sleep disturbance, attentional fatigue, and demographic and medical characteristics. Sleep disturbance, a subscale of the Pittsburgh Sleep Quality Index, is measured by asking 9 questions about sleep disturbances. Attentional fatigue was measured by the Attentional Function Index. Descriptive statistics and multiple regression were performed to assess the impact of sleep disturbance on attentional fatigue, controlling for covariates.

Results:

Sixty-eight female BCS, ranging from 29 to 68 years old (mean [SD], 52.1 [8.6] years old) and, on average, 4.97 (SD, 3.36) years posttreatment, participated. Thirty-four percent of BCS had poor to moderate attention function. Sleep disturbance significantly predicted attentional fatigue (P < .05), explaining 16% of the variance, F
4,57 = 2.68, P < .04, R
2 = 0.16.

Conclusions:

Clinicians can assess and intervene to decrease sleep disturbance, which may also improve attentional fatigue in BCS. However, sleep disturbance is only 1 contributing factor. Further investigation into factors contributing to attentional fatigue in BCS is warranted.
Challenges in Pathologic Staging of Renal Cell Carcinoma
Authors: Williamson Sean R. , Rao Priya , Hes Ondrej , Epstein Jonathan I. , Smith Steven C. , Picken Maria M. , Zhou Ming , Tretiakova Maria S. , Tickoo Satish K. , Chen Ying-Bei , Reuter Victor E. , Fleming Stewart , Maclean Fiona M. , Gupta Nilesh S. , Kuroda Naoto , Delahunt Brett , Mehra Rohit , Przybycin Christopher G. , Cheng Liang , Eble John N. , Grignon David J. , Moch Holger , Lopez Jose I. , Kunju Lakshmi P. , Tamboli Pheroze , Srigley John R. , Amin Mahul B. , Martignoni Guido , Hirsch Michelle S. , Bonsib Stephen M. , Trpkov Kiril
Published: June 2018

Staging criteria for renal cell carcinoma differ from many other cancers, in that renal tumors are often spherical with subtle, finger-like extensions into veins, renal sinus, or perinephric tissue. We sought to study interobserver agreement in pathologic stage categories for challenging cases. An online survey was circulated to urologic pathologists interested in kidney tumors, yielding 89% response (31/35). Most questions included 1 to 4 images, focusing on: vascular and renal sinus invasion (n=24), perinephric invasion (n=9), and gross pathology/specimen handling (n=17). Responses were collapsed for analysis into positive and negative/equivocal for upstaging. Consensus was regarded as an agreement of 67% (2/3) of participants, which was reached in 20/33 (61%) evaluable scenarios regarding renal sinus, perinephric, or vein invasion, of which 13/33 (39%) had ≥80% consensus. Lack of agreement was especially encountered regarding small tumor protrusions into a possible vascular lumen, close to the tumor leading edge. For gross photographs, most were interpreted as suspicious but requiring histologic confirmation. Most participants (61%) rarely used special stains to evaluate vascular invasion, usually endothelial markers (81%). Most agreed that a spherical mass bulging well beyond the kidney parenchyma into the renal sinus (71%) or perinephric fat (90%) did not necessarily indicate invasion. Interobserver agreement in pathologic staging of renal cancer is relatively good among urologic pathologists interested in kidney tumors, even when selecting cases that test the earliest and borderline thresholds for extrarenal extension. Disagreements remain, however, particularly for tumors with small, finger-like protrusions, closely juxtaposed to the main mass.
Comedonecrosis Revisited
Authors: Fine Samson W. , Al-Ahmadie Hikmat A. , Chen Ying-Bei , Gopalan Anuradha , Tickoo Satish K. , Reuter Victor E.
Published: June 2018

