Utility of Indocyanine Green for Sentinel Lymph Node Biopsy in Pediatric Sarcoma and Melanoma.

BACKGROUND: Indocyanine green (ICG) is a fluorescent dye with increasing use for adult sentinel lymph node biopsy (SLNB). The utility of ICG in pediatric oncology remains understudied. We aim to describe our experience using ICG for SLNB in pediatrics versus standard blue dye. METHODS: A retrospective review of pediatric patients with melanoma or sarcoma who underwent SLNB with technetium plus ICG or blue dye from 2014 to 2023 at a large academic children's hospital was conducted. RESULTS: Twenty-four patients were included; 58.3% were male with median age 13 years (range 4-21 years). The majority had a melanocytic tumor (91.7%) and 8.3% had sarcoma. All patients received technetium with concomitant blue dye (62.5%) or ICG (37.5%). ICG more reliably identified radioactive SLNs, compared to blue dye (mean 100% vs 78.3 ± 8.3%, p = 0.03). There was no significant difference in median operative time (ICG 82 min [68-203] vs blue dye 93 min [78-105], p = 0.84). Seven patients had positive SLNs (29.2%), with recurrence in 2 patients (8.3%) and 1 death (4.2%). There were no adverse events. CONCLUSION: ICG-directed SLNB in children is a safe and effective alternative to blue dye. Use of ICG did not add to operative time, and more often identified sentinel nodes versus blue dye. TYPE OF STUDY: Original Research Article, Retrospective Comparative Study. LEVEL OF EVIDENCE: III.

Evaluation of critical care burden following traumatic injury from two randomized controlled trials.

Trauma resuscitation practices have continued to improve with new advances targeting prehospital interventions. The critical care burden associated with severely injured patients at risk of hemorrhage has been poorly characterized. We aim to describe the individual and additive effects of multiorgan failure (MOF) and nosocomial infection (NI) on delayed mortality and resource utilization. A secondary analysis of harmonized data from two large prehospital randomized controlled trials (Prehospital Air Medical Plasma (PAMPer) Trial and Study of Tranexamic Acid during Air and Ground Medical Prehospital Transport (STAAMP) Trial) was conducted. Only those patients who survived beyond the first 24 hours post-injury and spent at least one day in the ICU were included. Patients were stratified by development of MOF only, NI only, both, or neither and diagnosis of early (≤ 3 days) versus late MOF (> 3 days). Risk factors of NI and MOF, time course of these ICU complications, associated mortality, and hospital resource utilization were evaluated. Of the 869 patients who were enrolled in PAMPer and STAAMP and who met study criteria, 27.4% developed MOF only (n = 238), 10.9% developed NI only (n = 95), and 15.3% were diagnosed with both MOF and NI (n = 133). Patients developing NI and/or MOF compared to those who had an uncomplicated ICU course had greater injury severity, lower GCS, and greater shock indexes. Early MOF occurred in isolation, while late MOF more often followed NI. MOF was associated with 65% higher independent risk of 30-day mortality when adjusting for cofounders (OR 1.65; 95% CI 1.04-2.6; p = 0.03), however NI did not significantly affect odds of mortality. NI was individually associated with longer mechanical ventilation, ICU stay, hospital stay, and rehabilitation requirements, and the addition of MOF further increased the burden of inpatient and post-discharge care. MOF and NI remain common complications for those who survive traumatic injury. MOF is a robust independent predictor of mortality following injury in this cohort, and NI is associated with higher resource utilization. Timing of these ICU complications may reveal differences in pathophysiology and offer targets for continued advancements in treatment.

Accuracy of Risk Estimation for Surgeons Versus Risk Calculators in Emergency General Surgery.

