bluuebunny/crossref_metadata_2025 huggingface dataset:
Tumor-to-Nipple Distance in Selecting Patients for Nipple-sparing Mastectomy
Authors: Kracoff-Sella Sharon L. , Allweis Tanir M. , Bokov Inna , Kadar-Sfarad Hadas , Shifer Yehonatan , Golzman Evgenia , Egozi Dana
Published: January 2021

Introduction:

Nipple-sparing mastectomy (NSM) is a valid option for carefully selected cases. Oncologic guidelines have not been established, but proximity of the tumor to the nipple, tumor size, lymph node involvement, and neoadjuvant chemotherapy have been suggested as contraindications to nipple preservation. This study describes our experience with NSM in relation to these factors, in particular distance of tumor from the nipple, to help establish evidence-based guidelines for NSM.

Method:

All NSM procedures performed at our institution between 2014 and 2018 were reviewed. The tumor-to-nipple distance was measured for each patient using mammography, ultrasound, or magnetic resonance imaging. All patients underwent a frozen section (FS) biopsy of the base of the nipple during surgery, and if cancer was detected, the procedure was converted to a skin-sparing mastectomy. Patients were followed for postoperative complications and cancer recurrence.

Results:

Sixty-eight patients (98 breasts) underwent NSM with immediate reconstruction. Fifty-three patients (78%) underwent the procedure for breast cancer. Nipple involvement was detected on FS in 1 patient and on permanent pathology after a negative FS in 1 patient. Forty-three percent of our patients had a tumor-to-nipple distance of ≤2 cm. During a mean follow-up of 32.5 months (±19.4 months), no locoregional recurrences were observed; however, distant metastasis occurred in 3 patients.

Conclusions:

When histologic examination from the base of the nipple is negative (either by FS or permanent pathology), NSM can be considered oncologically safe. Lack of nipple involvement by preoperative clinical and imaging assessment and intraoperative FS is sufficient to classify patients as suitable for NSM.
Lymphatic Malformation Treated with Lymphatic Malformation–Venous Anastomosis Under Local Anesthesia
Authors: Furuse Kiichi , Kato Motoi , Morishita Yuya , Kumagai Tomoyo , Nakatsukasa Shuichi , Kuwata Tomoyuki
Published: January 2021

Lymphatic malformation (LM) can occur in the head and neck regions and cause cosmetic problems in adults. Sclerotherapy and surgical resection have been frequently applied; however, both are far from being minimally invasive in terms of aesthetic satisfaction, including the aesthetic downtime. We performed a less-invasive treatment using the venous anastomosis technique, named the lymphatic malformation–venous anastomosis (LMVA), mainly in pediatric patients with intractable microcystic lesions, in whom general anesthesia was required because the pediatric patients could not remain still. Here, we report the case of a 35-year-old man with a cystic submandibular LM successfully treated with LMVA under local anesthesia. He presented with a gradually enlarging LM on the neck. For improving aesthetics, LMVA was planned under local anesthesia. Lymphography by injecting indocyanine green revealed no inflow or outflow connection to the malformation; thus, we created an outflow bypass using the sidewall of the LMVA technique. The patient was discharged on the following day of the operation without any postoperative complications. A volumetric analysis 6 months later showed a 43.5% reduction of the malformation, with the patient being completely satisfied with the result. To the best of our knowledge, there has been no previous report on performing LMVA under local anesthesia in an adult. LMVA can be a novel treatment of choice when other options are less feasible.
Targeted Muscle Reinnervation for Symptomatic Neuromas Utilizing the Terminal Anterior Interosseous Nerve
Authors: Grome Luke J. , Agrawal Nikhil A. , Wang Eric , Netscher David T.
Published: January 2021

Sensory nerve trauma at the level of the wrist can lead to debilitating neuromas. Targeted muscle reinnervation (TMR) is an effective therapy for the treatment of neuromas. Here we propose the use of the terminal anterior interosseous nerve (AIN) as a viable recipient for TMR. All superficial sensory nerves around the wrist, including the dorsal ulnar sensory nerve, the distal lateral antebrachial cutaneous nerve, the distal branches of the superficial branch of the radial nerve, and the palmar cutaneous branch of the median nerve were dissected in 2 cadaver specimens. The AIN branch to pronator quadratus was divided just distal to the final branch of flexor pollicis longus to preserve adequate length for TMR. The sensory nerves at the wrist were fully dissected to identify a viable location for coaptation to the AIN. After the cadaveric concept was demonstrated, the technique was successfully used in a clinical case. In summary, the distal AIN is a versatile recipient for TMR as a treatment of painful sensory neuromas at the level of the wrist, with minimal donor-site morbidity.
Deep Inferior Epigastric Artery Perforator Flap Reconstruction for Breast Burn Deformities
Authors: Tugertimur Buğra , Dec Wojciech
Published: January 2021

The anterior chest wall is commonly involved in pediatric burn injuries. In women, deep thermal injuries may result in damage to the breast bud and breast skin, which can disrupt breast development and result in long-term deformities. In adulthood, the techniques frequently applied to correct these deformities focus on scar release in combination with skin grafting and implant-based procedures; however, these techniques often result in suboptimal aesthetic outcomes. In this report, we present superior outcomes from applying an autologous breast reconstruction technique to this challenging problem.
Videographic Analysis of Blink Dynamics following Upper Eyelid Blepharoplasty and Its Association with Dry Eye
Authors: Mak Felix H. W. , Ting Michelle , Edmunds Matthew R. , Harker Anthony , Edirisinghe Mohan , Duggineni Sirisha , Murta Fabiola , Ezra Daniel G.
Published: January 2021

Background:

This study was undertaken to characterize the effects of upper eyelid blepharoplasty on blink dynamics and to evaluate the hypothesis that changes in blink dynamics following blepharoplasty are associated with postoperative dry eye.

