bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluating the Pharmacological Management of Terminal Delirium in Imminently Dying Patients With and Without the Comfort Measure Order Set
Authors: Sutherland Megan , Stilos Kalli (Kalliopi)
Published: July 2019

Terminal delirium is a distressing irreversible process that occurs frequently in the dying phase, often misdiagnosed and undertreated. A previous study in our organization revealed that terminal delirium was a poorly managed symptom at end of life. Pharmacological options are available in an existing order set to manage this symptom. The management plans of 41 patients identified as having terminal delirium were further evaluated. Elements extracted included medications prescribed to manage terminal delirium, whether medication changes occurred, and whether they were administered and effective. Patients with the order set were more comfortable as compared with the group without. Both groups had several changes made by the palliative care team. Nurses did not administer prescribed as-needed medication to more than one-third of patients. Modifications will be made to the existing order set, and additional education for staff will be organized.
For Better or Worse: Facebook Use and Wellbeing Among Community Mental Health Care Clients
Authors: Kjelsaas Kathleen , Mecklenburgh Naomi , von Hippel Courtney , Brener Loren
Published: July 2019

Online social networking is ubiquitous, but research regarding its relationship to wellbeing has yielded contradictory results. This study examined the relationship between Facebook use and wellbeing among community mental health service clients. Twenty-six clients from a community mental health service provided access to their Facebook page. Seven aspects of 3674 Facebook posts were coded, and cross-lagged multilevel models were estimated over three periods to establish the relationship between Facebook use and wellbeing over time. Some aspects of Facebook use were related to wellbeing within the same period, although this pattern of relationships did not emerge longitudinally. Although Facebook has the potential to forge social connections for those who are socially isolated, Facebook use was neither helpful nor harmful over time among people with mental health problems. Given the prevalence of social networking, a clearer understanding of its impact on wellbeing is critical for mental health providers.
Home-Based Computerized Cognitive Training for Postoperative Cognitive Dysfunction After Lung Transplantation in Elderly Population
Authors: Song Yanping , Cui Xueling , Zhang Yan , Gao Huiying , Cai Qiaoying , Mu Zhenzhen
Published: July 2019

Postoperative cognitive dysfunction is a severe outcome after lung transplantation, especially in the elderly lung transplant recipients. Home-based computerized cognitive training (CCT) is a widely used intervention for cognition improvement, but its efficacy has not been validated in this population. A randomized controlled trial was conducted to analyze the effect of CCT on elderly lung transplant recipients. The participants received either an 8-week CCT intervention or usual care. The changes of cognitive function were assessed between preintervention (T1), postintervention (T2), and 12 weeks postintervention (T3). Among the 46 participants, 91.3% completed the interventions. The CCT group performed better than the control group on Digit-Span Forward Test (T3: p = 0.0044) and Verbal Fluency Test (T3: p = 0.0331), indicating the efficacy of CCT on verbal memory in the elderly lung transplant recipients. Although varied impacts were observed on different cognitive domains, it seems promising to use CCT on the elderly population after lung transplantation.
Relationship Gender Equality and Couples' Uptake of Oral Human Immunodeficiency Virus Self-Testing Kits Delivered by Pregnant Women in Kenya
Authors: Vrana-Diaz Caroline J. , Korte Jeffrey E. , Gebregziabher Mulugeta , Richey Lauren , Selassie Anbesaw , Sweat Michael , Gichangi Anthony
Published: July 2019

Background

Higher gender equality is associated with many human immunodeficiency virus (HIV) preventive behaviors, including HIV testing. HIV self-testing is a relatively new testing technology that could assist with HIV prevention. However, there are no studies examining gender equality and HIV self-testing. We examined the associations between gender equality and couples' uptake of HIV self-testing among heterosexual couples expecting a child in central Kenya.

Methods

This analysis used data from a HIV self-testing randomized intervention trial among pregnant women attending antenatal care and their male partners. The primary exposures were gender equality (measured by the male partner's attitudes toward intimate partner violence, and the woman's report on her household decision making power), and the primary outcome was couples' uptake of HIV self-testing. Generalized linear mixed models framework was used to account for site-level clustering.

Results

In comparison to male partners reporting high acceptance of intimate partner violence, couples with male partners reporting medium acceptance (odds ratio, 2.36; 95% confidence interval, 0.99–5.63) or low acceptance (odds ratio, 2.50; 95% confidence interval, 1.20–5.21) were significantly more likely to use HIV self-testing. Gender equality measured by decision making power was not associated with couples' uptake of HIV self-testing.

Conclusions

This study is the first of its kind to examine the association between gender equality and couples' HIV self-testing. This holds important implications for HIV self-testing as we strive to achieve the United Nations Programme on HIV/acquired immune deficiency syndrome goal that 90% of individuals living with HIV should know their status.
Prevalence and Correlates of Trichomonas vaginalis Infection Using the OSOM Rapid Point-of-Care Test Among Women Attending New York City Sexual Health Clinics, May–July 2016
Authors: Fallon Susan A. , Pathela Preeti , Mikati Tarek
Published: July 2019

Using electronic medical record data and OSOM Trichomonas Rapid Tests, Trichomonas vaginalis prevalence was 9.3% among women attending New York City sexual health clinics in 2016. Positivity was associated with black race (adjusted odds ratios 3.73; 95% confidence interval, 1.9–7.1) and vaginal pH of 4.5 or greater (adjusted odds ratios, 1.9; 95% CI, 1.2–3.3).
Repetitive Transcranial Magnetic Stimulation on Motor Recovery for Patients With Stroke
Authors: He Yanjin , Li Kaiting , Chen Qing , Yin Jingyang , Bai Dingqun
Published: July 2019

Objective

A systematic review and meta-analysis were conducted to determine the efficacy of repetitive transcranial magnetic stimulation in recovering motor function in patients with stroke.