INTRODUCTION: Surgical risk calculators have expanded in both number and sophistication of their predictive approach. These calculators are gaining popularity as validated tools to help surgeons estimate mortality and complications following emergency general surgery (EGS). However, the accuracy of risk estimates generated by these calculators compared to risk estimation by practicing surgeons has not been explored. METHODS: Acute care surgeons at a quaternary care center prospectively estimated 30-d mortality and complications for adult EGS patients (2019-2021). Surgeon predictions were compared to Predictive OpTimal Trees in Emergency Surgery Risk (POTTER) and NSQIP estimates. Observed-to-expected (O:E) ratios of median aggregate estimates were calculated. C-statistics for surgeon and calculator estimations were utilized to quantify predictive accuracy. RESULTS: Among 150 patients (median 61 y, 45% male), 30-d mortality was 15% (n = 23). Observed rates of prolonged mechanical ventilation and acute renal failures were 30% and 10%, respectively. Overall, surgeon predictions were similar to risk calculator estimates for mortality (c-statistics 0.843 [surgeon] versus 0.848 [POTTER] and 0.815 [NSQIP]) and need for prolonged ventilation (c-statistics 0.801 versus 0.722 and 0.689, respectively). Surgeons tended to overestimate complication risks. Surgeon experience was not significantly associated with mortality prediction in an adjusted model. CONCLUSIONS: Acute care surgeons at a quaternary care center predicted postoperative mortality and complications with similar discrimination when compared to surgical risk calculators. Surgeon expertise should be utilized in conjunction with risk calculators when counseling EGS patients regarding anticipated postoperative outcomes. Surgeons should be cognizant of patterns in overestimation or underestimation of complications.

Rapid detection of platelet inhibition and dysfunction in traumatic brain injury: A prospective observational study.

BACKGROUND: Rapid platelet function testing is frequently used to determine platelet function in patients with traumatic intracranial hemorrhage (tICH). Accuracy and clinical significance of decreased platelet response detected by these tests is not well understood. We sought to determine whether VerifyNow and whole blood aggregometry (WBA) can detect poor platelet response and to elucidate its clinical significance for tICH patients. METHODS: We prospectively enrolled patients with isolated tICH between 2018 and 2020. Demographics, medical history, injury characteristics, and patient outcomes were recorded. Platelet function was determined by VerifyNow and WBA testing at the time of arrival to the trauma bay and 6 hours later. RESULTS: A total of 221 patients were enrolled, including 111 patients on no antiplatelet medication, 78 on aspirin, 6 on clopidogrel, and 26 on aspirin and clopidogrel. In the trauma bay, 29.7% and 67.7% of patients on no antiplatelet medication had poor platelet response on VerifyNow and WBA, respectively. Among patients on aspirin, 72.2% and 82.2% had platelet dysfunction on VerifyNow and WBA. Among patients on clopidogrel, 67.9% and 88.9% had platelet dysfunction on VerifyNow and WBA. Patients with nonresponsive platelets had similar in-hospital mortality (3 [3.0%] vs. 6 [6.3%], p = 0.324), tICH progression (26 [27.1%] vs. 24 [26.1%], p = 0.877), intensive care unit admission rates (34 [34.3%] vs. 38 [40.0%), p = 0.415), and length of stay (3 [interquartile range, 2-8] vs. 3.2 [interquartile range, 2-7], p = 0.818) to those with responsive platelets. Platelet transfusion did not improve platelet response or patient outcomes. CONCLUSION: Rapid platelet function testing detects a highly prevalent poor platelet response among patients with tICH, irrespective of antiplatelet medication use. VerifyNow correlated fairly with whole blood aggregometry among patients with tICH and platelet responsiveness detectable by these tests did not correlate with clinical outcomes. In addition, our results suggest that platelet transfusion may not improve clinical outcomes in patients with tICH. LEVEL OF EVIDENCE: Diagnostic tests, level II.

Healthcare providers' perceived support from their organization is associated with lower burnout and anxiety amid the COVID-19 pandemic.

