Aging and sympathetic transduction to blood pressure in humans: methodological and physiological considerations.

Recent reports suggest that quantification of signal-averaged sympathetic transduction is influenced by resting muscle sympathetic nerve activity (MSNA) and burst occurrence relative to the average mean arterial pressure (MAP). Herein, we asked how these findings may influence age-related reductions in sympathetic transduction. Beat-to-beat blood pressure and MSNA were recorded during 5 min of rest in 27 younger (13 females: age, 25 ± 5 yr; BMI, 25 ± 4 kg/m2) and 26 older (15 females: age, 59 ± 5 yr; BMI, 26 ± 4 kg/m2) healthy adults. All MSNA bursts were signal averaged together. Beat-to-beat MAP values were then split into low (T1), middle (T2), and high (T3) tertiles, and signal-averaged transduction was calculated within each tertile. Resting MSNA was higher in older adults and MAP was similar between groups. Older adults exhibited blunted overall MAP transduction (younger, Δ1.5 ± 0.6 vs. older, Δ0.9 ± 0.7 mmHg; P = 0.005), which was irrespective of relation to prevailing MAP. A greater proportion of bursts occurred above the average MAP in older adults (P < 0.001), and a larger proportion of these bursts were associated with depressor responses (P = 0.005). Nonetheless, assessment of bursts above the average MAP associated with pressor responses revealed similar age-associated reductions in transduction (younger, Δ2.6 ± 1.6 vs. older, Δ1.7 ± 0.8 mmHg; P = 0.016). These findings indicate an age-related increase in burst occurrence above the average resting MAP, which alone does not explain blunted transduction, thereby supporting the physiological underpinnings of age-related decrements in sympathetic transduction to blood pressure.NEW & NOTEWORTHY The current study demonstrated that aging is associated with a greater prevalence of sympathetic bursts occurring above the average blood pressure, which offers both methodologically and physiologically relevant information regarding aging and sympathetic control of blood pressure. These data support age-related reductions in sympathetic transduction via a reduced pressor response to sympathetic bursts irrespective of the prevailing absolute blood pressure value, along with increases in sympathetic outflow necessary to maintain blood pressure.

Core body temperature changes before sleep are associated with nocturnal heart rate variability.

Core body temperature (CBT) reductions occur before and during the sleep period, with the extent of presleep reductions corresponding to sleep onset and quality. Presleep reductions in CBT coincide with increased cardiac parasympathetic activity measured via heart rate variability (HRV), and while this appears to persist into the sleep period, individual differences in presleep CBT decline and nocturnal HRV remain unexplored. The purpose of the current study was to assess the relationship between individual differences in presleep CBT reductions and nocturnal heart rate (HR) and HRV in a population of 15 objectively poor sleeping adults [10 males, 5 females; age, 33 ± 4 yr; body mass index (BMI) 27 ± 1 kg/m2] with the hypothesis that blunted CBT rate of decline would be associated with elevated HR and reduced nocturnal HRV. Following an adaptation night, all participants underwent an overnight, in-laboratory sleep study with simultaneous recording of polysomnographic sleep including electrocardiography (ECG) and CBT recording. Correlations between CBT rate of change before sleep and nocturnal HRV were assessed. Blunted rate of CBT decline was significantly associated with increased heart rate (HR) in stage 2 (N2; R = 0.754, P = 0.001), stage 3 (N3; R = 0.748, P = 0.001), and rapid-eye movement (REM; R = 0.735, P = 0.002). Similarly, blunted rate of CBT decline before sleep was associated with reduced HRV across sleep stages. These findings indicate a relationship between individual differences in presleep thermoregulatory processes and nocturnal cardiac autonomic function in poor sleeping adults.NEW & NOTEWORTHY Core body temperature (CBT) reductions before sleep onset coincide with increases in heart rate variability (HRV) that persist throughout the sleep period. However, the relationship between individual differences in the efficiency of presleep core temperature regulation and nocturnal heart rate variability remains equivocal. The present study reports an association between the magnitude of presleep core body temperature changes and nocturnal parasympathetic activity, highlighting overlap between thermoregulatory processes before sleep and nocturnal cardiac autonomic function.

