Does the use of Acellular Dermal Matrices (ADM) in women undergoing pre-pectoral implant-based breast reconstruction increase operative success versus non-use of ADM in the same setting? A systematic review.

BACKGROUND: Breast cancer is the most common malignancy among women in the UK. Reconstruction - of which implant-based breast reconstruction (IBBR) is the most common - forms a core part of surgical management of breast cancer. More recently, pre-pectoral IBBR has become common as technology and operative techniques have evolved. Many surgeons use acellular dermal matrix (ADM) in reconstruction however there is little evidence in literature that this improves surgical outcomes. This review will assess available evidence for surgical outcomes for breast reconstructions using ADM versus non-use of ADM. METHODS: A database search was performed of Ovid Medline, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (2012-2022). Studies were screened using inclusion and exclusion criteria. Risk of Bias was assessed using the Newcastle Ottawa scale and ROBIS tools. Analysis and meta-analysis were performed. RESULTS: This review included 22 studies (3822 breast reconstructions). No significant difference between overall complications and failure rates between ADM and non-ADM use was demonstrated. Capsular contracture, wound dehiscence and implant rippling had significant differences however these results demonstrated high heterogeneity thus wider generalisation may be inaccurate. Patient quality of life scores were not recorded consistently or comparably between papers. CONCLUSIONS: This review suggests a lack of significant differences in most complications between ADM use and non-use for pre-pectoral IBBR. If no increase in complications exists between groups, this has significant implications for surgical and legislative decision-making. There is, however, inadequate evidence available on the topic and further research is required.

Establishing an equipoise: Does the use of acellular dermal matrices in pre-pectoral implant-based breast reconstruction improve outcomes?

INTRODUCTION: Breast cancer is the most common malignancy among women in the United Kingdom. Surgical management commonly comprises mastectomy and reconstruction, of which implant-based breast reconstruction (IBBR) is the most prevalent. Acellular dermal matrices (ADM) are widely used in pre-pectoral IBBR; however, there is limited high-quality evidence supporting their efficacy. This study aimed to establish an equipoise via an expert consensus survey. METHODS: An online survey was designed with a steering group of experts. Questions covered participant information, opinions regarding surgical outcomes with ADM use in pre-pectoral IBBR and opinions regarding the available scientific evidence on the topic. The survey was advertised via national and international professional organisations. Quantitative and qualitative analyses were performed. RESULTS: Thirty-two participants from the UK, Italy and Australia completed the survey. Key findings of this study included disagreement among participants regarding the surgical outcomes associated with ADM use. Participants who believed that ADM reduced the risk of short-term complications and implant failure/explantation comprised a minority (21.9%). Participants who felt that ADM use improved cosmetic outcomes and reduced long-term complications were a relative majority at 43.8% and 40.6%, respectively. Furthermore, 56.3% of the participants felt that there was scarce scientific evidence on the topic. CONCLUSIONS: This study provides insights from international surgeons, establishing a lack of consensus on surgical outcomes, efficacy and evidence-base supporting the use of ADMs in pre-pectoral IBBR. Given this clinical equipoise, alongside the growing burden of breast cancer associated morbidity and need for reconstruction, the implications of this study are that large-scale, prospective, randomised-controlled data are needed to establish whether ADM use in pre-pectoral breast reconstruction improves the outcomes.

Rural Suicide: Demographics, Causes, and Treatment Implications.

Suicide rates in rural areas are higher than urban areas and growing, with current treatment developments only exacerbating this discrepancy. Within individual factors, both age and gender relate to and intersect with personal values related to self-reliance and attitudes toward mental health difficulties and treatment to increase suicide risk. The lethality ubiquitous in rural environments and occupations is a leading factor in rural suicide rates, with other factors such as race alternately noted to be a key factor but with more mixed findings. The cultural values of rural communities as typically negative toward mental health disclosure and treatment contribute to the disengagement of rural communities from treatment that may otherwise prevent suicides, exacerbating the physical lack of treatment access many rural communities experience. Working within the primary care system alongside increased telehealth utilization are suggested to reduce rural suicide rates.

Prolonged operative time is a risk factor for adverse postoperative outcomes in the unilateral deep inferior epigastric perforator (DIEP) flap surgery: A retrospective cohort study.