Methods:

The voluntary blink of 14 eyes of 7 patients with dermatochalasis undergoing upper eyelid blepharoplasty was recorded with a high-speed camera preoperatively and 6–8 months postoperatively, alongside a group of 11 controls. The images were analyzed for palpebral aperture, blink duration, and maximum velocity during opening and closing phases. Patients undergoing blepharoplasty were assessed for dry eye symptoms pre- and postoperatively at 6–8 months using the ocular surface disease index score.

Results:

Despite intraoperative orbicularis oculi resection, there was no significant compromise of blink duration or maximum velocity of eyelid opening or closure post-blepharoplasty. Postoperatively, patients had an increase in palpebral aperture compared with both preoperatively (8.71 versus 7.85 mm; P = 0.013) and control groups (8.71 versus 7.87 mm; P = 0.04). Postoperatively at 6–8 months, there was an increase in dry eye symptoms in 6 of 7 patients compared with preoperatively (ocular surface disease index, 16.6 versus 12.5; P < 0.05). There was no positive correlation between the increase in palpebral aperture and the increase in dry eye symptoms (r = –0.4; P = 0.30).

Conclusions:

Using modern videographic technology, this study demonstrates that upper eyelid blepharoplasty results in an increase in resting palpebral aperture but has no effect on dynamic blink parameters. Changes in palpebral aperture or blink dynamics are unlikely to be the cause of dry eye syndrome following blepharoplasty.
Outcome-based Comparative Study to Examine the Correction of Columella Deformities following Rhinoplasty
Authors: Uppal Rajan , Yousif Ali H. , Maheshwari Kavish
Published: January 2021

Background:

The columella is an underrepresented part of rhinoplasty. The objective of this study was to assess the outcome of columella correction following rhinoplasty and to assess any differences in the open and endonasal approach.

Methods:

This is a retrospective study involving 65 rhinoplasty patients, who were divided into 2 groups depending on whether they had an open or endonasal approach. Fifteen patients underwent the open procedure, and 50 patients underwent the endonasal approach. Patients who underwent endonasal rhinoplasty were compared with open rhinoplasty patients in terms of their final outcome, with a focus on the columellar correction. The classification by Rohrich and Liu and Gunter’s distance between the nasal axis and columella were used to assess the correction.

Results:

The overall incidence of columellar correction was 90% in the endonasal group (45 of 50 patients) and 67% in the open approach group (10 of 15 patients); a comparison shows aPvalue of 0.043 (<0.05). An estimated 49 of 50 patients (98%) from the endonasal group saw a reduction in the nasal axis–columella distance when compared with the open rhinoplasty group, who saw a reduction in 12 of 15 patients (80%); statistical analysis shows aPvalue of 0.036 (<0.05). The quantitative reduction in this distance in all patients when compared between the 2 groups had aPvalue of <0.001, suggesting a greater overall reduction using the endonasal approach. This may be related to differences in distribution of the deformities within the 2 groups.

Conclusions:

There is no standard way to correct the columella, but it is important to identify the deformity and the need to correct it. In our patients, we found comparable outcomes in achieving a satisfactory columella in the open and endonasal groups.
Crowd-Sourced Reliability of an Assessment of Lower Facial Aging Using a Validated Visual Scale
Authors: Kelly Jason D. , Comstock Bryan , Kowalewski Timothy M. , Smartt James M.
Published: January 2021

Background:

Reliable and valid assessments of the visual endpoints of aesthetic surgery procedures are needed. Currently, most assessments are based on the opinion of patients and their plastic surgeons. The objective of this research was to analyze the reliability of crowdworkers assessing de-identified photographs using a validated scale that depicts lower facial aging.

Methods:

Twenty photographs of the facial nasolabial region of various non-identifiable faces were obtained for which various degrees of facial aging were present. Independent crowds of 100 crowd workers were tasked with assessing the degree of aging using a photograph numeric scale. Independent groups of crowdworkers were surveyed at 4 different times (weekday daytime, weekday nighttime, weekend daytime, weekend nighttime), once a week for 2 weeks.

Results:

Crowds assessing midface region photographs had an overall correlation of R = 0.979 (weekday daytime R = 0.991; weekday nighttime R = 0.985; weekend daytime R = 0.997; weekend nighttime R = 0.985). Bland−Altman test for test-retest agreement showed a normal distribution of assessments over the various times tested, with the differences in the majority of photographs being within 1 SD of the average difference in ratings.