Trial of a patient-directed eHealth program to ameliorate perinatal depression: the MomMoodBooster2 practical effectiveness study.

BACKGROUND: Depression is one of the most common complications of childbirth, and is experienced by approximately 17% of pregnant women and 13% of postpartum women. An estimated 85% of these women go untreated-an alarming statistic given the serious consequences for the mother, her child, other family members, and society. Professional societies (the American College of Obstetricians and Gynecologists and American Academy of Pediatrics) have recommended improvements in screening and treatment. Meta-analyses indicate that cognitive behavioral therapy eHealth interventions are efficacious for depression, generally, and for perinatal depression, specifically. Earlier controlled trials have established the effectiveness and acceptability of MomMoodBooster (including an Australian version, MumMoodBooster), an eHealth program for ameliorating postpartum depression. OBJECTIVE: This study aimed to evaluate the effectiveness of a perinatal version of MomMoodBooster encompassing both prenatal and postpartum content in a healthcare delivery setting already providing universal screening and referral of at-risk patients as part of routine care. STUDY DESIGN: A practical effectiveness study randomly assigned 95 pregnant and 96 postpartum women screened as depressed and satisfying eligibility criteria to experimental groups: the healthcare organization's perinatal depression care program (routine-care group) and routine care+MomMoodBooster2 program (eHealth group). Eligibility criteria included: pregnant or <1 year postpartum, ≥18 years of age, no active suicidal ideation, access to broadband internet via desktop/laptop, tablet, or smartphone, and English language proficiency. RESULTS: Intent-to-treat analyses of group effects used fixed-effects growth models to assess 12-week posttest change in outcomes. Results showed that both groups had significantly decreased depression severity, anxiety, stress, and automatic thoughts, and increased behavioral activation and self-efficacy. Relative to the routine-care group, the eHealth group displayed significantly greater decreases in depression severity and stress. These group comparisons were not moderated by depression severity (screening or baseline), anxiety, stress, or pregnant/postpartum status. Almost all (93%; n=89) women in the eHealth group visited their program, of whom 99% visited program sessions (M sessions visited=4.3±2.0; M total session duration=73.0±70.2 minutes; 49% viewed all 6 sessions). Among confirmed eHealth program users who provided ratings, 96% (79/82) rated their program as easy to use, 83% rated it helpful, and 93% (76/82) indicated that they would recommend it. CONCLUSION: Results support the effectiveness of using MomMoodBooster2 as a treatment option for perinatal women with depression, especially when combined with universal depression screening and referral. Consequently, the eHealth program shows promise as a tool to increase the reach of treatment delivery and to potentially reduce the number of untreated perinatal women with depression.

Modeling Female Social Aggression: Predictors from Multiple Developmental Contexts.

A diverse array of proposed antecedents of social aggression (SA) were examined in two studies. This work is informed by ecological systems theory and examined predictors from the micro- and mesosystems. In Study 1, women (n = 284). completed measures of aggression, digit ratio, emotional intelligence (EI), agreeableness, parenting styles, attachment insecurity with parents and peers, and television (TV) consumption. Aggression correlated with EI, agreeableness, parental authoritarianism, attachment insecurity with fathers and peers, and TV consumption; these variables accounted for 22% of the variance in SA. Father attachment insecurity moderated the TV-SA association, suggesting that positive experiences with parents can buffer negative effects of TV consumption. Study 2 aimed to increase the predictive power of the model. Females (n = 115) completed measures of aggression, digit ratio, EI, agreeableness, parental authoritarianism, interparental conflict, dominance goals, popularity goals, physical appearance comparison, and TV consumption. Aggression correlated with EI, agreeableness, interparental conflict, dominance goals, popularity goals, and appearance comparison. Together, these variables accounted for 40% of the variance in SA; agreeableness, dominance goals, and popularity goals were significant predictors. Interparental conflict moderated the TV-SA association, again suggesting that positive experiences with parents can cushion effects of TV consumption. Implications for development of SA are discussed.

Tissue Adhesive Compared With Sterile Strips After Cesarean Delivery: A Randomized Controlled Trial.

