What a Ratchet! A Gripping Case Report of an Entrapped Finger with an Unyielding Wrench.

Finger entrapment with rings or ring-like objects is an uncommon possible hand emergency. In cases in which noncutting removal is ineffective, ring cutters or dental drills with carbide or diamond burs have been successfully used. However, objects composed of hard metallic alloys, such as lug nuts or wrenches, are often resistant to such equipment. In these instances, larger diameter metal cutting burrs or rasps may be more advantageous. Due to their increased size and cutting power, these tools are better suited to handle the toughness of hard metals. In this case report, we present the effective and efficient removal of a stainless steel wrench from an entrapped digit using a helicoidal rasp. Availability of this instrument within orthopedic departments may prevent the delays often described in the treatment of finger entrapment when traditional cutting equipment fails.

Prevalence, clinical characteristics, and management of silicone lymphadenopathy: A systematic review of the literature.

INTRODUCTION: Implant-based breast augmentations and reconstructions are one of the most common surgical procedures performed by plastic surgeons in the United States, which has rapidly increased in popularity since the 2000s. Silicone lymphadenopathy (SL) is a complication of breast implants that involves migration of silicone to nearby soft tissue/lymph nodes. Data on its clinical features and management is scarce. METHODS: SL-related search terms were used to find articles in 3 databases. Of 598 articles, 101 studies met the inclusion criteria. Demographics, clinical presentation, workup, and management data were analyzed. RESULTS: Of 279 cases of SL and 107 with information on initial diagnosis, 35 (33%) were incidental. The most common symptom was painless lymphadenopathy, followed by painful lymphadenopathy. 251 (95%) and 13 (5%) patients had silicone and saline implants, respectively. 149 (68%) patients had implant rupture. Axillary lymphadenopathy was the most affected region (136 cases, 72%), followed by internal mammary (40 cases, 21%), cervical/supraclavicular (36 cases, 19%), and mediastinal (24 cases, 13%) regions. 25% of patients underwent fine-needle aspiration, 12% core needle biopsy, and 59% excisional biopsy. 32% of cases underwent explantation and/or implant exchange. The most common indication for surgery was implant rupture. Histology showed multinucleated giant cells, large histiocytes, and silicone accumulation. CONCLUSIONS: SL is a complication associated with breast implants. The majority of patients are asymptomatic, and most cases are managed conservatively. Minority need a biopsy and surgical interventions due to abnormal imaging, persistent symptoms, and/or implant rupture. Workup and management should be tailored to the patient.

Techniques and Outcomes in Microsurgical Treatment of Posttraumatic Lymphedema: A Systematic Review.

BACKGROUND: The microsurgical treatment of lymphedema has been well-studied and has been shown to be effective, especially in cancer-related lymphedema. Posttraumatic lymphedema (PTL) is a debilitating condition that remains understudied and underreported, and surgical techniques for PTL treatment are not well-represented in the literature. The purpose of this study was to systematically review all published reports of physiologic surgical interventions for PTL. METHODS: A search was conducted on PubMed, MEDLINE, Embase, and Web of Science, from January 1, 2000 to December 6, 2022, using keywords "PTL," "lymphedema," and "surgery" to identify reports of PTL treated with microsurgical lymphatic reconstruction techniques. PTL cases treated with ablation, debulking, or decongestive therapy were excluded. RESULTS: A total of 18 records that met the inclusion criteria were identified, representing 112 patients who underwent microsurgical operations for PTL. This included 60 cases of lymph flow restoration (LFR) via lymph axiality and interpositional flap transfer, 29 vascularized lymph node transfers, 11 lymphatic vessel free flaps, 10 lymphovenous anastomoses (LVAs), and 2 autologous lymphovenous transfers. Outcomes were primarily reported as clinical improvement or LFR by lymphatic imaging. All studies showed qualitative improvement of symptoms and reports with quantitative data showed statistically significant improvements. CONCLUSION: PTL is currently underrepresented in lymphedema treatment literature, however, our results show that microsurgical techniques are successful in treating lymphedema in PTL patients. Increasing awareness of PTL and establishing standardized diagnostic criteria and treatment options will help clinicians better understand how to diagnose and treat this condition. Prospective and comparative studies are needed to determine true prevalence of PTL and optimal treatment strategies.