Design

A comprehensive literature search was performed to identify studies published before September 20, 2018. Electronic databases were searched. Standard mean differences and 95% confidence intervals were used to evaluate the effects of repetitive transcranial magnetic stimulation. The stability and sensitivity of the results and sources of heterogeneity were also analyzed. The Cochrane Risk of Bias Tool was used to determine the quality of the studies.

Result

Twenty randomized controlled trials (N = 841 patients) were included. The results showed that repetitive transcranial magnetic stimulation is beneficial to patients with poststroke hemiplegia, as demonstrated by the following four scales: the Fugl-Meyer Assessment (standard mean difference = 0.635, 95% confidence interval = 0.421 to 0.848); grip strength (standard mean difference = 1.147, 95% confidence interval = 0.761 to 1.534); Barthel Index (Standard mean difference = 0.580, 95% confidence interval = 0.377 to 0.783); and National Institutes of Health Stroke Scale (standard mean difference = −0.555, 95% confidence interval = −0.813 to −0.298). Few adverse events were observed.

Conclusions

The analysis showed that low-frequency repetitive transcranial magnetic stimulation has a positive effect on grip strength and lower limb function as assessed by FMA.
A Model-Based Cost-Effectiveness Analysis of an Exercise Program for Lung Cancer Survivors After Curative-Intent Treatment
Authors: Ha Duc , Kerr Jacqueline , Ries Andrew L. , Fuster Mark M. , Lippman Scott M. , Murphy James D.
Published: July 2019

Objective

The cost-effectiveness of exercise interventions in lung cancer survivors is unknown. We performed a model-based cost-effectiveness analysis of an exercise intervention in lung cancer survivors.

Design

We used Markov modeling to simulate the impact of the Lifestyle Interventions and Independence for Elders exercise intervention compared with usual care for stage I–IIIA lung cancer survivors after curative-intent treatment. We calculated and considered incremental cost-effectiveness ratios of less than US $100,000/quality-adjusted life-year as cost-effective and assessed model uncertainty using sensitivity analyses.

Results

The base-case model showed that the Lifestyle Interventions and Independence for Elders exercise program would increase overall cost by US $4740 and effectiveness by 0.06 quality-adjusted life-years compared with usual care and have an incremental cost-effectiveness ratio of US $79,504/quality-adjusted life-year. The model was most sensitive to the cost of the exercise program, probability of increasing exercise, and utility benefit related to exercise. At a willingness-to-pay threshold of US $100,000/quality-adjusted life-year, Lifestyle Interventions and Independence for Elders had a 71% probability of being cost-effective compared with 27% for usual care. When we included opportunity costs, Lifestyle Interventions and Independence for Elders had an incremental cost-effectiveness ratio of US $179,774/quality-adjusted life-year, exceeding the cost-effectiveness threshold.

Conclusions

A simulation of the Lifestyle Interventions and Independence for Elders exercise intervention in lung cancer survivors demonstrates cost-effectiveness from an organization but not societal perspective. A similar exercise program for lung cancer survivors may be cost-effective.
Comparison of Surgical Encounter Direct Costs for Three Methods of Cubital Tunnel Decompression
Authors: Kazmers Nikolas H. , Lazaris Evangelia L. , Allen Chelsea M. , Presson Angela P. , Tyser Andrew R.
Published: July 2019

Background:

In situ decompression, subcutaneous transposition, and submuscular transposition for cubital tunnel syndrome have historically yielded similar outcomes. The authors’ null hypothesis is that no differences exist in surgical encounter total direct costs for in situ decompression, subcutaneous transposition, and submuscular transposition.

Methods:

Adult patients treated surgically for cubital tunnel syndrome by four fellowship-trained hand surgeons between August of 2011 and December of 2016 were identified by CPT code (64718) at their tertiary academic institution. Patients with prior elbow surgery or fracture/dislocation and those undergoing revision or additional simultaneous procedures were excluded. Using their institution’s information technology value tools, the authors extracted prospectively collected surgical encounter total direct costs data for each surgical encounter. Costs were compared between groups and modeled using univariate and multivariable gamma regression.

Results:

In situ decompression, subcutaneous transposition, and submuscular transposition were performed on 45, 62, and 14 unique surgical encounters, respectively, with mean surgical times of 28.0, 46.5, and 50.0 minutes, respectively. Costs differed significantly between surgical methods. Surgical method and provider significantly affected surgical encounter total direct costs in the univariate model. Multivariable modeling demonstrated that subcutaneous transposition was 1.18-fold more costly than in situ decompression and submuscular transposition was 1.55-fold more costly than in situ decompression while controlling for age, sex, and provider.