BACKGROUND: Currently, one published study documented operative time (OT) as a predictor for postoperative outcomes in bilateral deep inferior epigastric perforator (DIEP) flap breast reconstructions. No literature has investigated this in unilateral DIEP flaps. We aimed to determine the relationship between unilateral OT, postoperative complications, unplanned reoperations (UR), and extended length-of-stay (eLOS). METHODS: Patients who underwent elective unilateral DIEP reconstruction from 2018 to 2023 at a tertiary centre in London, United Kingdom, were retrospectively analysed. Patients were divided into four groups depending on OT quartiles to define a critical cut-off period. Data on extensive covariates, including procedural complexity, was recorded and used in univariable and multivariable regression models. RESULTS: The final cohort contained 173 patients. After risk-adjustment, ≥421-minute operations led to a significantly higher overall complication rate (HR: 2.14, 95% CI: 1.26, 3.64, p = 0.005) relative to <421 min. Significantly higher odds of eLOS were observed in the ≥460-minute group (OR: 2.07, 95% CI: 1.07, 3.99, p = 0.03) compared to <460 min. There was no significant effect on the rate of postoperative UR across any OT group. CONCLUSIONS: We confirmed OT was an independent predictor for postoperative outcomes in the DIEP flap, and demonstrated this in unilateral reconstructions. A clinical maximum threshold of 7 h was derived based on this cohort to help guide future surgical practice. Efficiency can be achieved by meticulous preoperative planning and process standardisation, multiple senior surgeons working per flap, and smooth teamwork between specialities and intraoperative staff.

A Single-center Comparison of Unipedicled and Bipedicled Diep Flap Early Outcomes in 98 Patients.

The deep inferior epigastric perforator (DIEP) flap is the gold standard for autologous breast reconstruction. One or two pedicles may be used. Our study is the first to compare unipedicled and bipedicled DIEP flaps on donor and recipient site outcomes in the same patient cohort. Methods: This is a retrospective cohort study comparing DIEP flap outcomes between 2019 and 2022. Results: There were 98 patients, categorized differently for recipient or donor site. The recipient groups were unilateral unipedicled (N = 52), bilateral unipedicled (N = 15), and unilateral bipedicled (N = 31), and donor site groups were unipedicled (N = 52) and bipedicled (N = 46, including bilateral unipedicled and unilateral bipedicled). Bipedicled DIEP flaps had 1.15 times greater odds of donor site complication (95% CI, 0.52-2.55). Adjusting for operative time that was longer in bipedicled DIEP flaps (P < 0.001), odds ratio decreased, and there was a lower probability of donor site complication for bipedicled flaps (OR, 0.84; 95% CI, 0.31-2.29). Odds of recipient area complication was not significantly different between groups. Unilateral unipedicled DIEP flaps had significantly higher rates of revisional elective surgery than unilateral bipedicled DIEP flaps (40.4% versus 12.9%; P = 0.029). Conclusions: We demonstrate no significant difference in donor site morbidity between unipedicled and bipedicled DIEP flaps. Bipedicled DIEP flaps do have slightly higher rates of donor site morbidity, which can be partly explained by longer operative times. There is no significant difference in recipient site complications, and bipedicled DIEP flaps can reduce rates of further elective surgery.

Corrigendum: Seasonal decline in leaf photosynthesis in perennial switchgrass explained by sink limitations and water deficit.

[This corrects the article DOI: 10.3389/fpls.2022.1023571.].

Waiting time for Mohs Micrographic Surgery and the associated increase in lesion size of basal cell carcinoma.

BACKGROUND: The first-line treatment for basal cell carcinoma (BCC) involved either surgical excision (SE) or Mohs micrographic surgery (MMS). The current waiting time for MMS and whether this is associated with worsening of outcome is unknown. We aim to look at the waiting time for MMS upon review at the Outpatient Specialist Dermatology Clinic and the increase in lesion size during this time period. METHODS: A retrospective analysis of all patients who underwent MMS for biopsy-proven BCC over a duration of 5 years was performed. Variables analysed included patient age, sex, location, histologic subtype, lesion size at initial presentation, lesion size during MMS, defect size following MMS, waiting time for MMS, and projected defect size if lesions were treated with SE at earlier time point. RESULTS: A total of 233 patients were included in the final analysis. The mean wait time between referral to MMS was 215.8±125.7 days. The mean maximum diameter of lesions was 9.34±5.23 mm at referral for MMS and 11.91±6.60 mm at presentation for MMS, hence an increase of 3.01±3.03 mm (p=0.001, paired t-test), which equates to 1.41±0.42 times increase. The mean maximum diameter of the actual defect size post-MMS was 18.03±9.45mm, while the projected diameter of defect post SE was 15.29±5.71 mm, hence, smaller by 3.27±5.51 mm (p=0.001, paired t-test) compared with actual defect size post-MMS. CONCLUSION: This study highlights that the lesion grows significantly during the long wait for MMS. Hence, an increase in capacity for MMS is essential to reduce the waiting time for surgery which could lead to a defect which is easier to reconstruct with better outcome for patients.

