A Systematic Review of Simulation in Burn Care: Education, Assessment, and Management.

Assessment and management of burns require nuanced, timely interventions in high-stake settings, creating challenges for trainees. Simulation-based education has become increasingly popular in surgical and nonsurgical subspecialties to supplement training without compromising patient safety. This study aimed to systematically review the literature on existing burn management-related simulations. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles describing burn-specific surgical and nonsurgical simulation models were included. The model type, study description, simulated skills, assessment methods, fidelity, cost, and outcomes were collected. Of 3,472 articles, 31 met inclusion criteria. The majority of simulations were high-fidelity (n=17, 54.8%). Most were immersive (n=17, 54.8%) and used synthetic benchtop models (n=13, 41.9%), whereas none were augmented/virtual reality. Simulations of acute and early surgical intervention techniques (n=16, 51.6%) and burn wound assessments (n=15, 48.4%) were the most common, whereas burn reconstruction was the least common (n=3, 9.7%). Technical skills were taught more often (n=29, 93.5%) than non-technical skills (n=15, 48.4%). Subjective assessments (n=18, 58.1%) were used more often than objective assessments (n=23, 74.2%). Of the studies that reported costs, 91.7% (n=11) reported low costs. This review identified the need to expand burn simulator options, especially for burn reconstruction, and highlighted the paucity of animal, cadavers, and augmented/virtual reality models. Developing validated, accessible burn simulations to supplement training may improve education, patient safety, and outcomes.

The Impact of Intraoperative Vasopressor Use and Fluid Status on Flap Survival in Traumatic Lower Extremity Reconstruction.

INTRODUCTION: Historically, the use of intraoperative vasopressors during free flap lower extremity reconstruction has been proposed to adversely affect flap survival due to concerns about compromising flap perfusion. This study aims to analyze the impact of intraoperative vasopressor use and fluid administration on postoperative outcomes in patients undergoing traumatic lower extremity (LE) reconstruction. METHODS: Patients who underwent LE free flap reconstruction between 2015-2023 at a Level 1 Trauma Center were retrospectively reviewed. Statistical analysis was conducted to evaluate the association between vasopressor use and intraoperative fluids with partial/complete flap necrosis, as well as the differential effect of vasopressor use on flap outcomes based on varying fluid levels. RESULTS: 105 LE flaps were performed over an 8-year period. Vasopressors were administered intraoperatively to 19 (18.0%) cases. Overall flap survival and limb salvage rates were 97.1% and 93.3%, respectively. Intraoperative vasopressor use decreased the overall risk of postoperative flap necrosis (OR 0.00005, 95% CI [9.11x10-9-0.285], p=0.025), while a lower net fluid balance increased the risk of this outcome (OR 0.9985, 95% CI [0.9975-0.9996], p=0.007). Further interaction analysis revealed that vasopressor use increased the risk of flap necrosis in settings with a higher net fluid balance (OR 1.0032, 95% CI [1.0008-1.0056], p-interaction=0.010). CONCLUSION: This study demonstrated that intraoperative vasopressor use and adequate fluid status may be beneficial in improving flap outcomes in LE reconstruction. Vasopressor use with adequate fluid management can optimize hemodynamic stability when necessary during traumatic LE microvascular reconstruction without concern for increased risk of flap ischemia.

Evaluation of Induction Immunosuppression and Risk of Incisional Hernia After Liver Transplantation.

INTRODUCTION: Liver transplantation (LT) is a technically complex operation and usually performed on ill patients. A major postoperative morbidity is incisional hernia, occurring in 9.5%-32.4% of cases. There are mixed results in transplant studies regarding potential risk factors. Additionally, the literature is lacking in the relationship between specific immunosuppressive induction agents administered during LT and postoperative incisional hernia. METHODS: A single center, retrospective cohort study of patients who underwent primary LT between 4/2011-1/2018 was conducted. Clinical variables including demographics and comorbidities were reviewed. The primary end point was the development of an incisional hernia following LT. Sub analysis was performed for secondary end points to determine potential risk factors, including immunosuppressive induction agent. RESULTS: Overall, 418 patients met inclusion criteria. At 5 y post-LT, there were 66/271 (24.4%) and 53/147 (36.1%) patients diagnosed with an incisional hernia in the methylprednisolone and basiliximab groups, respectively. After propensity score matching, there was no difference in incisional hernia development between induction agents, P = 0.19. For patients with body mass index ≥30 and postoperative seroma of the abdominal wall, the hazard ratios were 2.67 (95% CI = 1.7, 4.3) and 2.03 (95% CI = 1.1, 3.9), respectively. CONCLUSIONS: Incisional hernia rate after LT was 28.5% at 5 y. Our analysis found that immunosuppressive induction agent at LT was not associated with the development of postoperative incisional hernia. However, preoperative obesity (body mass index ≥30) and postoperative seroma of the abdominal wall were potential risk factors. Further studies are needed to delineate if these risk factors remain across institutions and in alternative settings.