Conclusions:

Surgical costs differed significantly between in situ decompression, subcutaneous transposition, and submuscular transposition. Given historically similar outcomes reported for these techniques, cost differences should be considered in addition to clinical factors to inform surgical decision-making for cubital tunnel syndrome patients.
Subcutaneous-Only Gluteal Fat Grafting: A Prospective Study of the Long-Term Results with Ultrasound Analysis
Authors: Cansancao Alvaro Luiz , Condé-Green Alexandra , David Joshua A. , Vidigal Rafael A.
Published: July 2019

In recent years, gluteal fat augmentation has exhibited some of the most significant growth among all plastic surgery procedures. However, as the popularity of and media attention to gluteal fat augmentation continue to rise, reports of fatalities, largely attributed to fat embolism, have raised valid concerns. Many plastic surgeons inject fat in the intramuscular plane and claim better graft take in the muscles and the possibility of injecting more volume in the gluteal region. Because of the large caliber of vessels, subcutaneous fat augmentation has been a preference of many. However, the long-term outcome of fat injected into the subcutaneous layer has been questionable, and there is a lack of prospective quantitative studies of subcutaneous-only fat grafting. Therefore, the authors evaluated the long-term maintenance of gluteal adipose thickness when fat was injected only subcutaneously. Fifty consecutive female patients were evaluated in this prospective clinical study. All patients underwent gluteal fat augmentation in the subcutaneous plane only. Ultrasound analysis of the adipose tissue thickness of the gluteal region was performed preoperatively, immediately postoperatively, and at 12 months postoperatively. Immediate postoperative measurements revealed an average increase in gluteal subcutaneous layer thickness of 56.51 percent (range, 39.5 to 108.6 percent) (p < 0.0001). At 12 months postoperatively, the gluteal adipose tissue thickness decreased by an average of 18.16 percent (range, 6.8 to 24.8 percent) (p < 0.0001). Subcutaneous-only gluteal fat augmentation is shown to be as effective as previous studies reporting intramuscular fat injection with regard to long-term fat retention in the buttocks.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Making Sense of Stem Cells and Fat Grafting in Plastic Surgery: The Hype, Evidence, and Evolving U.S. Food and Drug Administration Regulations
Authors: Rohrich Rod J. , Wan Dinah
Published: July 2019

Autologous fat grafting and adipose-derived stem cells are two distinct entities with two different risk profiles, and should be regulated as such. Autologous fat grafting prepared with the additional step of stromal vascular fraction isolation is considered a form of “stem cell therapy” given the high concentration of stem cells found in stromal vascular fraction. Much ambiguity existed in the distinction between autologous fat grafting and stromal vascular fraction initially, in terms of both their biological properties and how they should be regulated. The market has capitalized on this in the past decade to sell unproven “stem cell” therapies to unknowing consumers while exploiting the regulatory liberties of traditional fat grafting. This led to a Draft Guidance from the U.S. Food and Drug Administration in 2014 proposing stricter regulations on fat grafting in general, which in turn elicited a response from plastic surgeons, who have safely used autologous fat grafting in the clinical setting for over a century. After a series of discussions, the U.S. Food and Drug Administration released its Final Guidance in November of 2017, which established clear distinctions between autologous fat grafting and stromal vascular fraction and their separate regulations. By educating ourselves on the U.S. Food and Drug Administration’s final stance on fat grafting and stem cell therapy, we can learn how to navigate the regulatory waters for the two entities and implement their clinical use in a responsible and informed manner.
Universal Measures of Support Are Needed: A Cross-Sectional Study of Health Literacy in Patients with Dupuytren’s Disease
Authors: Roy Mélissa , Okrainec Karen , Novak Christine B. , von Schroeder Herbert P. , Urbach David R. , McCabe Steven J.
Published: July 2019

Background:

Health literacy represents the degree to which patients can understand and act on health information. The relevance of health literacy to health care delivery, outcomes, and overall surgical care is unambiguous. This study aimed (1) to determine the prevalence of limited health literacy in patients diagnosed with Dupuytren’s contracture and (2) to identify independent predictors of limited health literacy.

Methods:

This cross-sectional study included patients with Dupuytren’s disease and with self-reported English fluency. The Newest Vital Sign, a rapid, validated, and reliable screening tool, was selected to measure health literacy. An exploratory multivariable logistic regression model was used to identify possible predictors of limited health literacy.

Results:

A total of 185 patients met eligibility criteria and were included. From those, 82 (44 percent) were found to have limited health literacy, defined as a score of 3 or less on the Newest Vital Sign. The domain of prose literacy was most highly scored compared to numeracy and document literacy. Lower household income was associated with a 4.7-fold increase in the odds of having limited health literacy. Being an immigrant also increased the odds of having limited health literacy by a factor of 3.6. Sensitivity analyses and subgroup analyses (based on education, maternal language, and immigration status) corroborated these independent predictor findings.