Land-based climate solutions for the United States.

Meeting end-of-century global warming targets requires aggressive action on multiple fronts. Recent reports note the futility of addressing mitigation goals without fully engaging the agricultural sector, yet no available assessments combine both nature-based solutions (reforestation, grassland and wetland protection, and agricultural practice change) and cellulosic bioenergy for a single geographic region. Collectively, these solutions might offer a suite of climate, biodiversity, and other benefits greater than either alone. Nature-based solutions are largely constrained by the duration of carbon accrual in soils and forest biomass; each of these carbon pools will eventually saturate. Bioenergy solutions can last indefinitely but carry significant environmental risk if carelessly deployed. We detail a simplified scenario for the United States that illustrates the benefits of combining approaches. We assign a portion of non-forested former cropland to bioenergy sufficient to meet projected mid-century transportation needs, with the remainder assigned to nature-based solutions such as reforestation. Bottom-up mitigation potentials for the aggregate contributions of crop, grazing, forest, and bioenergy lands are assessed by including in a Monte Carlo model conservative ranges for cost-effective local mitigation capacities, together with ranges for (a) areal extents that avoid double counting and include realistic adoption rates and (b) the projected duration of different carbon sinks. The projected duration illustrates the net effect of eventually saturating soil carbon pools in the case of most strategies, and additionally saturating biomass carbon pools in the case of forest management. Results show a conservative end-of-century mitigation capacity of 110 (57-178) Gt CO2 e for the U.S., ~50% higher than existing estimates that prioritize nature-based or bioenergy solutions separately. Further research is needed to shrink uncertainties, but there is sufficient confidence in the general magnitude and direction of a combined approach to plan for deployment now.

Reducing adverse impacts of Amazon hydropower expansion.

Proposed hydropower dams at more than 350 sites throughout the Amazon require strategic evaluation of trade-offs between the numerous ecosystem services provided by Earth's largest and most biodiverse river basin. These services are spatially variable, hence collective impacts of newly built dams depend strongly on their configuration. We use multiobjective optimization to identify portfolios of sites that simultaneously minimize impacts on river flow, river connectivity, sediment transport, fish diversity, and greenhouse gas emissions while achieving energy production goals. We find that uncoordinated, dam-by-dam hydropower expansion has resulted in forgone ecosystem service benefits. Minimizing further damage from hydropower development requires considering diverse environmental impacts across the entire basin, as well as cooperation among Amazonian nations. Our findings offer a transferable model for the evaluation of hydropower expansion in transboundary basins.

Results of the United States Food and Drug Administration Clinical Trial of the CustomFlex Artificial Iris.

PURPOSE: To evaluate safety and efficacy of a custom-manufactured artificial iris device (CustomFlex Artificial Iris; HumanOptics AG) for the treatment of congenital and acquired iris defects. DESIGN: Multicenter, prospective, unmasked, nonrandomized, interventional clinical trial. PARTICIPANTS: Patients with photophobia, sensitivity secondary to partial or complete congenital or acquired iris defects, or both. METHODS: Eyes were implanted from November 26, 2013, to December 1, 2017, with a custom, foldable artificial iris by 1 of 4 different surgical techniques. Patients were evaluated 1 day, 1 week, and 1, 3, 6, and 12 months after surgery. At each examination, slit-lamp findings, intraocular pressure, implant position, subjective visual symptoms, and complications were recorded. Corrected distance visual acuity (CDVA) and endothelial cell density (ECD) were measured at 3, 6, or 12 months as additional safety evaluations. The 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) was used to assess health-related quality of life affected by vision. The Global Aesthetic Improvement Scale was used to assess cosmetic results. MAIN OUTCOME MEASURES: Photosensitivity, glare, visual symptoms, NEI VFQ-25 score, Global Aesthetic Improvement Scale rating, prosthesis-related adverse events, intraocular lens (IOL)-related adverse events, and surgery-related adverse events 12 months after surgery. RESULTS: At the 12-month postoperative examination, a 59.7% reduction in marked to severe daytime light sensitivity (P < 0.0001), a 41.5% reduction in marked to severe nighttime light sensitivity (P < 0.0001), a 53.1% reduction in marked to severe daytime glare (P < 0.0001), and a 48.5% reduction in severe nighttime glare (P < 0.0001) were found. A 15.4-point improvement (P < 0.0001) in the NEI VFQ-25 total score was found, and 93.8% of patients reported an improvement in cosmesis as measured by the Global Aesthetic Improvement Scale 12 months after surgery. No loss of CDVA of > 2 lines related to the device was found. Median ECD loss was 5.3% at 6 months after surgery and 7.2% at 12 months after surgery. CONCLUSIONS: The artificial iris surpassed all key safety end points for adverse events related to the device, IOL, or implant surgery and met all key efficacy end points, including decreased light and glare sensitivity, improved health-related quality of life, and satisfaction with cosmesis. The device is safe and effective for the treatment of symptoms and an unacceptable cosmetic appearance created by congenital or acquired iris defects.

