bluuebunny/crossref_metadata_2025 huggingface dataset:
The Surgical Apgar Score
Authors: Pittman Elliot , Dixon Elijah , Duttchen Kaylene
Published: February 2023

Objectives:

To review the current literature evaluating the performance of the Surgical Apgar Score (SAS).

Background:

The SAS is a simple metric calculated at the end of surgery that provides clinicians with information about a patient’s postoperative risk of morbidity and mortality. The SAS differs from other prognostic models in that it is calculated from intraoperative rather than preoperative parameters. The SAS was originally derived and validated in a general and vascular surgery population. Since its inception, it has been evaluated in many other surgical disciplines, large heterogeneous surgical populations, and various countries.

Methods:

A database and gray literature search was performed on March 3, 2020. Identified articles were reviewed for applicability and study quality with prespecified inclusion criteria, exclusion criteria, and quality requirements. Thirty-six observational studies are included for review. Data were systematically extracted and tabulated independently and in duplicate by two investigators with differences resolved by consensus.

Results:

All 36 included studies reported metrics of discrimination. When using the SAS to correctly identify postoperative morbidity, the area under the receiver operating characteristic curve or concordance-statistic ranged from 0.59 in a general orthopedic surgery population to 0.872 in an orthopedic spine surgery population. When using the SAS to identify mortality, the area under the receiver operating characteristic curve or concordance-statistic ranged from 0.63 in a combined surgical population to 0.92 in a general and vascular surgery population.

Conclusions:

The SAS provides a moderate and consistent degree of discrimination for postoperative morbidity and mortality across multiple surgical disciplines.
Determinants, Costs, and Consequences of Common Bile Duct Injury Requiring Operative Repair Among Privately Insured Individuals in the United States, 2003–2020
Authors: Elser Holly , Bergquist John R. , Li Amy Y. , Visser Brendan C.
Published: February 2023

Objective:

Characterize the determinants, all-cause mortality risk, and healthcare costs associated with common bile duct injury (CBDI) following cholecystectomy in a contemporary patient population.

Background:

Retrospective cohort study using nationwide patient-level commercial and Medicare Advantage claims data, 2003–2019. Beneficiaries ≥18 years who underwent cholecystectomy were identified using Current Procedure Terminology (CPT) codes. CBDI was defined by a second surgical procedure for repair within one year of cholecystectomy.

Methods:

We estimated the association of common surgical indications and comorbidities with risk of CBDI using logistic regression; the association between CBDI and all-cause mortality using Cox proportional hazards regression; and calculated average healthcare costs associated with CBDI repair.

Results:

Among 769,782 individuals with cholecystectomy, we identified 894 with CBDI (0.1%). CBDI was inversely associated with biliary colic (odds ratio [OR] = 0.82; 95% confidence interval [CI]: 0.71–0.94) and obesity (OR = 0.70, 95% CI: 0.59–0.84), but positively associated with pancreas disease (OR = 2.16, 95% CI: 1.92–2.43) and chronic liver disease (OR = 1.25, 95% CI: 1.05–1.49). In fully adjusted Cox models, CBDI was associated with increased all-cause mortality risk (hazard ratio = 1.57, 95% CI: 1.38–1.79). The same-day CBDI repair was associated with the lowest mean overall costs, with the highest mean overall costs for repair within 1 to 3 months.

Conclusions:

In this retrospective cohort study, calculated rates of CBDI are substantially lower than in prior large studies, perhaps reflecting quality-improvement initiatives over the past two decades. Yet, CBDI remains associated with increased all-cause mortality risks and significant healthcare costs. Patient-level characteristics may be important determinants of CBDI and warrant ongoing examination in future research.
Resident Operative Autonomy and Attending Verbal Feedback Differ by Resident and Attending Gender
Authors: Filiberto Amanda C. , Abbott Kenneth L. , Shickel Benjamin , George Brian C. , Cochran Amalia L. , Sarosi George A. , Upchurch Gilbert R. , Loftus Tyler J.
Published: February 2023

Objectives:

This study tests the null hypotheses that overall sentiment and gendered words in verbal feedback and resident operative autonomy relative to performance are similar for female and male residents.

Background:

Female and male surgical residents may experience training differently, affecting the quality of learning and graduated autonomy.

Methods:

A longitudinal, observational study using a Society for Improving Medical Professional Learning collaborative dataset describing resident and attending evaluations of resident operative performance and autonomy and recordings of verbal feedback from attendings from surgical procedures performed at 54 US general surgery residency training programs from 2016 to 2021. Overall sentiment, adjectives, and gendered words in verbal feedback were quantified by natural language processing. Resident operative autonomy and performance, as evaluated by attendings, were reported on 5-point ordinal scales. Performance-adjusted autonomy was calculated as autonomy minus performance.

Results:

The final dataset included objective assessments and dictated feedback for 2683 surgical procedures. Sentiment scores were higher for female residents (95 [interquartile range (IQR), 4–100] vs 86 [IQR 2–100]; P < 0.001). Gendered words were present in a greater proportion of dictations for female residents (29% vs 25%; P = 0.04) due to male attendings disproportionately using male-associated words in feedback for female residents (28% vs 23%; P = 0.01). Overall, attendings reported that male residents received greater performance-adjusted autonomy compared with female residents (P < 0.001).