A systematic review of surgical simulation in gender affirmation surgery.

The burgeoning field of gender affirmation surgery (GAS) has become increasingly complex, challenging plastic surgeons to meet high standards for their patients. During the COVID-19 pandemic, the emphasis on remote learning ushered in the increased use of surgical simulation training, offering residents the opportunity to trial challenging procedures before treating patients. This systematic review seeks to summarize current simulation training models used in GAS. A systematic review was conducted according to PRISMA-P guidelines using the following databases: PubMed, Medline, Scopus, Embase, Web of Science, and Cochrane. Inclusion criteria were English-language peer-reviewed articles on surgical simulation techniques or training related to the field of gender surgery. Skills and techniques taught and assessed, model type, equipment, and cost were abstracted from articles. Our search criteria identified 1650 articles, 10 of which met the inclusion criteria for data extraction. Simulation models included those that involved cadavers (n = 2), synthetic benchtop (n = 5), augmented/virtual reality (n = 2), and 3D-printed interfaces (n = 1). The most common procedure involved breast or pectoral reconstruction and/or augmentation (n = 5), followed by vaginal reconstruction (n = 3). One simulation model involved facial GAS. All models focused on surgical technique and anatomy, three on suture skills or knot-tying, and one on surgical decision-making. The evolving field of GAS requires that plastic surgery trainees be knowledgeable on surgical techniques surrounding this scope of practice. Surgical simulation not only teaches residents how to master techniques but also helps address the sensitive nature of GAS.

Open Surgical Treatment of Middle Cerebral Artery Aneurysms: A Single-Center Series in the Endovascular Era.

OBJECTIVE: We review the outcomes of open surgical treatment of middle cerebral artery aneurysms (MCAAs) at a single center, focusing on aneurysm obliteration rates and functional outcomes at the most recent follow-up. These findings can be used for future comparisons of surgical outcomes with MCAAs. METHODS: We retrospectively reviewed cases from a prospectively maintained database of patients receiving open surgical treatment for ruptured or unruptured MCAAs between July 2014 and December 2022. We utilized patients' modified Rankin Scale (mRS) score and Glasgow Outcome Scale score as functional outcome measures. Means, standard deviations, medians, and interquartile ranges were calculated, and a student's t test or its nonparametric equivalent was used to compare subgroups. RESULTS: One hundred fifty patients (114 women, 76%; mean age 55.0 ± 14.7 years) with a total of 156 MCAAs comprised 152 cases; 85 (56%) ruptured and 71 (46%) unruptured. Bypass was performed in 34 cases (22.4%); 18 ruptured (51.4%) and 16 unruptured (48.6%). Intraoperative rupture occurred in 5 (5%) ruptured and 1 (2%) unruptured cases. Onwe hundred forty-five patients (95.4%) had aneurysm obliteration with initial surgery, with 98.4% of patients having complete occlusion at 40.2± 65.5 weeks of follow-up. Intrahospital mortality occurred in 7 (6.9%) ruptured versus 1 (2.0%) unruptured case. Fifty-two (51.5%) of the ruptured compared to 43 (86%) unruptured patients were discharged home, with the remaining patients requiring inpatient rehabilitation or long-term hospitalization. The ruptured group had a mean hospital stay of 18.4 ± 10.5 days versus. 5.7 ± 6.0 days for unruptured. Length of stay, discharge mRS/ Glasgow Outcome Scale, and mRS at 4-6 weeks favored unruptured cases (P < 0.0001-0.0336). Mean change in mRS from presentation to last follow-up favored ruptured cases (-0.7 ± 1.2 vs. -0.04 ± 1.2, P = 0.0215). CONCLUSIONS: Open surgery remains a safe and definitive treatment option for MCAAs in the endovascular era.