The Yearly Periodicity of Operative Upper Extremity Trauma: A Retrospective Study of "Trauma Season".

BACKGROUND: Upper extremity (UE) trauma requiring operative care increases during the summer and fall months, which the authors colloquially refer to as "trauma season." METHODS: CPT databases were queried for codes related to acute UE trauma at a single level-1 trauma center. Monthly CPT code volume was tabulated for 120 consecutive months and average monthly volume was calculated. Raw data were plotted as a time series and transformed as a ratio to the moving average. Autocorrelation was applied to the transformed data set to detect yearly periodicity. Multivariable modeling quantified the proportion of volume variability attributable to yearly periodicity. Subanalysis assessed presence and strength of periodicity in four age groups. RESULTS: A total of 11,084 CPT codes were included. Monthly trauma-related CPT volume was highest in July through October and lowest in December through February. Time-series analysis revealed yearly oscillation in addition to a growth trend. Autocorrelation revealed statistically significant positive and negative peaks at a lag of 12 and 6 months, respectively, confirming yearly periodicity. Multivariable modeling revealed R 2 attributable to periodicity of 0.53 ( P < 0.01). Periodicity was strongest in younger populations and weaker in older populations. R 2 was 0.44 for ages 0 to 17, 0.35 for ages 18 to 44, 0.26 for ages 45 to 64, and 0.11 for ages 65 and older. CONCLUSIONS: Operative UE trauma volumes peak in the summer and early fall and reach a winter nadir. Periodicity accounts for 53% of trauma volume variability. The authors' findings have implications for allocation of operative block time and personnel and expectation management over the course of the year.

Insights into the mechanism of mycelium transformation of Streptomyces toxytricini into pellet.

Formation of the mycelial pellet in submerged cultivation of Streptomycetes is unwanted in industrial fermentation processes as it imposes mass transfer limitations, changes in the rheology of a medium, and affects the production of secondary metabolites. Though detailed information is not available about the factors involved in regulating mycelial morphology, it is studied that culture conditions and the genetic information of strain play a crucial role. Moreover, the proteomic study has revealed the involvement of low molecular weight proteins such as; DivIVA, FilP, ParA, Scy, and SsgA proteins in apical growth and branching of hyphae, which results in the establishment of the mycelial network. The present study proposes the mechanism of pellet formation of Streptomyces toxytricini (NRRL B-5426) with the help of microscopic and proteomic analysis. The microscopic analysis revealed that growing hyphae contain a bud-like structure behind the apical tip, which follows a certain organized path of growth and branching, which was further converted into the pellet when shake flask to the shake flask inoculation was performed. Proteomic analysis revealed the production of low molecular weight proteins ranging between 20 and 95 kDa, which are involved in apical growth and hyphae branching and can possibly participate in the regulation of pellet morphology.

Facial Trauma Operative Volume Demonstrates Consistent and Significant Yearly Periodicity.

