Inpatient versus Outpatient Alveolar Bone Grafting: A Nationwide Cost Analysis.

OBJECTIVE: To compare postoperative outcomes and costs between inpatient and outpatient ABG in the United States. DESIGN: Retrospective cohort. SETTING: Multi-institutional/national. PATIENTS AND PARTICIPANTS: Patients who underwent ABG (n = 6649) were identified in the National Surgical Quality Improvement Program Pediatric database from 2012-2021. Inpatient and outpatient cohorts were matched using coarsened exact matching. MAIN OUTCOMES MEASURE(S): Thirty-day readmission, reoperation, and complications. A modified Markov model was developed to estimate the cost difference between cohorts. One-way and probabilistic sensitivity analyses were performed. RESULTS: After matching, 3718 patients were included, of which 1859 patients were in each hospital-setting cohort. The inpatient cohort had significantly higher rates of reoperations (0.6% vs. 0.2%; p = 0.032) and surgical site infections (0.8% vs. 0.2%; p = 0.018). The total cost of outpatient ABG was estimated to be $10,824 vs. $20,955 for inpatient ABG, resulting in $10,131 cost savings per patient. Probabilistic sensitivity analysis revealed that all 10,000 simulations resulted in consistent cost savings for the outpatient cohort that ranged from $8000 to $24,000. CONCLUSIONS: Outpatient ABG has become increasingly more popular over the past ten years, with a majority of cases being performed in the ambulatory setting. If deemed safe for the individual patient, outpatient ABG may confer a lower risk of nosocomial complications and offer significant cost savings to the healthcare economy.

Does prehabilitation before esophagectomy improve postoperative outcomes? A systematic review and meta-analysis.

Esophagectomy for esophageal cancer is associated with high morbidity. It remains unclear whether prehabilitation, a strategy aimed at optimizing patients' physical and mental functioning prior to surgery, improves postoperative outcomes. A systematic review and meta-analysis was conducted to evaluate the effect of prehabilitation on post-operative outcomes after esophagectomy. Data sources included Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and PEDro, with information from 1 January 2000 to 5 August 2023. The analysis included randomized controlled trials and observational studies that compared prehabilitation interventions to standard care prior to esophagectomy. A random effects model was used to generate a pooled estimate for pairwise meta-analysis, meta-analysis of proportions, and meta-analysis of means. A total of 1803 patients were included with 584 in randomized controlled trials (RCTs) and 1219 in observational studies. In the randomized evidence, there were no significant differences between prehabilitation and control in the odds of postoperative pneumonia (15.0 vs. 18.9%, odds ratio (OR) 1.06 [95% confidence interval (CI): 0.66;1.72]) or pulmonary complications (14 vs. 25.6%, OR 0.68 [95% CI: 0.32;1.45]). In the observational data, there was a reduction in both postoperative pneumonia (22.5 vs. 32.9%, OR 0.48 [95% CI: 0.28;0.83]) and pulmonary complications (26.1 vs. 52.3%, OR 0.35 [95% CI: 0.17;0.75]) with prehabilitation. Hospital and intensive care unit length of stay (days), operative mortality, and severe complications (Clavien-Dindo ≥ 3) did not differ between groups in both the randomized data and observational data. Prehabilitation demonstrated reductions in postoperative pneumonia and pulmonary complications in observational studies, but not RCTs. The overall certainty of these findings is limited by the low quality of the available evidence.

Midface Growth Potential in Unoperated Clefts: A Systematic Review and Meta-Analysis.