BACKGROUND: Professional burnout represents a significant threat to the American healthcare system. Organizational and individual factors may increase healthcare providers' susceptibility or resistance to burnout. We hypothesized that during the COVID-19 pandemic, 1) higher levels of perceived organizational support (POS) are associated with lower risk for burnout and anxiety, and 2) anxiety mediates the association between POS and burnout. METHODS: In this longitudinal prospective study, we surveyed healthcare providers employed full-time at a large, multihospital healthcare system monthly over 6 months (April to November 2020). Participants were randomized using a 1:1 allocation stratified by provider type, gender, and academic hospital status to receive one of two versions of the survey instrument formulated with different ordering of the measures to minimize response bias due to context effects. The exposure of interest was POS measured using the validated 8-item Survey of POS (SPOS) scale. Primary outcomes of interest were anxiety and risk for burnout as measured by the validated 10-item Burnout scale from the Professional Quality (Pro-QOL) instrument and 4-item Emotional Distress-Anxiety short form of the Patient Reported Outcome Measurement Information System (PROMIS) scale, respectively. Linear mixed models evaluated the associations between POS and both burnout and anxiety. A mediation analysis evaluated whether anxiety mediated the POS-burnout association. RESULTS: Of the 538 participants recruited, 402 (75%) were included in the primary analysis. 55% of participants were physicians, 73% 25-44 years of age, 73% female, 83% White, and 44% had ≥1 dependent. Higher POS was significantly associated with a lower risk for burnout (-0.23; 95% CI -0.26, -0.21; p<0.001) and lower degree of anxiety (-0.07; 95% CI -0.09, -0.06; p = 0.010). Anxiety mediated the associated between POS and burnout (direct effect -0.17; 95% CI -0.21, -0.13; p<0.001; total effect -0.23; 95% CI -0.28, -0.19; p<0.001). CONCLUSION: During a health crisis, increasing the organizational support perceived by healthcare employees may reduce the risk for burnout through a reduction in anxiety. Improving the relationship between healthcare organizations and the individuals they employ may reduce detrimental effects of psychological distress among healthcare providers and ultimately improve patient care.

Impact of a Surgical Subspecialty Roundtable on Career Perception for Preclerkship Medical Students.

BACKGROUND: Limited exposure to surgical subspecialties during medical school may be responsible for decreasing medical student interest in surgery. Although most medical schools have surgery interest groups to increase exposure, our aim was to evaluate the impact of a focused surgical subspecialty roundtable on preclerkship students' perceptions of surgical careers. METHODS: Faculty members from each surgical subspecialty shared their experiences and led roundtable discussions with five to seven first- and second-year medical students at a time (total n = 59). Pre-event and post-event surveys were administered to assess students' interest in surgery, knowledge of training paths, values related to specialty selection, and perception of surgeons. RESULTS: Forty students completed pre-event and post-event surveys. The number of students who were extremely or very interested in surgery increased after this event (65% versus 72.5%, P < 0.001). The greatest number of students indicated an interest in orthopedic surgery, and the fewest indicated an interest in neurosurgery. After the event, thirteen (32.5%) students changed their preferences for the subspecialty in which they were most interested. Students demonstrated improved knowledge of training length and integrated residencies (83.8% versus 96.3%, P = 0.003). The perceived importance of intellectual challenge, research opportunities, and training length decreased, whereas the importance of compensation, work/life balance, long-term patient follow-up, and the job market increased. Students' perceptions of surgeons' work/life balance (10% versus 25%, P < 0.001) and ability to be team players (82.5% versus 85%, P = 0.01) improved significantly after the roundtable. CONCLUSIONS: The surgical specialty roundtable increased students' interest in surgery, improved knowledge of training paths, and altered perceptions related to career decision-making.

Patient and surrogate attitudes via an interviewer-administered survey on exception from informed consent enrollment in the Prehospital Air Medical Plasma (PAMPer) trial.