The cross-leg free flap: A systematic review of the literature.

BACKGROUND: Free tissue transfer is a mainstay treatment for lower extremity soft tissue injuries. When the traditional cross-leg flap cannot provide enough coverage, a cross-leg free flap (CLFF) is a limb-saving alternative. The aim of this study is to conduct a systematic review of the literature published on the CLFF. METHODS: We conducted a systematic review of articles describing the CLFF, according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Inclusion criteria included articles with primary data on the CLFF. Exclusion criteria included those describing pedicled cross-leg flaps or lacking complete data. Data analysis was performed using SPSS 29.0. RESULTS: Our review included 28 articles encompassing 130 patients who underwent free tissue transfer. Most were male (63.8%) with a mean age of 32.4 years. Latissimus dorsi was the most common flap type (30.0%), followed by vertical rectus myocutaneous (20.0%). Average flap size was 301.8 cm2 , with trauma in the lower third of the leg being the most common indication (73.1%). The contralateral posterior tibialis was the most common recipient artery (84.1%) followed by the anterior tibialis (9.5%). Complications included amputation (1.4%), partial graft loss, thrombosis, hematoma, prolonged pain, nonunion, and seroma; a forest plot was used to illustrate the low overall adverse events rate. Although bivariate analysis identified age, flap size, type, location, and donor site as variables significantly impacting the incidence of complications (p < .05), this was not sustained in a multivariate logistic regression model. CONCLUSION: The CLFF remains an excellent option for limb salvage when a suitable recipient vessel is unavailable. Our review demonstrates 1.4% flap failure and an acceptable complication rate. While most cases in our review describe muscle flaps, we report a complex case of limb salvage using an unusually large anterolateral thigh flap.

Comparison of Postoperative Complications in Patients Undergoing Limb Salvage Reconstructive Surgery Based on Estimated Prevalence of Preexisting Peripheral Arterial Disease.

BACKGROUND: Limb salvage after lower extremity (LE) trauma requires optimal blood flow for successful microsurgical reconstruction. Peripheral arterial disease (PAD) decreases LE perfusion, affecting wound healing. Patients who present with LE trauma may have undiagnosed PAD, particularly those with atherosclerotic risk factors. This study assesses outcomes after LE salvage in patients at risk for PAD. METHODS: This retrospective review evaluated patients who underwent LE reconstruction at a level 1 trauma center between 2007 and 2022. Patients with a nontraumatic mechanism of injury, missing postoperative records, and unspecified race were excluded. Demographics, flap characteristics, and postoperative complications were abstracted. The prevalence of LE PAD was calculated using a validated risk assessment tool. RESULTS: At our institution, 285 LE flaps performed on 254 patients were included in the study. Patients were categorized by prevalence of PAD, including 12 (4.7%) with high risk, 45 (17.7%) with intermediate risk, and 197 (77.6%) patients with low risk. The high-risk cohort had higher rates of partial flap necrosis ( P = 0.037), flap loss ( P = 0.006), and amputation ( P < 0.001) compared with the low-risk group. Fewer high-risk patients achieved full ambulation compared with the low-risk ( P = 0.005) cohort. Overall flap survival and limb salvage rates were 94.5% and 96.5%, respectively. Among the intermediate- and high-risk cohorts, only 50.9% of patients received a preoperative vascular assessment, and 3.8% received a vascular surgery consultation. CONCLUSIONS: Peripheral arterial disease represents a reconstructive challenge to microvascular surgeons. Patients with high-risk for PAD had higher rates of partial flap necrosis, flap loss, and amputation. In the setting of trauma, emphasis should be placed on preoperative vascular assessment for patients at risk of having undiagnosed PAD. Prospective studies collecting ankle-brachial index assessments and/or angiography will help validate this study's findings.

Three-Vessel Anastomosis for Direct Multiterritory Cerebral Revascularization: Case Series.