OBJECTIVE: To assess whether tissue adhesive after closure of Pfannenstiel incision for cesarean delivery lowers the risk of wound complications when compared with sterile strips. METHODS: In this multicenter randomized controlled trial, women undergoing cesarean delivery using Pfannenstiel skin incision were randomized to receive tissue adhesive (2-octyl cyanoacrylate) compared with sterile strips after closure of the skin incision. The primary outcome was a composite of wound complications (drainage, cellulitis, abscess, seroma, hematoma, or isolated wound separation) within 8 weeks of delivery. Secondary outcomes included operative time, readmission, office or emergency department visits, or antibiotic use for wound complications, and patient satisfaction with the cesarean scar. With 80% power and a 95% CI, a sample size of 432 per group (n=864) was required to detect a 50% reduction in the primary outcome. A planned interim analysis was performed after 500 patients delivered. A conditional power analysis revealed that the probability of showing a benefit with tissue adhesive was extremely low (6.2%), and the study was halted owing to futility. RESULTS: Between November 2016 and April 2018, 504 patients were randomized, and follow-up was achieved in 479 (95%). Wound complications occurred in 18 out of 238 patients (7.6%) in the tissue adhesive group and 19 out of 241 patients (7.9%) in the sterile strips group (relative risk 0.96; 95% CI 0.51-1.78). There were no significant differences with regard to types of wound complications, operative time, readmission, office or emergency department visits, antibiotics prescribed for wound complications, or patient scar assessment scores of pain, stiffness, and irregularity between the two groups. However, tissue adhesive performed slightly better in regard to itchiness of scar and overall scar satisfaction. CONCLUSION: Compared with sterile strips, tissue adhesive after closure of Pfannenstiel incision for cesarean delivery is unlikely to lower the risk of wound complications. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02838017.

Firearm ownership among American veterans: findings from the 2015 National Firearm Survey.

BACKGROUND: While the majority of veteran suicides involve firearms, no contemporary data describing firearm ownership among US veterans are available. This study uses survey data to describe the prevalence of firearm ownership among a nationally representative sample of veterans, as well as veterans' reasons for firearm ownership. METHODS: A cross-sectional, nationally representative web-based survey conducted in 2015. RESULTS: Nearly half of all veterans own one or more firearms (44.9%, 95% CI 41.3-48.6%), with male veterans more commonly owning firearms than do female veterans (47.2%, 95% CI 43.4-51.0% versus 24.4%, 95%CI 15.6-36.1%). Most veteran firearm owners own both handguns and long guns (56.5%, 95% CI 51.1-61.8%); a majority cite protection as a primary reason for firearm ownership (63.1%, 95% CI 58.2-67.8%). CONCLUSIONS: The current study is the first to provide detailed, nationally representative information about firearm ownership among U.S. veterans. Better understanding firearm ownership among veterans can usefully inform ongoing suicide prevention efforts aiming to facilitate lethal means safety among vulnerable veterans during at-risk periods.

Reconstruction of Congenital Mandibular Hypoplasia With Microvascular Free Fibula Flaps in the Pediatric Population: A Paradigm Shift.

BACKGROUND: The microvascular free fibula flap has become the gold standard for reconstruction of complex mandibular defects since its description by Hidalgo in 1989. Prior studies have demonstrated its safety and efficacy in the pediatric population. However, this reconstructive method is often used only as a last resort for correction of congenital mandibular hypoplasia, after failure of bone grafting and distraction osteogenesis. The authors describe our experience using this technique, facilitated by virtual planning and prefabricated cutting jigs, for children with severe congenital mandibular hypoplasia. METHODS: All patients with mandibular reconstruction with a fibula flap in children with congenital mandibular hypoplasia between 2009 and 2014 by the senior authors were identified. Each patient underwent preoperative computed tomography scanning and virtual surgical planning to create custom cutting jigs for creation of the mandibular defect and fibular osteotomies. Preoperative, intraoperative, and postoperative medical records were examined in detail. RESULTS: Five patients age 10 to 18 with congenital mandibular hypoplasia and Pruzansky Grade III mandibles underwent microvascular free fibula flap for mandibular reconstruction during this period. Flap success rate was 100%. All patients underwent subsequent revision procedures to improve symmetry or for hardware removal. The 4 patients in our series who required dental implants were able to have them placed into their mandibular reconstruction. CONCLUSIONS: Preoperative virtual planning and prefabricated cutting jigs allow for precise complex fibula reconstruction of the mandible in the pediatric population. Additionally, virtual planning facilitates concomitant orthognathic procedures in patients with hemifacial microsomia. Our early success in this patient population leads us to suggest that while the free fibula can be safely and successfully used after multiple prior surgical interventions in the same anatomic region, it can also be a powerful tool for primary correction of congenital mandibular hypoplasia.