Conclusions:

Limited health literacy is common among patients with Dupuytren’s contracture. System level changes are necessary such as the access and integration to clinical care of universal measures of support to promote productive patient-surgeon interactions.
Effective Application of Mixed Reality Device HoloLens: Simple Manual Alignment of Surgical Field and Holograms
Authors: Mitsuno Daisuke , Ueda Koichi , Hirota Yuka , Ogino Mariko
Published: July 2019

The technology used to add information to a real visual field is defined as augmented reality technology. Augmented reality technology that can interactively manipulate displayed information is called mixed reality technology. HoloLens from Microsoft, which is a head-mounted mixed reality device released in 2016, can display a precise three-dimensional model stably on the real visual field as hologram. If it is possible to accurately superimpose the position/direction of the hologram in the surgical field, surgical navigation-like use can be expected. However, in HoloLens, there was no such function. The authors devised a method that can align the surgical field and holograms precisely within a short time using a simple manual operation. The mechanism is to match the three points on the hologram to the corresponding marking points of the body surface. By making it possible to arbitrarily select any of the three points as a pivot/axis of the rotational movement of the hologram, alignment by manual operation becomes very easy. The alignment between the surgical field and the hologram was good and thus contributed to intraoperative objective judgment. By using the method of this study, the clinical usefulness of the mixed reality device HoloLens will be expanded.
The Use of Botulinum Toxin Type A in the Healing of Thyroidectomy Wounds: A Randomized, Prospective, Placebo-Controlled Study
Authors: Phillips Timothy J. , Fung Elaine , Rigby Matthew H. , Burke Emily , Hart Robert D. , Trites Jonathan R. B. , Gassner Holger G. , Taylor S. Mark
Published: July 2019

Background:

Recent research has indicated that botulinum toxin type A may have an inhibitory effect on the formation of fibroblasts and thus possibly decreases the severity of scar formation. Therefore, a trial was designed to assess the effects of botulinum toxin type A on scar formation after thyroid surgery.

Methods:

A double-blind, randomized, controlled trial was designed. All patients underwent a preoperative survey to assess scar history. All patients underwent a total thyroidectomy, hemithyroidectomy, or parathyroidectomy through a standardized incision. At the conclusion of the case, one half of the incision was injected with botulinum toxin type A, and the other half was injected with saline (placebo). The scars were then evaluated at 4 weeks, 6 months, and 1 year postoperatively using subjective scar analysis scales.

Results:

A total of 40 patients were enrolled. There was no significant difference in scarring at any of the time points between the botulinum toxin type A–treated and placebo sides of the incision. A subgroup analysis was performed that examined the effects of botulinum toxin type A on those with a severe scar history. This demonstrated a significant decrease in scarring at 6 months postoperatively on the botulinum toxin type A–treated side.

Conclusions:

This study indicates that botulinum toxin type A administration immediately after surgical closure of a thyroid incision does not demonstrate a difference in scar outcomes compared with the control side. However, there was less scarring in subjects who had a severe scar history. This study found opposite results to a similarly designed study. Further study is required to determine the optimal use of botulinum toxin type A for wound healing.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, II.
Injectable Allograft Adipose Matrix Supports Adipogenic Tissue Remodeling in the Nude Mouse and Human
Authors: Kokai Lauren E. , Schilling Benjamin K. , Chnari Evangelia , Huang Yen-Chen , Imming Emily A. , Karunamurthy Arivarasan , Khouri Roger K. , D’Amico Richard A. , Coleman Sydney R. , Marra Kacey G. , Rubin J. Peter
Published: July 2019

Background:

Adipose tissue reaches cellular stasis after puberty, leaving adipocytes unable to significantly expand or renew under normal physiologic conditions. This is problematic in progressive lipodystrophies, in instances of scarring, and in soft-tissue damage resulting from lumpectomy and traumatic deformities, because adipose tissue will not self-renew once damaged. This yields significant clinical necessity for an off-the-shelf de novo soft-tissue replacement mechanism.

Methods:

A process comprising separate steps of removing lipid and cellular materials from adipose tissue has been developed, creating an ambient temperature-stable allograft adipose matrix. Growth factors and matrix proteins relevant to angiogenesis and adipogenesis were identified by enzyme-linked immunosorbent assay and immunohistochemistry, and subcutaneous soft-tissue integration of the allograft adipose matrix was investigated in vivo in both the athymic mouse and the dorsum of the human wrist.

Results:

Allograft adipose matrix maintained structural components and endogenous growth factors. In vitro, adipose-derived stem cells cultured on allograft adipose matrix underwent adipogenesis in the absence of media-based cues. In vivo, animal modeling showed vasculature formation followed by perilipin A–positive tissue segments. Allograft adipose matrix maintained soft-tissue volume in the dorsal wrist in a 4-month investigation with no severe adverse events, becoming palpably consistent with subcutaneous adipose.

Conclusions:

Subcutaneous implantation of allograft adipose matrix laden with retained angiogenic and adipogenic factors served as an inductive scaffold for sustaining adipogenesis. Tissue incorporation assessed histologically from both the subcutaneous injection site of the athymic nude mouse over 6 months and human dorsal wrist presented adipocyte morphology residing within the injected scaffold.
Urethral Reconstruction in Anterolateral Thigh Flap Phalloplasty: A 93-Case Experience
Authors: D’Arpa Salvatore , Claes Karel , Lumen Nicholas , Oieni Sebastiano , Hoebeke Piet , Monstrey Stan
Published: July 2019

Background:

Urethral reconstruction in anterolateral thigh flap phalloplasty cannot always be accomplished with one flap, and the ideal technique has not been established yet. In this article, the authors’ experience with urethral reconstruction in 93 anterolateral thigh flap phalloplasties is reported.