Conclusions:

Sentiment and gendered words in verbal feedback and performance-adjusted operative autonomy differed for female and male general surgery residents. These findings suggest a need to ensure that trainees are given appropriate and equitable operative autonomy and feedback.
Peritoneal Bridging Versus Nonclosure in Laparoscopic Ventral Hernia Repair
Authors: Ali Fathalla , Sandblom Gabriel , Forgo Bianka , Wallin Göran
Published: February 2023

Introduction:

Postoperative seroma and pain are common problems following laparoscopic intraperitoneal onlay mesh (IPOM) repair of ventral hernias. These adverse outcomes may be avoided by dissecting and using the peritoneum in the hernial sac to bridge the hernia defect.

Methods:

This was a patient- and outcome assessor-blinded, parallel-design, randomized controlled trial comparing nonclosure and peritoneal bridging approaches in patients scheduled for elective midline ventral hernia repair. The primary endpoint was seroma volume on ultrasonography. The secondary endpoints were postoperative pain, recurrence, and complications.

Results:

Between November 2018 and December 2020, 112 patients were randomized, of whom 60 were in the nonclosure group and 52 were in the peritoneal bridging group. The seroma volume in the nonclosure and peritoneal bridging groups were 17 cm3 (6–53 cm3) versus 0 cm3 (0–26 cm3) at 1-month follow-up (P = 0.013). The median volume was zero at the 3-, 6-, and 12-month follow-ups in both groups. No significant differences were observed in early postoperative pain (P = 0.447) and in recurrence rate (P = 0.684). There were 4 (7%) and 1 (2%) perioperative complications that lead to reoperations in simple IPOM (sIPOM) and IPOM with peritoneal bridging (IPOM-pb), respectively.

Conclusions:

Seroma was less prevalent after IPOM-pb at 1-month follow-up compared with sIPOM, with similar postoperative pain 1 week after index surgery in both groups. At subsequent follow-ups, the differences in seroma were not statistically significant. Further studies are required to confirm these results. Trial registration (NCT04229940).
Lower Neighborhood Socioeconomic Status May Influence Medical Complications, Emergency Department Utilization, and Costs of Care After 1-2 Level Lumbar Fusion
Authors: Gordon Adam M. , Elali Faisal R. , Ng Mitchell K. , Saleh Ahmed , Ahn Nicholas U.
Published: February 2023

Study Design.

Retrospective Case-Control Study

Objectives.

The objectives were to determine whether patients from poor social determinants of health (SDOH), undergoing primary 1-2 level lumbar fusion (1-2LF), demonstrate differences in: 1) medical complications; 2) emergency department (ED) utilizations; 3) readmission rates; and 4) costs of care.

Summary.of Background Data.

Measures of socioeconomic disadvantage may enable improved targeting and prevention of potentially increased healthcare utilization. The Area Deprivation Index (ADI) is a validated index of 17 census-based markers of material deprivation and poverty.

Methods.

A retrospective query of the 2010-2020 PearlDiver database was performed for primary 1-2 level lumbar fusions for degenerative lumbar pathology. High ADI (scale: 0-100) is associated with a greater disadvantage. Patients with high ADI (90%+) were 1:1 propensity-score matched to controls (ADI:0-89%) by age, gender, and Elixhauser Comorbidity Index (ECI). This yielded 34,442 patients, evenly matched between cohorts. Primary outcomes were to compare 90-day complications, ED utilizations, readmissions, and costs of care. Multivariable logistic regression models computed the odds-ratios (OR) of ADI on complications, ED utilizations, and readmissions. P values less than 0.05 were significant.

Results.

Patients with a high ADI incurred higher rates and odds of developing respiratory failures (1.17 vs. 0.87%; OR: 1.35,P=0.005). Acute kidney injuries (2.61 vs. 2.29%; OR: 1.14,P=0.056), deep venous thromboses (0.19% vs. 0.17%; OR: 1.14,P=0.611), cerebrovascular accidents (1.29% vs. 1.31%; OR: 0.99,P=0.886), and total medical complications (23.35% vs. 22.93%; OR: 1.02,P=0.441) were similar between groups. High ADI patients experienced higher rates and odds of ED visits within 90 days (9.67% vs. 8.91%; OR: 1.10,P=0.014) and overall 90-day expenditures ($54,459 vs. $47,044;P<0.001).

Conclusions.

Socioeconomically disadvantaged patients have increased rates and odds of respiratory failure within 90 days. ED utilization within 90 days of surgery was higher in socioeconomically disadvantaged patients. SDOH could be used to inform healthcare policy and improve post-discharge care.

Level of Evidence.

Level III
Risk Factors for Unplanned ICU Readmission Among Trauma Patients: Age Matters
Authors: Laytin Adam D. , Sims Carrie A.
Published: February 2023

OBJECTIVES:

To determine the frequency of unplanned ICU readmission (UIR) among adult (18–64) and elderly (65+) trauma patients and to compare the risk factors for UIR and its clinical impact between age groups.

DESIGN:

Retrospective cohort study using clinical data from a statewide trauma registry.

SETTING:

All accredited trauma centers in Pennsylvania.

PATIENTS:

Consecutive adult and elderly trauma patients requiring admission from the emergency department to the ICU between 2012 and 2017.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

Among the 48,340 included in the analysis, 49.5% were elderly and 3.8% experienced UIR. UIR was 1.7 times more likely among elderly patients and was associated with increased hospital length of stay in both age groups. UIR was associated with an absolute increased risk of hospital mortality of 6.1% among adult patients and 16.9% among elderly patients experiencing UIR. In addition to overall injury severity and burden of preexisting medical conditions, specific risk factors for UIR were identified in each age group. In adult but not elderly patients, UIR was significantly associated with history of stroke, peptic ulcer disease, cirrhosis, diabetes, and malignancy. In elderly but not adult patients, UIR was also significantly associated with chronic kidney disease.