BACKGROUND AND OBJECTIVE: Cerebral revascularization of multiple territories traditionally requires multiple constructs, serial anastomoses, or a combination of direct and indirect approaches. A novel 3-vessel anastomosis technique allows for direct, simultaneous multiterritory cerebral revascularization using a single interposition graft. We herein present our experience with this approach. METHODS: Retrospective review of perioperative data and outcomes for patients undergoing multiterritory cerebral revascularization using a 3-vessel anastomosis from 2019 to 2023. RESULTS: Five patients met inclusion criteria (median age 53 years [range 12-73]). Three patients with complex middle cerebral artery aneurysms (1 ruptured) were treated with proximal ligation or partial/complete clip trapping and multiterritory external carotid artery-M2-M2 revascularization using a saphenous vein interposition graft. Two patients with moyamoya disease, prior strokes, and predominately bilateral anterior cerebral artery hypoperfusion were treated with proximal superficial temporal artery-A3-A3 revascularization using a radial artery or radial artery fascial flow-through free flap graft. No patients experienced significant surgery-related ischemia. Bypass patency was 100%. One patient had new strokes from vasospasm after subarachnoid hemorrhage. One patient required a revision surgery for subdural hematoma evacuation and radial artery fascial flow-through free flap debridement, without affecting bypass patency or neurologic outcome. On hospital discharge, median Glasgow Outcome Scale and modified Rankin Scale scores were 4 (range 3-5) and 2 (range 0-5), respectively. On follow-up, 1 patient died from medical complications of their presenting stroke; Glasgow Outcome Scale and modified Rankin Scale scores were otherwise stable or improved. CONCLUSION: The 3-vessel anastomosis technique can be considered for simultaneous revascularization of multiple intracranial territories.

Gaps in plastic surgery training: A comparative literature review of assessment tools in plastic surgery and general surgery.

Assessment tools for grading technical and nontechnical skills, such as operative technique and professionalism, are well established in general surgery. Less is known regarding the application of these tools in plastic surgery training. This study is a comparative review of the most prevalent assessment tools and rubrics utilized in general and plastic surgery. Two parallel systematic reviews of the literature utilizing PubMed and Cochrane were conducted for articles published between 1990 and 2022. Searches used Boolean operators specific to assessment tools in general and plastic surgery. Fourteen studies met the inclusion criteria for general surgery assessment tools, and 21 studies were included for plastic surgery assessment tools. Seven studies (50%) evaluated technical skills in general surgery, whereas 15 studies (71%) assessed technical skills in plastic surgery with commonality found in the evaluation of principles, such as tissue and instrument handling and operative flow. Task-specific evaluation tools were described for both general and plastic surgeries. Five studies evaluated nontechnical skills, such as communication and leadership in general surgery, whereas no plastic surgery studies solely examined nontechnical assessment tools. Our literature review demonstrates that standardized skill assessments in plastic surgery are lacking compared with those available in general surgery. Plastic surgery programs should consider implementing competency-based assessment tools in surgical coaching and training for technical and nontechnical skills. More research is necessary in plastic surgery to optimize the evaluation of nontechnical skills.

Combined open revascularization and endovascular treatment of complex intracranial aneurysms: case series.

Background and purpose: The treatment of complex intracranial aneurysms can be challenging with stand-alone open or endovascular techniques, particularly after rupture. A combined open and endovascular strategy can potentially limit the risk of extensive dissections with open-only techniques, and allow for aggressive definitive endovascular treatments with minimized downstream ischemic risk. Materials and methods: Retrospective, single-institution review of consecutive patients undergoing combined open revascularization and endovascular embolization/occlusion for complex intracranial aneurysms from 1/2016 to 6/2022. Results: Ten patients (4 male [40%]; mean age 51.9 ± 8.7 years) underwent combined open revascularization and endovascular treatment of intracranial aneurysms. The majority of aneurysms, 9/10 (90%), were ruptured and 8/10 (80%) were fusiform in morphology. Aneurysms of the posterior circulation represented 8/10 (80%) of the cases (vertebral artery [VA] involving the posterior inferior cerebellar artery [PICA] origin, proximal PICA or anterior inferior cerebellar artery/PICA complex, or proximal posterior cerebral artery). Revascularization strategies included intracranial-to-intracranial (IC-IC; 7/10 [70%]) and extracranial-to-intracranial (EC-IC; 3/10 [30%]) constructs, with 100% postoperative patency. Initial endovascular procedures (consisting of aneurysm/vessel sacrifice in 9/10 patients) were performed early after surgery (0.7 ± 1.5 days). In one patient, secondary endovascular vessel sacrifice was performed after an initial sub-occlusive embolization. Treatment related strokes were diagnosed in 3/10 patients (30%), largely from involved or nearby perforators. All bypasses with follow-up were patent (median 14.0, range 4-72 months). Good outcomes (defined as a Glasgow Outcomes Scale ≥4 and modified Rankin Scale ≤2) occurred in 6/10 patients (60%). Conclusion: A variety of complex aneurysms not amenable to stand-alone open or endovascular techniques can be successfully treated with combined open and endovascular approaches. Recognition and preservation of perforators is critical to treatment success.