Seasonal decline in leaf photosynthesis in perennial switchgrass explained by sink limitations and water deficit.

Leaf photosynthesis of perennial grasses usually decreases markedly from early to late summer, even when the canopy remains green and environmental conditions are favorable for photosynthesis. Understanding the physiological basis of this photosynthetic decline reveals the potential for yield improvement. We tested the association of seasonal photosynthetic decline in switchgrass (Panicum virgatum L.) with water availability by comparing plants experiencing ambient rainfall with plants in a rainfall exclusion experiment in Michigan, USA. For switchgrass exposed to ambient rainfall, daily net CO2 assimilation ( A n e t ' ) declined from 0.9 mol CO2 m-2 day-1 in early summer to 0.43 mol CO2 m-2 day-1 in late summer (53% reduction; P<0.0001). Under rainfall exclusion shelters, soil water content was 73% lower and A n e t ' was 12% and 26% lower in July and September, respectively, compared to those of the rainfed plants. Despite these differences, the seasonal photosynthetic decline was similar in the season-long rainfall exclusion compared to the rainfed plants; A n e t ' in switchgrass under the shelters declined from 0.85 mol CO2 m-2 day-1 in early summer to 0.39 mol CO2 m-2 day-1 (54% reduction; P<0.0001) in late summer. These results suggest that while water deficit limited A n e t ' late in the season, abundant late-season rainfalls were not enough to restore A n e t ' in the rainfed plants to early-summer values suggesting water deficit was not the sole driver of the decline. Alongside change in photosynthesis, starch in the rhizomes increased 4-fold (P<0.0001) and stabilized when leaf photosynthesis reached constant low values. Additionally, water limitation under shelters had no negative effects on the timing of rhizome starch accumulation, and rhizome starch content increased ~ 6-fold. These results showed that rhizomes also affect leaf photosynthesis during the growing season. Towards the end of the growing season, when vegetative growth is completed and rhizome reserves are filled, diminishing rhizome sink activity likely explained the observed photosynthetic declines in plants under both ambient and reduced water availability.

Hospitality Towards People with Mental Illness in the Church: a Cross-cultural Qualitative Study.

Mental illness is a prevalent concern that affects Christian churches in North America in significant ways. Previous studies on the relationship between mental illness and the church have found that beliefs and practices within the church can contribute to stigma towards people with mental illness. Yet, the typical experience of people with mental illness who attend church has been found to be positive, suggesting that there are considerable resources within the church for supporting those who experience mental health problems. One such resource is the concept of hospitality, which promotes a sense of belonging for those with mental illness in the church. This qualitative study advances the construct of hospitality as a helpful paradigm for addressing mental health needs within the church, capturing perspectives and practices that are currently in place or seen as necessary by church attendees. The study methodology also emphasized the need to incorporate cultural considerations that are appropriate for the racial and ethnic make-up of particular churches. Semistructured focus group interviews were conducted with participants from eight churches that were either predominantly African American, Asian American, Latinx, or multi-ethnic. Findings resulting from content analysis of transcripts indicated that hospitality was a broadly helpful construct for addressing mental health concerns in the church, though some cultural differences existed in the understanding and application of hospitality. Both the interface of the findings with the existing scholarly literature and the relevance of findings for church leaders are discussed.

UK Guidelines for Lipomodelling of the Breast on behalf of Plastic, Reconstructive and Aesthetic Surgery and Association of Breast Surgery Expert Advisory Group.

Lipomodelling has become increasingly popular for reconstructive, aesthetic and therapeutic indications. The guidelines summarise available evidence for indications, training, technique, audit and outcomes in lipomodelling and also highlight areas for further research.

The meta-gut: community coalescence of animal gut and environmental microbiomes.

All animals carry specialized microbiomes, and their gut microbiota are continuously released into the environment through excretion of waste. Here we propose the meta-gut as a novel conceptual framework that addresses the ability of the gut microbiome released from an animal to function outside the host and alter biogeochemical processes mediated by microbes. We demonstrate this dynamic in the hippopotamus (hippo) and the pools they inhabit. We used natural field gradients and experimental approaches to examine fecal and pool water microbial communities and aquatic biogeochemistry across a range of hippo inputs. Sequencing using 16S RNA methods revealed community coalescence between hippo gut microbiomes and the active microbial communities in hippo pools that received high inputs of hippo feces. The shared microbiome between the hippo gut and the waters into which they excrete constitutes a meta-gut system that could influence the biogeochemistry of recipient ecosystems and provide a reservoir of gut microbiomes that could influence other hosts. We propose that meta-gut dynamics may also occur where other animal species congregate in high densities, particularly in aquatic environments.