CONCLUSIONS:

UIR is associated with worse clinical outcomes in both adult and elderly trauma patients, but risk factors and the magnitude of impact differ between age groups. Interventions to mitigate the risk of UIR that take into account patients’ age group and specific risk factors may improve outcomes.
Change in End-Tidal Co 2 After Mini-Fluid Challenge to Determine Fluid Responsiveness
Authors: Budnick Isadore M. , Popovich John J. , Barros Andrew J. , Kadl Alexandra
Published: February 2023

OBJECTIVES:

Distributive shock is a major cause of morbidity and mortality in the ICU. IV fluid resuscitation is a vital intervention to improve cardiac output and end-organ perfusion during the initial resuscitation and for those who remain fluid responsive. Noninvasive measures of fluid responsiveness are lacking. The aim of this study is to assess whether changes in end-tidal c
o
2 after mini-fluid challenge, or 250 mL bolus, can predict fluid responsiveness in mechanically ventilated patients with distributive shock.

DESIGN:

Single-center prospective study.

SETTING:

Patients were enrolled from 2019 to 2021 from the medical ICU within a single academic hospital.

PATIENTS:

Thirty-eight patients with paired measurements of fluid responsiveness as determined by bioreactance who were admitted to the ICU with a diagnosis of distributive shock and on mechanical ventilation.

INTERVENTIONS:

Stroke volume index (SVI), cardiac index, heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and ETco
2 were measured before and after completion of a mini-fluid challenge. Test characteristics of change in ETco
2 (ΔETco
2) greater than or equal to 2 after mini-fluid challenge to determine fluid responsiveness were calculated with percentage change in SVI greater than or equal to 10% used as the reference standard.

MEASUREMENTS AND MAIN RESULTS:

The sensitivity and specificity of a ΔETco
2 greater than or equal to 2 mm Hg as a predictor of a change in SVI greater than or equal to 10% following a mini-fluid challenge were 20.0% and 91.3%, respectively. The area under the receiver operating characteristic curve was 0.62.

CONCLUSIONS:

A ΔETco
2 greater than or equal to 2 mm Hg after mini-fluid challenge has limited test performance for determining fluid responsiveness in intubated patients with distributive shock.
Efficacy and Safety of Sugammadex to Shorten Time-to-Extubation Following Cardiac Surgery: A Single-Center Randomized Placebo-Controlled Trial
Authors: Bardia Amit , Treggiari Miriam M. , Dai Feng , Johnson Chanel , Singh Manila , Kunze Kim , Tickoo Mayanka , Tantawy Hossam , Giersson Arnar , Darr Umer , Schonberger Robert B.
Published: February 2023

OBJECTIVES:

Residual neuromuscular blockade (NMB) is an important and modifiable factor associated with prolonged mechanical ventilation after cardiac surgery. Studies evaluating the use of sugammadex for residual NMB reversal in the post-cardiac surgery ICU setting are lacking. We conducted a randomized trial to determine the efficacy of sugammadex in reducing time to extubation in patients admitted to the ICU after cardiac surgery.

DESIGN:

Single-center, randomized, double-blind, placebo-controlled trial.

SETTING:

University-based cardiothoracic ICU.

SUBJECTS:

Patients (n = 90) undergoing elective aortic valve replacement (AVR) and/or coronary artery bypass grafting (CABG) surgery.

INTERVENTIONS:

Participants were randomized to receive either sugammadex (2 mg/kg) or placebo after arrival to the ICU.

MEASUREMENTS AND MAIN RESULTS:

The primary study endpoint was time from study drug administration to extubation. Of the 90 patients included in the study (45 in each group), a total of 68 patients underwent CABG, 13 AVR, and nine combined AVR and CABG. Baseline characteristics and intraoperative anesthetic medications were comparable between groups. Patients in sugammadex group had reduced time to extubation compared with the placebo group (median [interquartile range (IQR)]—sugammadex group: 126.0 min [84.0–274.0 min] vs placebo: 219.0 min [121.0–323.0 min]; difference in means [95% CI], 72.8 [1.5-144.1 min]; p = 0.01. There were no differences in negative inspiratory force (mean [sd]—sugammadex group: 33.79 cm H2O [8.39 cm H2O] vs placebo: –31.11 cm H2O [7.17 cm H2O]) and vital capacity (median [IQR]—sugammadex group: 1.1 L [0.9–1.3 L] vs placebo: 1.0 L [0.9–1.2 L]). There were no differences between groups in postoperative blood product requirement, dysrhythmias, length of ICU, or hospital stay. There were no serious adverse events in either group.

CONCLUSIONS:

This randomized trial showed that the administration of sugammadex after cardiac surgery decreased time to extubation by approximately 1 hour. Larger trials may be required to confirm these findings and determine the clinical implications.
Child Opportunity Index and Hospital Utilization in Children With Traumatic Brain Injury Admitted to the PICU
Authors: Gray Monica M. , Malay Sindhoosha , Kleinman Lawrence C. , Stange Kurt C. , Borawski Elaine A. , Shein Steven L. , Slain Katherine N.
Published: February 2023

IMPORTANCE:

The need to understand how Community-based disparities impact morbidity and mortality in pediatric critical illness, such as traumatic brain injury. Test the hypothesis that ZIP code-based disparities in hospital utilization, including length of stay (LOS) and hospital costs, exist in a cohort of children with traumatic brain injury (TBI) admitted to a PICU using the Child Opportunity Index (COI).

DESIGN:

Multicenter retrospective cohort study.

SETTING:

Pediatric Health Information System (PHIS) database.