Methods:

Ninety-three anterolateral thigh phalloplasties performed over 13 years at a single center were retrospectively reviewed to evaluate outcomes of the different urethral reconstruction techniques used: anterolateral thigh alone without urethral reconstruction (n = 7), tube-in-tube anterolateral thigh flap (n = 5), prelaminated anterolateral thigh flap with a skin graft (n = 8), anterolateral thigh flap combined with a free radial forearm flap (n = 29), anterolateral thigh flap combined with a pedicled superficial circumflex iliac artery perforator flap (n = 38), and anterolateral thigh flap combined with a skin flap from a previous phalloplasty (n = 6). Seventy-nine phalloplasties were performed for female-to-male sex reassignment surgery. The others were performed in male patients with severe penile insufficiency.

Results:

Urethral complication rates (fistulas and strictures) were as follows: tube-in-tube anterolateral thigh flap, 20 percent; prelaminated anterolateral thigh flap, 87.5 percent; free radial forearm flap urethra, 37.9 percent; superficial circumflex iliac artery perforator urethral reconstruction, 26.3 percent; and skin flap from previous phalloplasty, 16.7 percent.

Conclusions:

When tube-in-tube urethra reconstruction is not possible (94.2 percent of cases), a skin flap such as the superficial circumflex iliac artery perforator flap or the radial forearm flap is used for urethral reconstruction in anterolateral thigh phalloplasties. Flap prelamination is a second choice that gives high stricture rates. If a penis is present, its skin should be used for urethral reconstruction and covered with an anterolateral thigh flap. With these techniques, 91.86 percent of patients are eventually able to void while standing.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Elegance in Upper Lip Reconstruction
Authors: Salibian Ara A. , Zide Barry M.
Published: July 2019

Restoration of the upper lip provides a reconstructive challenge because of its anatomical and aesthetic requirements. This article provides a “where is it on the lip” approach to reconstruct small to subtotal defects of the upper lip that are feasible to perform in the office setting. Emphasis is placed on adherence to core principles, attention to macroaesthetic and microaesthetic landmarks, and technical refinements of well-established reconstructive techniques. These tenets include algorithms for central and lateral defects, precise use of the Abbe flap, use of local tissue rearrangement and skin grafts, and appropriate management of scars. A strong understanding of the anatomical and aesthetic nuances of the upper lip will allow for enhancement of conventional reconstructive procedures to optimize functional and aesthetic outcomes.
Implant-Based Breast Reconstruction: Hot Topics, Controversies, and New Directions
Authors: Frey Jordan D. , Salibian Ara A. , Karp Nolan S. , Choi Mihye
Published: July 2019

Learning Objectives:

After studying this article, the participant should be able to: 1. Evaluate appropriate patients best suited for one- or two-stage alloplastic breast reconstruction. 2. Discuss and apply the unique advantages and disadvantages of scaffold use and different implant types in breast reconstruction to maximize outcomes. 3. Develop a plan for patients undergoing implant-based breast reconstruction requiring postmastectomy radiation therapy. 4. Analyze the evidence with regard to antibiotic prophylaxis in implant-based breast reconstruction. 5. Recognize and critique novel technical and device developments in the field of alloplastic breast reconstruction, enabling appropriate patient selection.

Implant-based, or alloplastic, breast reconstruction is the most common method of breast reconstruction in the United States. Within implant-based reconstruction, many techniques and reconstructive strategies exist that must be tailored for each individual patient to yield a successful reconstruction. Not unexpectedly, many hot topics and controversies in this field have emerged, including stages of reconstruction, use of scaffolds, permanent implant type, strategies for postmastectomy radiation therapy, and antibiotic prophylaxis. In addition, there has been an evolution in technical and device development in recent years. Therefore, plastic surgeons must be on the forefront of knowledge to approach implant-based breast reconstruction in an evidence-based fashion to best treat their patients.
Genetic Testing for Breast Cancer Susceptibility Should Be Offered before Unilateral Abdominally Based Free Flap Breast Reconstruction
Authors: Dayan Erez , Chittenden Anu , Garber Judy E. , Wo Luccie , Caterson Stephanie A. , Carty Matthew J. , Erdmann-Sager Jessica
Published: July 2019

Background:

Pathogenic mutations have been identified in approximately 10 percent of patients who present with breast cancer. Notably, failure to identify deleterious genetic mutations has particular implications for patients undergoing abdominally based breast reconstruction, as the donor site can be used only once. The authors sought to determine: (1) how many patients underwent genetic testing before unilateral abdominally based free flap breast reconstruction; (2) how often deleterious mutations were detected after abdominally based free flap breast reconstruction; and (3) the cost-effectiveness of expanding genetic testing in this patient population.

Methods:

The authors retrospectively identified all patients who underwent unilateral abdominally based free flap breast reconstruction at Brigham and Women’s Hospital/Dana-Farber Cancer Institute between 2007 and 2016. Chart review was performed to collect relevant demographic and clinical data. Relevant hospital financial data were obtained.

Results:

Of the 713 who underwent free flap breast reconstruction, 160 patients met inclusion criteria, and mean follow-up was 5.8 years. Three patients (1.9 percent of 160) underwent contralateral surgery after completing reconstruction, two of whom had BRCA2 and one with ATM mutation. One hundred eleven patients met National Comprehensive Cancer Network guidelines for genetic testing, but of those only 55.9 percent (62 patients) were tested. Financial data revealed that testing every patient in the cohort would result in a net savings of $262,000.