OBJECTIVES: With increased focus on early resuscitation methods following injury to improve patient outcomes, studies are employing exception from informed consent (EFIC) enrollment. Few studies have assessed patients' opinions following participation in an EFIC study, and none have been conducted within the realm of traumatic hemorrhage. We surveyed those patients and surrogates previously enrolled in the Prehospital Air Medical Plasma (PAMPer) Trial to clarify their opinions related to consent and emergency research. METHODS: Telephone calls were made between January-June 2019 to all patients who were enrolled under EFIC in the PAMPer study at the Pittsburgh site (169 of the 501 total patients enrolled, May 2014-Oct 2017) and their surrogates. Questions gauging approval of EFIC enrollment were asked before discussion of PAMPer trial outcomes, after disclosure of positive outcomes, and after a hypothetical negative trial outcome was proposed. RESULTS: Of the total 647 telephone calls made, ninety-three interviews, reflecting 70 of 169 patient enrollments, were conducted. This included 13 in which only the patient was interviewed, 23 in which the patient and a surrogate were interviewed, and 34 in which only a surrogate was interviewed. Nearly half (48.4%) of respondents did not recall their personal or family member enrollment in the study. No patients or surrogates recalled hearing about the study through community consultation or being aware of opt out procedures. Patients and surrogates were glad they were enrolled (90.3%), agreed with EFIC use for their personal enrollment (88.17%), and agreed with the general use of EFIC for the PAMPer study (81.7%). Disclosure of the true positive PAMPer study outcome resulted in a significant increase in opinions regarding personal enrollment, EFIC for personal enrollment, and EFIC for general enrollment (all p < 0.001). Disclosure of a hypothetical neutral or negative study outcome resulted in significant decreases in opinions regarding EFIC for personal enrollment (p = 0.003) and EFIC for general enrollment (p < 0.001). CONCLUSIONS: Clinical trial participants with traumatic hemorrhagic shock enrolled with EFIC, and surrogates of such participants, are generally accepting of EFIC. The results of the trial in which EFIC was utilized significantly affected patient and surrogate agreement with personal and general EFIC enrollment.

Association of Prehospital Plasma With Survival in Patients With Traumatic Brain Injury: A Secondary Analysis of the PAMPer Cluster Randomized Clinical Trial.

Importance: Prehospital plasma administration improves survival in injured patients at risk for hemorrhagic shock and transported by air ambulance. Traumatic brain injury (TBI) is a leading cause of death following trauma, but few early interventions improve outcomes. Objective: To assess the association between prehospital plasma and survival in patients with TBI. Design, Setting, and Participants: The Prehospital Air Medical Plasma (PAMPer) trial was a pragmatic, multicenter, phase 3, cluster randomized clinical trial involving injured patients who were at risk for hemorrhagic shock during air medical transport to a trauma center. The trial was conducted at 6 US sites with 9 level-I trauma centers (comprising 27 helicopter emergency services bases). The original trial analyzed 501 patients, including 230 patients who were randomized to receive plasma and 271 randomized to standard care resuscitation. This secondary analysis of a predefined subgroup included patients with TBI. Data analysis was performed from October 2019 to February 2020. Interventions: Patients were randomized to receive standard care fluid resuscitation or 2 units of thawed plasma. Main Outcomes and Measures: The primary outcome was mortality at 30 days. Patients with TBI were prespecified as a subgroup for secondary analysis and for measurement of markers of brain injury. The 30-day survival benefit of prehospital plasma in subgroups with and without TBI as diagnosed by computed tomography was characterized using Kaplan-Meier survival analysis and Cox proportional hazard regression. Results: In total, 166 patients had TBI (median [interquartile range] age, 43.00 [25.00-59.75] years; 125 men [75.3%]). When compared with the 92 patients who received standard care, the 74 patients with TBI who received prehospital plasma had improved 30-day survival even after adjustment for multiple confounders and assessment of the degree of brain injury with clinical variables and biomarkers (hazard ratio [HR], 0.55; 95% CI, 0.33-0.94; P = .03). Receipt of prehospital plasma was associated with improved survival among patients with TBI with a prehospital Glasgow Coma Scale score of less than 8 (HR, 0.56; 95% CI, 0.35-0.91) and those with polytrauma (HR, 0.50; 95% CI, 0.28-0.89). Patients with TBI transported from the scene of injury had improved survival following prehospital plasma administration (HR, 0.45; 95% CI, 0.26-0.80; P = .005), whereas patients who were transferred from an outside hospital showed no difference in survival for the plasma intervention (HR, 1.00; 95% CI, 0.33-3.00; P = .99). Conclusions and Relevance: These findings are exploratory, but they suggest that receipt of prehospital plasma is associated with improved survival in patients with computed tomography-positive TBI. The prehospital setting may be a critical period to intervene in the care of patients with TBI. Future studies are needed to confirm the clinical benefits of early plasma resuscitation following TBI and concomitant polytrauma. Trial Registration: ClinicalTrials.gov Identifier: NCT01818427.

Long-gap peripheral nerve repair through sustained release of a neurotrophic factor in nonhuman primates.