PATIENTS:

Children 0–18 years old admitted to a PHIS hospital with a diagnosis of TBI from January 2016 to December 2020 requiring PICU care. To identify the most severely injured children, a study-specific definition of “Complicated TBI” was created based on radiology, pharmacy, and procedure codes.

INTERVENTIONS:

None.

Main Outcomes and Measures:

Using nationally normed ZIP code-level COI data, patients were categorized into COI quintiles. A low COI ZIP code has low childhood opportunity based on weighted indicators within educational, health and environmental, and social and economic domains. Population-averaged generalized estimating equation (GEE) models, adjusted for patient and clinical characteristics examined the association between COI and study outcomes, including hospital LOS and accrued hospital costs. The median age of this cohort of 8,055 children was 58 months (interquartile range [IQR], 8–145 mo). There were differences in patient demographics and rates of Complicated TBI between COI levels. The median hospital LOS was 3.0 days (IQR, 2.0–6.0 d) and in population-averaged GEE models, children living in very low COI ZIP codes were expected to have a hospital LOS 10.2% (95% CI, 4.1–16.8%; p = 0.0142) longer than children living in very high COI ZIP codes. For the 11% of children with a Complicated TBI, the relationship between COI and LOS was lost in multivariable models. COI level was not predictive of accrued hospital costs in this study.

CONCLUSIONS:

Children with TBI requiring PICU care living in low-opportunity ZIP codes have higher injury severity and longer hospital LOS compared with children living in higher-opportunity ZIP codes. Additional studies are needed to understand why these differences exist.
Extracorporeal Membrane Oxygenation for COVID-19: Comparison of Outcomes to Non-COVID-19–Related Viral Acute Respiratory Distress Syndrome From the Extracorporeal Life Support Organization Registry
Authors: Chandel Abhimanyu , Puri Nitin , Damuth Emily , Potestio Christopher , Peterson Lars-Kristofer N. , Ledane Julia , Rackley Craig R. , King Christopher S. , Conrad Steven A. , Green Adam
Published: February 2023

OBJECTIVES:

To compare complications and mortality between patients that required extracorporeal membrane oxygenation (ECMO) support for acute respiratory distress syndrome (ARDS) due to COVID-19 and non-COVID-19 viral pathogens.

DESIGN:

Retrospective observational cohort study.

SETTING:

Adult patients in the Extracorporeal Life Support Organization registry.

PATIENTS:

Nine-thousand two-hundred ninety-one patients that required ECMO for viral mediated ARDS between January 2017 and December 2021.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

The primary outcomes of interest were mortality during ECMO support and prior to hospital discharge. Time-to-event analysis and logistic regression were used to compare outcomes between the groups. Among 9,291 included patients, 1,155 required ECMO for non-COVID-19 viral ARDS and 8,136 required ECMO for ARDS due to COVID-19. Patients with COVID-19 had longer duration of ECMO (19.6 d [interquartile range (IQR), 10.1–34.0 d] vs 10.7 d [IQR, 6.3–19.7 d];p< 0.001), higher mortality during ECMO support (44.4% vs 27.5%;p< 0.001), and higher in-hospital mortality (50.2% vs 34.5%;p< 0.001). Further, patients with COVID-19 were more likely to experience mechanical and clinical complications (membrane lung failure, pneumothorax, intracranial hemorrhage, and superimposed infection). After adjusting for pre-ECMO disease severity, patients with COVID-19 were more than two times as likely to die in the hospital compared with patients with non-COVID-19 viral ARDS.

CONCLUSIONS:

Patients with COVID-19 that require ECMO have longer duration of ECMO, more complications, and higher in-hospital mortality compared with patients with non-COVID-19–related viral ARDS. Further study in patients with COVID-19 is critical to identify the patient phenotype most likely to benefit from ECMO and to better define the role of ECMO in the management of this disease process.
Gracilis Muscle Interposition for the Treatment of Rectovaginal Fistula: A Systematic Review and Pooled Analysis
Authors: Maspero Marianna , Otero Piñeiro Ana , Steele Scott R. , Hull Tracy L.
Published: February 2023

BACKGROUND:

A rectovaginal fistula is a debilitating condition that often severely impacts quality of life. Despite many treatment options available, the best surgical treatment is far from being established and many patients will undergo several procedures before fistula closure is achieved. Gracilis muscle interposition, i.e. the transposition of the gracilis muscle into the rectovaginal septum, is an option for complex and persistent fistulasF, but literature on the subject is scarce, mainly consisting of small case series.

OBJECTIVE:

To assess the success rate of gracilis muscle interposition for the surgical treatment of rectovaginal fistula.

DATA SOURCES:

MEDLINE, EMBASE, Cochrane Library, Web of Science

STUDY SELECTION:

Studies comprising at least 5 patients who underwent gracilis muscle interposition for rectovaginal fistula were included. No date or language restrictions were applied.

INTERVENTION:

Gracilis muscle interposition.

MAIN OUTCOME MEASURES:

The primary outcome is fistula closure rate (%). Other domains analyzed are stoma closure rate, postoperative complications, quality of life, fecal continence, sexual function.

RESULTS:

Twenty studies were included, for a total of 384 patients. The pooled fistula closure rate for gracilis muscle interposition was 64% (95% CI, 53% - 74%, range, 33 – 100%). Risk factors for failure were smoking, underlying Crohn’s disease and more than 2 previous repairs, while stoma formation was associated with improved outcomes. Postoperative complications ranged from 0 to 37%, mostly related to surgical site occurrences at the harvest site and perineal area. No deaths occurred. Gracilis muscle interposition improved quality of life and fecal continence, while impairment of sexual function was common.

LIMITATIONS:

Most of the included studies were small case series.