Outcomes of Local Versus Free Flaps for Reconstruction of the Proximal One-Third of the Leg.

BACKGROUND: Reconstruction of the proximal one-third of the leg often requires soft tissue transfer to facilitate limb salvage. Tissue transfers are usually local or free flaps depending on wound dimensions, location, and surgeon preference. Historically, the proximal third of the leg was covered with pedicle flaps, but recently, we have used more free flaps in this position. Using data from a level 1 trauma center, we sought to evaluate outcomes of surgical management of proximal-third leg reconstruction across local and free flaps. METHODS: This is an institutional review board-approved, retrospective chart review undertaken at LAC + USC Medical Center from 2007 to 2021. Patient history, demographics, flap characteristics, Gustilo-Anderson fracture classification, and outcomes were collected and analyzed in an internal database. Outcomes of interest included flap failure rates, postoperative complications, and long-term ambulatory status. RESULTS: Among 394 lower extremity flaps placed, 122 flaps involved the proximal-third leg across 102 patients. Average age of patients was 42.8 ± 15.2 years; of note, the free flap cohort was significantly younger than the local flap cohort (P = 0.019). Ten local flaps suffered from infectious complications: osteomyelitis (n = 6) and hardware infection (n = 4), versus only 1 free flap that suffered from hardware infection; notably, these differences were not significant across cohorts. Free flaps had significantly more flap revisions (13.3%; P = 0.039) and overall flap complications (20.0%; P = 0.031) compared with local flaps; however, partial flap necrosis (4.9%) and flap loss (3.3%) were not significantly different across cohorts. Overall flap survival was 96.7%, and full ambulation was achieved in 42.2% of patients without significant differences across cohorts. CONCLUSIONS: Our evaluation of proximal-third leg wounds demonstrates fewer infectious outcomes with free flaps compared with local flaps. There are multiple confounding variables; however, this finding may speak to the reliability of a robust free flap. Overall, there was no significant difference in patient comorbidities across flap cohorts with great overall flap survival. Ultimately, flap selection did not affect rates of flap necrosis, flap loss, or final ambulatory status.

Left atrial appendage closure during cardiac surgery: Safe but underutilized in California.

Objective: Left atrial appendage (LAA) closure is associated with reduced rates of stroke in patients with atrial fibrillation (AF). We evaluated trends in LAA closure, the association of LAA closure with stroke/systemic embolism, and its safety profile in patients with AF who underwent cardiac surgery in California. We further tested for hospital-level variation in concomitant LAA closure. Methods: Adults who underwent coronary artery bypass grafting and/or valve surgery with preoperative AF were identified in the 2016 to 2019 Office of Statewide Health Planning and Development databases. Propensity score matching was performed to study risk-adjusted associations of LAA closure with ischemic stroke/systemic embolism. Hospital-level variation was studied using intraclass correlation coefficients. Results: Among 18,434 patients with AF who underwent coronary artery bypass grafting/valve surgery, 47.7% received LAA closure. Rates of LAA closure increased from 44.4% to 51.4% from 2016 to 2019 (P < .001). In 4652 propensity score-matched patients, LAA closure was associated with reduced incidence of stroke/systemic embolism at discharge (1.6% vs 3.1%; P < .001) and readmission with stroke/systemic embolism at 1 year (2.9% vs 4.5%; P = .004). LAA closure was not associated with acute kidney injury, pulmonary complications, blood transfusion, reoperation, or in-hospital mortality. Approximately 18% of the risk-adjusted variation in LAA use was attributed to the hospital, with median center-level rate of 44.9% (interquartile range, 29.6%-57.4%). Conclusions: LAA closure was associated with minimal surgical morbidity, and reduced short- and midterm incidence of stroke/systemic embolism. Although the use of LAA closure has increased, substantial variation exists among programs in California, suggesting the need for further standardization of care.