Severe injuries to peripheral nerves are challenging to repair. Standard-of-care treatment for nerve gaps >2 to 3 centimeters is autografting; however, autografting can result in neuroma formation, loss of sensory function at the donor site, and increased operative time. To address the need for a synthetic nerve conduit to treat large nerve gaps, we investigated a biodegradable poly(caprolactone) (PCL) conduit with embedded double-walled polymeric microspheres encapsulating glial cell line-derived neurotrophic factor (GDNF) capable of providing a sustained release of GDNF for >50 days in a 5-centimeter nerve defect in a rhesus macaque model. The GDNF-eluting conduit (PCL/GDNF) was compared to a median nerve autograft and a PCL conduit containing empty microspheres (PCL/Empty). Functional testing demonstrated similar functional recovery between the PCL/GDNF-treated group (75.64 ± 10.28%) and the autograft-treated group (77.49 ± 19.28%); both groups were statistically improved compared to PCL/Empty-treated group (44.95 ± 26.94%). Nerve conduction velocity 1 year after surgery was increased in the PCL/GDNF-treated macaques (31.41 ± 15.34 meters/second) compared to autograft (25.45 ± 3.96 meters/second) and PCL/Empty (12.60 ± 3.89 meters/second) treatment. Histological analyses included assessment of Schwann cell presence, myelination of axons, nerve fiber density, and g-ratio. PCL/GDNF group exhibited a statistically greater average area occupied by individual Schwann cells at the distal nerve (11.60 ± 33.01 µm2) compared to autograft (4.62 ± 3.99 µm2) and PCL/Empty (4.52 ± 5.16 µm2) treatment groups. This study demonstrates the efficacious bridging of a long peripheral nerve gap in a nonhuman primate model using an acellular, biodegradable nerve conduit.

Personalizing Decision-Making for Patients Choosing Contralateral Prophylactic Mastectomy: A Utility Analysis of Genetic Factors and the Relative Risk of Breast Cancer.

INTRODUCTION: There has been an increasing trend of patients with breast cancer electing to undergo contralateral prophylactic mastectomy (CPM), despite the lack of evidence showing long-term survival benefit. We aim to quantify the tiered amount of genetic and surgical complication risk deemed necessary to justify CPM. METHODS: A review of breast cancer-affiliated genetic mutations and morbidity rates of breast cancer surgery from a single institution was compiled. A survey using a utility analysis was created. Severity of breast cancer genetic risk and morbidity risk warranting CPM was quantified and evaluated. RESULTS: A total of 143 surveys were submitted by women of the general population. Data analysis confirmed previous predictions that at a hypothetical increased risk of contralateral breast cancer (CBC), about twice the proportion of women will elect CPM. With over 10 times the baseline risk and no surgical complications, 98.6% of women chose CPM. There was a decrease in affirmative responses with increasing morbidity. This decrease was least prominent at higher genetic risk, illustrating that when women are at a higher risk of CBC, the surgical morbidity rate has less of an impact on their decision for CPM. CONCLUSION: At increased risk of CBC, women are likely to elect for CPM. We anticipate that these findings will encourage the growing use of personalized medicine, with the potential to tailor breast cancer treatment plans for each patient's personal genetic profile.

INTRODUCTION: Les patientes atteintes d'un cancer du sein tendent de plus en plus à opter pour une mastectomie prophylactique controlatérale (MPC) malgré l'absence de données en démontrant les avantages sur la survie à long terme. Les chercheurs visaient à quantifier le risque génétique et de complications chirurgicales progressif, considéré comme nécessaire pour justifier une MPC. MÉTHODOLOGIE: Les chercheurs ont analysé des mutations génétiques liées au cancer du sein et les taux de morbidité associés à la chirurgie du cancer compilés dans un seul établissement. Ils ont créé un sondage faisant appel à une analyse utilitaire. Ils ont quantifié et évalué la gravité du risque génétique de cancer du sein et du risque de morbidité justifiant la MPC. RÉSULTATS: Des femmes de la population générale ont remis un total de 143 sondages. L'analyse des données a confirmé les prédictions antérieures selon lesquelles, environ deux fois la proportion de femmes choisiront une MPC devant un risque hypothétique accru de cancer du sein controlatéral (CSC). Malgré plus de dix fois le risque initial et l'absence de complications chirurgicales, 98,6 % des femmes optaient pour la MPC. Les réponses affirmatives diminuaient proportionnellement à l'augmentation de la morbidité. Cette diminution était moins évidente en cas de risque génétique plus élevé, ce qui démontre que lorsque les femmes sont plus vulnérables à un CSC, le taux de morbidité chirurgicale a moins de conséquences sur leur décision de MPC. CONCLUSION: Lorsqu'elles courent un risque accru de CSC, les femmes sont susceptibles d'opter pour une MPC. D'après les chercheurs, ces observations encourageront l'utilisation croissante d'une médecine personnalisée, qui aura le potentiel d'adapter les plans thérapeutiques du cancer du sein en fonction du profil génétique de chaque patiente.