Roll, Spin, Wash, or Filter? Processing of Lipoaspirate for Autologous Fat Grafting: An Updated, Evidence-Based Review of the Literature.

BACKGROUND: The use of autologous adipose tissue harvested through liposuction techniques for soft-tissue augmentation has become commonplace among cosmetic and reconstructive surgeons alike. Despite its longstanding use in the plastic surgery community, substantial controversy remains regarding the optimal method of processing harvested lipoaspirate before grafting. This evidence-based review builds on prior examinations of the literature to evaluate both established and novel methods for lipoaspirate processing. METHODS: A comprehensive, systematic review of the literature was conducted using Ovid MEDLINE in January of 2015 to identify all relevant publications subsequent to the most recent review on this topic. Randomized controlled trials, clinical trials, and comparative studies comparing at least two of the following techniques were included: decanting, cotton gauze (Telfa) rolling, centrifugation, washing, filtration, and stromal vascular fraction isolation. RESULTS: Nine articles comparing various methods of processing human fat for autologous grafting were selected based on inclusion and exclusion criteria. Five compared established processing techniques (i.e., decanting, cotton gauze rolling, centrifugation, and washing) and four publications evaluated newer proprietary technologies, including washing, filtration, and/or methods to isolate stromal vascular fraction. CONCLUSIONS: The authors failed to find compelling evidence to advocate a single technique as the superior method for processing lipoaspirate in preparation for autologous fat grafting. A paucity of high-quality data continues to limit the clinician's ability to determine the optimal method for purifying harvested adipose tissue. Novel automated technologies hold promise, particularly for large-volume fat grafting; however, extensive additional research is required to understand their true utility and efficiency in clinical settings.

Neurovascular compromise due to true brachial artery aneurysm at the site of a previously ligated arteriovenous fistula: Case report and review of literature.

True arterial aneurysms of the upper extremity are rare. The case described is that of a 48-year-old man presenting with median neuropathy and distal vascular compromise 4 years after ligation of a brachiocephalic arteriovenous fistula. We describe our approach and present a review of the relevant literature.

Do Prior Abdominal Surgeries Increase Complications in Abdominally Based Breast Reconstructions?

BACKGROUND: A large proportion of patients presenting for autologous breast reconstruction have a history of prior abdominal surgeries such as obstetric, gynecologic, or general surgical procedures. The impact of prior abdominal wall violation on the ability to perform free tissue transfer from the abdomen needs to be explored and characterized. The purpose of this study was to assess the impact of prior abdominal surgery on perfusion-related complications and donor-site morbidity in free tissue abdominal transfer. METHODS: All patients who underwent abdominally based free tissue transfer for breast reconstruction from 2005 to 2011 at the Hospital of the University of Pennsylvania were included. In addition to collecting data on standard patient past medical histories, comorbidities, and case characteristics, we also noted specific types of prior abdominal surgeries, number of prior surgeries, and if the rectus sheath was violated. Outcomes assessed included thrombotic complications, flap loss, major surgical complications, minor surgical complications, delayed wound healing, and subsequent hernia formation. RESULTS: Eight hundred twelve patients underwent 1257 free flap breast reconstructions during the study period. Four hundred seventeen (51.4%) women had undergone prior abdominal surgery. The most common prior abdominal surgeries included total abdominal hysterectomy and/or bilateral salpingo-oophorectomy (35.7%), cesarean delivery (33.8%), and appendectomy (12.7%). No significant differences were noted in the number of major intraoperative complications (P = 0.68), total thrombotic events (P = 0.339), or flap losses (P = 0.53). Patients who had undergone prior rectus sheath violation were found to experience a greater amount of delayed healing of the donor site (22.7% vs 16.5%, P = 0.03). Additionally, a higher rate of postoperative hernia formation was noted in patients who had undergone prior hernia repairs (13.6% vs 3.3%, P = 0.04). CONCLUSIONS: A significant portion of patients presenting for breast reconstruction have had prior abdominal surgeries. This study demonstrates that these prior procedures represent an acceptable level of risk; although this issue should still be addressed during preoperative patient counseling. In patients with prior hernia repairs, however, additional care should be given to the fascial closure as these patients may be at higher risk for subsequent hernia formation after abdominally based breast reconstruction.

