Comparing the effect of distance to treatment facility on reconstruction and breast conservation therapy for early-stage invasive ductal carcinoma between the nation and the mountain region.

BACKGROUND: Our objective is to evaluate the effect of distance to facility on the use of breast conservation therapy and reconstruction for early stage breast cancer. METHODS: Utilizing the National Cancer Database, we identified females, age <65, with Stage I invasive ductal carcinoma from 2004 to 2015. Using logistic regression, we compared radiation, mastectomy, and reconstruction treatment patterns. A subgroup analysis was performed within the mountain region (MR). RESULTS: Nationwide, there are decreasing odds of radiation, increasing odds of mastectomy, and increasing odds of reconstruction. Patients living farther were less likely to receive radiation, more likely to undergo mastectomy, with no effect on reconstruction. Within the MR, patients living farther from their facility were less likely to receive radiation, more likely to undergo mastectomy, however, they were less likely to undergo reconstruction. CONCLUSIONS: Nationwide and within the MR, patients living farther from their facility are less likely to receive radiation and more likely to undergo mastectomy. There is a disparity between the MR and the nation in use of reconstruction for this population.

Comparing treatment patterns of hepatocellular carcinoma at academic centers and non-academic centers within the Mountain Region.

BACKGROUND: Our objective is to explore differences in survival and treatment approaches for hepatocellular carcinoma (HCC) between academic centers (ACs) and non-academic centers (NACs), which may contribute to disparities in the Mountain Region (MR). METHODS: Using the National Cancer Database, HCC cases from 2004 to 2015 in the MR were divided into AC and NAC subgroups. Cox-proportional hazard regression and binary logistic regression were performed to analyze survival, compare treatment patterns, and examine the effect of facility type and surgical approach on margin status. RESULTS: Treatment at ACs, compared to NACs, is associated with improved survival. At ACs, the odds of surgical or systemic treatment were higher. The odds of receiving radiation and positive margins was lower. Overall, the odds of positive margins was higher with laparoscopic compared to open or an unspecified surgical approach; this relationship persisted on subgroup analysis of NACs, but not ACs. CONCLUSIONS: Treatment of HCC at an AC in the MR increases the odds of surgery and improves survival. A laparoscopic approach increases the odds of positive margins, irrespective of center type.

Enhancement of Viable Adipose-Derived Stem Cells in Lipoaspirate by Buffering Tumescent with Sodium Bicarbonate.

BACKGROUND: Fat grafting is a growing field within plastic surgery. Adipose-derived stem cells (ASCs) and stromal vascular fracture (SVF) may have a role in fat graft survival. Our group previously demonstrated a detrimental effect on ASC survival by the lidocaine used in tumescent solution. Sodium bicarbonate (SB) buffers the acidity of lidocaine. The purpose of this study was to determine whether SB buffering is a practical method to reduce ASC and SVF apoptosis and necrosis seen with common lidocaine-containing tumescent solution. METHODS: Human patients undergoing bilateral liposuction for any indication were included in this study. An internally controlled, split-body design was utilized. Tumescent liposuction on one side of the body was conducted with tumescent containing lidocaine. On the opposite side, liposuction was conducted by adding SB to the tumescent. Tumescent solution and lipoaspirate pH were measured. Lipoaspirate from each side was processed for SVF isolation and ASC culture. The number of viable ASCs was counted and SVF apoptosis/necrosis was examined. RESULTS: The pH of the SB-buffered tumescent was significantly higher than that of the standard tumescent, an effect also seen in the lipoaspirate. Adipose-derived stem cell survival in the SB-buffered lipoaspirate was approximately 53% higher. However, there was no significant difference in SVF apoptosis and necrosis between the groups. CONCLUSIONS: The acidic standard tumescent solution commonly used in liposuction diminishes ASC viability from lipoaspirates. Sodium bicarbonate buffering tumescent solution can enhance ASC viability, but does not affect SVF apoptosis and necrosis. We recommend buffering tumescent with SB to potentially improve fat graft take. Our findings advocate for further research investigating mechanisms and optimal harvest techniques that maximize SVF/ASC survival and the clinical effect on overall fat graft viability.

Random flap survival with hyperbaric oxygen: daily versus twice-daily treatments.