CONCLUSIONS:

Gracilis muscle interposition is a safe and moderately effective treatment that could be taken into consideration as second- or third-line therapy for recurrent RVF.

PROSPERO registration number: CRD42022319621
Surgical Matricectomy Versus Phenolization in the Treatment of Ingrown Toenails: A Randomized Controlled Trial
Authors: Shajil Chandana , Kumari Rashmi
Published: February 2023

BACKGROUND

Treatment of ingrown toenail includes various nonsurgical and surgical treatments. However, there is no consensus on the ideal first-choice treatment.

OBJECTIVE

To compare phenolization versus surgical matricectomy (SM) after lateral nail plate avulsion in terms of efficacy, recurrence rates, postoperative outcomes, and cosmesis.

METHODS

The authors enrolled 45 consenting patients and randomized them into 2 groups (Group 1 = phenolization and Group 2 = SM) using stratified block randomization and followed them up at 1 week, 1 month, and 6 months.

RESULTS

The median percentage improvement in pain visual analog scale (VAS) score was comparable between the 2 groups (p = 0.793). The mean photo VAS showed significant improvement in Group 1 at 1 week (p = 0.00) and 1 month (p = 0.02) but not at 6 months (p = 0.44). The median number of days for pain relief (p = 0.169), for healing (p = 0.192), and for resuming work (p = 0.136) were not significantly different between the 2 groups. The time required to regain normal morphology was significantly longer in Group 2 (p = 0.006). None of the patients in either group presented with recurrence at 6 months and 1 year. The authors observed failure of treatment in 1 patient in Group 2.

CONCLUSION

Both procedures were equally efficacious, had minimal complications, and showed no recurrence at 6 months and 1 year.
Efficacy of Platelet-Rich Plasma Versus Autologous Fat Transfer With Nanofat in the Treatment of Infraorbital Dark Circles: A Single-Blinded Randomized Comparative Clinical Trial
Authors: Kadry Ahmed , Gamal Ahmed , Alkhalifah Azzam , Ibrahim Shady Mahmoud Attia
Published: February 2023

BACKGROUND

Treating infraorbital dark circles is one of the commonest aesthetic demands worldwide. Autologous fat transfer is commonly used to treat dark circles by filling the grooves, without effect on skin quality. Platelet-rich plasma has been reported to improve skin quality. Autologous fat can be emulsified and filtered to produce nanofat, which is then injected superficially in the dark circles to improve skin quality and discoloration.

OBJECTIVE

To compare the efficacy of platelet-rich plasma versus combined fat transfer and nanofat in treating infraorbital dark circles.

MATERIALS AND METHODS

30 patients with infraorbital dark circles of combined etiological factors were randomized into 2 equal groups: Group A treated with platelet-rich plasma and Group B treated with autologous fat transfer with emulsified fat injection.

RESULTS

Excellent and moderate responses were observed in 3 (20%) and 2 (13%) patients in group A versus 7 (46.7%) and 4 (27%) in group B, respectively. Nonresponders were 8 (53.3%) in group A and only 1 patient (6.7%) in group B. The difference was statistically significant regarding improvement (p = .048) and patient satisfaction (p = .032).

CONCLUSION

Autologous fat transfer with nanofat is significantly superior to platelet-rich plasma in improvement and satisfaction.
An unusual case of long-term survival with excellent quality of life after surgery of rectal cancer with metastasis to the liver, lung, and scalp
Authors: Tsui Yu-Wen , Tsai Chia-Yu , Chen Hung-Chi
Published: February 2023

With improvements in therapies for colorectal cancer, patient survival can be extended remarkably. Multiple treatment modalities can be combined, and collaboration among different departments is important. A patient presented with rectal cancer with metastases to the liver, lungs, and scalp, which were excised completely. The scalp lesion recurred twice, and the final procedure was a free flap reconstruction after wide excision. Since then, there has been no recurrence, and the patient has had an excellent quality of life after 8 years of follow-up. The overall survival of colorectal cancer is increasing owing to improvements in surgery, chemotherapy, and targeted therapy. Aggressive treatment is helpful in patients with metastatic colorectal cancer.
Rational use of antimicrobials: a nationwide cross-sectional survey among people of Pakistan
Authors: Khadka Sitaram , Hashmi Furqan K. , Yadav Gopal K. , Lamichhane Sabitri , Giri Santoshi , Tariq Fatima , Amin Sabahat , Zaheer Warda , Akram Kiran , Asghar Ifra , Zahra Kainat , Bajwa Faiza , Ul-ain Noor , Adnan Muhammad A.J.
Published: February 2023

Background:

The misuse of antibiotics in low- and middle-income countries is getting escalated leading to the emergence of antimicrobial resistance. This study aims to evaluate the knowledge, behavior, and practice of antimicrobial misuse among the Pakistani population for the implementation of an effective stewardship plan that ensures the rational use of medicines.

Methods:

It was a nationwide cross-sectional survey conducted among 1011 participants in Pakistan from March 2022 to August 2022. Statistical analysis was done through SPSS v21. The original Bloom’s cut-off point was utilized to categorize the participants’ overall knowledge, behavior, and practice. The χ2 test was used to test for group differences. For multivariable logistic regression analyses, adjusted odds ratio (AOR) was calculated at 95% CI.