PURPOSE: Facial trauma requiring operative care increases during the summer and fall months, which is colloquially referred to as trauma season. The purpose of this study is to determine if there is a quantifiable and statistically significant yearly periodicity of operative facial trauma volume. MATERIALS AND METHODS: To confirm the existence and quantify the magnitude of trauma season, we conducted a retrospective cohort study. The Plastic Surgery divisional billing database was queried for Current Procedural Terminology (CPT) codes related to acute facial trauma. The outcome variable is monthly CPT code volume and calendar month is the predictor. Monthly CPT volume was tabulated for 120 consecutive months. Raw data were plotted as a time series and transformed as a ratio to the moving average. Autocorrelation was applied to the transformed dataset to detect yearly periodicity. Multivariable modeling quantified the proportion of volume variability (R2) attributable to yearly periodicity. Subanalysis assessed presence and strength of periodicity in 4 age groups. Patient identifiers, demographic information, surgeon, and date of surgery were collected as covariates. RESULTS: One thousand six hundred fifty eight CPT codes obtained through Plastic Surgery billing records were included. Mean age at presentation was 32.5 ± 16.3 years (range = 85.05). Monthly trauma-related CPT volume was highest in June-September and lowest in December-February. Time series analysis revealed yearly oscillation, in addition to a growth trend. Autocorrelation revealed statistically significant positive and negative peaks at a lag of 12 and 6 months, respectively, confirming the presence of yearly periodicity. Multivariable linear modeling revealed R2 attributable to periodicity of 0.23 (P = .008). Periodicity was strongest in younger populations and weaker in older populations. R2 = 0.25 for ages 0-17, R2 = 0.18 for ages 18-44, R2 = 0.16 for ages 45-64, and R2 = 0.034 for ages ≥ 65. CONCLUSION: Operative facial trauma volumes peak in the summer and early fall and reach a winter nadir. This periodicity is statistically significant and accounts for 23% of overall trauma volume variability at our Level 1 trauma hospital. Younger patients drive the majority of this effect. Our findings have implications for operative block time and personnel allocation, in addition to expectation management over the course of the year.

Functional Thenar Reconstruction: A Case Report and Systematic Review of the Literature.

ABSTRACT: Reconstruction of the thumb is among the most complex challenges faced by hand surgeons. Meaningful functional recovery of the thumb is dependent mainly on thumb opposition and palmar abduction. Free functional muscle transfer provides neurotized, robust soft tissue coverage that can achieve dynamic reconstruction of thenar musculature in a single stage.We present a case of a free neurotized segmental gracilis muscle transfer for thenar reconstruction and a systematic review of thenar reconstruction with free functional muscle transfer in the literature. A teenage male patient with a gunshot-induced thenar defect was reconstructed using a free neurotized gracilis muscle measuring 5 × 11 cm. The obturator nerve was coapted to the recurrent motor branch of the median nerve. The patient reached M4 strength at 10 months with functional use of his thumb. A systematic review of options for functional thenar reconstruction revealed 14 studies describing functional thenar reconstruction in 44 patients. Successful functional flaps described included gracilis muscle, pronator quadratus muscle, pectoralis minor muscle, abductor hallucis muscle, extensor digitorum brevis muscle, and serratus anterior muscle. Microsurgical transfer of a functional muscle is an excellent option for single-stage thenar reconstruction of both form and function. There are a number of available donor sites with equivalent size and bulk to that of native thenar musculature.

Osteotomies, Core Decompression, and Denervation for the Treatment of Kienböck Disease.

Various osteotomies, core decompression, and denervation all have demonstrated favorable outcomes in treatment of Kienböck disease. Given the rarity of this disease, there is a dearth of high-level comparative studies to direct treatment. In this article, the authors review the current literature surrounding these techniques, and provide summary recommendations for the procedure choice.

Progress and challenges in the biofoundry of immunosuppressants: From process to practice.

Microorganisms are known to produce pharmaceutically important secondary metabolites that are used as drug moieties in the treatment of various disorders. Discovery of one such class of drugs called immunosuppressants led the way for new and improved treatment regimens for the cases of organ rejections as well as for autoimmune diseases. Uncovering the role of these secondary metabolites as immunomodulators had increased their demand in the global drug market. However, this was soon overshadowed by the low amount of product obtained after fermentation and tedious downstream processing for the recovery of product. Hence, continuous efforts are being made to enhance their production by unveiling the basic biosynthetic pathways involved in their synthesis. From unearthing these immunosuppressants to their rapid development towards commercialization, these drugs have gained a significant place in the world market. Hence, the present review is focused on the progress and challenges in the production and downstream processing of different immunosuppressants (tacrolimus, cyclosporine, rapamycin, and mycophenolic acid). This is the first review report on how the market demand of immunosuppressants could be fulfilled by exploring biofoundry approaches to achieve the goal.