A Comparative Analysis of Surgical Wound Infection Methods: Predictive Values of the CDC, ASEPSIS, and Southampton Scoring Systems in Evaluating Breast Reconstruction Surgical Site Infections.

Infection is the most significant complication in breast reconstruction surgery. While the Center for Disease Control and Prevention (CDC) is the most prevalent tool for surgical site infection (SSI) diagnosis, ASEPSIS and Southampton scoring methods have been speculated to be more sensitive. The ASEPSIS scoring system previously demonstrated much better interrater reliability than the CDC. We sought to assess the predictive value of various wound scoring methods in breast reconstruction SSIs. A retrospective analysis of all single-institution breast reconstruction infections from January 2013 to June 2016 was performed. Patients' postoperative wound-related complications were collected. Southampton, CDC, and modified ASEPSIS scores-extended to 30 postoperative days-were calculated. Relative predictive values for implant-based reconstruction were evaluated. Among the 22 reviewed cases, ASEPSIS scores greater than 30 resulted in a more than 50% rate of implant-based breast reconstruction failure. There was a significant positive correlation between ASEPSIS score and failure rate (P = .022). A Southampton classification of B-minor complication (60% failure)-had a greater associative risk of reconstruction failure than a classification of C-major complication (23% failure)-or classification of D-major hematoma (0% failure). The CDC score had no predictive value of success versus failure of reconstruction. While the CDC criteria and Southampton scoring systems demonstrated little clinical use, the ASEPSIS scoring system shows substantial predictive value for breast reconstruction SSIs. New procedure protocols should be implemented to require detailed surgical notes including the proportion of the wounds affected by inflammatory responses to allow for easier wound score calculation by these alternate scoring systems.

UNE ANALYSE COMPARATIVE DES MÉTHODES D'INFECTION DES PLAIES CHIRURGICALES LES VALEURS PRÉDICTIVES DES SYSTÈMES DE SCORE DU CDC DE L'ASEPSIS ET DE SOUTHAMPTON POUR ÉVALUER LES INFECTIONS AU SIÈGE DE RECONSTRUCTION MAMMAIRE: L'infection est la principale complication en cas de reconstruction mammaire. L'outil du Center for Disease Control (CDC) est le plus prévalent pour diagnostiquer l'infection au siège de l'opération, mais on spécule que les méthodes de score de l'ASEPSIS et de Southampton sont plus sensibles. L'ASEPSIS a déjà démontré une fiabilité interévaluateur bien meilleure que l'outil du CDC. Les chercheurs ont cherché à évaluer la valeur prédictive de diverses méthodes de score des plaies en cas d'infection au siège de la reconstruction mammaire. Les chercheurs ont effectué une analyse rétrospective de toutes les infections des reconstructions mammaires dans un seul établissement entre janvier 2013 et juin 2016. Ils ont colligé les complications liées aux plaies postopératoires des patients. Ils ont calculé les scores de Southampton, de CDC et de l'ASEPSIS modifiés, prolongées jusqu'à 30 jours après l'opération, et évalué les valeurs prédictives relatives des reconstructions mammaires par implant. Dans les 22 cas analysés, les scores de l'ASEPSIS supérieurs à 30 entraînaient un taux d'échec de reconstructions mammaires par implant supérieur à 50%. Il y avait une corrélation positive importante entre le score de l'ASEPSIS et le taux d'échec (p=0,022). Une classification de Southampton de B (complication mineure, échec de 60%) comportait un risque associatif plus important d'échec de la reconstruction qu'une classification de C (complication majeure, échec de 23%) ou de D (hématome majeur, échec de 0 %). Le score de CDC n'avait aucune valeur prédictive de succès par rapport à l'échec de reconstruction. Les critères de CDC et les systèmes de score de Southampton se sont révélés de peu d'intérêt clinique, mais le système de score de l'ASEPSIS a une valeur prédictive substantielle d'infection au siège de la reconstruction mammaire. Il faut adopter de nouveaux protocoles d'intervention pour exiger la prise de notes chirurgicales détaillées, y compris la proportion de plaies touchées par les réponses inflammatoires pour calculer plus facilement le score des plaies au moyen de ces autres systèmes de score.