Results:

The majority of the respondents were female 69.3%, in a state of good health 81.5%, and non-health care professionals 64.0%. More than half of the participants (55.3%) demonstrated true knowledge, whereas more than four-fifths (88.6%) and almost half (47.9%) of the participants showed moderate to good behavior and practice about the rational use of antimicrobials. The employed participants (AOR: 2.12, 95% CI: 1.51–2.98), health professionals (AOR: 1.64, 95% CI: 1.25–2.17), urban residents (AOR: 1.61, 95% CI: 1.12–2.38) and participants without comorbidities (AOR: 1.89, 95% CI: 1.32–2.70) had significant association with good/true knowledge. Lower education (AOR: 1.69, 95% CI: 1.06–2.70), rural residence (AOR: 2.06, 95% CI: 1.42–3.01), and lower monthly income <50 PKR (AOR: 1.67, 95% CI: 1.28–2.17) were significant factors affecting practice about rational use of antimicrobials. However, none of the factors had significant association with behavior of the participants.

Conclusion:

Implementation of an effective management plan for rational use of medicines is suggested to halt antibiotic misuse which harms public health. Adequate training programs for health care professionals and educational interventions for the general public are required. Strict enforcement of rules and regulations, Drug Sale Rules 2007, and implementation of Pakistan’s National Action Plan on antimicrobial resistance are essential.
Topical Dimethyl Sulfoxide for Congested Nipple–areolar Complexes in Breast Surgery: A Pilot Study
Authors: Silverstein Max L. , McLean Paige , Crowley Jiwon S. , Gosman Amanda A.
Published: February 2023

Background:

Necrosis of the nipple–areolar complex (NAC) is a major complication of breast surgery that most commonly results from venous congestion. Several conservative rescue therapies have been proposed for relieving NAC congestion, but each carries certain drawbacks, including cost and side effect profile. In this study, we evaluated the effectiveness of topical dimethyl sulfoxide (DMSO), an inexpensive compound with vasodilatory, free radical scavenging, and antiinflammatory properties in rescuing congested NACs.

Methods:

We conducted a review of all 15 patients treated with DMSO for NAC congestion at our institution between May 2019 and October 2020. DMSO was applied in liquid form on a soaked gauze pad in the hospital; patients were instructed to apply a DMSO cream to the NAC twice a day following discharge. Patient characteristics and data related to DMSO treatment and NAC healing were compared via univariate analysis.

Results:

Eighteen congested NACs from 15 patients who underwent mastectomy, breast reduction, mastopexy, or breast reconstruction were treated with DMSO. Of the 18 treated NACs, 15 healed with DMSO treatment alone. The average length of DMSO treatment was 9.4 ± 8.5 days (mean ± standard deviation); NAC healing took place over 9.9 ± 9.6 days. There were no complications related to DMSO treatment.

Conclusions:

This pilot study shows that DMSO may be an effective topical treatment for NAC congestion following breast surgery. Given its low cost, ease of application, and lack of side effects, future studies should prospectively compare DMSO against other topical treatments, like nitroglycerin ointment.
Hybrid Stromal Vascular Fraction (Hybrid-SVF): A New Paradigm in Mechanical Regenerative Cell Processing
Authors: Tiryaki Tunc , Cohen Steven Roy , Canikyan Turkay Serli , Kocak Polen , Sterodimas Aris , Schlaudraff Kai-Uwe , Akgün Demir Işil , Agovino Annarita , Kul Yaren
Published: February 2023

Background:

Enzymatic digestion of extracellular matrix (ECM) from lipoaspirate is the conventional form of harvesting stromal vascular fraction (SVF) called enzymatically digested SVF (E-SVF). Mechanical SVF (M-SVF) isolation has emerged as an alternative method, but it has also some limitations in terms of lower cell viability and diminished cell counts. To enhance the SVF qualitatively and quantitatively, we propose a novel concept called "hybrid-SVF,” in which we combine M-SVF with the concentrated parts of adipose tissue after centrifugation, which is called stromal vascular matrix (SVM).

Methods:

Hybrid-SVF injection was applied as an adjunctive therapy to fat grafting in 88 patients and 11 samples were evaluated in the laboratory for cell count, viability and cell activity.

Results:

Experimental results determined that SVM part showed higher cellular activity. SVM and M-SVF showed higher cellular potency than E-SVF. Clinically, none of the patients required an additional session for fat grafting since there was no significant graft resorption. However, seven patients asked for further volume augmentation due to their individual preferences. No major complication was encountered.

Conclusions:

The usage of hybrid-SVF has a very high regenerative potential due to the ECM support and exceptionally high cell yield in addition to preserved cell potency. Although there are ongoing studies focusing on optimizing cell counts and further clinical applications, we believe that our preliminary results might create a paradigm shift in the area of regenerative fat grafting.
Left Internal Mammary Vein Size and Its Impact on Microsurgical Breast Reconstruction
Authors: Seth Akhil K. , Halvorson Eric G. , Caterson Stephanie A. , Carty Matthew J. , Erdmann-Sager Jessica
Published: February 2023

Background:

The internal mammary vessels are the preferred recipient during free-flap breast reconstruction (FFBR). Previous studies have demonstrated that the left internal mammary vein (IMV) is consistently smaller than the right, but with unclear clinical implications. This study explores the impact of IMV size difference on FFBR complication rates.

Methods:

Abdominal-based FFBRs were retrospectively reviewed. Venous coupler size was considered a proxy for IMV diameter. Outcomes of three patient cohorts (all, unilateral, and bilateral reconstructions) were analyzed with univariate and multivariate analysis.