PURPOSE: Hyperbaric oxygen (HBO2) therapy is used to improve the survival of compromised flaps. Compromised flaps are complications encountered postsurgically, or in traumatic degloving or avulsion injuries. Failed flaps lead to persistence of the defect, requirement of another donor site, and psychosocial sequelae. Although evidence of the benefit of HBO2 therapy is significant, there is no consensus on the optimal treatment regimen. The purpose of this study is to examine whether twice-daily treatments (BID HBO2) provide additional benefit compared to daily treatments (QD HBO2) in a rat compromised random flap model. METHODS: A rat random flap model was used with subjects divided into three groups: 1) control group; 2) QD HBO2; and 3) BID HBO2, where HBO2 was performed with 100% oxygen at 2.5 atmospheres absolute/ATA (253 kPa) for 90 minutes. After 10 days, areas of flap necrosis were measured and biopsies were taken for histologic analysis. Statistical analysis was performed using ANOVA and paired t-tests. A P-value ⟨0.05 was considered significant. RESULT: Both treatment groups had significantly increased mean flap survival compared to controls (P⟨0.05). There was no significant difference in flap survival between the QD and BID groups. Capillary proliferation in the QD group was increased compared with controls. CONCLUSION: Both QD and BID HBO2 protocols can significantly decrease random flap necrosis. However, the results of this study suggest there is no additional benefit gained with BID treatments. Clinical studies are warranted to confirm these findings and assist in formalization of protocols for the use of HBO2in treating compromised random flaps.

Research: Testing of a Novel Portable Body Temperature Conditioner Using a Thermal Manikin.

A battery-operated active cooling/heating device was developed to maintain thermoregulation of trauma victims in austere environments while awaiting evacuation to a hospital for further treatment. The use of a thermal manikin was adopted for this study in order to simulate load testing and evaluate the performance of this novel portable active cooling/heating device for both continuous (external power source) and battery power. The performance of the portable body temperature conditioner (PBTC) was evaluated through cooling/heating fraction tests to analyze the heat transfer between a thermal manikin and circulating water blanket to show consistent performance while operating under battery power. For the cooling/heating fraction tests, the ambient temperature was set to 15°C ± 1°C (heating) and 30°C ± 1°C (cooling). The PBTC water temperature was set to 37°C for the heating mode tests and 15°C for the cooling mode tests. The results showed consistent performance of the PBTC in terms of cooling/heating capacity while operating under both continuous and battery power. The PBTC functioned as intended and shows promise as a portable warming/cooling device for operation in the field.

Tumescent Liposuction without Lidocaine.

BACKGROUND: Our previous study demonstrated that lidocaine has a negative impact on adipose-derived stem cell (ASC) survival. Currently for large-volume liposuction, patients often undergo general anesthesia; therefore, lidocaine subcutaneous anesthesia is nonessential. We hypothesized that removing lidocaine from tumescent might improve stromal vascular fraction (SVF) and ASC survival from the standard tumescent with lidocaine. Ropivacaine is also a commonly used local anesthetic. The effect of ropivacaine on ASC survival was examined. METHODS: Adults who underwent liposuction on bilateral body areas were included (n = 10). Under general anesthesia, liposuction on 1 area was conducted under standard tumescent with lidocaine. On the contralateral side, liposuction was conducted under the modified tumescent without lidocaine. Five milliliters of lipoaspirate were processed for the isolation of SVF. The adherent ASCs were counted after 24 hours of SVF culture. Apoptosis and necrosis of SVF cells were examined by Annexin/propidium iodide staining and analyzed by flow cytometry. RESULTS: Average percentage of live SVF cells was 68.0% ± 4.0% (28.5% ± 3.8% of apoptosis and 3.4% ± 1.0% of necrosis) in lidocaine group compared with 86.7% ± 3.7% (11.5% ± 3.1% of apoptosis and 1.8% ± 0.7% of necrosis) in no-lidocaine group (P = 0.002). Average number of viable ASC was also significantly lower (367,000 ± 107) in lidocaine group compared with that (500,000 ± 152) in no-lidocaine group (P = 0.04). No significant difference was found between lidocaine and ropivacaine on ASC cytotoxicity. CONCLUSIONS: Removing lidocaine from tumescent significantly reduced SVF and ASC apoptosis in the lipoaspirate. We recommend tumescent liposuction without lidocaine, particularly if patient's lipoaspirate will be used for fat grafting.

Elimination of reperfusion-induced microcirculatory alterations in vivo by adipose-derived stem cell supernatant without adipose-derived stem cells.