Endoscopic Brow Lift Fixation With Mitek Suture Anchors: A 9-Year Experience of a New "Ideal" Technique.

PURPOSE: In recent years, the endoscopic technique has emerged as a minimally invasive approach to forehead rejuvenation, although the specific need for and mode of brow fixation for endoscopic brow lifts remain under considerable debate. An ideal fixation device should provide non-palpable long-lasting fixation and allow retention of the device post-operatively without the need for removal. It should also allow precise intraoperative adjustment for symmetry and correction of brow ptosis. METHODS: The authors describe an endoscopic brow lift technique using an absorbable bone anchor, Mitek Microfix. A retrospective chart review was conducted in patients who underwent endoscopic brow lift procedures utilizing this fixation method at an academic practice. Outcomes evaluated included operative times, reoperation rates, palpability, fixation device permanence, incremental costs comparisons to conventional methods, efficacy, and technical learning curve. Complication rates were evaluated and the economic, incremental cost analysis of current fixation methods was reviewed. RESULTS: Eighty-two patients underwent single-procedure endoscopic brow fixation using the Mitek anchor over a 9-year period (2005-2014). The mean operative time was 100 minutes. There were no cases of implant palpability, alopecia, or other postoperative complications. Two patients underwent revision secondary lifts after an average of 5.5 months for temporal ptosis. CONCLUSION: The Mitek Microfix QuickAnchor provides durable, long-lasting fixation without device palpability. Its technical ease of use is demonstrated by the reasonable mean operative time achieved with the active involvement of resident surgeons. This device is operator-friendly, easy to use, fully indwelling, and provides lasting fixation without the development of palpability or alopecia.

OBJECTIFS: Ces dernières années, la technique endoscopique est devenue une approche peu invasive du rajeunissement du front, mais la nécessité et le moyen de fixer les sourcils font l'objet de vifs débats. Le dispositif de fixation idéal doit être non palpable, durable et demeurer en place sans devoir être retiré. Il doit également assurer le rajustement intraopératoire précis de la symétrie et de la correction de la ptose des sourcils. MÉTHODOLOGIE: Les auteurs décrivent une technique de redrapage endoscopique des sourcils à l'aide de l'ancre osseuse absorbable Mitek Microfix. Ils ont procédé à une analyse rétrospective des dossiers des patients qui avaient subi un redrapage endoscopique des sourcils à l'aide de cette méthode de fixation dans un cabinet universitaire. Ils ont évalué la durée de l'opération, le taux de réopérations, la palpabilité, la permanence du dispositif de fixation, les comparaisons des coûts différentiels par rapport aux méthodes traditionnelles, l'efficacité et la courbe d'apprentissage technique. Ils ont également évalué le taux de complications et examiné l'analyse des coûts différentiels des méthodes de fixation. RÉSULTATS: Sur une période de neuf ans (de 2005 à 2014), 82 patients ont subi une seule intervention de fixation endoscopique des sourcils à l'aide de l'ancre Mitek. L'opération durait 100 minutes en moyenne. Il n'y a eu aucun cas de palpabilité de l'implant, d'alopécie ou d'autres complications postopératoires. Deux patients ont subi un redrapage secondaire après une ptose temporale au bout d'une période moyenne de 5,5 mois. CONCLUSION: L'ancre Mitek Microfix QuickAnchor procure une fixation durable sans palpabilité du dispositif. La simplicité de la technique est démontrée par le temps moyen raisonnable de l'opération obtenu avec la participation active de résidents en chirurgie. Ce dispositif à demeure est facile à utiliser pour l'opérateur et procure une fixation durable sans apparition de palpabilité ou d'alopécie.