Phosphorus availability and leaching losses in annual and perennial cropping systems in an upper US Midwest landscape.

Excessive phosphorus (P) applications to croplands can contribute to eutrophication of surface waters through surface runoff and subsurface (leaching) losses. We analyzed leaching losses of total dissolved P (TDP) from no-till corn, hybrid poplar (Populus nigra X P. maximowiczii), switchgrass (Panicum virgatum), miscanthus (Miscanthus giganteus), native grasses, and restored prairie, all planted in 2008 on former cropland in Michigan, USA. All crops except corn (13 kg P ha-1 year-1) were grown without P fertilization. Biomass was harvested at the end of each growing season except for poplar. Soil water at 1.2 m depth was sampled weekly to biweekly for TDP determination during March-November 2009-2016 using tension lysimeters. Soil test P (0-25 cm depth) was measured every autumn. Soil water TDP concentrations were usually below levels where eutrophication of surface waters is frequently observed (> 0.02 mg L-1) but often higher than in deep groundwater or nearby streams and lakes. Rates of P leaching, estimated from measured concentrations and modeled drainage, did not differ statistically among cropping systems across years; 7-year cropping system means ranged from 0.035 to 0.072 kg P ha-1 year-1 with large interannual variation. Leached P was positively related to STP, which decreased over the 7 years in all systems. These results indicate that both P-fertilized and unfertilized cropping systems may leach legacy P from past cropland management.

UK Guidelines on the Diagnosis and Treatment of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) on behalf of the Medicines and Healthcare products Regulatory Agency (MHRA) Plastic, Reconstructive and Aesthetic Surgery Expert Advisory Group (PRASEAG).

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon T cell Non-Hodgkin Lymphoma (NHL) associated with breast implants. Raising awareness of the possibility of BIA-ALCL in anyone with breast implants and new breast symptoms is crucial to early diagnosis. The tumour begins on the inner aspect of the peri-implant capsule causing an effusion, or less commonly a tissue mass to form within the capsule, which may spread locally or to more distant sites in the body. Diagnosis is usually made by cytological, immunohistochemical and immunophenotypic evaluation of the peri-implant fluid: pleomorphic lymphocytes are characteristically anaplastic lymphoma kinase (ALK) negative and strongly positive for CD30. BIA-ALCL is indolent in most patients but can progress rapidly. Surgical removal of the implant with the intact surrounding capsule (total en-bloc capsulectomy) is usually curative. Late diagnosis may require more radical surgery and systemic therapies and although these are usually successful, poor outcomes and deaths have been reported. By adopting a structured approach, as suggested in these guidelines, early diagnosis and successful treatment will minimize the need for systemic treatments, reduce morbidity and the risk of poor outcomes. These guidelines provide an evidence-based and systematic framework for the assessment and treatment of patients with suspected or proven BIA-ALCL and are aimed at all clinicians involved in the care of people with breast implants.

UK Guidelines on the Diagnosis and Treatment of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) on behalf of the Medicines and Healthcare products Regulatory Agency (MHRA) Plastic, Reconstructive and Aesthetic Surgery Expert Advisory Group (PRASEAG).

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon T cell Non-Hodgkin Lymphoma (NHL) associated with breast implants. Raising awareness of the possibility of BIA-ALCL in anyone with breast implants and new breast symptoms is crucial to early diagnosis. The tumour begins on the inner aspect of the peri-implant capsule causing an effusion, or less commonly a tissue mass to form within the capsule, which may spread locally or to more distant sites in the body. Diagnosis is usually made by cytological, immunohistochemical and immunophenotypic evaluation of the aspirated peri-implant fluid: pleomorphic lymphocytes are characteristically anaplastic lymphoma kinase (ALK) negative and strongly positive for CD30. BIA-ALCL is indolent in most patients but can progress rapidly. Surgical removal of the implant with the intact surrounding capsule (total en-bloc capsulectomy) is usually curative. Late diagnosis may require more radical surgery and systemic therapies and although these are usually successful, poor outcomes and deaths have been reported. By adopting a structured approach, as suggested in these guidelines, early diagnosis and successful treatment will minimize the need for systemic treatments, reduce morbidity and the risk of poor outcomes.