Comparative Evaluation of the Electronic Residency Application Service Versus the Plastic Surgery Common Application to a Single Institution in the 2022 Integrated Plastic Surgery Match.

BACKGROUND: The Plastic Surgery Common Application (PSCA) has emerged as a low-cost alternative application portal to the Electronic Residency Application Service (ERAS) for integrated plastic surgery applicants. During the 2021 to 2022 application cycle, our plastic surgery residency program accepted both the PSCA and ERAS applications to help recruit candidates otherwise deterred by prohibitively high application costs. We sought to determine how the PSCA compared with the ERAS application in a standardized review of applications scores. METHODS: The PSCA and ERAS applications from 28 candidates who received interviews from the Keck School of Medicine were analyzed. These 56 applications were randomly assigned across 22 independent reviewers. Each reviewer scored applications on a scale of 1 to 5 with regard to communication skills, leadership, intellectual curiosity, compatibility with the program, service, and perseverance. Mean scores between the applications were compared using 2-tailed z tests, with statistical significance set at P < 0.05. RESULTS: The 56 residency applications had a combined mean score of 4.21 (95% confidence interval [CI], 4.13-4.29). The mean score of PSCA applications (4.19; 95% CI, 4.08-4.31) did not significantly differ from the mean score of ERAS applications (4.24; 95% CI, 4.12-4.35; P = 0.57). The PSCA and ERAS applications did not have a significant difference in the mean scores for any review category. CONCLUSION: There was no difference between the overall scores and the scores of each review category between the PSCA and ERAS applications, suggesting that the PSCA may be a reasonable alternative to ERAS for medical students applying to plastic surgery residency.

A Novel Bypass Technique to Prevent Vexing Spinal Cord Ischemia in Endovascular Thoracoabdominal Aortic Intervention.

BACKGROUND: Spinal cord ischemia remains a devastating complication when treating patients with complex thoracoabdominal aortic aneurysms using fenestrated endovascular aortic repair. This approach is progressively deployed. However, to date, no strategy has been identified to reduce the feared risk of spinal cord ischemia. OBJECTIVE: To introduce a novel bypass technique using a customized composite graft to create a direct extra-anatomic revascularization before fenestrated endovascular aortic repair in patients with high-risk of spinal cord ischemia. METHODS: To demonstrate this novel concept, we present here a clinical case that reports the strategy of this novel concept in detail. An 83-year-old man with medical history of endovascular repair of an abdominal aortic aneurysm and thoracic aorta presented with a type IA endoleak, located along the posterior superior aspect of the aortic stent graft adjacent to the lumbar arteries. A multidisciplinary plan was developed, which included a novel bypass from the profunda femoris to the left L1 radicular artery before fenestrated endovascular aortic repair to prevent spinal cord ischemia. RESULTS: The patient successfully receives the novel extra-anatomic revascularization bypass before fenestrated endovascular aortic repair. During the first implementation of this strategy, no intraoperative difficulties and postoperative complications were observed. CONCLUSION: This case demonstrates a novel surgical technique before fenestrated endovascular aortic repair for prevention of spinal cord ischemia. In addition, this concept provides a promising direction to not only complement the existing surgical techniques but also to generate more future innovations.

Antibiotic bead pouch versus negative pressure wound therapy at initial management of AO/OTA 42 type IIIB open tibia fracture may reduce fracture related infection: A retrospective analysis of 113 patients.