The relationship of red blood cell transfusion to intestinal mucosal injury in premature infants.

OBJECTIVE: To determine the incidence of intestinal mucosal injury before and after transfusions in premature infants. STUDY DESIGN: Urine was collected throughout the hospital stay of 62 premature infants and specimens obtained within 24h before and after transfusion were assayed for intestinal fatty acid binding protein (iFABP). A urinary iFABP:creatinine ratio (iFABPu:Cru) of 2.0pg/nmol was considered elevated. RESULT: Forty-nine infants were transfused. iFABPu:Cru was elevated following 71 (75.6%) of 94 transfusions for which urine was available. In 51 (71.8%) of these, iFABPu:Cru was also elevated prior to the transfusion. Among four cases of transfusion-associated NEC, iFABPu was elevated following every sentinel transfusion and prior to three of them. CONCLUSION: Subclinical intestinal mucosal injury is frequent following blood transfusions in premature infants and, when present, usually precedes transfusion. This suggests that transfusion may not be a primary mediator of intestinal injury so much as anemia and its associated conditions. LEVEL OF EVIDENCE: Prognosis study/level 3.

Examining the validity of the ACS-NSQIP Risk Calculator in plastic surgery: lack of input specificity, outcome variability and imprecise risk calculations.

American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) created the Surgical Risk Calculator, to allow physicians to offer patients a risk-adjusted 30-day surgical outcome prediction. This tool has not yet been validated in plastic surgery. A retrospective analysis of all plastic surgery-specific complications from a quality assurance database from September 2013 through July 2015 was performed. Patient preoperative risk factors were entered into the ACS Surgical Risk Calculator, and predicted outcomes were compared with actual morbidities. The difference in average predicted complication rate versus the actual rate of complication within this population was examined. Within the study population of patients with complications (n=104), the calculator accurately predicted an above average risk for 20.90% of serious complications. For surgical site infections, the average predicted risk for the study population was 3.30%; this prediction was proven only 24.39% accurate. The actual incidence of any complication within the 4924 patients treated in our plastic surgery practice from September 2013 through June 2015 was 1.89%. The most common plastic surgery complications include seroma, hematoma, dehiscence and flap-related complications. The ACS Risk Calculator does not present rates for these risks. While most frequent outcomes fall into general risk calculator categories, the difference in predicted versus actual complication rates indicates that this tool does not accurately predict outcomes in plastic surgery. The ACS Surgical Risk Calculator is not a valid tool for the field of plastic surgery without further research to develop accurate risk stratification tools.

Complications of gastrojejunal feeding tubes in children.

BACKGROUND: Long-term gastrojejunal (GJ) feeding is an increasingly popular alternative to gastric fundoplication for children with pathologic reflux, particularly those with neurologic impairment. We sought to evaluate morbidity associated with GJ feeding tubes in a large population of children. MATERIALS AND METHODS: The records of all children who underwent placement of a GJ feeding tube in a large children's hospital between January 2005 and September 2013 were reviewed. Indications for GJ feedings were noted. Events including a requirement for tube replacement and intestinal complications attributable to a GJ tube that required a laparotomy were evaluated. Risk factors for morbidity were assessed. RESULTS: A total of 124 children underwent GJ tube placement at an average age of 5.0 y (2 mo-16 y). Of the total, 83 (66%) subjects were neurologically impaired and 108 (87%) had gastroesophageal reflux. Of those, 55 (44%) had undergone prior laparoscopic fundoplication. Persistent reflux symptoms occurred in 22 (17.6%). Subjects underwent an average of 2.75 tube replacements per year and those under 2 y old had almost four. Four children (3.2%) required emergent laparotomy for intestinal perforation due to a GJ tube. These subjects were significantly younger (12 mo) than those without perforations (60.6 mo, P < 0.005). CONCLUSIONS: GJ feeding tubes were associated with notable morbidity ranging from persistent reflux to dislodgement and intestinal perforation. Together with issues of inconvenience with continuous feedings, these complications should be taken into account in children and particularly infants, in whom GJ feedings are being considered as an alternative to fundoplication.