Conclusions:

Crowd assessments of facial aging in de-identified photographs displayed very strong concordance with each other, regardless of time of day or week. This shows promise toward obtaining reliable assessments of pre and postoperative results for aesthetic surgery procedures. More work must be done to quantify the reliability of assessments for other pretreatment states or the corresponding results following treatment.
Combining Preservation and Structured Rhinoplasty: Septal Extension Grafts and the Interdomal Hanger
Authors: Nakamura Fernando , Luitgards Bruno Ferreira , Ronche Ferreira José C.
Published: January 2021

Preservation rhinoplasty is a new philosophy in the field of rhinoplasty, focusing on preserving and reshaping nasal structures. However, the authors suggest some patients are not good candidates for preservation rhinoplasty. Patients with underprojected noses and thick skin need a septal extension graft for tip support and to achieve maximum tip definition. In this article, we describe a new technique to combine septal extension graft with the preservation of tip ligaments, called interdomal hanger. It allows the surgeon to benefit from increased tip support in rotation and projection. The technique consists of the preservation of the interdomal ligament, which is then stabilized above the septal extension graft working as a suspensory sling. With this technique, the surgeon can mix important steps of preservation rhinoplasty and benefit from the support of the septal extension grafts.
Use of a Bioabsorbable Implant-Acellular Dermal Matrix Construct to Facilitate Oncoplastic Breast-conserving Surgery
Authors: Schwartz Jean-Claude D.
Published: January 2021

Deformity after partial mastectomy for breast cancer is not uncommon. The immediate replacement of breast volume by a bioabsorbable implant has been shown to facilitate tissue ingrowth, maintain breast contour, reduce scarring and fibrosis, and preserve cosmesis. Soft tissue coverage is critical to minimize palpability and to prevent infection and extrusion of this device, especially after radiotherapy. This coverage is often not possible after significant oncological resection or in leaner patients. Here, we describe the use of a bioabsorbable implant-acellular dermal matrix construct in patients with insufficient soft tissue coverage after wide local excision.
Non-microvascular Successful Management of Near-total Ear Avulsion
Authors: Albdour Mahammad , Ammar Hamad M. , Alnaser Mutaz M.S. , Alzaben Faisal Saud , Malek Suha
Published: January 2021

Traumatic ear avulsion represents a difficult challenge for all reconstructive surgeons; hence, replantation and reattachment will provide the best aesthetic outcome. However, when microsurgery is not possible, the surgeon must choose the most appropriate alternative method to address the concern. We are reporting a case of a near-total right ear external auricle amputation attached only by small skin bridge. The patient was admitted to our institute 22 hours after sustaining an injury during a motor vehicle collision. He was successfully managed by reattaching the external auricle into the anatomical place, with the repair of cartilage. This was followed by applying a daily protocol for venous congestion with the use of subcutaneous and intradermal injection of low-molecular-weight heparin daily for 10 days with gradual tapering of the dose. The external auricle survived with no complications or morbidity. Subcutaneous and intradermal low-molecular-weight heparin can be used effectively in cases of severe venous congestion of avulsed ear with adequate arterial inflow without causing any morbidity.
Combination of pembrolizumab and lenvatinib is a potential treatment option for heavily pretreated recurrent and metastatic head and neck cancer
Authors: Chen Tien-Hua , Chang Peter Mu-Hsin , Yang Muh-Hwa
Published: January 2021

Background:

Immunotherapy has become the current standard of care for recurrent and metastatic head and neck squamous cell carcinoma (R/M HNSCC). One potential approach to improve immunotherapy efficacy is to combine pembrolizumab, an anti-PD-1 agent, with lenvatinib, a potent multikinase inhibitor. In this study, we presented our up-to-date experience with pembrolizumab/lenvatinib combination therapy in heavily pretreated R/M HNSCC.

Methods:

Patients who had R/M HNSCC, were ineligible for curative treatment, progressed after at least two lines of systemic treatment and had received pembrolizumab/lenvatinib combination therapy were enrolled in this study. The primary endpoint was the objective response rate. The secondary endpoints included the disease control rate, overall survival, progression-free survival, and the duration of response.

Results:

A total of 14 patients were enrolled in this study. All the patients had received at least two lines of systemic treatment and radiation therapy, and 71% of patients had failed previous anti-PD-1 treatment. The objective response rate of pembrolizumab/lenvatinib combination therapy was 28.6% (95% confidence interval [CI], 5.0%-52.2%). The disease control rate was 42.9% (95% CI, 17.0%-68.8%). The overall survival and progression-free survival were 6.2 months (95% CI, 2.9-9.6) and 4.6 months (95% CI, 0.05-0.9.2), respectively. Of those who had failed previous anti-PD-1 therapy, partial responses were observed in two patients. All the patients with partial responses were in the tumor proportion score <50 and combined positive score 1 to 19 groups.

Conclusion:

Our study provided up-to-date evidence that pembrolizumab/lenvatinib combination therapy achieved objective responses in both heavily pretreated and anti-PD-1 refractory R/M HNSCC patients. This study supported the use of pembrolizumab/lenvatinib combination therapy in R/M HNSCC patients without standard of care.
Exercise and Obesity: The role of exercise in prevention, weight loss, and maintenance of weight loss
Authors: Secor Mimi
Published: January 2021

The dramatic increase in overweight and obesity rates poses a public health threat and is a mandate for nurse practitioners to address this challenge in clinical practice. Exercise plays an essential role in prevention, initial weight loss, and maintenance of weight loss and recommendations for physical activity differ for each category. Intensity of exercise, duration, and effectiveness of various types of physical activity are reviewed. Possible reasons why exercise-focused weight loss goals are not attained are also explored. Nurse practitioners are assuming an increasingly important role in combating the obesity epidemic and can make a positive impact by implementing effective, evidence-based, exercise-focused strategies for prevention, initial weight loss, and maintenance of weight loss.
Pandemics and Mental Health Through the Lens of Literature
Authors: Panayi Adriana C. , Haug Valentin
Published: January 2021