BACKGROUND: In the present study, the authors hypothesized that adipose-derived stem cells in cell culture may secrete multiple cytokines in the supernatant, which might have a significant impact in vivo on the reperfusion-induced microcirculatory alterations and endothelial dysfunction. METHODS: Fat tissue was surgically harvested from rat flanks and processed for adipose-derived stem cell isolation; cells (1 × 10(6)) were subcultured for 3, 6, 9, and 12 days without passage. The postcultivated medium was harvested with medium change every 3 days. After centrifugation, the supernatant was collected and stored at -20°C. Supernatant collected on day 9 was analyzed for eight oxidative stress cytokines by an enzyme-linked immunosorbent assay strip. The effect of the supernatant on the reperfusion-induced microcirculatory alterations was examined in the vascular pedicle of isolated rat cremaster muscles subjected to 4 hours of ischemia followed by 2 hours of reperfusion. RESULTS: Enzyme-linked immunosorbent assay results demonstrated that adipose-derived stem cells produced several highly expressed cytokines in the supernatant. The average concentration of interleukin-6, in particular, was 5-fold higher compared with control. The reperfusion-induced vasospasm, arteriole stagnation, and the capillary no-reflow that often appear in the early phase of reperfusion were eliminated by adipose-derived stem cell supernatant. CONCLUSIONS: Adipose-derived stem cells in cell culture display cytokine secretory properties that enable the cells to act through paracrine signaling. The supernatant even without cells could be used as a paracrine agent to interfere with the reperfusion-induced microcirculatory alterations and endothelial dysfunction.

Targeted amino acid supplementation in diabetic foot wounds: pilot data and a review of the literature.

BACKGROUND: Diabetic foot wounds are a highly morbid and costly complication of diabetes mellitus. Targeted amino acid supplementation, by increasing tissue hydroxyproline concentrations, has been implicated in improved wound outcomes in surgical incisions and chronic wounds, and after radiation injury. A major component of collagen, hydroxyproline is a surrogate marker used commonly for tissue collagen concentrations. This paper reviews the literature pertaining to amino acid supplementation and wound healing, and also evaluates our pilot data relating to supplementation with arginine, glutamine, and beta-hydroxy-beta-methylbutyrate (HMB) in the treatment of diabetic foot ulcers. METHODS: For the pilot study, nine patients scheduled to undergo wound debridement for diabetic foot ulcers were randomized prospectively to be a part of either a placebo group or a treatment group that received supplementation twice daily for 2 wks. Tissue samples were collected both before and after 2 wk of supplementation. The results of assay of the samples for hydroyproline were then analyzed via a one tailed Student t-test to evaluate tissue concentrations of hydroxyproline. For the literature review in the study, the MEDLINE/PubMed database was reviewed, using search terms contained in the Medical Subject Headings (MeSH). RESULTS: The treatment group in the study exhibited a significantly greater hydroxyproline concentration after supplementation than before it (p=0.03). The mean percent change in the tissue hydroxyproline concentration for arginine, glutamine, and HMB group was +67.8%, with a standard deviation (SD) of 129.89. The mean percent change for the corresponding amino acids in the placebo group was -78.4%, with an SD of 20.55. The review of the MEDLINE/PubMed literature revealed only two human studies of amino acid supplementation in patients with diabetic foot wounds, one of which found a significant improvement in wound-depth and wound-appearance scores. CONCLUSIONS: Given the results of our pilot study, and on the basis of a review of the literature, the administration of a simple amino acid supplement may improve the healing of diabetic foot wounds via increased collagen production.

Lidocaine-induced ASC apoptosis (tumescent vs. local anesthesia).