ABSTRACT: Competing hypotheses for the development of midface hypoplasia in patients with cleft lip and palate include both theories of an intrinsic restricted growth potential of the midface and extrinsic surgical disruption of maxillary growth centers and scar growth restriction secondary to palatoplasty. The following meta-analysis aims to better understand the intrinsic growth potential of the midface in a patient with cleft lip and palate unaffected by surgical correction. A systematic review of studies reporting cephalometric measurements in patients with unoperated and operated unilateral cleft lip and palate (UCLP), bilateral cleft lip and palate (BCLP), and isolated cleft palate (iCP) abstracted SNA and ANB angles, age at cephalometric analysis, syndromic diagnosis, and patient demographics. Age and Region-matched controls without cleft palate were used for comparison. SNA angle for unoperated UCLP (84.5 ±â€Š4.0°), BCLP (85.3 ±â€Š2.8°), and ICP (79.2 ±â€Š4.2°) were statistically different than controls (82.4 ±â€Š3.5°), (all P ≤ 0.001). SNA angles for operated UCLP (76.2 ±â€Š4.2°), BCLP (79.8 ±â€Š3.6°), and ICP (79.0 ±â€Š4.3°) groups were statistically smaller than controls (all P ≤ 0.001). SNA angle in unoperated ICP (n = 143) was equivalent to operated ICP patients (79.2 ±â€Š4.2° versus 79.0 ±â€Š4.3° P = 0.78). No unoperated group mean SNA met criteria for midface hypoplasia (SNA < 80). Unoperated UCLP/BLCP exhibit a more robust growth potential of the maxilla, whereas operated patients demonstrate stunted growth compared to normal phenotype. Unoperated ICP demonstrates restricted growth in both operated and unoperated patients. As such, patients with UCLP/BCLP differ from patients with ICP and the factors affecting midface growth may differ.Level of Evidence: IV.

The Evolving Clinical Presentation of Acute Rejection in Facial Transplantation.

IMPORTANCE: Acute rejection is one of the most frequent complications in facial transplantation, with potentially severe consequences for the recipient if overlooked. Clinical signs, such as erythema or edema, are helpful to diagnose acute rejection in the early follow-up stage; however, it is not well known whether these clinical signs remain reliable markers of acute rejection beyond the second posttransplant year. OBJECTIVE: To determine the diagnostic value of clinical signs of acute rejection after facial transplantation over time. DESIGN, SETTING, AND PARTICIPANTS: A retrospective, single-center cohort study was conducted of patients who underwent facial transplantation at Brigham and Women's Hospital between April 2009 and October 2014, with up to an 8-year follow-up. Medical records were reviewed until September 30, 2017. The medical records from 104 encounters with 7 patients who underwent partial or full facial transplantation were analyzed for symptoms of rejection, immunosuppressive therapy, and histopathologic findings. MAIN OUTCOMES AND MEASURES: The occurrence of 5 clinical signs of acute rejection were evaluated: erythema, edema, exanthema, suture line erythema, and mucosal lesions. Odds ratios (ORs) were calculated to determine the statistically significant association of these signs with the histopathologic diagnosis of rejection. In addition, tacrolimus blood levels, as a surrogate marker of immunosuppressive therapy, were evaluated. RESULTS: Of the 7 patients included in the study, 5 were men. The mean follow-up was 66 months (range, 35-101). Of 104 clinical encounters, 46 encounters (44.2%) represented rejection episodes and 58 encounters (55.8%) represented no-rejection episodes. Beyond 2 years posttransplantation, only erythema (OR, 6.53; 95% CI, 1.84-20.11; P = .004) and exanthema (OR, ∞; 95% CI, 2.2-∞; P = .004) were demonstrated to be reliable clinical signs of acute rejection in facial transplantation. There was also a statistically significant association of subtherapeutic tacrolimus levels with late rejection episodes (OR, 3.79; 95% CI, 1.25-12.88; P = .03). In addition, the occurrence of subclinical rejection was more frequent during later follow-up times (7 [24.1%] late rejections vs 1 [5.9%] early rejection). Five of 8 subclinical rejections (62.5%) were associated with subtherapeutic tacrolimus levels. CONCLUSIONS AND RELEVANCE: Clinical signs of acute rejection in facial transplantation appear to be of limited diagnostic value, particularly after the second postoperative year. Until alternative biomarkers for rejection are identified, protocol skin biopsies will remain necessary for guiding assessments of allograft rejection. LEVEL OF EVIDENCE: 3.