Depictions of pandemics presented through the lens of literary authors and poets have everlasting power. In this article, we explore the psychosocial impact of pandemics, as presented through literature and poetry, and attempt to draw similarities with the current COVID-19 pandemic. We explore topics such as fear and anxiety, hopelessness, and suicide ideation. Overall, the psychological devastation caused by epidemics has influenced many major writers and will undoubtedly impact the writers of our generation. These writings are perhaps the richest source of knowledge of humanity's remarkable capacity to endure suffering.
Algorithm-Driven Substance Use Disorder Treatment for Inner-City Clients With Serious Mental Illness and Multiple Impairments
Authors: McHugo Gregory J. , Drake Robert E. , Haslett William R. , Krassenbaum Sarah R. , Mueser Kim T. , Sweeney Mary Ann , Kline John , Harris Maxine
Published: January 2021

Mental health clients with serious mental illness in urban settings experience multiple chronic stresses related to poverty, unemployment, discrimination, homelessness, incarceration, hospitalization, posttraumatic stress disorder, pain syndromes, traumatic brain injury, and other problems. Substance use disorder exacerbates these difficulties. This study examined the efficacy of algorithm-driven substance use disorder treatments for 305 inner-city mental health clients with multiple challenges. Researchers assessed substance use quarterly using a combination of standardized self-reports and case manager ratings. Of the 305 multiply impaired clients who began treatment, 200 (66%) completed 2 years of treatment. One fourth (n = 53) of the completers were responders who developed abstinence and improved community function; one half (n = 97) were partial responders, who reduced substance use but did not become abstinent; and one fourth (n = 50) were nonresponders. Evidence-based interventions for substance use disorder can be effective for multiply impaired, inner-city clients, but numerous complications may hinder recovery.
Navigating the Differential Diagnosis for Oncocytic Salivary Gland Lesions (Cytology and Histology)
Authors: Centeno Barbara A. , Wenig Bruce M.
Published: January 2021

Oncocytic lesions of the parotid gland include nonneoplastic entities and benign and malignant neoplasms. The most common benign neoplasm is Warthin tumor, which can be correctly diagnosed using fine-needle aspiration (FNA) or core biopsy in most cases. However, accurate FNA and/or biopsy preoperative diagnosis of many entities in this category is limited by sampling and overlap in morphological features among the different entities. We report the case of a 77-year-old man who presented with a right parotid mass identified on magnetic resonance imaging and computed tomography scan that was cystic with necrosis and with possible papillary growth in the cyst. The FNA smears were scantly cellular, with a few representative groups with significant nuclear crowding and overlapping in a bloody background. The cells had oncocytic cytoplasm, an increased nuclear-to-cytoplasmic ratio, and round-to-oval nuclei with prominent nucleoli. Necrosis, mitoses, and significant nuclear pleomorphism were not identified. The findings were interpreted as consistent with an oncocytoid/oncocytic salivary gland neoplasm. The cell block was acellular, so the neoplasm could not be further characterized by ancillary studies. The patient underwent a right superficial parotidectomy. The histopathological diagnosis was oncocytic carcinoma primarily based on the identification of perineural invasion. Oncocytic carcinoma is a rare, high-grade malignancy of salivary glands. This case will be used to discuss the differential diagnosis of oncocytoid/oncocytic salivary gland lesions on both cytopathology and histopathology and provide a pragmatic approach to the diagnostic evaluation. Indications for available ancillary testing will also be reviewed.
Sialadenitis of the Major Salivary Glands: A Tumor-Like Lesion of Various Etiologies and Morphological Appearances
Authors: Hernandez-Prera Juan C.
Published: January 2021

Inflammatory conditions of salivary glands—so-called sialadenitis—may clinically and histologically resemble a true neoplasm and result in a surgical resection. This review summarizes distinctive morphological patterns of inflammation that affect major salivary glands, and within this context, an unusual case of sialadenitis is also presented.
Essential statistical principles of clinical trials of pain treatments
Authors: Dworkin Robert H. , Evans Scott R. , Mbowe Omar , McDermott Michael P.
Published: January 2021

This article presents an overview of fundamental statistical principles of clinical trials of pain treatments. Statistical considerations relevant to phase 2 proof of concept and phase 3 confirmatory randomized trials investigating efficacy and safety are discussed, including (1) research design; (2) endpoints and analyses; (3) sample size determination and statistical power; (4) missing data and trial estimands; (5) data monitoring and interim analyses; and (6) interpretation of results. Although clinical trials of pharmacologic treatments are emphasized, the key issues raised by these trials are also directly applicable to clinical trials of other types of treatments, including biologics, devices, nonpharmacologic therapies (eg, physical therapy and cognitive-behavior therapy), and complementary and integrative health interventions.
Research design considerations for chronic pain prevention clinical trials: IMMPACT recommendations
Authors: Gewandter Jennifer S. , Dworkin Robert H. , Turk Dennis C. , Farrar John T. , Fillingim Roger B. , Gilron Ian , Markman John D. , Oaklander Anne Louise , Polydefkis Michael J. , Raja Srinivasa N. , Robinson James P. , Woolf Clifford J. , Ziegler Dan , Ashburn Michael A. , Burke Laurie B. , Cowan Penney , George Steven Z. , Goli Veeraindar , Graff Ole X. , Iyengar Smriti , Jay Gary W. , Katz Joel , Kehlet Henrik , Kitt Rachel A. , Kopecky Ernest A. , Malamut Richard , McDermott Michael P. , Palmer Pamela , Rappaport Bob A. , Rauschkolb Christine , Steigerwald Ilona , Tobias Jeffrey , Walco Gary A.
Published: January 2021

