Associations of COVID-19-related fear with kidney disease quality of life and its subscales among hemodialysis patients as modified by health literacy: a multi-hospital survey.

Background: Receiving hemodialysis treatment makes end-stage renal disease (ESRD) patients highly vulnerable amidst the COVID-19 pandemic. Hence, their kidney disease quality of life (KDQOL) is affected. We aimed to examine the association between fear of COVID-19 (FCoV-19) and KDQOL, and the effect modification of Health literacy (HL) on this association. Material and Methods: A survey was conducted at 8 hospitals from July 2020 to March 2021 on 972 patients. Data collection includes socio-demographic factors, clinical parameters, HL, digital healthy diet literacy (DDL), hemodialysis diet knowledge (HDK), FCoV-19, suspected COVID-19 symptoms (S-COVID-19-S), and KDQOL. Results: Higher HL scores B = 0.13 (95% CI = 0.06-0.21, p = 0.001) and HDK scores B = 0.58 (95% CI = 0.31-0.85, p = 0.001) were associated with higher KDQOL scores. Whereas, S-COVID-19-S B = -6.12 (95% CI = -7.66 to - 4.58, p = 0.001) and FCoV-19 B = -0.91 (95% CI = -1.03 to - 0.80, p = 0.001) were associated with lower KDQOL scores. Notably, higher HL scores significantly attenuate the negative impact of FCoV-19 on overall KDQOL and the kidney disease component summary. Conclusions: In hemodialysis patients, FCoV-19 and S-COVID-19-S were associated with a lower KDQOL. Health literacy significantly mitigates the negative impact of FCoV-19 on KDQOL. Strategic public health interventions to improve HL are suggested to protect patient's KDQOL during the pandemic.

The Postoperative Breast: Imaging Findings and Diagnostic Pitfalls After Breast-Conserving Surgery and Oncoplastic Breast Surgery.

Breast surgery is the cornerstone of treatment for early breast cancer. Historically, mastectomy and conventional breast-conserving surgery (BCS) were the main surgical techniques for treatment. Now, oncoplastic breast surgery (OBS), introduced in the 1990s, allows for a combination of BCS and reconstructive surgery to excise the cancer while preserving or enhancing the contour of the breast, leading to improved aesthetic results. Although imaging after conventional lumpectomy demonstrates typical postsurgical changes with known evolution patterns over time, OBS procedures show postsurgical changes/fat necrosis in locations other than the lumpectomy site. The purpose of this article is to familiarize radiologists with various types of surgical techniques for removal of breast cancer and to distinguish benign postoperative imaging findings from suspicious findings that warrant further work-up.

Current Research on the Use of the Omental Flap in Breast Reconstruction and Post-Mastectomy Lymphedema: A Focus on Omental-Vascularized Lymph Node Transfer.

The novel use of the omental flap in breast reconstruction has been increasing in research popularity within the last few decades. This technique has its roots in the early 20th century as surgeons explored the use of the omentum for a variety of reconstructive purposes across various surgical subspecialties. The current literature shows evidence of the benefits of using the omentum in autologous breast reconstruction compared to the more traditional abdominal, flank, thigh, and gluteal donor flap reconstruction. This method introduces a viable option for patients that do not meet the criteria for the traditional autologous reconstruction techniques allowing for the restoration of more natural appearing breasts without the added complication of donor-site mortality. Additionally, the omentum, with its rich source of vascularized lymph nodes, has been studied as a potential source for lymph node transfer in the treatment of mastectomy-associated lymphedema. In this review, we highlight the most recent research on the current practices of omental-based breast reconstruction techniques and their use in postmastectomy lymphedema. We discuss the history and natural progression of the development of omental-based reconstruction as an autologous breast reconstruction technique, highlight the latest advances and challenges for the utility of the omental flap in current surgical procedures, and present future directions for the potential role of omental-based breast reconstruction in postmastectomy breast surgery.

Digital Healthy Diet Literacy and Fear of COVID-19 as Associated with Treatment Adherence and Its Subscales among Hemodialysis Patients: A Multi-Hospital Study.