INTRODUCTION: Fracture related infection (FRI) may be a devastating complication of open tibial shaft fractures. We sought to determine if antibiotic bead pouch, negative pressure wound therapy, or negative pressure wound therapy over antibiotic beads as the initial coverage method for type IIIB open tibial shaft fractures is associated with risk of FRI. PATIENTS AND METHODS: Retrospective cohort study with radiograph and chart review of patients aged ≥16 years with isolated, displaced, extra-articular, Gustilo-Anderson type IIIB open diaphyseal AO/OTA 42 tibial fractures requiring rotational or free tissue transfer for soft tissue coverage at one Level 1 trauma center between 2007 and 2020. An association of dressing applied at the first surgical debridement (application of antibiotic bead pouch, negative pressure wound therapy, or combined therapy) with a primary outcome of FRI requiring debridement or amputation was analyzed by multivariable logistic regression considering demographic, injury, and treatment characteristics. RESULTS: 113 patients met eligibility criteria. Median follow-up was 33 months (interquartile range 5-88). 41 patients were initially treated with NPWT, 59 with ABP, and 13 with ABP+NPWT at the initial surgical debridement. 39 (35%) underwent subsequent debridement or amputation for FRI. One amputation occurred in the ABP group for refractory deep surgical site infection (p = 0.630). Initial wound management with an antibiotic bead pouch versus either negative pressure wound therapy alone or negative pressure wound therapy combined with an antibiotic bead pouch was associated with lower odds of debridement or amputation for FRI (ß = -1.08, 95% CI -2.00 to -0.17, p = 0.02). CONCLUSIONS: In our retrospective analysis, antibiotic bead pouch for initial coverage of type IIIB open tibial shaft fractures requiring flap coverage was associated with a lower risk of FRI requiring debridement or amputation than negative pressure wound therapy applied with or without antibiotic beads. A prospective clinical trial is warranted.

Arterial Anastomosis Using Microsurgical Techniques in Adult Live Donor Liver Transplant: A Focus on Technique and Outcomes at a Single Institution.

BACKGROUND: Microvascular hepatic artery reconstruction (MHAR) is associated with decreased rates of hepatic artery thrombosis (HAT) in living donor liver transplantation (LDLT). There is a paucity of literature describing the learning points and initiation of this technique at the institutional level. The objective of this study is to report our institutional experience using MHAR in adult LDLT with a focus on technique and outcomes. METHODS: A retrospective review of adult patients who underwent LDLT from January 2012 to December 2020 was conducted. Patients were divided into two groups, those who underwent LDLT without MHAR and with MHAR. We analyzed cases for technical data including donor and recipient artery characteristics, anastomotic techniques, intraop events, and postop complications. A Mann-Whitney test was performed to compare outcomes between non-MHAR and MHAR patients. RESULTS: Fifty non-MHAR and 50 MHAR patients met inclusion criteria. Median age at transplantation was 58 (interquartile range [IQR] 11.8) and 57.5 years (IQR 14.5), respectively. Median follow-up for MHAR patients was 12.8 months (IQR 11.6). The most common recipient arteries were the right hepatic artery (HA) (58%) and left HA (20%). Median size of recipient and donor arteries were 3.3 mm (IQR 0.7) and 3.1 mm (IQR 0.7), resulting in a median mismatch size of 0.3 mm (IQR 0.4). Median microanastomosis time was 44 minutes (IQR 0). HAT, graft failure, and mortality rates were higher in the non-MHAR cohort (6% vs. 0%, 8% vs. 0%, and 16% vs. 6%, respectively); however, these did not reach statistical significance. CONCLUSION: This study found lower rates of HAT and graft failure after implementing MHAR, though statistical significance was not achieved. Larger cohort studies are needed to further assess the potential benefit of MHAR in adult LDLT. From our experience, MHAR requires cooperation between the transplant and microsurgical teams, with technical challenges overcome with appropriate instrumentation and planning.

Regional Variation in the Use and Outcomes of Transcatheter Aortic Valve Replacement in California.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has been widely adopted for management of aortic stenosis. The purpose of this study was to examine regional access to and outcomes following TAVR in California. METHODS: Patients undergoing TAVR or isolated surgical aortic valve replacement (SAVR) from 2008 to 2019 in California were identified in the Office of Statewide Health Planning and Development database. California was divided into seven regions: Northern California, San Francisco Bay Area, Central California, Los Angeles, Inland Empire, Orange, and San Diego. Regional TAVR volumes were normalized to Medicare beneficiaries or isolated SAVR volume. Outcomes included risk-adjusted 30-day mortality and major adverse cardiovascular and cerebral events (MACCE). Trends were studied using non-parametric tests, and regional outcomes using logistic regression. RESULTS: TAVR volume increased annually since 2011, with 7148 cases performed in California in 2019. After normalization, variation in utilization of TAVR was evident, with the least performed in Central California. TAVR to SAVR ratios in 2019 were greatest in Northern California, Los Angeles, and San Diego, and least in the Inland Empire. After risk adjustment, there were no significant regional differences in 30-day mortality, but lower 30-day MACCE in the San Francisco Bay Area. CONCLUSIONS: Regional differences in TAVR utilization exist, with limited access in Central California and the Inland Empire, but risk-adjusted outcomes are similar. Efforts to reach underserved areas through existing program expansion or regional referrals may distribute transcatheter technology more equitably across California.