Although certain risk factors can identify individuals who are most likely to develop chronic pain, few interventions to prevent chronic pain have been identified. To facilitate the identification of preventive interventions, an IMMPACT meeting was convened to discuss research design considerations for clinical trials investigating the prevention of chronic pain. We present general design considerations for prevention trials in populations that are at relatively high risk for developing chronic pain. Specific design considerations included subject identification, timing and duration of treatment, outcomes, timing of assessment, and adjusting for risk factors in the analyses. We provide a detailed examination of 4 models of chronic pain prevention (ie, chronic postsurgical pain, postherpetic neuralgia, chronic low back pain, and painful chemotherapy-induced peripheral neuropathy). The issues discussed can, in many instances, be extrapolated to other chronic pain conditions. These examples were selected because they are representative models of primary and secondary prevention, reflect persistent pain resulting from multiple insults (ie, surgery, viral infection, injury, and toxic or noxious element exposure), and are chronically painful conditions that are treated with a range of interventions. Improvements in the design of chronic pain prevention trials could improve assay sensitivity and thus accelerate the identification of efficacious interventions. Such interventions would have the potential to reduce the prevalence of chronic pain in the population. Additionally, standardization of outcomes in prevention clinical trials will facilitate meta-analyses and systematic reviews and improve detection of preventive strategies emerging from clinical trials.
Local Triamcinolone Treatment Affects Inflammatory Response in Seroma Exudate of Abdominoplasty Patients: A Randomized Controlled Trial
Authors: Anker Alexandra M. , Felthaus Oliver , Prantl Lukas , Geis Sebastian , Brébant Vanessa , Kehrer Andreas , Strauss Catharina , Ruewe Marc , Vykoukal Jody , Klein Silvan M.
Published: January 2021

Background:

As the leading complication of abdominoplasty, seroma formation might represent an inflammatory process in response to surgical trauma. This prospective randomized trial investigated whether local administration of the antiinflammatory agent triamcinolone could prevent seroma accumulation.

Methods:

Weekly and cumulative seroma volumes were compared between the study groups A, B, and C over a 4-week follow-up (group A, with drain, without triamcinolone; group B, without drain, without triamcinolone; group C, without drain, with triamcinolone). Aspirated seroma samples were analyzed by enzyme-linked immunosorbent assay for selective inflammatory mediators.

Results:

Triamcinolone significantly reduced cumulative seroma volume (n = 60; mA 845 ± SDA 578 ml, mC 236 ± SDC 381 ml, p = 0.001). The most accentuated suppressive effect of triamcinolone was observed shortly after the treatment (week 1) (mA1 616 ± SDA1 457 ml, mB1 153 ± SDB1 161 ml, mC1 22 ± SDC1 44 ml, p
A1/C1 < 0.001, p
B1/C1 = 0.014). Local triamcinolone administration resulted in a differential concentration of interleukin-6 (IL-6) and matrix metalloproteinase-9 (MMP-9 (week 1) in seroma exudate as measured by enzyme-linked immunosorbent assay (mIL-6A1 1239 ± SDA1 59 pg/ml, mIL-6C1 848 ± SDC1 80 pg/ml, p < 0.001; mMMP-9A1 2343 ± SDA1 484 pg/ml, mMMP-9C1 376 ± SDC1 120 pg/ml, p = 0.001).

Conclusions:

Local administration of 80 mg of triamcinolone reduced postabdominoplasty seroma accumulation significantly. Under triamcinolone treatment, suppressed levels of IL-6 and MMP-9 in seroma fluid were observed. Notably, inflammatory marker suppression correlated clinically with a decrease in seroma accumulation.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, II.
Patient Blood Management Strategies to Avoid Transfusions in Body Contouring Operations: Controlled Clinical Trial
Authors: Enrique Bayter-Marin Jorge , Cárdenas-Camarena Lázaro , Peña William E. , Durán Héctor , Ramos-Gallardo Guillermo , Robles-Cervantes José Antonio , McCormick-Méndez Mauricio , Rocio Gómez-González Sonia , Liliana Plata-Rueda Erika
Published: January 2021

Background:

Anemia is a frequent process of morbidity and mortality in body contouring procedures. In aesthetic surgery, there are no standardized processes to minimize bleeding during surgery. For this reason, a study was designed to implement patient blood management strategies to reduce bleeding and transfusions in patients undergoing body contouring operations.

Methods:

From January of 2017 to May of 2018, a prospective cohort-type observational study was conducted, including two groups of patients undergoing single or combined body contouring procedures. The first group did not receive patient blood management strategies, whereas the second group did receive these strategies. These measures consisted of preoperative strategies to ensure the patient had optimal hemoglobin and hematocrit levels and supportive intraoperative measures to minimize blood loss. The results were validated with different statistical tests according to the variables studied.

Results:

A total of 409 patients were included in the study and were divided into two groups. The anthropometric and hemoglobin variables were similar in both groups. The 207 patients for whom patient blood management strategies were implemented lost an average of 1.2 g/dl less hemoglobin at 72 hours than the 202 patients for whom patient blood management strategies were not implemented (p ≤ 0.0001).