Results:

Our cohort consisted of 582 patients who underwent 874 abdominal-based FFBR, with a similar number of unilateral (n = 290) and bilateral (n = 292), and right (n = 424) and left (n = 450) reconstructions. Mean follow-up was over 4-years. For all reconstructions, the left IMV (2.7 ± 0.4 mm) was smaller than the right (3.0 ± 0.4 mm) (P < 0.0001). Complication rates between left- and right-sided FFBR were similar, but with a trend toward increased fat necrosis on the left (n = 17, 3.8% versus n = 8, 1.9%). Further subgroup analysis showed significantly higher fat necrosis in unilateral left-sided FFBR (n = 12 versus n = 2, P = 0.02), with left-sided FFBR being an independent risk factor for fat necrosis on multivariate analysis.

Conclusions:

The left-side IMV is significantly smaller than the right IMV. In bilateral reconstructions, the smaller size of the left IMV did not result in a greater risk of complications; however, in unilateral FFBR, fat necrosis was significantly higher on the left side.
Operative Time Predicts Postoperative Outcomes in Bilateral DIEP Flap Reconstruction: Multivariate 1000 Flap Analysis
Authors: Haddock Nicholas T. , Wen Y. Edward , Steppe Cyrus , Shang Zhiguo , Teotia Sumeet S.
Published: February 2023

Background:

Skin-to-skin operative time (OT) as a risk factor for adverse postoperative outcomes in microvascular breast reconstruction has not been thoroughly investigated. This study evaluates OT’s impact on length of stay (LOS), overall morbidity, individual complications, and unplanned reoperation (UR) in deep inferior epigastric artery perforator (DIEP) flaps, with a primary objective of identifying a clinically relevant time of decreased odds.

Methods:

Patients who underwent bilateral DIEP flaps from 2010 to 2021 by two senior surgeons (N.T.H. and S.S.T.) with standardized surgical and postoperative protocols were retrospectively reviewed. One thousand flaps (500 patients) were analyzed with extensive multivariate regression equations to adjust for potential confounders, including intraoperative complexity. The odds of postoperative complication, extended LOS (eLOS, defined as ≥5 days) were compared across OT per hour and OT intervals.

Results:

After risk-adjustment, each hour of OT increased morbidity by 19%, UR by 8.7%, and LOS by 6.5 hours (all P < 0.001). For eLOS, procedures ≤5 hours had 9.5 times lower odds than ≥5 hours (P = 0.050), 5–7 hours had comparable odds (P = 0.540), and 7–9 hours had 5.5 times lower odds than procedures ≥ 9 hours (P < 0.001). Last, a multivariate linear regression showed that LOS can be calculated from OT: LOS (days) =1.527 + 0.272 × OT (hours) (R2 = 0.308; P < 0.001).

Conclusions:

OT (per hour) independently predicts morbidity, UR and LOS in DIEP flaps. Furthermore, 5 and 9 hours are critical cutoffs for eLOS. These findings emphasize the benefits of decreasing OT through efficiency models, such as process analysis, team-based intraoperative protocols, and co-surgery model.
Central Mandibular Reconstruction by Semiopen Wedge Osteotomy Double-barrel Fibula Flap for a Slim Aesthetic Appearance
Authors: Tsuge Itaru , Yamanaka Hiroki , Katsube Motoki , Sowa Yoshihiro , Sakamoto Michiharu , Morimoto Naoki
Published: February 2023

Mandibular reconstruction involving the central segment after malignant tumor resection requires the achievement of both functional and aesthetic quality. Three-dimensional reproduction based on the concept of a double arc composed of a marginal arc and an occlusal arc is important. Most reports of fibula flaps applied three-segmented closed wedge fibula osteotomy (bilateral and central segments); however, the aesthetic outcome sometimes became too stout for female patients because of the large central segment. We performed four-segmented fibula osteotomy for a 78-year-old woman using a semiopen wedge technique characterized by a half-open wedge and half-closed wedge. This procedure obtained a slim mandibular contour and made double-barrel reconstruction easier to apply. We used titanium plates that were prebent according to the shape of a three-dimensional model constructed from CT data. Small bone cortex fragments made from a surplus fibula segment were inserted in a half-opened area. The build-up preparation for central mandibular reconstruction was all performed at the lower leg area before cutting the peroneal pedicle. This prefabricated double-barrel fibula free flap was transferred to the mandibular defect with arterial and venous anastomosis to the right superior thyroid artery, right external jugular vein, and right common facial vein. Although the patient was nearly 80 years of age, the bone segments, including free cortex tips, were fused with smooth remodeling. Semiopen wedge osteotomy can be a key to reproducing an aesthetically slim feminine chin with a functional height of mandibular bone maintained for stability of the dental prosthesis.
A Pilot Investigation into Targeted Muscle Reinnervation for Complex Regional Pain Syndrome, Type II
Authors: Shin Stephanie E. , Haffner Zoë K. , Chang Brian L. , Kleiber Grant M.
Published: February 2023

Background:

Complex regional pain syndrome (CRPS) is a debilitating condition, characterized by severe pain with vascular, motor, or trophic changes. Varied presentations make this a diagnostic and therapeutic challenge. There is a lack of high-quality evidence demonstrating efficacy for most existing therapies, particularly with surgical intervention for type II CRPS (CRPS-II). Targeted muscle reinnervation (TMR) is a surgical technique to transfer the terminal end of a divided nerve to a recipient motor nerve, shown to limit phantom limb pain, residual limb pain, and postamputation neuroma pain.

Methods:

Herein, we describe a series of 13 patients undergoing TMR for CRPS-II by a single surgeon from 2018 to 2021 in the upper (38%) and lower extremities (62%). All patients had a diagnosis of CRPS-II with either traumatic or postsurgical etiology, each seeking TMR with or without concomitant treatment to control their pain after previous therapies had failed. Three patients had previous lower extremity amputation, whereas three others received lower extremity amputation at the time of TMR, each indicated for control of CRPS pain.