Conclusions:

During a relatively short follow-up period, a small percentage of patients were diagnosed with pathogenic mutations and underwent contralateral mastectomy and reconstruction. However, because of the costliness of surgery and the decreased cost of genetic testing, it is cost-effective to test every patient before unilateral abdominally based free flap breast reconstruction.
The Analgesic Effects of Liposomal Bupivacaine versus Bupivacaine Hydrochloride Administered as a Transversus Abdominis Plane Block after Abdominally Based Autologous Microvascular Breast Reconstruction: A Prospective, Single-Blind, Randomized, Controlled Trial
Authors: Ha Austin Y. , Keane Grace , Parikh Rajiv , Odom Elizabeth , Tao Yu , Zhang Li , Myckatyn Terence M. , Guffey Ryan
Published: July 2019

Background:

Postoperative pain control after abdominally based autologous microvascular breast reconstruction is critical to functional recovery, patient satisfaction, and early discharge. The transversus abdominis plane block using 0.25% bupivacaine hydrochloride has been shown to be effective, but it is limited by a short duration of effect. Liposomal bupivacaine is a recently U.S. Food and Drug Administration–approved preparation of bupivacaine that can provide up to 72 hours of pain relief. The purpose of this randomized, controlled trial was to compare the analgesic efficacy of liposomal bupivacaine and conventional bupivacaine.

Methods:

This study was a prospective, single-blind, randomized, controlled trial of 44 patients undergoing abdominally based autologous breast reconstruction between June of 2016 and February of 2018 performed by a single surgeon. Each patient was randomized to receive either 266 mg of liposomal bupivacaine or 75 mg of conventional bupivacaine to the transversus abdominis plane at the conclusion of the reconstruction procedure. All patients were managed postoperatively according to an enhanced recovery protocol.

Results:

In our study of 44 patients, 22 patients received a transversus abdominis plane block with conventional bupivacaine and 22 patients received liposomal bupivacaine. There were no significant differences with regard to any outcome measure. No differences were found in total opioid consumption (p= 0.98), Quality of Recovery-15 scores (p= 0.72), pain scores (p= 0.39), or length of stay (p= 0.20).

Conclusion:

In the setting of a robust enhanced recovery after surgery protocol, liposomal bupivacaine does not confer advantages over conventional bupivacaine when used as single injections in transversus abdominis plane blocks after abdominally based microvascular breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, II.
What Happened after the Poly Implant Prothèse Recall? A Prospective Cohort Study of 808 Implants into the Predictive Value of Implant Rupture on Postexchange Complications
Authors: Kappos Elisabeth A. , Fitzgerald Éilis , Haug Martin D. , Quaba Omar , Quaba Awf
Published: July 2019

Background:

Problems with a variety of breast implants have emerged with consequences for patients’ health and safety. The authors’ goal was to follow up on their Poly Implant Prothèse patients after their implant exchange.

Methods:

This single-center, single-surgeon, prospective cohort study lasted from 2012 until 2017. Implant size, implantation interval, surgical details, and complications were registered. The Clavien-Dindo classification was used to grade postoperative complications. Logistic regression was used to investigate whether rupture, interval between implantation and explantation, and new implant size were predictors of postexchange complications.

Results:

The authors explanted 808 implants in 404 patients. The rupture rate was 30.9 percent per patient and 20.2 percent per implant. The capsular contracture rate at the time of exchange was low, with 1.86 percent of implants and 2.7 percent of patients; 97.8 percent of patients elected implant exchange and only 2.2 percent just wanted their implants removed. The mean follow-up after implant exchange was 5.2 years, with the last mandatory outpatient appointment usually being scheduled 6 to 12 months after implant exchange. The authors found that 74 patients (18.3 percent) and 124 implants (15.3 percent) had postexchange complications, the majority of them minor (83 percent Clavien-Dindo grade I). Patients with a ruptured implant at the time of exchange were significantly more likely to develop postexchange complications than were patients without rupture.

Conclusions:

This is the first study providing such a complete long-term postexchange follow-up of a single surgeon’s Poly Implant Prothèse implant cohort. Implant rupture at the time of exchange had a high predictive value for postexchange complications in the authors’ series of 808 implants and 404 Poly Implant Prothèse recall patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
An In Vitro Model Assessing the Penetration of Hyaluronidase through Optic Nerve Dura for Management of Hyaluronic Acid Facial Filler Embolism
Authors: Adulkar Namrata , Cheng Charles , Lee Lawrence , Rasmussen Steve , Dolman Peter J. , Yin Vivian T.
Published: July 2019

Background:

Blindness from ophthalmic or central retinal artery embolism is one of the most devastating complications of cosmetic filler facial injections. A proposed therapy to mitigate visual loss is prompt retrobulbar injection of hyaluronidase into the retrobulbar space. Despite Zhu et al. showing a lack of evidence and very limited published literature for reversing visual loss with this intervention, it is still widely accepted as a treatment for filler-related emboli. The purpose of this study was to evaluate the penetration of hyaluronidase through optic nerve dura using an in vitro model.