Treatment adherence (TA) is a critical issue and is under-investigated in hemodialysis patients. A multi-center study was conducted from July 2020 to March 2021 on 972 hemodialysis patients in eight hospitals in Vietnam to explore the factors associated with TA during the COVID-19 pandemic. Data were collected, including socio-demographics, an End-Stage Renal Disease Adherence Questionnaire (ESRD-AQ), 12-item short-form health literacy questionnaire (HLS-SF12), 4-item digital healthy diet literacy scale (DDL), 10-item hemodialysis dietary knowledge scale (HDK), 7-item fear of COVID-19 scale (FCoV-19S), and suspected COVID-19 symptoms (S-COVID19-S). Bivariate and multivariate linear regression models were used to explore the associations. Higher DDL scores were associated with higher TA scores (regression coefficient, B, 1.35; 95% confidence interval, 95%CI, 0.59, 2.12; p = 0.001). Higher FCoV-19S scores were associated with lower TA scores (B, -1.78; 95%CI, -3.33, -0.24; p = 0.023). In addition, patients aged 60-85 (B, 24.85; 95%CI, 6.61, 43.11; p = 0.008) with "very or fairly easy" medication payment ability (B, 27.92; 95%CI, 5.89, 44.95; p = 0.013) had higher TA scores. Patients who underwent hemodialysis for ≥5 years had a lower TA score than those who received <5 years of hemodialysis (B, -52.87; 95%CI, -70.46, -35.28; p < 0.001). These findings suggested that DDL and FCoV-19S, among other factors, should be considered in future interventions to improve TA in hemodialysis patients.

A Novel Fat-Augmented Omentum-Based Construct for Unilateral and Bilateral Free-Flap Breast Reconstruction in Underweight and Normal Weight Women Receiving Nipple or Skin-Sparing Mastectomies.

BACKGROUND: Autologous tissue has proven advantages, however it is often not an option for women of low or normal body mass index (BMI). Omentum has been used sparingly, typically as a pedicled flap to correct breast deformities, but is considered suboptimal for full breast reconstruction. We developed a new construct, the omental fat-augmented free flap (O-FAFF) as an alternative for breast reconstruction. METHODS: O-FAFF involves laparoscopic omentum harvesting, creation of an acellular dermal matrix shell for its encasement, and lipoinjection to augment volume. The gastroepiploic vessels are microsurgically anastomosed to internal mammary vessels. Tissue and O-FAFF construct weights as well as outcomes are reported. RESULTS: Thirty-four consecutive women (50 breasts) received O-FAFF breast reconstruction after 18 unilateral and 16 bilateral mastectomies (10 non-nipple-sparing, 40 nipple-sparing). Thirty-seven were immediate and 13 were revisions of previous breast reconstructions. Patient mean age was 48.2 (range 23-73) years and mean BMI was 22.3 (range 17.6-32.4) kg/m2. Mean follow-up was 14.8 (range 3-33) months. The median weight of the omentum was 161.7 g (range 81-852, interquartile range [IQR] 102) and the mean ratio of fat to omentum weight was 0.73 (range 0.22-1.38) and 1.97 (range 0.24-3.8) for unilateral and bilateral cases, respectively. Postoperative pain scores and oral morphine equivalent consumption were more favorable for the O-FAFF group compared with controls (p < 0.001). Follow-up breast MRI demonstrated intact perfusion and no fat necrosis. CONCLUSIONS: The O-FAFF is ideally suited for women of lower BMI and could dramatically increase the number of women who are candidates for autologous breast reconstruction.

Osteoporosis Risk in Hemodialysis Patients: The Roles of Gender, Comorbidities, Biochemical Parameters, Health and Diet Literacy.