Reprogramming of antibiotics to combat antimicrobial resistance.

This review outlines a literature-based approach with illustrative examples of drug repurposing (one molecule, multiple targets), which will be useful in tackling the problem of antimicrobial resistance (AMR). Globally, the demands for new drugs have increased due to multidrug-resistant pathogens and emerging viruses. Keeping these facts in view, drug repurposing started for utilization of a drug in a different way from a preexisting drug, which reduces the time and cost of development of a new drug. Repurposing increases the potency of a drug and reduces its toxicity level, as it is required in lower amounts, supporting the utilization of the drug as a new therapeutic option. This will be further explored to highlight the application in AMR.

Panniculectomy at the time of living donor renal transplantation: An 8-year experience.

Panniculectomy can be performed as a prophylactic procedure preceding transplantation to enable obese patients to meet criteria for renal transplantation. No literature exists on combined renal transplant and panniculectomy surgery (LRT-PAN). We describe our 8-year experience performing LRT-PAN. A retrospective chart review of all patients who had undergone LRT-PAN from 2010 to 2018 was conducted. Data were collected on patient demographics, allograft survival and function, and postoperative course. Fifty-eight patients underwent LRT-PAN. All grafts survived, with acceptable function at 1 year. Median length of stay was 4 days with a mean operative duration of 363 minutes. The wound complication rate was 24%. Ninety-day readmission rate was 52%, with medical causes as the most common reason for readmission (45%), followed by wound (32%) and graft-related complications (23%). Body mass index, diabetes status, and previous immunosuppression did not influence wound complication rate or readmission (P = .7720, P = .0818, and P = .4830, respectively). Combining living donor renal transplant and panniculectomy using a multidisciplinary team may improve access to transplantation, particularly for the obese and postobese population. This combined approach yielded shorter-than-expected hospital stays and similar wound complication rates, and thus should be considered for patients in whom transplantation might otherwise be withheld on the basis of obesity.

Association of Toll-like receptor 4 with hepatitis A virus infection in Assam.

Hepatitis A virus (HAV) which causes liver disease is recognized by Toll-like receptors (TLRs) through the viral nucleic acid, initiating the host defense response. The study aims to analyze the role of TLR4 rs11536889 polymorphism in the pathogenesis of hepatitis A cases from Assam. There was significant correlation between TLR4 SNP G/C (rs11536889) and between acute viral hepatitis (AVH) A cases and controls. The correlation of the 3 different genotypes GG, GC and CC of TLR4 rs11536889 with the TLR4 mRNA expression level in all the HAV cases groups have been found to be statistically significant (p <0.001). TLR4 expression was most significantly upregulated in the acute HAV cases, HAV with cholestasis cases and even the HAV caused fulminant hepatitis failure (FHF) cases with the CC genotype of TLR4 rs11536889. The upregulation is mostly seen in the cases with the CC genotype of TLR4 rs11536889 and thus indicates that the mutant variant of TLR4 rs11536899 (CC) may have an effect on the expression of TLR4 at the transcription level. Our study did not show any significant association between AVH and HAV caused FHF (p = 0.32, OR = 0; p = 0.59, OR = 2.06 at 95% CI) among the genotypes GG, GC and CC. Our data suggest that TLR4 gene polymorphism rs11536889 may play a prominent role in HAV disease susceptibility and TLR4 expression in population from Assam.

Apparent Age is a Reliable Assessment Tool in 20 Facelift Patients.