From the advent of the Gleason grading system for prostate cancer, cancer displaying intraluminal necrotic cells and/or karyorrhexis within cribriform/solid architecture, a phenomenon termed “comedonecrosis,” has been assigned pattern 5. Intraductal carcinoma (IDC-P) shows morphologic overlap with high-grade cribriform/solid adenocarcinoma architecturally and cytologically and may also show central necrosis, yet due to the presence of basal cells at the duct periphery is not currently assigned a grade in clinical practice. On the basis of observations from routine clinical cases, we hypothesized that comedonecrosis was more significantly associated with IDC-P than invasive disease. From a large series of mapped radical prostatectomy specimens (n=933), we identified 125 high-grade (≥Gleason score 4+3=7), high-volume tumors with available slides for review. All slides were examined for the presence of unequivocal comedonecrosis. Standard immunohistochemistry for basal cell markers was performed to detect basal cell labeling in these foci. In total, 19 of 125 (15%) cases showed some ducts with comedonecrosis—9 cases with 1 focus and 10 cases with ≥2 foci; in all, a total of 73 foci of true comedonecrosis were evaluated. Immunohistochemical stains revealed labeling for basal cell markers in a basal cell distribution for at least some comedonecrosis foci in 18 of 19 (95%) cases, 12 with IDC-P exclusively and 6 with a mix of IDC-P and invasive carcinoma comedonecrosis foci. These results suggest that comedonecrosis is strongly associated with IDC-P and hence, the routine assignment of pattern 5 to carcinoma exhibiting comedonecrosis should be reconsidered.
Role of Fractionated Fat in Blending the Lid-Cheek Junction
Authors: Rohrich Rod J. , Mahedia Monali , Shah Nilay , Afrooz Paul , Vishvanath Lavanya , Gupta Rana K.
Published: June 2018

Background:

Fat grafting has been used extensively in plastic surgery in the past two decades. Here, the authors report the retrospective comparison of patients who underwent fractionated fat injection to blend the lid-cheek junction with those who had regular fat injection.

Methods:

After obtaining institutional review board approval, a retrospective review of patients who underwent lower blepharoplasty with fractionated fat injection for blending the lid-cheek junction from January of 2014 through October of 2015 was performed. The results were compared to those of lower blepharoplasty patients who did not have fractionated fat injected before January of 2014. Twelve prospectively selected patients underwent histopathologic and gene expression comparisons.

Results:

A comparison of complications between the two groups revealed no significant differences. Furthermore, there was no significant difference between the two groups for sequelae of fractionated fat injection and regular fat injection. The gene expression analysis of the fractionated and regular fat did not show any difference between undifferentiated and differentiated cells. In addition, Oil Red O staining of the fractionated and regular fat after differentiation showed that cells from both fat groups differentiated equally well.

Conclusions:

Fractionated fat injection appears to be a safe addition in blending the lid-cheek junction in the five-step lower blepharoplasty. There is no fat nodule formation with injection of fractionated fat injection compared with injection of regular fat performed superficially in the tear trough area. Contrary to what has previously been shown, the presence of viable cells in fractionated fat was noted.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
When Is Teenage Plastic Surgery versus Cosmetic Surgery Okay? Reality versus Hype: A Systematic Review
Authors: Rohrich Rod J. , Cho Min-Jeong
Published: June 2018

Plastic surgery in teenagers has become popular in past decades because of an increase in self-awareness and desire to “fit in” with their peers. In 2016, over 229,551 cosmetic procedures were performed in patients who are younger than 19 years. The trend of plastic surgery in adolescents is increasing, and it is important for plastic surgeons to perform safe and appropriate procedures in this group. To this date, there is a myriad of literature on the psychological and ethical issues concerning plastic surgery in teenagers. However, studies regarding the safety of performing plastic surgery in this population are scarce. The rationale for this article is to study this issue in depth by means of a systematic review. The authors discuss the current indications, safety, patient satisfaction, and ethical considerations of teenage plastic surgery and make recommendations for future studies on this important area.
Optimizing Perforator Selection: A Multivariable Analysis of Predictors for Fat Necrosis and Abdominal Morbidity in DIEP Flap Breast Reconstruction
Authors: Hembd Austin , Teotia Sumeet S. , Zhu Hong , Haddock Nicholas T.
Published: June 2018

Background:

This study aims to elucidate the important predicting factors for fat necrosis and abdominal morbidity in the patient undergoing deep inferior epigastric artery perforator flap reconstruction.

Methods:

The authors conducted a retrospective review of 866 free-flap breast reconstructions performed at one institution from 2010 to 2016. Twenty-eight potential predictors were included in multivariable analyses to control for possible confounding interactions.