Reduced Hypoxia-Related Genes in Porcine Limbs in Ex Vivo Hypothermic Perfusion Versus Cold Storage.

BACKGROUND: Ischemia-reperfusion injury remains the major limiting factor for limb replantation and transplantation. Static cold storage (SCS) on ice currently represents the standard mode of preservation but is limited to 6 h of duration. Ex vivo machine perfusion has evolved as a potential alternative to safely extend the duration of ex vivo preservation by providing continuous supply of oxygen and nutrients. This study aims to evaluate underlying molecular mechanisms of both preservation modalities. METHODS: We assessed molecular changes in amputated porcine forelimbs stored on ice at 4°C for 2 h (n = 2) and limbs perfused with Perfadex solution at 10°C for 2 h (n = 3) or 12 h (n = 3) before replantation. Muscle biopsies were examined for histological changes and gene expression levels using H&E staining and a hypoxia-related PCR gene array, respectively. RESULTS: Histology revealed only minor differences between the ice (SCS) and perfusion groups after 2 h of preservation, with decreased muscle fiber disruption in the perfusion groups compared with the ice (SCS) group. Perfused limbs demonstrated downregulation of genes coding for glycolytic pathways and glucose transporters after 2 h and 12 h when compared with SCS after 2 h. Similarly, genes that induce angiogenesis and those that are activated on DNA damage were downregulated in both perfusion groups as compared with SCS. CONCLUSIONS: Perfusion of porcine limbs resulted in less activation of hypoxia-related gene families when compared with SCS. This may indicate a state more closely resembling physiological conditions during perfusion and potentially limiting ischemic injury. Our study confirms ex vivo perfusion for up to 12 h as a viable alternative for preservation of vascularized composite tissues.

Kidney Dysfunction After Vascularized Composite Allotransplantation.

BACKGROUND: Kidney dysfunction is a major complication after nonrenal solid organ transplants. Transplantation of vascularized composite allografts (VCA) has yielded successful midterm outcomes despite high rates of acute rejection and greater requirements of immunosuppression. Whether this translates in higher risks of kidney complications is unknown. METHODS: Ninety-nine recipients of facial or extremity transplants from the Brigham and Women's Hospital (BWH) and the International Registry on Hand and Composite Tissue Transplantation (IR) were reviewed. We assessed immunosuppression, markers of renal function over time, as well as pretransplant and posttransplant renal risk factors. RESULTS: Data were obtained from 10 patients from BWH (age at transplant, 42.5 ± 13.8 years) and 89 patients (37.8 ± 11.5 years) from IR. A significant rise in creatinine levels (BWH, P = 0.0195; IR, P < 0.0001) and drop in estimated glomerular filtration rate (GFR) within the first year posttransplant was observed. The BWH and IR patients lost a mean of 22 mL/min GFR and 60 mL/min estimated GFR in the first year, respectively. This decrease occurred mostly in the first 6 months posttransplant (BWH). Pretransplant creatinine levels were not restored in either cohort. A mixed linear model identified multiple variables correlating with renal dysfunction, particularly tacrolimus trough levels. CONCLUSIONS: Kidney dysfunction represents a major complication posttransplantation in VCA recipients early on. Strategies to mitigate this complication, such as reducing calcineurin inhibitor trough levels or using alternative immunosuppressive agents, may improve long-term patient outcomes. Standardizing laboratory and data collection of kidney parameters and risk factors in VCA patients will be critical for better understanding of this complication.

Quality of Life and Psychosocial Functioning 2 Years Following Facial Transplantation.