BACKGROUND: The purpose for the present study was to determine which anesthetic method, local anesthesia versus tumescent, is superior for liposuction in terms of adipose-derived stem cell (ASC) survival in lipoaspirate; which component, lidocaine versus lidocaine with epinephrine, in anesthetic solutions could affect ASC survival; and which mechanism, necrosis versus apoptosis, is involved in lidocaine-induced ASC death. METHODS: Human lipoaspirates were harvested using standard liposuction technique. Individuals scheduled for liposuction on bilateral body areas gave consent and were included in the study. On one area, liposuction was conducted under local anesthesia with lidocaine/epinephrine. On the contralateral area, liposuction was accomplished with tumescent wetting solution containing lidocaine/epinephrine. Lipoaspirates were processed for the isolation of stromal vascular fraction (SVF). ASC survival was determined by the number of adherent ASCs after 24 h of SVF culture. Lidocaine dose-response (with or without epinephrine) on cultured ASCs was examined. Lidocaine-induced ASC apoptosis and necrosis was determined by Annexin V-FITC/Propidium Iodide (PI) assay and analyzed by flow cytometry. RESULTS: All of the participants were female adults. The average age was 45 ± 4.0 years (±SEM) and the average BMI was 28 ± 1.0 (±SEM). Lipoaspirate samples (n = 14) treated by local anesthesia (n = 7/group) or tumescent anesthesia (n = 7/group) were investigated. Liposuction sites were located in the hip or thigh. The average number of adherent ASCs was 1,057 ± 146 k in the local anesthesia group, which was significantly lower than the 1,571 ± 111 k found in the tumescent group (P = 0.01). ASC survival was significantly lower in the lidocaine group and in a dose-dependent manner as compared to the correspondent PBS controls (P < 0.05 or P < 0.01). ASC survival was significantly lower in both the lidocaine and lidocaine with epinephrine groups when compared to PBS controls. Annexin/PI assay showed that ASC apoptosis (but not necrosis) in the lidocaine group was significantly higher than that in the corresponding PBS control (P = 0.026). CONCLUSIONS: Tumescent anesthesia is the superior method for liposuction with respect to ASC preservation compared to local anesthesia. Lidocaine could cause significant ASC apoptosis.

The effect of lipoaspirates cryopreservation on adipose-derived stem cells.

BACKGROUND: Autologous fat grafting has gained popularity, particularly with the discovery of adipose-derived stem cells (ADSC). The possibility of freezing lipoaspirates (LA) for later use has intriguing clinical potential. However, the effect of LA cryopreservation on ADSC is unclear. OBJECTIVES: The authors explore the effect of LA cryopreservation on ADSC viability. METHODS: Human LA (n = 8) were harvested using a standard technique. Lipoaspirate samples were either processed immediately as fresh LA (A) or stored at -20°C and then at -80°C for 30 days with (B) or without (C) freezing medium. Stromal vascular fraction (SVF) was separated from adipocytes and either cultured to obtain purified ADSC or processed for the isolation of 3 distinct ADSC subpopulations (CD90(+)/CD45(-), CD105(+)/CD45(-), and CD34(+)/CD31(-)). Apoptosis and necrosis were determined by an annexin V/propidium iodide assay and quantified by flow cytometry. The capability of ADSC for long-term proliferation and differentiation was also examined. RESULTS: There were no significant differences in the apoptosis and necrosis of adipocytes, SVF, or ADSC between groups A and B. However, cell viability in SVF and ADSC was significantly compromised in group C as compared with group B (P < .01) due to higher ADSC apoptosis but not necrosis. The viable ADSC isolated from fresh or frozen LA were cultured for more than 20 passages and demonstrated similar patterns and speed of proliferation with strong capability to differentiate, evidenced by cell doubling time and positive staining with Oil Red O (Sigma-Aldrich, St Louis, Missouri) and alkaline phosphatase. CONCLUSIONS: Lipoaspirates cryopreservation had a significant impact on ADSC apoptosis but not on ADSC necrosis, proliferation, or differentiations. Freezing medium provides significant protection against ADSC apoptosis.

Analysis for apoptosis and necrosis on adipocytes, stromal vascular fraction, and adipose-derived stem cells in human lipoaspirates after liposuction.