Results:

Four hundred nine total deep inferior epigastric artery perforator flaps were included in the statistical analysis. Of these, 14.4 percent had flap fat necrosis, 21.3 percent had an abdominal wound or complication, and 6 percent had an abdominal bulge or hernia. Analysis showed an increase in the odds of fat necrosis with increasing flap weight (OR, 1.002 per 1-g increase; p = 0.0002). A decrease in the odds of fat necrosis was seen with lateral row (OR, 0.29; p = 0.001) and both medial and lateral row perforator flaps (OR, 0.21; p = 0.001), if indocyanine green angiography was used (OR, 0.46; p = 0.04), and with increasing total flow rate of the flap (OR, 0.62 per 1-mm/second increase; p = 0.05). Increased odds of abdominal bulge or hernia were seen with lateral row or both medial and lateral row perforators (OR, 3.21; p = 0.05) versus medial row perforator-based flaps, and with patients who had an abdominal wound postoperatively (OR, 2.59; p = 0.05).

Conclusions:

The authors’ results suggest that using larger caliber perforators and perforators from the lateral row alone, or in addition to medial row perforators, can decrease fat necrosis more than simply harvesting more perforators alone. However, lateral and both medial and lateral row perforator flaps come at the cost of increasing abdominal bulge rates.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, III.
Transversus Abdominis Plane Blocks in Microsurgical Breast Reconstruction: Analysis of Pain, Narcotic Consumption, Length of Stay, and Cost
Authors: Salibian Ara A. , Frey Jordan D. , Thanik Vishal D. , Karp Nolan S. , Choi Mihye
Published: June 2018

Background:

Transversus abdominis plane blocks are increasingly being used in microvascular breast reconstruction. The implications of these blocks on specific reconstructive, patient, and institutional outcomes remain to be fully elucidated.

Methods:

Patients undergoing abdominally based microvascular breast reconstruction from 2015 to 2017 were reviewed. Length of stay, complications, narcotic consumption, donor-site pain, and hospital expenses were compared between patients who did and did not receive transversus abdominis plane blocks with liposomal bupivacaine. Outcomes were subsequently compared in patients with elevated body mass index.

Results:

Fifty patients (43.9 percent) received blocks [27 (54.0 percent) under ultrasound guidance] and 64 patients (56.1 percent) did not. Patients with the blocks had significantly decreased oral and total narcotic consumption (p = 0.0001 and p < 0.0001, respectively) and significantly less donor-site pain (3.3 versus 4.3; p < 0.0001). There was no significant difference in hospital expenses between the two cohorts ($21,531.53 versus $22,050.15 per patient; p = 0.5659). Patients with a body mass index of 25 kg/m2 or greater who received a block had a significantly decreased length of stay (3.8 days versus 4.4 days; p = 0.0345) and decreased narcotic consumption and postoperative pain compared with patients without blocks. Patients with a body mass index less than 25 kg/m2 did not have a significant difference in postoperative pain, narcotic consumption, or length of stay between groups.

Conclusions:

Transversus abdominis plane blocks with liposomal bupivacaine significantly reduce oral and total postoperative narcotic consumption and donor-site pain in all patients after abdominally based microvascular breast reconstruction without increasing hospital expenses. The blocks also significantly decrease length of stay in patients with a body mass index greater than or equal to 25 kg/m2.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Seasonal Impact on Surgical-Site Infections in Body Contouring Surgery: A Retrospective Cohort Study of 602 Patients over a Period of 6 Years
Authors: Duscher Dominik , Kiesl David , Aitzetmüller Matthias Michael , Wenny Raphael , Schableger Karl , Staud Clement Johannes , Pollhammer Michael Stefan , Shamiyeh, M.D. Andreas , Huemer Georg M.
Published: June 2018

Background:

Postoperative surgical-site infections are severe complications following body contouring surgery. Here, the authors evaluate whether surgical-site infection rates are influenced by higher temperatures during the summer season.

Methods:

We enrolled 602 patients who underwent body contouring surgery between 2009 and 2015 in a retrospective cohort study. Data collected included demographics, surgical data, and postoperative outcome. Body contouring surgery procedures included lower and upper body lift, abdominoplasty, breast reduction, mastopexy, brachioplasty, and thigh lift. Infection rates were calculated on a seasonal basis and compared using Fisher’s exact test and logistic regression analysis.