Free flap lower extremity reconstruction in the obese population: does weight matter?

The obesity epidemic continues to grow, and we have observed greater numbers of obese individuals among patients seeking lower extremity reconstruction at our institution. These patients may present a greater reconstructive challenge, thus we sought to identify risk factors and differences in outcomes among patients undergoing lower extremity reconstruction.In this study we have performed a retrospective cohort analysis of patients undergoing lower extremity reconstruction with free tissue transfer at our institution from 2005 to 2012. Patients were classified using the World Health Organization criteria for obesity. Records were reviewed for patient characteristics, mechanism of injury, indications for reconstruction, and surgical technique, with a focus on intraoperative and early postoperative complications and outcomes.A total of 43 out of the 119 patients undergoing lower extremity reconstruction were obese (body mass index ≥ 30). Mechanism of injury, wound location, and the indications for reconstruction were similar in both cohorts. No significant differences were found in operative characteristics and techniques, including the type of flap utilized, operative time, or thrombotic events. No significant differences were seen in complication rates overall, however, obese patients more frequently needed second flaps (11.6 vs. 0%, p=0.005).This study concludes that successful lower extremity reconstruction can be performed in the obese population, with few differences in complication rates and outcomes relative to healthy weight patients.

Free tissue transfer for complex reconstruction of the lower extremity: experience of a young microsurgeon.

To examine the limb salvage experience of a young microsurgeon to determine risk factors for complications and demonstrate lessons learned through cases in practice. We performed a retrospective review of lower extremity (LE) reconstruction between 2007 and 2012 performed by the senior author. This analysis focused on medical comorbidities, mechanisms, indications, and perioperative complications. A total of 61 free tissue transfers were performed with a 95% LE salvage rate. The most common donor site was the anterolateral thigh (ALT) (n = 39). Infection (n = 25) and trauma (n = 25) were the most common indications for intervention. A total of 18 complications were reported, with 8 defined as major complications. Total flap loss occurred in three patients. Through increased utilization of the ALT and adherence to lessons learned over time, improvements in outcomes can occur, giving patients the best possible chance at limb salvage.

Abdominal wall reconstruction in the obese: an assessment of complications from the National Surgical Quality Improvement Program datasets.

BACKGROUND: This study utilizes the American College of Surgeons National Surgical Quality Improvement Program database to better understand the impact of obesity on perioperative surgical morbidity in abdominal wall reconstruction (AWR). METHODS: We reviewed the 2005 to 2010 American College of Surgeons National Surgical Quality Improvement Program databases, identifying cases of AWR and examining early complications in the context of obesity (body mass index > 30, World Health Organization classes 1 to 3). RESULTS: Of 1,695 patients undergoing AWR, 1,078 (63.2%) patients were obese (mean body mass index = 37.6 kg/m(2)). Major surgical complications (15.3% vs 10.1%, P = .003), wound complications (12.5% vs 8.1%, P = .006), medical complications (16.2% vs 11.2%, P = .005) and return to the operating room (9.1% vs 5.4%, P = .006) were significantly increased, while renal complications (1.9% vs .8%, P = .09) neared significance. On logistic regression, obesity only directly led to a significantly increased odds of having a renal complication (odds ratio = 4.4, P = .04). Complications were still noted to increase with World Health Organization classification, including a concerning incidence of venous thromboembolism. CONCLUSIONS: Although the incidence of complications increased with obesity, obesity itself does not appear to increase the odds of perioperative morbidity. Specific care should be given to VTE prophylaxis and to preventing renal complications.