Integration of Universal Germline Genetic Testing for All New Breast Cancer Patients.

BACKGROUND: The American Society of Breast Surgeons recommends genetic testing (GT) for all women with breast cancer (BC), but implementation and uptake of GT has not been well-described. METHODS: A retrospective chart review was performed for newly diagnosed BC patients or patients with a newly identified recurrence of BC seen in a multidisciplinary clinic (MDBC) who were offered genetic counseling (GC) and GT. RESULTS: The 138 women attending the MDBC had a median age of 54 years and comprised non-Hispanic whites (46%), Asians (28%), Hispanics (17%), blacks (4%), and other (5%). Of the 105 (76%) patients without prior GT, 100 (95%) accepted GC, with 93 (93%) of these 100 patients undergoing GT. The patients meeting the National Comprehensive Cancer Network (NCCN) guidelines for GT were more likely to undergo GT. Testing was performed with a 67- to 84-gene panel, together with an 8- to 9-gene STAT panel if needed. Among 120 patients with reports available, including 33 patients previously tested, 15 (12%) were positive (1 BLM, 1 BRCA1, 3 BRCA2, 1 BRIP1, 1 CFTR, 1 CHEK2, 1 MUTYH, 1 PALB2, 1 PRSS1, 1 RAD50, 1 RET, and 2 TP53), 44 (37%) were negative, and 61 (51%) had an uncertain variant. The median time to STAT results (n = 50) was 8 days. The STAT results were available before surgery for 47 (98%) of the 48 STAT patients undergoing surgery. CONCLUSIONS: New BC patients attending the MDBC demonstrated high rates of acceptance of GC and GT. The combination of GC and GT can offer timely information critical to patient risk assessment and treatment planning.

Identification of DOT1L inhibitor in a screen for factors that promote dopaminergic neuron survival.

Parkinson's disease (PD) is a common neurodegenerative disorder characterized by the progressive loss of dopaminergic (DA) neurons in the substantia nigra region of the midbrain. Diagnostic criteria for PD require that at least two of three motor signs are observed: tremor, rigidity, and/or bradykinesia. The most common and effective treatment for PD is Levodopa (L-DOPA) which is readily converted to DA and has been the primary treatment since the 1960's. Dopamine agonists have also been developed but are less effective than L-DOPA. Although the lack of a model system to study PD has hampered efforts to identify treatments, diverse screening strategies have been proposed for identification of new pharmaceutical candidates. Here, we describe a pilot screen to identify candidate molecules from a bioactive compound library, that might increase formation, maintenance and/or survival of DA neurons in vitro. The screen used a previously characterized reporter construct consisting of the luciferase gene inserted downstream of the endogenous tyrosine hydroxylase (TH) gene and neurons differentiated from human pluripotent stem cells for 18 days. The reporter mimics expression of TH and includes a secreted luciferase whose activity can be measured non-invasively over multiple timepoints. Screening of the bioactive compound library resulted in the identification of a single molecule, SGC0946, that is an inhibitor of DOT1L (Disruptor Of Telomeric silencing 1-Like) which encodes a widely-conserved histone H3K79 methyltransferase that is able to both activate and repress gene transcription. Our results indicate that SGC0946 increased reporter luciferase activity with a single treatment for 48-h post-plating being equivalent to continuous treatment. Moreover, data suggested that the total number of neurons differentiated in the assays was comparable from experiment to experiment under different SGC0946 treatments over time. In contrast, data suggested that the survival and/or maintenance of DA neurons might be specifically enhanced by SGC0946 treatment. These results document the feasibility of a set of tools for further exploration of small molecules that may impact DA neuron differentiation, maintenance and/or survival. Results provide evidence in support of other reports that indicate inhibition of DOT1L may play an important role in maintenance and survival of neural progenitor cells (NPCs) and their lineage-specific differentiation.