Results:

There were 136 patients (125 women and 11 men) in the warm season [June to August; with an average temperature of 67.622°F (19.79°C)] and 466 patients (438 women and 28 men) in the cold seasons group [September to May, with an average temperature of 45.45 °F (7.47°C)]. The composition of the study cohorts was comparable. The average age was 40 years and the average body mass index was 27 kg/m2. From a total of 602 patients, the authors observed 33 surgical-site infections, representing a rate of 5.48 percent. A statistically significant increase of postoperative surgical-site infections could be detected during summer (10.29 percent versus 4.08 percent; p = 0.0071), representing an increase of 150 percent. In addition, a logistic regression analysis determined “season” as the strongest predictor for surgical-site infections, with a risk increase of 2.693 times in the warm season.

Conclusions:

Body contouring operations are elective procedures, making careful risk consideration an absolute prerequisite. The authors demonstrate a significantly increased infection risk during summer and establish a causal link between the warm season and surgical-site infection accumulation. Consequently, preoperative patient information and operative planning should be adjusted accordingly.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, II.
Not All Breast Implants Are Equal: A 13-Year Review of Implant Longevity and Reasons for Explantation
Authors: Van Slyke Aaron C. , Carr Michael , Carr Nicholas J.
Published: June 2018

Background:

Augmentation mammaplasty is the most common aesthetic procedure. Textured implants control implant position and have improved capsular contracture rates; however, the impact of texturing on longevity and clinical findings at explantation is unclear.

Methods:

All cases of explantation between January of 2005 and April of 2017 from an aesthetic practice were reviewed retrospectively. Patient demographics, implant characteristics, time to explantation, and clinical presentation and intraoperative findings at explantation were analyzed.

Results:

Five hundred thirty-nine breast implants were explanted during the study period: 249 saline, 147 smooth gel, 123 Biocell, and 20 other nonaggressively textured breast implants. Average time from placement to explantation was 7.5, 5.6, 4.9, and 4.0 years for saline, other textured, smooth gel, and Biocell implants, respectively (p = 3.25e-08). The percentage of implants removed associated with implant performance failure was 50.3, 57.4, 75.0, and 85.4 percent for smooth gel, saline, other textured, and Biocell implants, respectively (p = 7.25e-09). In addition, 21.1 percent of Biocell implants versus 1.4 percent of all other implants presented with pain (p = 2.71e-15). Forty-five Biocell implants had double capsules; this phenomenon was not observed with any other implant type (p = 5.85e-37). Seven Biocell implants had late seromas, compared to three late seromas with any other implant type (p = 0.0013).

Conclusions:

Here, the authors provide evidence that Biocell implants have the shortest time to explantation and the highest proportion of implants associated with implant performance failure. This information should complement the informed consent process when selecting an appropriate implant.
Robotic Nipple-Sparing Mastectomy with Immediate Prosthetic Breast Reconstruction: Surgical Technique
Authors: Sarfati Benjamin , Struk Samuel , Leymarie Nicolas , Honart Jean-François , Alkhashnam Heba , Kolb Frédéric , Rimareix Françoise
Published: June 2018

Robotic nipple-sparing mastectomy could be a significant advancement in the treatment and prophylaxis of selected breast cancers. Motion-scaling, high-resolution, three-dimensional optics; tremor elimination; and instruments with enhanced precision with 7 degrees of freedom have allowed surgeons to overcome the limitations experienced with the endoscopic approach in breast surgery. Advantages of this procedure, in comparison with the open technique, are a shorter and more acceptable scar located in the lateral thoracic region, and greater respect for the vascularization of the mastectomy skin flap, because there is no incision on the breast and no retractors are used. The authors recently received approval from both the French health authorities and the ethics committee to carry out a clinical trial in their institution to assess feasibility, reproducibility, and safety of robotic nipple-sparing mastectomy with immediate prosthetic breast reconstruction. The aims of this article are to describe the surgical technique they have developed, and to share, through a video, the clinical experience gained from over 60 procedures performed so far.
Prevention of infectious diseases in patients with Good syndrome
Authors: Multani Ashrit , Gomez Carlos A. , Montoya José G.
Published: June 2018

Purpose of review

Good syndrome is a profoundly immunocompromising condition with heterogeneous immune deficits characterized by the presence of thymoma, low-to-absent B-lymphocyte counts, hypogammaglobulinemia, and impaired cell-mediated immunity. Opportunistic infectious diseases associated with Good syndrome represent a diagnostic and therapeutic challenge, given their protean clinical manifestations. Although these infectious complications have been reviewed in prior publications, recommendations regarding their prevention have been lacking.