Methods:

At study conclusion, five 1-cm-long segments of fresh optic nerve were obtained and injected with highly crosslinked hyaluronic acid filler, then ligated on both ends in a watertight fashion. The sections were immersed in three concentrations of hyaluronidase solution for 24 hours. Histopathologic examination of the specimen was performed to assess the presence of filler.

Results:

The optic nerve sections were 1.1 cm (range, 0.8 to 1.2 cm). Three were immersed in 20 ml of 1500 IU/ml hyaluronidase solution and two were immersed in saline as control. After 24 hours, there was a persistence of hyaluronic acid within the optic nerves.

Conclusions:

There is a lack of evidence for penetration of optic nerve sheath by hyaluronidase. This raises question about the effectiveness of retrobulbar injection of hyaluronidase in reversing filler-related blindness. Further studies are needed before this can be adopted as the treatment of choice.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, V.
The Interplay of Mechanical Stress, Strain, and Stiffness at the Keloid Periphery Correlates with Increased Caveolin-1/ROCK Signaling and Scar Progression
Authors: Dohi Teruyuki , Padmanabhan Jagannath , Akaishi Satoshi , Than Peter A. , Terashima Masao , Matsumoto Noriko N. , Ogawa Rei , Gurtner Geoffrey C.
Published: July 2019

Background:

Fibroproliferative disorders result in excessive scar formation, are associated with high morbidity, and cost billions of dollars every year. Of these, keloid disease presents a particularly challenging clinical problem because the cutaneous scars progress beyond the original site of injury. Altered mechanotransduction has been implicated in keloid development, but the mechanisms governing scar progression into the surrounding tissue remain unknown. The role of mechanotransduction in keloids is further complicated by the differential mechanical properties of keloids and the surrounding skin.

Methods:

The authors used human mechanical testing, finite element modeling, and immunohistologic analyses of human specimens to clarify the complex interplay of mechanical stress, strain, and stiffness in keloid scar progression.

Results:

Changes in human position (i.e., standing, sitting, and supine) are correlated to dynamic changes in local stress/strain distribution, particularly in regions with a predilection for keloids. Keloids are composed of stiff tissue, which displays a fibrotic phenotype with relatively low proliferation. In contrast, the soft skin surrounding keloids is exposed to high mechanical strain that correlates with increased expression of the caveolin-1/rho signaling via rho kinase mechanotransduction pathway and elevated inflammation and proliferation, which may lead to keloid progression.

Conclusions:

The authors conclude that changes in human position are strongly correlated with mechanical loading of the predilection sites, which leads to increased mechanical strain in the peripheral tissue surrounding keloids. Furthermore, increased mechanical strain in the peripheral tissue, which is the site of keloid progression, was correlated with aberrant expression of caveolin-1/ROCK signaling pathway. These findings suggest a novel mechanism for keloid progression.
Variation in the Desire for Cleft Revision Surgery among Children, Caregivers, and Surgeons
Authors: Ranganathan Kavitha , Kochkodan Jeanne M. , Baker Michaella K. , Matusko Niki , Bennett Katelyn G. , Shapiro Danielle N. , Warschausky Seth A. , Vercler Christian J. , Kasten Steven J. , Buchman Steven R. , Waljee Jennifer F.
Published: July 2019

Background:

Although revision surgery is part of the reconstructive process for children with cleft lip and/or cleft palate, the indications for revision vary, and the extent to which surgeons and families agree on appearance is unclear. The authors sought to understand the extent to which children with cleft lip and/or cleft palate, surgeons, caregivers, and control observers agree on satisfaction with appearance and the desire for revision.

Methods:

Children with cleft lip and/or cleft palate (n = 100) and their caregivers (n = 100) were surveyed regarding satisfaction with appearance using the Cleft Evaluation Profile. Surgeons (n = 10) and control observers (n = 10) rated photographs of these children using questions analogous to the Cleft Evaluation Profile. General linear model repeated measures analysis of variance were used to detect significant differences between raters, with an alpha of 0.05.

Results:

The children reported greater satisfaction with appearance across all domains compared with surgeons (nose, 7.77 versus 5.51, p < 0.001; lip, 7.94 versus 5.90, p < 0.001; maxilla, 8.16 versus 6.56, p < 0.001) and general observers (nose, 7.78 versus 6.00, p < 0.001; lip, 7.80 versus 6.12, p < 0.001; maxilla, 8.16 versus 7.40, p < 0.001). Children and caregivers expressed similar degrees of satisfaction with appearance of the lip (5.48 ± 1.69 versus 5.6 ± 1.49, p > 0.5) and maxilla (6.08 ± 1.1 versus 5.8 ± 1.2, p = 0.07). There was no significant relationship between children and surgeons in terms of the desire for revision surgery (p = 0.44).

Conclusions:

All groups expressed differing levels of satisfaction with cleft-specific aspects of appearance. Importantly, children were more satisfied than all other groups. Care must be taken to evaluate perceptions of all stakeholders before moving forward with cleft revision surgery.
A Cultured Autologous Dermo-epidermal Skin Substitute for Full-Thickness Skin Defects: A Phase I, Open, Prospective Clinical Trial in Children
Authors: Meuli Martin , Hartmann-Fritsch Fabienne , Hüging Martina , Marino Daniela , Saglini Monia , Hynes Sally , Neuhaus Kathrin , Manuel Edith , Middelkoop Esther , Reichmann Ernst , Schiestl Clemens
Published: July 2019

Background:

The management of deep partial-thickness and full-thickness skin defects remains a significant challenge. Particularly with massive defects, the current standard treatment, split-thickness skin grafting, is fraught with donor-site limitations and unsatisfactory long-term outcomes. A novel, autologous, bioengineered skin substitute was developed to address this problem.