Conclusions:

Patient blood management strategies, such as increasing hemoglobin before surgery, and strategies to minimize blood loss during surgery, proved to be effective at reducing bleeding in patients undergoing body contouring surgery, also decreasing the need to perform postoperative blood transfusions.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, II.
Noninvasive Management of Pediatric Isolated, Condylar Fractures: Less Is More?
Authors: Lopez Joseph , Lake Isabel V. , Khavanin Nima , Kachniarz Bartlomiej , Najjar Omar , Pourtaheri Navid , Redett Richard J. , Manson Paul N. , Dorafshar Amir H.
Published: January 2021

Background:

The purpose of this study was to examine injury patterns in pediatric mandibular condylar fractures and to propose and evaluate the validity of an institutional treatment algorithm for such fractures.

Methods:

A retrospective chart review was conducted on pediatric patients who presented to the authors’ institution with isolated mandibular condylar fractures between 1990 and 2016. Patients were categorized by dentition, and information regarding demographics, injury characteristics, management, and complications was compiled.

Results:

Forty-three patients with 50 mandibular condylar fractures were identified. Twelve patients (27.9 percent) had deciduous dentition, 15 (34.9 percent) had mixed dentition, and 16 (37.2 percent) had permanent dentition. The most common fracture pattern in all groups was diacapitular [n = 30 (60 percent)]; however, older groups showed higher rates of condylar base fractures and bilateral fractures (p = 0.029 and p = 0.011, respectively). Thirty-one patients (72.1 percent) were treated with nonoperative management, 10 (23.2 percent) with closed treatment and mandibulomaxillary fixation, and two (4.7 percent) with open treatment and mandibulomaxillary fixation; nonoperative treatment was more common in younger patients (p = 0.008). Management for 10 patients (23.2 percent) was nonadherent to the treatment algorithm. Eight patients had complications (18.6 percent). Common complications included temporomandibular joint ankylosis (n = 2) and malocclusion (n = 2). Although complications were seen in all groups, adherence to the algorithm was associated with an 81.8 percent reduction in odds of complications (p = 0.032).

Conclusions:

Nonoperative management has a low complication rate in deciduous children. Children with permanent/mixed dentition may undergo closed treatment and mandibulomaxillary fixation if they have malocclusion/contralateral open bite, significant condylar dislocation, and ramus height loss greater than 2 mm.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Fibula Jaw-in-a-Day with Minimal Computer-Aided Design and Manufacturing: Maximizing Efficiency, Cost-Effectiveness, Intraoperative Flexibility, and Quality
Authors: Chang Yang-Ming , Wei Fu-Chan
Published: January 2021

The vascularized fibular flap has been the mainstay for mandibular reconstruction for over 30 years. Its latest evolutionary step is the jaw-in-a-day operation, during which the fibula flap and dental prosthesis restoration are performed in a single stage. Computer-aided design and manufacturing technology in mandibular reconstruction has gained popularity, as it simplifies the procedure and produces excellent outcomes. However, it is costly, time-consuming, and limited in cases that involve complex defects, including bone and soft-tissue coverage. Moreover, it does not allow for intraoperative changes in the surgical plan, including defect size and recipient vessel selection.

The authors describe their approach, including a conventional technique for fibula osteoseptocutaneous flap harvest without the need for a premanufactured cutting guide, using bundled wooden tongue spatulas instead, a stereolithographic model to customize commercially ready-made reconstruction plates, and two pieces of resin to maintain occlusive alignment of the remaining jaw segments during mandibular osteotomy. Dental implants are inserted free-hand. Vector guides are then connected to the implants following insertion into the fibula to confirm acceptable alignment and subsequently replaced with scan sensors. An intraoperative digital scan is used to design and to produce a dental prosthesis by in-house milling of a polymethylmethacrylate block. From our 10-case experience over the past 3 years, we have found that our approach offers a reliable method that matches the excellent outcomes seen using full computer-assisted design and manufacturing technology. It is time- and cost-effective, not limited to relatively simple jaw defects, and can readily accommodate intraoperative changes of surgical plan.
Radiation Oncology Applications in Plastic and Reconstructive Surgery: A Nonsystematic Review of Concepts and Principles
Authors: Kotha Vikas S. , Rewari Amar , Lakhiani Chrisovalantis , Zolper Elizabeth G. , Orio Peter F. , Stimac Gregory , Chadab Tara M. , Fan Kenneth L. , Evans Karen K. , Song David H.
Published: January 2021

Careful consideration of radiotherapy can determine the success of reconstructive therapy. There is a broad spectrum of radiotherapy modalities, both benign and malignant. Delivery mechanisms differ in the physical design, setup, radiation source, administrable dosage, and mode of delivery. This range of options allows radiation oncologists to tailor individualized treatment; however, radiotherapy concepts can be challenging for nonspecialists. The purpose of this article is to review general radiation oncology concepts, including essential equipment and radiobiology, and provide plastic surgeons with a basic conceptual understanding to facilitate effective multidisciplinary collaboration with radiation oncologists.
A Rare Patient With Midline Facial Cleft
Authors: Zhou Xinli , Chen Renji , Guo Siyuan
Published: January 2021

Midline facial cleft, namely Tessier number 0 cleft, is the most common kind of craniofacial cleft, which is described as a median facial dysrhaphia, involving the midline structures of the face below the orbit. The authors report a patient with midline facial cleft, having palatal cleft, absent premaxilla and nasal septum, and other associated features. Clinical features, surgical treatment, and possible etiology have been elaborated in this clinical report.
Alive and at home: Five-year outcomes in older adults following emergency general surgery
Authors: Guttman Matthew P. , Tillmann Bourke W. , Nathens Avery B. , Saskin Refik , Bronskill Susan E. , Huang Anjie , Haas Barbara
Published: January 2021

BACKGROUND

While the short-term risks of emergency general surgery (EGS) admission among older adults have been studied, little is known about long-term functional outcomes in this population. Our objective was to evaluate the relationship between EGS admission and the probability of an older adult being alive and residing in their own home 5 years later. We also examined the extent to which specific EGS diagnoses, need for surgery, and frailty modified this relationship.