Results:

Of the patients receiving TMR within 1 year of CRPS diagnosis, all three reported improved function, and two patients were able to tolerate a prosthetic for ambulation after previous pain prevented prosthetic use. Of the entire cohort, all but one patient reported reduced pain interference or improved function.

Conclusions:

These outcomes suggest that TMR may provide some benefit to reducing pain severity patients with CRPS, even after a more chronic disease course. Further prospective trials are warranted.
Preclinical Study of Radiation on Fat Flap Regeneration under Tissue-engineering Chamber: Potential Consequences for Breast Reconstruction
Authors: Cleret Damien , Gradwohl Marion , Dekerle Lucie , Drucbert Anne-Sophie , Idziorek Thierry , Pasquier David , Blanchemain Nicolas , Payen Julien , Guerreschi Pierre , Marchetti Philippe
Published: February 2023

Background:

Use of a tissue-engineering chamber (TEC) for growth of fat flap is a promising approach for breast reconstruction. Here, we evaluated in a preclinical model the effects of radiation on adipose tissue growth either before or after 3D-printed bioresorbable TEC implantation.

Methods:

Twenty-eight female Wistar rats were distributed into three groups: TEC implantation as nonirradiated controls (G1), TEC insertion followed by irradiation 3 weeks later (G2), and irradiation 6 weeks before TEC insertion (G3). G2 and G3 received 33.3 Gy in nine sessions of 3.7 Gy. Growth of the fat flap was monitored via magnetic resonance imaging. At 6 months after implantation, fat flaps and TECs were harvested for analysis.

Results:

Irradiation did not alter the physicochemical features of poly(lactic-co-glycolic acid)-based TECs. Compared with G1, fat flap growth was significantly reduced by 1.6 times in irradiated G2 and G3 conditions. In G2 and G3, fat flaps consisted of mature viable adipocytes sustained by CD31+ vascular cells. However, 37% (3 of 8) of the G2 irradiated adipose tissues presented a disorganized architecture invaded by connective tissues with inflammatory CD68 + cells, and the presence of fibrosis was observed.

Conclusions:

Overall, this preclinical study does not reveal any major obstacle to the use of TEC in a radiotherapy context. Although irradiation reduces the growth of fat flap under the TEC by reducing adipogenesis and inducing inconsistent fibrosis, it does not impact flap survival and vascularization. These elements must be taken into account if radiotherapy is proposed before or after TEC-based breast reconstruction.
Interrupting Negative-pressure Wound Therapy with Dakin’s Solution Is Associated with Increased Skin Graft Survival
Authors: Liao Christopher D. , Deccico John-Brandon , Cuzzone Daniel , George Finny , Xipoleas George D.
Published: February 2023

Background:

Negative-pressure wound therapy (NPWT) has improved split-thickness skin graft (STSG) survival rates, but prolonged application increases bacterial bioburden. Antimicrobial NPWT adjuncts have demonstrated efficacy, but strong evidence is lacking. We hypothesized that simultaneously replacing NPWT dressings within 48–72 hours and cleansing with Dakin's solution—a well-known antimicrobial agent—would increase STSG take.

Methods:

We performed a controlled retrospective case series on three groups of STSG patients treated between January 2014 and December 2020: bolster dressings, continuous NPWT (C-NPWT), and Dakin's NPWT (D-NPWT). Patients with documented measurements of STSG survival were included. The primary outcome was the percentage of STSG take calculated by survival area using surgical tape measures 2 weeks after surgery.

Results:

Fifty-nine patients were followed up for greater than or equal to 3 months. Average wound size for bolsters was smaller than that for D-NPWT (83 cm2 versus 204 cm2; P < 0.05). Average treatment time was 6.4 ± 2.4 days (bolsters), 6.5 ± 0.9 days (C-NPWT), and 2.8 ± 0.9 days (D-NPWT; P < 0.01). Average percentage of STSG take was 92% ± 0% (bolsters), 82% ± 0% (C-NPWT), and 99% ± 0% (D-NPWT; P < 0.01); there were significant differences between bolsters versus C-NPWT (P < 0.05) and C-NPWT versus D-NPWT (P < 0.05), but not between bolsters and D-NPWT.

Conclusions:

Interrupting NPWT with 0.125% Dakin’s solution cleansing is associated with increased STSG survival compared with standard NPWT protocols, but not bolster dressings. These findings warrant further investigation due to limitations of this retrospective case series.
Hepatic fibrosis: Targeting peroxisome proliferator-activated receptor alpha from mechanism to medicines
Authors: Gong Lijun , Wei Fang , Gonzalez Frank J. , Li Guolin
Published: February 2023

Liver fibrosis is the result of sustained chronic liver injury and inflammation leading to hepatocyte cell death followed by the formation of fibrous scars, which is the hallmark of NASH and alcoholic steatohepatitis and can lead to cirrhosis, HCC, and liver failure. Although progress has been made in understanding the pathogenesis and clinical consequences of hepatic fibrosis, therapeutic strategies for this disease are limited. Preclinical studies suggest that peroxisome proliferator-activated receptor alpha plays an important role in preventing the development of liver fibrosis by activating genes involved in detoxifying lipotoxicity and toxins, transrepressing genes involved in inflammation, and inhibiting activation of hepatic stellate cells. Given the robust preclinical data, several peroxisome proliferator-activated receptor alpha agonists have been tested in clinical trials for liver fibrosis. Here, we provide an update on recent progress in understanding the mechanisms by which peroxisome proliferator-activated receptor alpha prevents fibrosis and discuss the potential of targeting PPARα for the development of antifibrotic treatments.