BACKGROUND: Face transplantation is a novel option for patients with severe facial disfigurement. Quality of life (QoL) outcomes of face transplantation remain poorly understood. OBJECTIVES: We sought to evaluate psychosocial functioning among 6 patients undergoing facial transplantation. METHODS: We prospectively assessed depressive symptoms, health status, mental and physical QoL, and self-esteem at 3-month intervals for 2 years. Social desirability was assessed pretransplant. RESULTS: On average, before transplantation, patients generally reported minimal to subthreshold depressive symptoms, normal to high health status, normal mental-health QoL, slightly below normal physical-health QoL, and normal to high self-esteem. Most endorsed high social desirability. As patients recovered from surgery, hospitalization, and immunosuppression induction, physical-health QoL generally deteriorated 3 months posttransplantation. Posttransplant trajectories show that perceived health state improved; health status and mental and physical health-related QoL slightly improved; self-esteem remained stable and high; and overall depressive symptoms remained stable but 3 patients experienced a depressive episode. CONCLUSIONS: Pretransplant ceiling effects may render improvements difficult to quantify. Future research should use mixed methods including population-specific measures with demonstrated sensitivity to change.

Perceived social support among patients with burn injuries: A perspective from the developing world.

BACKGROUND: Social support is among the most well-established predictors of post-burn psychopathology after burn. Despite a disproportionately large burden of burns in the developing world, the nature of social support among burn patients in this context remains elusive. We, therefore, seek to investigate social support and its biopsychosocial determinants among patients with burn injuries in Pakistan. METHODS: A cross-sectional study of 343 patients presenting with burn injuries at four teaching hospitals in the Punjab province of Pakistan was conducted. Patient evaluation consisted of a multi-part survey of demographic status, clinical features, and social support as measured by the validated Urdu translation of the Multidimensional Scale of Perceived Social Support (MSPSS). Multiple regression analysis was performed to evaluate associations between patient characteristics and MSPSS score. RESULTS: Mean overall MSPSS score was 57.64 (std dev 13.57). Notable positive predictors of social support include male gender, Punjabi ethnicity, burn surface area, and ego resiliency. CONCLUSION: Our study reveals a troubling pattern of inadequate social support among certain subgroups of Pakistani burn patients. Addressing these inequities in the provision of social support must be prioritized as part of the global burn care agenda.

Predictors of post-traumatic stress disorder among burn patients in Pakistan: The role of reconstructive surgery in post-burn psychosocial adjustment.

BACKGROUND: Burns are a common cause of morbidity and mortality worldwide. Post-traumatic stress disorder (PTSD) is among the most prevalent psychopathologies documented among burn patients. However, little is known regarding the risk factors for post-burn PTSD outside the well-documented Western world context. The present study aims to elucidate the biopsychosocial correlates of PTSD among burn patients in Pakistan. METHODS: A total 343 burn patients were evaluated across four teaching hospitals in the Punjab province of Pakistan between August and December of 2016. "Patients aged 18 years or older, with no major comorbid illnesses, presenting for burn care at burn units or surgical departments of the listed hospitals were interviewed by trained healthcare providers using a validated questionnaire." Uni- and multivariate statistical analyses were used to evaluate associations between patient characteristics and PTSD symptomatology, as measured by the validated Urdu version of the Impact of Event Scale-Revised (IES-R). RESULTS: The prevalence of PTSD among our cohort was 69%. Lower educational attainment, ethnic minority status, unemployment, large burn surface area, prior suicidal ideation, and domestic violence were all associated with increased PTSD symptomatology. On the other hand, social support, ego resiliency, and reconstructive surgery were all associated with decreased PTSD symptomatology. CONCLUSION: There is a remarkably high prevalence of PTSD among burn patients in Pakistan. Improving accessibility to reconstructive surgery and social support may help to alleviate this burden.

Trendy Tattoos-Maybe a Serious Health Risk?

BACKGROUND: The literature reports many cases of cutaneous malignancy in the setting of skin tattoos. In this study, we review the reported incidence of and risk factors for tattoo-associated skin cancer. METHODS: A PubMed literature review was performed for all cases of tattoo-associated skin cancer, including squamous cell carcinoma, basal cell carcinoma, malignant melanoma, keratoacanthoma, and other rare skin malignancies (source: PubMed/until June 2017). RESULTS: The authors identified 51 publications and 63 total cases of tattoo-associated skin cancer. We also report on a single new case of tattoo-associated skin cancer observed at one of our co-authors' institutions. Among these 64 total cases, 58% were associated with black and blue inks and 34% were associated with red ink. CONCLUSIONS: Overall, while the strength of association remains unclear, the literature reports many cases of tattoo-associated skin cancer. Among these cases, black, blue, and red inks were particularly worrisome for their carcinogenic potential. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Tissue conservation for transplantation.