METHODS

We performed a population-based, retrospective cohort study of community-dwelling older adults (age, ≥65 years) admitted to hospital for one of eight EGS diagnoses (appendicitis, cholecystitis, diverticulitis, strangulated hernia, bowel obstruction, peptic ulcer disease, intestinal ischemia, or perforated viscus) between 2006 and 2018 in Ontario, Canada. Cases were matched to controls from the general population. Time spent alive and at home (measured as time to nursing home admission or death) was compared between cases and controls using Kaplan-Meier analysis and Cox models.

RESULTS

A total of 90,245 older adults admitted with an EGS diagnosis were matched with controls. In the 5 years following an EGS admission, cases experienced significantly fewer months alive and at home compared with controls (mean time, 43 vs. 50 months; p < 0.001). Except for patients operated on for appendicitis and cholecystitis, all remaining patient subgroups experienced reduced time alive and at home compared with controls (p < 0.001). Cases remained at elevated risk of nursing home admission or death compared with controls for the entirety of the 5-year follow-up (hazard ratio, 1.17–5.11).

CONCLUSION

Older adults who required hospitalization for an EGS diagnosis were at higher risk for death or admission to a nursing home for at least 5 years following admission compared with controls. However, most patients (57%) remained alive and living in their own home at the end of this 5-year period.

LEVEL OF EVIDENCE

Epidemiological, level III.
Interleukin 22 mitigates endothelial glycocalyx shedding after lipopolysaccharide injury
Authors: Taghavi Sharven , Abdullah Sarah , Duchesne Juan , Pociask Derek , Kolls Jay , Jackson-Weaver Olan
Published: January 2021

BACKGROUND

The endothelial glycocalyx (EG) on the luminal surface of endothelial cells contributes to the permeability barrier of vessels and prevents activation of the coagulation cascade. Endothelial glycocalyx damage, which occurs in the shock state, results in endotheliopathy. Interleukin (IL)-22 is a cytokine with both proinflammatory and anti-inflammatory properties, and how IL-22 affects the EG has not been studied. We hypothesized that IL-22:Fc, a recombinant fusion protein with human IL-22 and the Fc portion of human immunoglobulin G1 (which extends the protein half-life), would not affect EG shedding in endothelium after injury.

METHODS

Human umbilical vein endothelial cells (HUVECs) were exposed to 1 μg/mL lipopolysaccharide (LPS). Lipopolysaccharide-injured cells (n = 284) were compared with HUVECs with LPS injury plus 0.375 μg/mL of IL-22:Fc treatment (n = 293) for 12 hours. These two cohorts were compared with control HUVECs (n = 286) and HUVECs exposed to IL-22:Fc alone (n = 269). Cells were fixed and stained with fluorescein isothiocyanate-labeled wheat germ agglutinin to quantify EG. Total RNA was collected, and select messenger RNAs were quantified by real time - quantitative polymerase chain reaction (RT-qPCR) using SYBR green fluorescence.

RESULTS

Exposure of HUVECs to LPS resulted in degradation of the EG compared with control (5.86 vs. 6.09 arbitrary unit [AU], p = 0.01). Interleukin-22:Fc alone also resulted in degradation of EG (5.08 vs. 6.09 AU, p = 0.01). Treatment with IL-22:Fc after LPS injury resulted in less degradation of EG compared with LPS injury alone (5.86 vs. 5.08 AU, p = 0.002). Expression of the IL-22Ra1 receptor was not different for IL-22:Fc treated compared with LPS injury only (0.69 vs. 0.86 relative expression, p = 0.10). Treatment with IL-22:Fc after LPS injury resulted in less matrix metalloproteinase 2 (0.79 vs. 1.70 relative expression, p = 0.005) and matrix metalloproteinase 14 (0.94 vs. 2.04 relative expression, p = 0.02).

CONCLUSIONS

Interleukin-22:Fc alone induces EG degradation. However, IL-22:Fc treatment after LPS injury appears to mitigate EG degradation. This protective effect appears to be mediated via reduced expression of metalloproteinases.
Retained bullet fragments after nonfatal gunshot wounds: epidemiology and outcomes
Authors: Nee Nadya , Inaba Kenji , Schellenberg Morgan , Benjamin Elizabeth R. , Lam Lydia , Matsushima Kazuhide , Strumwasser Aaron M. , Demetriades Demetrios
Published: January 2021

BACKGROUND

With no consensus on the optimal management strategy for asymptomatic retained bullet fragments (RBF), the emerging data on RBF lead toxicity have become an increasingly important issue. There are, however, a paucity of data on the magnitude of this problem. The aim of this study was to address this by characterizing the incidence and distribution of RBF.