Methods:

To determine whether this skin substitute could safely provide permanent defect coverage, a phase I clinical trial was performed at the University Children’s Hospital Zurich. Ten pediatric patients with acute or elective deep partial- or full-thickness skin defects were included. Skin grafts of 49 cm2 were bioengineered using autologous keratinocytes and fibroblasts isolated from a patient’s small skin biopsy specimen (4 cm2), incorporated in a collagen hydrogel.

Results:

Graft take, epithelialization, infection, adverse events, skin quality, and histology were analyzed. Median graft take at 21 days postoperatively was 78 percent (range, 0 to 100 percent). Healed skin substitutes were stable and skin quality was nearly normal. There were four cases of hematoma leading to partial graft loss. Histology at 3 months revealed a well-stratified epidermis and a dermal compartment comparable to native skin. Mean follow-up duration was 15 months.

Conclusions:

In the first clinical application of this novel skin substitute, safe coverage of skin defects was achieved. Safety and efficacy phase II trials comparing the novel skin substitute to split-thickness skin grafts are ongoing.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Microvascular Reconstruction of the Nose with the Radial Forearm Flap: A 17-Year Experience in 47 Patients
Authors: Salibian Arthur H. , Menick Frederick J. , Talley John
Published: July 2019

Background:

Microvascular reconstruction of the nose was pioneered in China in the early 1970s using the radial forearm flap. Since then, different flaps, methods, and flap designs have been used to improve outcomes. Microvascular tissue transfer has become the first step of multistage reconstruction, which includes rebuilding the nasal framework, transferring a forehead flap for external skin coverage, and sculpting the nose for improved appearance and breathing. In this article, the authors present their long-term experience in microvascular reconstruction of the nose using the infolded radial forearm flap for full-thickness nasal defects, and a single circumferential flap for inner lining only.

Methods:

Fifty microvascular nasal reconstruction procedures were performed on 47 patients between 2000 and 2017 using the radial forearm flap. The reconstructions included total/subtotal nasal defects using a trapezoid-shaped forearm flap folded in one or two planes, and a rectangular flap positioned internally and circumferentially for lining only. The nasal defects were caused by cancer resection, trauma, infection, cocaine abuse, and failed attempts at nasal reconstruction.

Results:

Forty-seven flaps were transferred successfully for nasal reconstruction, with two immediate failures (4 percent) caused by flap insetting complications and one late loss. Forty-six patients completed the multistage nasal reconstruction. Follow-up was 1 to 17 years (average, 6 years).

Conclusion:

The radial forearm flap infolding technique is the authors’ method of choice for microvascular reconstruction of the nose because it allows placement of a primary dorsal cartilage graft for optimal vascularization, and uses the excess dorsal skin during forehead resurfacing to modify the lining inset and shape the nostrils.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
10-Year Experience Using Inspira Implants: A Review with Personal Anecdote
Authors: Mallucci Patrick L.
Published: July 2019

The article summarizes the author’s experience with Inspira implants. They were first introduced into the European market in 2006. The advent of the Inspira range heralded a fundamental change in the way round implants were perceived. The comprehensive matrix, the form stability of the gels, along with sophisticated manufacturing of the shell placed them as a premium product for use in both aesthetic and reconstructive breast surgery. The same principles of precise tissue-based planning, developed for anatomical implants, were being adopted for use with Inspira, leading to more predictable outcomes with high levels of patient satisfaction.
The Science of Cohesivity and Elements of Form Stability
Authors: Gabriel Allen , Maxwell G. Patrick
Published: July 2019

Silicone gel implants vary in terms of gel cohesivity and form stability. Various degrees of gel cohesivity are obtained by varying the density of crosslinking between silicone polymers. Less cohesive gels are less crosslinked, are more elastic, and have a softer feel while more cohesive gels more crosslinked, are less elastic, and have a firmer feel. When a highly cohesive gel is able to maintain its intended distribution within an implant, the gel is referred to as being form stable. Thus, a form-stable implant is able to retain its designed shape and dimensions in any position. Gel cohesivity and form stability influence breast shape, softness/firmness, and in vivo implant performance and an understanding of these parameters is critical to implant selection.
Maximizing Aesthetics and Patient Selection Utilizing Natrelle Inspira Line Implants in Aesthetic Breast Surgery
Authors: Kortesis Bill G. , Bharti Gaurav
Published: July 2019

Aesthetic breast augmentation has recently experienced a significant boom in options available to achieve an ideal outcome. Evolving prosthetic device technology has now brought an array of implant gels, implant shells, and fill ratios to customize shape, composition/fill, and feel of the augmented breast. With the vast portfolio of currently available implants, surgeons now have a greater ability to produce tailored and desired outcomes. The Natrelle Inspira line of breast implants by Allergan Medical is a comprehensive portfolio of implants starting with the Responsive series with the softest gel, the SoftTouch series, and the fully Cohesive series. These options allow surgeons to help tailor and create the breast that patients desire.