BACKGROUND: Although the literature is replete with favorable facelift results, there are few validated facial rejuvenation outcome measures. Apparent age (AA), a visual estimate of age by objective observers, has been utilized in several studies; although attractive, AA lacks validation. OBJECTIVE: The aim of this study is to examine the reliability of AA, highlighting the importance of the exclusive use of validated outcome measures in future studies. METHODS: Ten blinded reviewers assessed pre- and postoperative photographs of 32 patients who underwent facelift. Each reviewer completed 3 surveys at 3-month intervals composed of 40 randomly ordered photos; totaling 1200 photographs assigned an AA. The intra-class correlation coefficient was classified as "excellent," "good," "fair," or "poor." The accuracy of assigned AA, agreement within 5 years, and reduction in AA were also evaluated. RESULTS: The mean difference of preoperative true age from assigned AA was 2.74 ± 4.36 years. Forty-three percent of raters were within 5-years (±2.5) of the mean. Intra-rater reliability preoperatively and postoperatively were 0.77 (95% CI, 0.82-0.72) and 0.75 (95% CI, 0.79-0.71), respectively. Inter-rater reliability preoperatively was 0.98 (95% CI, 0.99-0.96), while postoperatively was 0.95 (95% CI, 0.99-0.95). Mean AA reduction was 5.23 ± 2.81, with an intra-rater reliability 0.15 (95% CI, 0.03-0.34) and inter-rater reliability 0.65 (95% CI, 0.84-0.38). CONCLUSION: Using current statistical measures and analysis, AA is an acceptable tool for pre- and postoperative facial evaluation when assessed by a group of 10 reviewers. Therefore, apparent age represents a reliable and valid objective observer assigned measure for evaluation of facelift outcomes.

Quantity of Lymph Nodes in the Vascularized Lymph Node Transfer Influences Its Lymphaticovenous Drainage.

BACKGROUND: The purpose of this study was to: (1) evaluate the mechanism of lymph drainage through a vascularized lymph node (VLN) flap, and (2) investigate if the number of VLNs impacts lymph transit time through the flap. METHODS: Twenty-seven axillary VLN flaps were elevated in 14 Sprague-Dawley rats and divided into three groups (n = 9 each) based on the number of lymph nodes present: group 1 (0-VLNs), group 2 (2-VLNs), and group 3 (4-VLNs). Indocyanine green (n = 8/group) and Alexa680-albumin (n = 1/group) were injected into the edge of flaps and the latency period between injection and fluorescence in the axillary vein was recorded. Stereomicroscopic fluorescent lymphography was performed to directly visualize lymphatic transit through VLNs. RESULTS: Fluorescence was detected in the axillary vein after 229s [47-476], 79s [15-289], and 56s [16-110] in group 1, 2, and 3, respectively (p < 0.01). There was a negative correlation between the number of VLNs in the flap and the latency period (r = -0.59; p < 0.05). Median flap weights were comparable in group 1, 2, and 3 (258 mg [196-349], 294 mg [212-407], 315 mg [204-386], respectively; p = 0.54). Stereoscopic lymphography allowed direct visualization of lymphatic fluid transit through VLNs. CONCLUSION: Lymphatic fluid in VLN flaps drains into the venous system mainly by passing through the afferent lymphatics and lymph nodes. A secondary mechanism appears to be the diffusion of fluid into the venous system via intratissue lymphaticovenous connections created during flap elevation. Increasing the number of lymph nodes in the flap is associated with a more rapid transit of fluid.

Acellular dermal matrix reduces capsule formation in two-stage breast reconstruction.