Osteoporosis is a common bone health disorder in hemodialysis patients that is linked with a higher morbidity and mortality rate. While previous studies have explored the associated factors of osteoporosis, there is a lack of studies investigating the impacts of health literacy (HL) and digital healthy diet literacy (DDL) on osteoporosis. Therefore, we aimed to investigate the associations of HL, DDL, and other factors with osteoporosis among hemodialysis patients. From July 2020 to March 2021, a cross-sectional study was conducted on 675 hemodialysis patients in eight hospitals in Vietnam. The data were collected by using the osteoporosis self-assessment tool for Asians (OSTA) and the 12-item short form of the health literacy questionnaire (HLS-SF12) on digital healthy diet literacy (DDL) and hemodialysis dietary knowledge (HDK). In addition, we also collected information about the socio-demographics, the clinical parameters, the biochemical parameters, and physical activity. Unadjusted and adjusted multinomial logistic regression models were utilized in order to investigate the associations. The proportion of patients at low, medium, and high levels of osteoporosis risk was 39.6%, 40.6%, and 19.8%, respectively. In the adjusted models, women had a higher likelihood of osteoporosis risk than men (odds ratio, OR, 3.46; 95% confidence interval, 95% CI, 1.86, 6.44; p < 0.001; and OR, 6.86; 95% CI, 2.96, 15.88; p < 0.001). The patients with rheumatoid arthritis (OR, 4.37; 95% CI, 1.67, 11.52; p = 0.003) and stomach ulcers (OR, 1.95; 95% CI, 1.01, 3.77; p = 0.048) were more likely to have a higher likelihood of osteoporosis risk than those without. The patients who had a higher waist circumference (WC), HL, and DDL were less likely to have a medium level of osteoporosis risk (OR, 0.95; 95% CI, 0.92, 0.98; p = 0.004; OR, 0.92; 95% CI, 0.88, 0.96; p < 0.001; OR, 0.96; 95% CI, 0.93, 0.99; p = 0.017, respectively) and a high level of osteoporosis risk (OR, 0.93; 95% CI, 0.89, 0.97; p = 0.001; OR, 0.89; 95% CI, 0.84, 0.94; p < 0.001; OR, 0.95; 95% CI, 0.91, 0.99; p = 0.008, respectively) compared with a low level of osteoporosis risk and to those with a lower WC, HL, and DDL. In addition, higher levels of hemoglobin (Hb) (OR, 0.79; 95% CI, 0.66, 0.95; p = 0.014), hematocrit (Hct) (OR, 0.95; 95% CI, 0.92, 0.99; p = 0.041), albumin (OR, 0.91; 95% CI, 0.83, 0.99; p = 0.030), and education (OR, 0.37; 95% CI, 0.16, 0.88; p = 0.025) were associated with a lower likelihood of a high level of osteoporosis risk. In conclusion, osteoporosis risk is highly prevalent in hemodialysis patients. Improved HL, DDL, education, WC, albumin, Hb, and Hct levels should be considered in preventing hemodialysis patients from developing osteoporosis.

The Associations of Suspected COVID-19 Symptoms with Anxiety and Depression as Modified by Hemodialysis Dietary Knowledge: A Multi-Dialysis Center Study.

During the COVID-19 pandemic, it is essential to evaluate hemodialysis patients' dietary knowledge, especially among those with COVID-19 related symptoms, in order to identify appropriate strategies in managing their mental health. The study's purposes were to test the psychometric properties of the hemodialysis dietary knowledge (HDK) scale, and to investigate the modifying impact of HDK on the associations of suspected COVID-19 symptoms (S-COVID-19-S) with anxiety and depression among hemodialysis patients. A cross-sectional study was conducted from July 2020 to March 2021 at eight hospitals across Vietnam. Data of 875 hemodialysis patients were analyzed, including socio-demographic, anxiety (the generalized anxiety disorder scale, GAD-7), depression (the patient health questionnaire, PHQ-9), S-COVID-19-S, HDK, health literacy, and digital healthy diet literacy. Confirmatory factor analysis (CFA) and logistic regression models were used to analyze the data. The HDK scale demonstrates the satisfactory construct validity with good model fit (Goodness of Fit Index, GFI = 0.96; Adjusted Goodness of Fit Index, AGFI = 0.90; Standardized Root Mean Square Residual, SRMR = 0.05; Root Mean Square Error of Approximation, RMSEA = 0.09; Normed Fit Index, NFI = 0.96; Comparative Fit Index, CFI = 0.96, and Parsimony goodness of Fit Index, PGFI = 0.43), criterion validity (as correlated with HL (r = 0.22, p < 0.01) and DDL (r = 0.19, p < 0.01), and reliability (Cronbach alpha = 0.70)). In the multivariate analysis, S-COVID-19-S was associated with a higher likelihood of anxiety (odds ratio, OR, 20.76; 95% confidence interval, 95%CI, 8.85, 48.70; p < 0.001) and depression (OR, 12.95; 95%CI, 6.67, 25.14, p < 0.001). A higher HDK score was associated with a lower likelihood of anxiety (OR, 0.70; 95%CI, 0.64, 0.77; p < 0.001) and depression (OR, 0.72; 95%CI, 0.66, 0.79; p < 0.001). In the interaction analysis, the negative impacts of S-COVID-19-S on anxiety and depression were mitigated by higher HDK scores (p < 0.001). In conclusion, HDK is a valid and reliable tool to measure dietary knowledge in hemodialysis patients. Higher HDK scores potentially protect patients with S-COVID-19-S from anxiety and depression during the pandemic.