METHODS

A trauma registry was used to identify all patients sustaining a gunshot wound (GSW) from July 1, 2015, to June 31, 2016. After excluding deaths during the index admission, clinical demographics, injury characteristics, presence and location of RBF, management, and outcomes, were analyzed.

RESULTS

Overall, 344 patients were admitted for a GSW; of which 298 (86.6%) of these were nonfatal. Of these, 225 (75.5%) had an RBF. During the index admission, 23 (10.2%) had complete RBF removal, 35 (15.6%) had partial, and 167 (74.2%) had no removal. Overall, 202 (89.8%) patients with nonfatal GSW were discharged with an RBF. The primary indication for RBF removal was immediate intraoperative accessibility (n = 39, 67.2%). The most common location for an RBF was in the soft tissue (n = 132, 58.7%). Of the patients discharged with an RBF, mean age was 29.5 years (range, 6.1–62.1 years), 187 (92.6%) were me, with a mean Injury Severity Score of 8.6 (range, 1–75). One hundred sixteen (57.4%) received follow-up, and of these, 13 (11.2%) returned with an RBF-related complication [infection (n = 4), pain (n = 7), fracture nonunion (n = 1), and bone erosion (n = 1)], with a mean time to complication of 130.2 days (range, 11–528 days). Four (3.4%) required RBF removal with a mean time to removal of 146.0 days (range, 10–534 days).

CONCLUSION

Retained bullet fragments are very common after a nonfatal GSW. During the index admission, only a minority are removed. Only a fraction of these are removed during follow-up for complications. As lead toxicity data accumulates, further follow-up studies are warranted.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.
Overcoming the Limits of Reconditioning: Seventeen Hours of EVLP With Successful Transplantation From Uncontrolled Circulatory Death Donor
Authors: Palleschi Alessandro , Rosso Lorenzo , Ruggeri Giulia Maria , Croci Giorgio Alberto , Rossetti Valeria , Citerio Giuseppe , Grasselli Giacomo , Nosotti Mario , Zanella Alberto
Published: January 2021

Background.

Uncontrolled donation after circulatory death (DCD) donors are an extraordinary resource to increase the number of lungs available for transplantation. However, the risk of the warm ischemia resulting from cardiac arrest to irreversibly damage the organs is considerable. Moreover, graft preservation issues and organizational problems often worsen the dangerous effects of warm ischemia. Ex vivo lung perfusion (EVLP) enables us to evaluate and recondition lungs whose functionality is doubtful, as well as to overcome the difficulties related to time and logistics.

Methods.

We report the case of uncontrolled DCD lungs successfully treated with an exceptionally prolonged EVLP. Because the donor’s blood count and liver biopsy showed signs of possible leukemia, EVLP was protracted up to 17 h while waiting for immunohistochemical analyses to rule out this diagnosis; eventually, the results came back negative, and the lungs were judged suitable for transplantation.

Results.

The recipient was a 32-y-old male individual with cystic fibrosis, colonized by Pandoraea pnomenusa. Bilateral transplantation required central extracorporeal membrane oxygenation. The patient was extubated after 36 h and was discharged 21 d after the operation. Despite early recolonization by Pandoraea pnomenusa and airway complications requiring pneumatic dilatation, he is alive and has a satisfactory respiratory function 15 mo after transplantation.

Conclusions.

Uncontrolled DCD represents a challenge due to both logistical issues and the complexity of graft evaluation before procurement. EVLP with cellular perfusate could be a valuable tool to overcome these limits. Nonetheless, caution should be exercised when interpreting the effects of this technique on airway healing.
New-onset Diabetes Mellitus After Adult Heart Transplantation and the Risk of Renal Dysfunction or Mortality
Authors: Vest Amanda R. , Cherikh Wida S. , Noreen Samantha M. , Stehlik Josef , Khush Kiran K.
Published: January 2021

Background.

Diabetes mellitus (DM) may occur either pre–heart transplantation (HT) or as new-onset DM post-HT. We sought to define the contemporary incidence of post-HT DM, evaluate risk factors for post-HT DM, and assess the impact of post-HT DM on major outcomes.

Methods.

The cohort included International Society for Heart and Lung Transplantation Thoracic Organ Transplant Registry adult primary HT-alone recipients, transplanted January 1995–June 2017, who survived to 1 y post-HT. DM status was characterized as (1) no DM pre-HT or post-HT; (2) pre-HT DM; or (3) post-HT DM (onset within 5 y of HT). Cox proportional hazards models were constructed to identify risk factors for post-HT DM onset, as well as risk factors for post-HT severe renal dysfunction and death/retransplantation.

Results.

Of 26 263 eligible subjects, 57% had no DM pre-HT or post-HT, 22% had pre-HT DM, and 21% had new-onset post-HT DM. Risk factors for the development of post-HT DM included use of tacrolimus or steroids at 1 y post-HT, as well as higher recipient age, female sex, ischemic cardiomyopathy, higher body mass index, pre-HT dialysis, and pre-HT steroid use. Post-HT DM within 5 y was associated with increased subsequent severe renal dysfunction (hazard ratio, 1.89; 95% confidence interval, 1.77-2.01) and death/retransplantation (hazard ratio, 1.38; 95% confidence interval, 1.32-1.45), compared with patients without post-HT DM.

Conclusions.

Post-HT DM is common, occurring in 21% of recipients within 5 y of HT. Post-HT DM is associated with increased risk of severe renal dysfunction and death or retransplantation.