The impact of anemia on microsurgical breast reconstruction complications and outcomes.

INTRODUCTION: Appropriate and adequate blood flow and oxygen delivery to a free flap is paramount to viability and success. We present a comprehensive examination of perioperative anemia, determining its prevalence and effect on complications and outcomes in autologous breast reconstruction. METHODS: We analyzed all autologous free flap breast reconstruction at the Hospital of the University of Pennsylvania from 2005 to 2011 with regards to anemia (hemoglobin (Hgb) <12 g dL(-1) ). Anemic patients were compared to those with Hgb > 12 g dL(-1) at preoperative and postoperative timepoints. Complications were analyzed relative to HgB levels and the incidence of anemia. Subgroups were analyzed based on worsening degrees of anemia. RESULTS: Overall, 839 patients were included in the analysis with an 18.3% incidence of preoperative anemia. No significant differences were noted in outcomes of these patients relative to their anemic state, although a higher percent did receive a blood transfusion (18% of anemic patients vs. 6% of nonanemic patients, P < 0.0001). There was a significant incidence of postoperative anemia (93.4%). A subgroup analysis demonstrated that worsening postoperative anemia was significantly related to preoperative HgB (P < 0.0001), bilateral cases (P < 0.0001), immediate reconstructions (P < 0.0001), increased estimated blood loss (P = 0.0001), and higher rates of intraoperative fluid administration (P = 0.025). A higher incidence of medical complications was observed in cohorts with HgB < 10 (P = 0.018). CONCLUSIONS: Anemia affects a significant portion of breast reconstruction patients. While preoperative anemia is not associated with increased risk of flap related complications, postoperative anemia may be associated with an increased risk of medical complications.

Complications following reduction mammaplasty: a review of 3538 cases from the 2005-2010 NSQIP data sets.

BACKGROUND: Reduction mammaplasty is an established and effective technique to treat symptomatic macromastia. Variable rates of complications have been reported, and there is a continued need for better outcome assessment studies. OBJECTIVE: The authors investigate predictors of postoperative complications following reduction mammaplasty using the National Surgery Quality Improvement Program (NSQIP) data sets. METHODS: The 2005-2010 American College of Surgeons NSQIP databases were reviewed to identify primary encounters for reduction mammaplasty using Current Procedural Terminology code 19318. Two complication types were recorded: major complications (deep infection and return to operating room) and any complication (all surgical complications). Preoperative patient factors and comorbidities, as well as intraoperative variables, were assessed. A multivariate regression analysis was used to identify independent predictors of complications. RESULTS: A total of 3538 patients were identified with an average age of 43 years and body mass index of 31.6 kg/m(2). Most patients underwent outpatient surgery (80.5%) with an average operative time of 180 minutes. The incidence of overall surgical complications was 5.1%. The following factors were independently associated with any surgical complications: morbid obesity (odds ratio [OR], 2.1; P < .001), active smoking (OR, 1.7; P < .001), history of dyspnea (OR, 2.0; P < .001), and resident participation (OR, 1.8; P = .01). The incidence of major surgical complications was 2.1%. Factors associated with major complications included active smoking (OR, 2.7; P < .001), dyspnea (OR, 2.6; P < .001), resident participation (OR, 2.1; P < .001), and inpatient surgery (OR, 1.8; P = .01). CONCLUSIONS: This study demonstrates overall incidence of complications in 1 in 20 patients and a 1 in 50 incidence of a major surgical complication. Noteworthy findings include the identification of morbid obesity as a significant predictor of overall morbidity and active smoking as a strong predictor of major surgical morbidity. These data can assist surgeons in preoperative counseling and enhance perioperative decision making.

Breast reconstruction in the morbidly obese patient: assessment of 30-day complications using the 2005 to 2010 National Surgical Quality Improvement Program data sets.