Fat Grafts Augmented With Vitamin E Improve Volume Retention and Radiation-Induced Fibrosis.

BACKGROUND: Treatments for radiation-induced fibrosis range from vitamin E (VE) and pentoxifylline (PTX) systemically to deferoxamine and fat grafting locally. Regarding fat grafting, volume retention hinders its long-term functionality and is affected by 2 factors: inflammation and necrosis secondary to hypovascularity. OBJECTIVE: The authors aimed to simultaneously improve fat graft retention and radiation-induced fibrosis by integrating VE and PTX into fat grafts locally. METHODS: Forty adult CD-1 nude male mice, 6 weeks old, underwent scalp irradiation and recovered for 4 weeks to allow for development of fibrosis. Mice received 200 µL of donor human fat graft to the scalp. Mice were separated into 4 conditions: no grafting, fat graft without treatment, graft treated with PTX, and graft treated with VE. Fat graft volume retention was monitored in vivo with micro-computed tomography scans at weeks 0, 1, 2, 4, 6, and 8 after grafting. Histological and cytokine analysis of the scalp skin and fat grafts were performed. RESULTS: VE-treated grafts had significant improvement in dermal thickness and collagen density of overlying skin compared with all other groups. VE decreased 8-isoprostane and increased CD31+ staining compared with the other grafted groups. Cytokine analysis revealed decreased inflammatory and increased angiogenic markers in both the fat graft and overlying skin of the VE group. Fat graft volume retention was significantly improved in the VE group starting at 1 week post grafting. CONCLUSIONS: Radiation-induced fibrosis and fat graft volume retention are both simultaneously improved with local administration of VE.

Creating a Biological Breast Implant with an Omental Fat-Augmented Free Flap.

SUMMARY: Women with inadequate myocutaneous or fasciocutaneous soft-tissue donor sites for breast reconstruction after mastectomy are mostly limited to implants. Alternative substitutes are needed for those who do not want-or in whom there are contraindications for-implant-based reconstruction. The authors report a novel technique using an omental fat-augmented free flap to create an autologous breast mound that has comparable shape and projection to a breast implant. Three patients with breast cancer who desired unilateral reconstruction were identified in the period 2019 to 2020. All had insufficient traditional autologous sites and were averse to the use of implants. A nipple-sparing mastectomy was performed, and the omentum was laparoscopically harvested and fat-grafted ex vivo and then encased in acellular dermal matrix for microvascular anastomoses. The body mass indexes of the three patients were 17.6, 25, and 28.3 kg/m2. Each individual's mastectomy specimens and corresponding omentum plus fat-grafting weights were 113.7/228, 271/293, and 270/360 g. No postoperative complications occurred. The reconstructed breast remains soft, with stable breast volume at 6 months and without evidence of fat necrosis. This novel use of fat grafting into an omental flap enveloped in acellular dermal matrix, the omental fat-augmented free flap, provides a viable and successful autologous alternative for patients who are not candidates for traditional autologous breast reconstruction options because of body habitus or personal preference.