BACKGROUND: Adipose-derived stem cells have become the most studied adult stem cells. The authors examined the apoptosis and necrosis rates for adipocyte, stromal vascular fraction, and adipose-derived stem cells in fresh human lipoaspirates. METHODS: Human lipoaspirate (n = 8) was harvested using a standard liposuction technique. Stromal vascular fraction cells were separated from adipocytes and cultured to obtain purified adipose-derived stem cells. A panel of stem cell markers was used to identify the surface phenotypes of cultured adipose-derived stem cells. Three distinct stem cell subpopulations (CD90/CD45, CD105/CD45, and CD34/CD31) were selected from the stromal vascular fraction. Apoptosis and necrosis were determined by annexin V/propidium iodide assay and analyzed by flow cytometry. RESULTS: The cultured adipose-derived stem cells demonstrated long-term proliferation and differentiation evidenced by cell doubling time and positive staining with oil red O and alkaline phosphatase. Isolated from lipoaspirates, adipocytes exhibited 19.7 ± 3.7 percent apoptosis and 1.1 ± 0.3 percent necrosis; stromal vascular fraction cells revealed 22.0 ± 6.3 percent of apoptosis and 11.2 ± 1.9 percent of necrosis; stromal vascular fraction cells had a higher rate of necrosis than adipocytes (p < 0.05). Among the stromal vascular fraction cells, 51.1 ± 3.7 percent expressed CD90/CD45, 7.5 ± 1.0 percent expressed CD105/CD45, and 26.4 ± 3.8 percent expressed CD34/CD31. CD34/CD31 adipose-derived stem cells had lower rates of apoptosis and necrosis compared with CD105/CD45 adipose-derived stem cells (p < 0.05). CONCLUSIONS: Adipose-derived stem cells had a higher rate of apoptosis and necrosis than adipocytes. However, the extent of apoptosis and necrosis was significantly different among adipose-derived stem cell subpopulations.

Nitrite attenuates ischemia-reperfusion-induced microcirculatory alterations and mitochondrial dysfunction in the microvasculature of skeletal muscle.

BACKGROUND: Recently, nitrite has been rediscovered as a physiologically relevant storage reservoir of nitric oxide in blood and it can readily be converted to nitric oxide under hypoxic and acidic conditions. In this study, the authors evaluated the therapeutic efficacy of nitrite on reperfusion-induced microcirculatory alterations and mitochondrial dysfunction in the microvasculature of skeletal muscle. METHODS: The authors used a vascular pedicle isolated rat cremaster model that underwent 4 hours of warm ischemia followed by 2 hours or 17 hours of reperfusion. At 5 minutes before reperfusion, normal saline, sodium nitrite (0.20 µM/minute/kg), or nitrite mixed with 2-(4-carboxyphenyl)-4,5-dihydro-4,4,5,5-tetramethylimidazoline-3-oxide-1-oxyl (potassium salt) (0.2 mg/minute/kg) was infused into the microcirculation of ischemic cremaster by means of intraarterial infusion. Ischemia-reperfusion-induced microcirculatory alterations were measured after 2 hours of reperfusion. Microvasculature of the cremaster muscle including the vascular pedicle was harvested to determine the mitochondrial dysfunction. The blood concentration of methemoglobin was also measured to determine the toxicity of nitrite. RESULTS: The authors found that nitrite significantly attenuated ischemia-reperfusion-induced vasoconstriction, arteriole stagnation, and capillary no-reflow in the early phase of reperfusion and the depolarization of mitochondrial membrane potential and cytochrome c release in the late phase of reperfusion. Nitrite-induced protection was significantly blocked by a nitric oxide scavenger (potassium salt). The methemoglobin results showed that the doses of nitrite we used in the present study were safe. CONCLUSION: The supplementation of a low dose of nitrite, directly into the microcirculation of ischemic muscle through local intraarterial infusion, significantly attenuated ischemia-reperfusion-induced microcirculatory alterations in vivo and mitochondrial dysfunction in vitro in the microvasculature of skeletal muscle.

The effect of shock resuscitation fluids on apoptosis.

BACKGROUND: Recent data suggest that the type of resuscitation fluid used to treat hemorrhagic shock contributes to cellular dysfunction METHODS: Rats were hemorrhaged, exposed to a hypovolemic shock period for 75 minutes, and then resuscitated for 1 hour. Treatment animals were assigned randomly to lactate Ringer's solution, normal saline solution, bicarbonate Ringer's solution, hypertonic saline solution, rat plasma solution, ketone Ringer's solution, or nonresuscitation. After resuscitation, lung and liver samples were collected and evaluated for apoptosis by using ligation-mediated polymerase chain reaction. RESULTS: Nonresuscitated shock rats had significantly higher levels of apoptosis in lung and liver. Rats treated with normal saline solution, bicarbonate Ringer's solution, ketone Ringer's solution, and hypertonic saline solution had significantly lower levels of apoptosis in lung compared with nonresuscitated animals. Rats treated with bicarbonate Ringer's solution and ketone Ringer's solution had significantly lower levels of apoptosis in liver tissue when compared with nonresuscitated animals. CONCLUSIONS: Cellular damage results from hemorrhagic shock. The use of resuscitation fluids decreases apoptosis during shock.