BACKGROUND: The authors assess the risk and safety profiles of both implant and autologous breast reconstructions in the morbidly obese population using the National Surgical Quality Improvement Program data sets. METHODS: The authors reviewed the 2005 to 2010 National Surgical Quality Improvement Program databases, identifying encounters for Current Procedural Terminology codes including either implant-based reconstruction or autologous reconstruction. Patients were classified and compared based on World Health Organization obesity criteria. Complications were divided into three categories: major surgical complications, wound complications, and medical complications. RESULTS: During the study period, 15,937 breast reconstructions were identified. The incidence of obesity was 27.1 percent, with 4.0 percent defined as class III (morbidly) obese. Morbidly obese patients had significantly higher rates of almost all complications compared with nonobese patients, including major surgical complications (p < 0.001), medical complications (p < 0.001), respiratory complications (p = 0.015), venous thromboembolism (p = 0.001), and wound complications (p < 0.001). These patients also were more likely to require a return to the operating room both for any reason (p < 0.001) and specifically for prosthesis/flap failure (p < 0.001). Morbid obesity was found to be an independent predictor of wound complications (OR, 2.1; p < 0.001), surgical complications (OR, 1.6; p < 0.001), medical complications (OR, 1.6; p = 0.01), and return to the operating room (OR, 1.5; p < 0.001). There was no significant difference in the 30-day surgical complication rates between implant and autologous reconstructions in the morbidly obese (p = 0.23). CONCLUSION: Morbid obesity is associated with a significantly increased risk of perioperative complications that translates into progressive, higher rates of overall morbidity, regardless of reconstructive modality. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Optimizing the fascial closure: an analysis of 1261 abdominally based free flap reconstructions.

BACKGROUND: Donor-site morbidity continues to be a significant complication in patients undergoing abdominally based breast reconstruction. The purposes of our study were to critically examine abdominal donor-site morbidity and to present our algorithm for optimizing donor site closure to reduce these complications. METHODS: We performed a retrospective cohort study examining all patients undergoing abdominally based free tissue transfer for breast reconstruction from 2005 to 2011 at our institution. Data were analyzed for overall donor site morbidity, as defined by hernia/bulge or reoperation for debridement and/or mesh removal and for hernia/bulge alone. RESULTS: A total of 812 patients underwent 1261 free tissue transfers. Fifty-three patients (6.5%) experienced donor-site morbidity, including 27 hernias/bulges (3.3%). No significant difference in overall abdominal morbidity was found between unilateral and bilateral reconstructions (P = 0.39) or the use of muscle in the flap (P = 0.11 unilateral msfTRAM, P = 0.76 bilateral). Prior lower abdominal surgery was associated with higher rates of donor-site morbidity (P = 0.04); hypertension (P = 0.012) and multiple medical comorbidities (P < 0.001) were also significantly more common in these patients. Obesity was the only patient characteristic associated with higher rates of hernia/bulge (P = 0.04). Delayed abdominal would healing was associated with hernia/bulge (P < 0.001); these patients were significantly more likely to develop this complication (odds ratio = 6.3, P < 0.001). CONCLUSIONS: Particular attention must be provided to donor-site closure in obese patients and those with hypertension and multiple medical comorbidities. Low rates of abdominal wall morbidity result from meticulous fascial reconstruction and reinforcement and careful attention to tension-free soft tissue closure.

Breast reconstruction modality outcome study: a comparison of expander/implants and free flaps in select patients.