Nanofibrillar Collagen Scaffold Enhances Edema Reduction and Formation of New Lymphatic Collectors after Lymphedema Surgery.

BACKGROUND: Treatment of secondary lymphedema remains challenging, with suboptimal rates of edema reduction following physiologic procedures (i.e., lymphaticovenous anastomosis and vascularized lymph node transfer). The objective of this study was to investigate the long-term effect of a nanofibrillar collagen scaffold on edema reduction in lymphedema patients treated with lymphaticovenous anastomosis or vascularized lymph node transfer. METHODS: A retrospective cohort study was performed, comparing stage 1 to 3 lymphedema patients who underwent lymphaticovenous anastomosis and/or vascularized lymph node transfer with or without delayed implantation of nanofibrillar collagen scaffold (BioBridge) from 2016 to 2019. The primary endpoint was excess volume reduction. Indocyanine green lymphatic mapping was performed to evaluate superficial lymphatic flow. RESULTS: Edema reduction was significantly greater for the BioBridge cohort (12-month follow-up, n = 18) compared to controls (18.2-month follow-up, n = 11) (111.5 ± 34.5 percent versus 70.0 ± 19.0 percent; p = 0.0004). This held true in lymphaticovenous anastomosis and vascularized lymph node transfer subgroup analysis. The average rate of edema reduction increased by 3.5-fold in lymphaticovenous anastomosis and 7.6-fold in vascularized lymph node transfer following BioBridge placement. Eighty-eight percent of patients with concurrent liposuction and BioBridge implantation maintained normal volumes at 13 months postoperatively. Lymphatic mapping following BioBridge placement showed significantly more new lymphatic collectors and decreased dermal backflow. The majority of patients (77.8 percent) achieved and maintained normal limb volume at an average total follow-up of 29 months. CONCLUSION: Nanofibrillar collagen scaffold implantation enhances overall effectiveness of physiologic procedures, even in the presence of liposuction, and is a promising adjunct therapy for treatment of lymphedema. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Preoperative ß-lactam antibiotic prophylaxis is superior to bacteriostatic alternatives in immediate expander-based breast reconstruction.

BACKGROUND: Staged implant-based breast reconstruction is the most common reconstructive modality following mastectomy. Postoperative implant infections can have a significant impact on adjuvant oncologic care and reconstructive outcome. Here, we investigate the impact of ß-lactam antibiotics (i.e., bactericidal) compared to alternative antibiotic agents on postoperative outcomes for implant-based breast reconstruction. METHODS: A retrospective analysis of patients who underwent immediate sub-pectoral tissue expander placement with an inferior acellular dermal matrix (ADM) sling at a single institution between May 2008 and July 2018 was performed. Patient demographics, comorbidities, and complication rates were retrieved. The impact of antibiotic regimen on postoperative outcomes, including infection rate and reconstructive failure, was investigated. RESULTS: A total of 320 patients with a mean age and BMI of 48.2 years and 25.0 kg/m2 , respectively, who underwent 542 immediate breast reconstructions were included in the study. The use of a ß-lactam antibiotic was protective against postoperative infection (odds ratio [OR] = 0.467, p = .046), infection requiring operative management (OR = 0.313, p = .022), and reconstructive failure (OR = 0.365, p = .028). Extended, that is, post-discharge, prophylaxis was not associated with any clinical benefit. CONCLUSION: The use of ß-lactam antibiotics for pre-/peri-operative prophylaxis is superior to alternative antibiotics with a bacteriostatic mechanism of action regarding rates of postoperative infection and reconstructive failure following immediate tissue expander-based breast reconstruction. Extended, that is, post-discharge, prophylaxis does not appear to be indicated, regardless of the antibiotic chosen.

Combined Liposuction and Physiologic Treatment Achieves Durable Limb Volume Normalization in Class II-III Lymphedema: A Treatment Algorithm to Optimize Outcomes.