Pathophysiological changes that occur during ischemia and subsequent reperfusion cause damage to tissues procured for transplantation and also affect long-term allograft function and survival. The proper preservation of organs before transplantation is a must to limit these injuries as much as possible. For decades, static cold storage has been the gold standard for organ preservation, with mechanical perfusion developing as a promising alternative only recently. The current literature points to the need of developing dedicated preservation protocols for every organ, which in combination with other interventions such as ischemic preconditioning and therapeutic additives offer the possibility of improving organ preservation and extending it to multiple times its current duration. This review strives to present an overview of the current body of knowledge with regard to the preservation of organs and tissues destined for transplantation.

Pure-tone audiometric threshold assessment with in-ear monitoring of noise levels.

OBJECTIVE: Our objective was to obtain reliable threshold measurements without a sound booth by using a passive noise-attenuating hearing protector combined with in-ear 1/3-octave band noise measurements to verify the ear canal was suitably quiet. DESIGN: We deployed laptop-based hearing testing systems to Tanzania as part of a study of HIV infection and hearing. An in-ear probe containing a microphone was used under the hearing protector for both the in-ear noise measurements and threshold audiometry. The 1/3-octave band noise spectrum from the microphone was displayed on the operator's screen with acceptable levels in grey and unacceptable levels in red. Operators attempted to make all bars grey, but focused on achieving grey bars at 2000 Hz and above. STUDY SAMPLE: 624 adults and 197 children provided 3381 in-ear octave band measurements. Repeated measurements from 144 individuals who returned for testing on three separate occasions were also analysed. RESULTS: In-ear noise levels exceeded the maximum permissible ambient noise levels (MPANL) for ears not covered, but not the dB SPL levels corresponding to 0 dB HL between 2000-4000 Hz. In-ear noise measurements were repeatable over time. CONCLUSIONS: Reliable audiometry can be performed using a passive noise-attenuating hearing protector and in-ear noise measurements.

Evaluation of balloon withdrawal forces with bare-metal stents, compared with Taxus and Cypher drug-eluting coronary stents: balloon, stent and polymer interactions.

BACKGROUND: There have been reports of serious complications related to difficulty removing the deflated Taxus stent delivery balloon after stent deployment. The purpose of this study was to determine whether the Taxus SIBS polymer was "sticky" and associated with an increase in the force required to remove the stent delivery balloon after stent deployment, using a quantitative, ex-vivo model. METHODS: Balloon-polymer-stent interactions during balloon withdrawal were measured with the Taxus Liberté, Liberté bare-metal stent (BMS; no polymer = control), the Cordis Cypher drug-eluting stent (DES; PEVA/PBMA polymer) and the BX Velocity (no polymer). We quantitatively measured the force required to remove the deflated stent delivery balloon from each of these stents in simulated vessels at 37 degrees C in a water bath. Balloon withdrawal forces were measured in straight (0 degree curve), mildly curved (20 degree curve) and moderately curved (40 degree curve) simulated vessel segments. RESULTS: The average peak force required to remove the deflated balloon catheter from the Taxus Liberté DES, the Liberté BMS, the Cypher DES, and the Bx Velocity BMS were similar in straight segments, but were much greater for the Taxus Liberté in the moderately curved segments (1.4 lbs vs. 0.11 lbs, 0.11 lbs and 0.12 lbs, respectively; p < 0.0001). CONCLUSION: The SIBS polymer of the Taxus Liberté DES appears to be "sticky" and is associated with high forces required to withdraw the deflated balloon from the deployed stent in curved segments. This withdrawal issue may help to explain the clinical complications that have been reported with this device.