BACKGROUND: Choosing a breast reconstructive modality after mastectomy is a critical step involving complex decisions. The authors provide outcomes data comparing two common reconstructive modalities to assist patients and surgeons in preoperative counseling and discussions. METHODS: A prospectively maintained database was queried identifying select patients undergoing expander/implant and abdominally based free flaps for breast reconstruction between 2005 and 2008. Variables evaluated included comorbidities, operations, time to reconstruction, complications, overall outcome, clinic visits, revisions, and costs. RESULTS: One hundred forty-two patients received free flaps and 60 received expander/implants. Expander/implant patients required more procedures (p < 0.001) but had shorter overall hospital lengths of stay (p < 0.001). The two cohorts experienced a similar rate of revision (p = 0.17). Free flap patients elected to undergo nipple-areola reconstruction more frequently (p = 0.01) and were able to sooner (p < 0.0001). Patients undergoing expander/implant reconstruction had a higher rate of failure (7.3 versus 1.3 percent, p = 0.008). Free flap patients achieved a stable reconstruction significantly faster (p = 0.0005), with fewer visits (p = 0.02). Cost analysis demonstrated total cost trended toward significantly lower in the free flap cohort (p = 0.15). Reconstructive modality was the only independent factor associated with time to stable reconstruction and reconstructive failure (p < 0.001 and p = 0.05, respectively). CONCLUSIONS: The authors' analysis revealed that free flap reconstructions required fewer procedures, had lower rates of complications and failures, had fewer clinic visits, and achieved a final, complete reconstruction faster than expander/implant reconstructions. Although autologous reconstruction is still not ideal for every patient, these findings can be used to enhance preoperative discussions when choosing a reconstructive modality. CLINICAL QUESTION/LEVEL OF EVIDENCE: : Therapeutic, III.

Free tissue transfer in the obese patient: an outcome and cost analysis in 1258 consecutive abdominally based reconstructions.

BACKGROUND: The authors' institution has seen an increase in obese and morbidly obese patients seeking autologous breast reconstruction. The authors provide a comprehensive outcome analysis of patients undergoing abdominally based autologous breast reconstruction. METHODS: The authors identified obese patients receiving free tissue transfer for breast reconstruction. World Health Organization body mass index criteria were used: nonobese (body mass index, 20 to 29.9 kg/m), class I (30 to 34.9 kg/m), class II (35 to 39.9 kg/m), and class III (>40 kg/m). Patient comorbidities, body mass index, complications (medical and surgical), and hospital resource use were examined. RESULTS: Eight-hundred twelve patients undergoing 1258 free tissue transfers for breast reconstruction were included. Overall, 66.5 percent (n = 540) were considered nonobese, 22.9 percent (n = 186) had class I obesity, 5.0 percent (n = 41) had class II, and 5.7 percent (n = 45) had class III. Obesity was associated with a significant increase in minor (p = 0.001) and major (p = 0.013) complications. Morbidly obese patients had significantly higher rates of total flap loss (p = 0.006) and longer operative times (p = 0.0002). Complications translated into greater cost and resource consumption (p < 0.001). Muscle-sparing transverse rectus abdominis myocutaneous flap experienced a significantly higher rate of hernia compared with other flaps (p = 0.02), without a difference in flap loss rate (p = 0.61). CONCLUSIONS: Increasing obesity is associated with increased perioperative risk in free abdominally based autologous breast reconstruction, which translated into greater perioperative morbidity, higher hospital cost, and increased health care resource consumption. Higher body mass index is directly related to intraoperative technical difficulty, flap loss, donor-site morbidity, and cost use. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

The virtual-patient pilot: testing a new tool for undergraduate surgical education and assessment.

BACKGROUND: The virtual patient (VP) is a web-based tool that allows students to test their clinical decision-making skills using simulated patients. METHODS: Three VP cases were developed using commercially available software to simulate common surgical scenarios. Surgical clerks volunteered to complete VP cases. Upon case completion, an individual performance score (IPS, 0-100) was generated and a 16-item survey was administered. Surgery shelf exam scores of clerks who completed VP cases were compared with a cohort of students who did not have exposure to VP cases. Descriptive statistics were performed to characterize survey results and mean IPS. RESULTS: Surgical clerks felt that the VP platform was simple to use, and both the content and images were well presented. They also felt that VPs enhanced learning and were helpful in understanding surgical concepts. Mean IPS at conclusion of the surgery clerkship was 69.2 (SD 26.5). Mean performance on the surgery shelf exam for the student cohort who had exposure to VPs was 86.5 (SD 7.4), whereas mean performance for the unexposed student cohort was 83.5 (SD 9). DISCUSSION: The VP platform represents a new educational tool that allows surgical clerks to direct case progression and receive feedback regarding clinical-management decisions. Its use as an assessment tool will require further validation.