Recent findings

Good syndrome usually occurs in adult patients between the ages of 40 and 70 years. Immunologically, it is characterized by low or absent peripheral blood B lymphocytes, hypogammaglobulinemia, and variable defects in cell-mediated immunity including low CD4+ T counts, inverted CD4+:CD8+ T-lymphocyte ratio, and reduced T-lymphocyte mitogen proliferative responses. Patients with Good syndrome are susceptible to a variety of infectious diseases, of which the most common are recurrent bacterial sinopulmonary infections, mucocutaneous candidiasis, and CMV tissue-invasive disease. Preventive guidelines including targeted antimicrobial prophylaxis and vaccination strategies can mitigate infectious complications in patients with Good syndrome.

Immunological deficits and infectious complications in Good syndrome have been described for over 60 years. Further research is needed to elucidate its exact pathogenesis and define the mechanistic relationship between thymoma and hypogammaglobulinemia. However, tailored prophylactic strategies can be recommended for patients with Good syndrome.
Neuroimaging advances in Parkinson's disease
Authors: Rispoli Vittorio , Schreglmann Sebastian R. , Bhatia Kailash P.
Published: June 2018

Purpose of review

Neuroimaging in Parkinson's disease is an evolving field, providing in-vivo insights into the structural and biochemical changes of the condition, although its diagnosis remains clinical. Here, we aim to summarize the most relevant recent advances in neuroimaging in Parkinson's disease to assess the underlying disease process, identify a biomarker of disease progression and guide or monitor therapeutic interventions.

Recent findings

The clinical applications of imaging technology increasingly allow to quantify pigments (iron, neuromelanin) on MRI, proteins (tau), cell markers (phosphodiesterases, microglia) and neurotransmitter receptors (dopamine, serotonin, noradrenalin, cholin) via PET protocols, activity maps by resting-state and task-dependent functional MRI, as well as microstructural changes (free water) through diffusion-based assessments. Their application provides increasing insight on the temporal and spatial dynamics of dopaminergic and other neurotransmitter systems as well as anatomical structures and circuits in Parkinson's disease. An expanding list of PET tracers increases the yield of functional studies.

This review summarizes the most recent, relevant advances in neuroimaging technology in Parkinson's disease. In particular, the combination of different imaging techniques seems promising to maximize the scope of future work, which should, among others, aim at identifying the best imaging marker of disease progression.
Genome-wide abundance of 5-hydroxymethylcytosine in breast tissue reveals unique function in dynamic gene regulation and carcinogenesis
Authors: Wilkins Owen M. , Johnson Kevin C. , Houseman E. Andres , King Jessica E. , Marsit Carmen J. , Christensen Brock C.
Published: June 2018

5-hydroxymethylcytosine (5hmC) is generated by oxidation of 5-methylcytosine (5mC), however little is understood regarding the distribution and functions of 5hmC in mammalian cells. We determined the genome-wide distribution of 5hmC and 5mC in normal breast tissue from disease-free women. Although less abundant than 5mC, 5hmC is differentially distributed, and consistently enriched among breast-specific enhancers and transcriptionally active chromatin. In contrast, regulatory regions associated with transcriptional inactivity were relatively depleted of 5hmC. Gene regions containing abundant 5hmC were significantly associated with lactate oxidation, immune cell function, and prolactin signaling pathways. In independent data sets, normal breast tissue 5hmC was significantly enriched among CpG loci demonstrated to have altered methylation in pre-invasive breast cancer and invasive breast tumors. Our findings provide a genome-wide map of nucleotide-level 5hmC in normal breast tissue and demonstrate that 5hmC is positioned to contribute to gene regulatory functions which protect against carcinogenesis.