Acellular dermal matrix (ADM) is commonly employed to create an inferior pocket for the tissue expander in two-stage breast reconstruction. The authors sought to determine whether placement of ADM during the first stage of reconstruction decreases the amount of capsule formation at implant exchange. Patients who underwent mastectomy and tissue expander reconstruction were included in this study. Two biopsies were obtained at the time of implant exchange, one from the pocket adjacent to the ADM and the other from the area adjacent to the pectoralis muscle. Pathology analysis was performed on each sample. Ten patients underwent immediate breast reconstruction with Alloderm during the 3-month study period. Capsule thickness was significantly greater in the areas where the expander was in direct contact with the pectoralis muscle (782 ± 194 µm) compared to those in contact with human acellular dermal matrix (hADM) (47·91 ± 110·82 µm; P < 0·05). Analysis of the sub-pectoral capsule demonstrated diffuse deposition of collagen, neutrophils, contractile myofibroblasts and synovia-like metaplasia, characteristic of a foreign body response. Conversely, within the inferior pocket where the hADM was in direct contact with the expander, we noted migration of host epithelial cells, fibroblasts, mesenchymal cells and angiogenesis, indicating host tissue regeneration. Acellular dermal matrix, when placed at the first stage of breast reconstruction, significantly reduces thickness and inflammatory character of the capsule in comparison to the patient's native tissue.

Metabolic Engineering of Microalgal Based Biofuel Production: Prospects and Challenges.

The current scenario in renewable energy is focused on development of alternate and sustainable energy sources, amongst which microalgae stands as one of the promising feedstock for biofuel production. It is well known that microalgae generate much larger amounts of biofuels in a shorter time than other sources based on plant seeds. However, the greatest challenge in a transition to algae-based biofuel production is the various other complications involved in microalgal cultivation, its harvesting, concentration, drying and lipid extraction. Several green microalgae accumulate lipids, especially triacylglycerols (TAGs), which are main precursors in the production of lipid. The various aspects on metabolic pathway analysis of an oleaginous microalgae i.e., Chlamydomonas reinhardtii have elucidated some novel metabolically important genes and this enhances the lipid production in this microalgae. Adding to it, various other aspects in metabolic engineering using OptFlux and effectual bioprocess design also gives an interactive snapshot of enhancing lipid production which ultimately improvises the oil yield. This article reviews the current status of microalgal based technologies for biofuel production, bioreactor process design, flux analysis and it also provides various strategies to increase lipids accumulation via metabolic engineering.

The Rise of Technology in Plastic Surgery Education: Is the Textbook Dead on Arrival (DOA)?

BACKGROUND: Over the past decade there has been a dramatic rise in the use of technology. Evaluating our use of technology is crucial to advancing the next generation of plastic surgeons. OBJECTIVES: The goals of this study were to assess the current use of technology by residents, help Program Directors allocate financial resources, and predict the future of technology and education. METHODS: A 17-question online survey was emailed to American Society for Aesthetic Plastic Surgery resident/fellow members (n = 447). The survey evaluated current use of technology, preferred use of educational resources, and directions for the future. Ample space was allocated for free response questions. RESULTS: The response rate was 40%. The average age of respondents was 32 years old (standard deviation 3.7). The majority (86.5%) of residents own iPhones, and 90% of residents own tablets. There was a heavy daily reliance on smartphone technology. Sixty percent of residents used physical textbooks on a weekly basis. The Plastic Surgery Education Network was used on a weekly basis by 42% of residents. In contrast, 78% of residents were not aware of, or had never used, the readily available digital aesthetic resource (RADAR) Resource iPad application. CONCLUSIONS: In order to remain at the forefront of education, we as a specialty need to adapt with technology. Program Directors should support integrating technology with electronic access to educational materials. There exists an opportunity in resident education to increase awareness and utilization of the RADAR Resource. The future of plastic surgery education will be reliant on platforms like the iPhone and iPad to conveniently provide large volumes of information with only a finger touch.

The 'French Fry' VAC technique: hybridisation of traditional open wound NPWT with closed incision NPWT.

Surgical site occurrences (SSO), specifically surgical site infections represent a significant burden in the US health care system. It has been hypothesised that postoperative dressing can help drive down SSO. We describe the successful use of a novel technique combining both closed incision and open negative pressure wound therapy in the management of a high-risk wound associated with lymphoedema of obesity.