INTRODUCTION: Outcomes of surgical lymphedema treatment are currently suboptimal. Physiologic procedures including lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) reestablish lymphatic flow but cannot correct fibroadipose deposition, whereas liposuction alone cannot prevent disease progression. We propose a treatment algorithm combining liposuction with LVA or VLNT that can achieve normal limb volumes and prevent disease progression in stage II-III lymphedema. METHODS: We performed a retrospective chart review of patients undergoing liposuction and physiologic lymphedema operations at our institution between January 2016 and June 2019. Patients were assigned to treatment groups according to their clinical presentation: physiologic first, followed by no further treatment (physiologic only) or liposuction (physiologic then liposuction); liposuction then physiologic; or simultaneous. Preoperative patient characteristics and sequence of operations were recorded. Compression garment usage was self-reported. Limb volumes were approximated as a truncated cone. RESULTS: Twenty-one patients met the inclusion criteria. The liposuction then physiologic group had significantly higher stage and excess limb volume at baseline, whereas the physiologic first groups had lower excess volume. While the physiologic only group had predominantly stage I disease, the patients who later required liposuction (physiologic then liposuction group) all had stage II disease. All groups achieved 82% to 106% mean excess volume reduction, and volume reduction was maintained for up to 2.4 years. Compression garment class was not reduced, but mean postoperative compression duration decreased from 12.5 to 7.5 h/d (P = 0.003). Ten of 11 patients with history of cellulitis had no further recurrence. CONCLUSION: Lymphedema represents a continuum of fluid and fibroadipose disease. Accurate staging and timely treatment with physiologic procedures and liposuction can normalize limb volume. We propose a treatment algorithm to optimize outcomes. Patients with predominantly nonpitting presentation benefit from liposuction to maximize removal of fibroadipose tissue and optimize postoperative compression, followed by LVA or VLNT to improve lymphatic drainage. Patients with primarily pitting edema are best treated with physiologic procedures initially, reserving selective liposuction as a second stage. Patients with mixed presentation are best served by single-stage combination procedures.

Cobalt-catalyzed, directed arylation of C-H bonds in N-aryl pyrazoles.

We report a method for directed ortho-arylation of N-aryl pyrazoles with arylboronic acids. Reactions proceeded in the presence of a Co(hfacac)2 catalyst, CeSO4 oxidant, and HFIP solvent. Functionalities such as nitro, ester, bromo, and ketone groups were compatible with the reaction conditions. Using heterocycles including thiophene and carbazole was also feasible.

Correction: Cobalt-catalyzed, directed arylation of C-H bonds in N-aryl pyrazoles.

[This corrects the article DOI: 10.1039/D1RA00975C.].

Diagnostic and Therapeutic Use of Botox for Breast Reconstruction.

INTRODUCTION: Breast reconstruction is most commonly performed using implant-based reconstruction. Patients with subpectoral implant placement with or without latissimus dorsi (LD) muscle coverage can experience muscle pain and animation deformity. Due to minimal literature describing the use of botulinum toxin (BTX-A) treatment for these side effects from implant-based reconstruction, we report our outcomes. METHODS: A retrospective chart review of breast reconstructive patients for a single surgeon was performed. Patients who underwent BTX-A injection for muscular pain, spasm, or animation deformity were identified and outcomes reviewed. They were also stratified based on radiation treatment and type of muscle flap used. RESULTS: Eleven patients were identified who had a submuscular pectoralis pocket and/or a pedicled latissimus dorsi flap. Nineteen breasts were treated. The average amount of time from the patient's last surgery to BTX-A injection was 11.2 months. 25-100 units were used per injection with an average of 60 units. Non-irradiated patients had signifycantly lower post-injection capsular contracture Baker grades and significantly lower amounts of BTX-A were injected. Patients who had both pectoralis major muscle and LD implant-reconstruction were significantly less likely to have improvement in pain/tightness. Most patients reported improvement or resolution of their pain and/or animation deformities. CONCLUSION: Implant-based reconstruction using the pectoralis major and/or LD muscles can be plagued with muscular pain, spasm, and animation deformities. The use of BTX-A is a diagnostic and therapeutic modality for these post-breast reconstruction patients with most patients having resolution of symptoms without the need for additional surgery.