In vivo electrochemical lipolysis of fat in a Yucatan pig model: A proof of concept study.

OBJECTIVES: Traditional fat contouring is now regularly performed using numerous office- based less invasive techniques. However, some limitations of these minimally invasive techniques include high cost or limited selectivity with performing localized contouring and reduction of fat. These shortcomings may potentially be addressed by electrochemical lipolysis (ECLL), a novel approach that involves the insertion of electrodes into tissue followed by application of a direct current (DC) electrical potential. This results in the hydrolysis of tissue water creating active species that lead to fat necrosis and apoptosis. ECLL can be accomplished using a simple voltage-driven system (V-ECLL) or a potential-driven feedback cell (P-ECLL) both leading to water electrolysis and the creation of acid and base in situ. The aim of this study is to determine the long-lasting effects of targeted ECLL in a Yucatan pig model. METHODS: A 5-year-old Yucatan pig was treated with both V-ECLL and P-ECLL in the subcutaneous fat layer using 80:20 platinum:iridium needle electrodes along an 8 cm length. Dosimetry parameters included 5 V V-ECLL for 5, 10, and 20 minutes, and -1.5 V P-ECLL, -2.5 V P-ECLL, -3.5 V P-ECLL for 5 minutes. The pig was assessed for changes in fat reduction over 3 months with digital photography and ultrasound. After euthanasia, tissue sections were harvested and gross pathology and histology were examined. RESULTS: V-ECLL and P-ECLL treatments led to visible fat reduction (12.1%-27.7% and 9.4%-40.8%, respectively) and contour changes across several parameters. An increased reduction of the superficial fat layer occurred with increased dosimetry parameters with an average charge transfer of 12.5, 24.3, and 47.5 C transferred for 5 V V-ECLL for 5, 10, and 20 minutes, respectively, and 2.0, 11.5, and 24.0 C for -1.5 V P-ECLL, -2.5 V P-ECLL, -3.5 V P-ECLL for 5 minutes, respectively. These dose-dependent changes were also evidenced by digital photography, gross pathology, ultrasound imaging, and histology. CONCLUSIONS: ECLL results in selective damage and long-lasting changes to the adipose layer in vivo. These changes are dose-dependent, thus allowing for more precise contouring of target areas. P-ECLL has greater efficiency and control of total charge transfer compared to V-ECLL, suggesting that a low-voltage potentiostat treatment can result in fat apoptosis equivalent to a high-voltage DC system.

Exploring feedback-controlled versus open-circuit electrochemical lipolysis in ex vivo and in vivo porcine fat: A feasibility study.

OBJECTIVES: Minimally invasive fat sculpting techniques are becoming more widespread with the development of office-based devices and therapies. Electrochemical lipolysis (ECLL) is a needle-based technology that uses direct current (DC) to electrolyze tissue water creating acid and base in situ. In turn, fat is saponified and adipocyte cell membrane lysis occurs. The electrolysis of water can be accomplished using a simple open-loop circuit (V-ECLL) or by incorporating a feedback control circuit using a potentiostat (P-ECLL). A potentiostat utilizes an operational amplifier with negative feedback to allow users to precisely control voltage at specific electrodes. To date, the variation between the two approaches has not been studied. The aim of this study was to assess current and charge transfer variation and lipolytic effect created by the two approaches in an in vivo porcine model. METHODS: Charge transfer measurements from ex vivo V-ECLL and P-ECLL treated porcine skin and fat were recorded at -1 V P-ECLL, -2 V P-ECLL, -3 V P-ECLL, and -5 V V-ECLL each for 5 min to guide dosimetry parameters for in vivo studies. In follow-up in vivo studies, a sedated female Yorkshire pig was treated with both V-ECLL and P-ECLL across the dorsal surface over a range of dosimetry parameters, including -1.5 V P-ECLL, -2.5 V P-ECLL, -3.5 V P-ECLL, and 5 V V-ECLL each treated for 5 min. Serial biopsies were performed at baseline before treatment, 1, 2, 7, 14, and 28 days after treatment. Tissue was examined using fluorescence microscopy and histology to compare the effects of the two ECLL approaches. RESULTS: Both V-ECLL and P-ECLL treatments induced in-vivo fat necrosis evident by adipocyte membrane lysis, adipocyte denuclearization, and an acute inflammatory response across a 28-day longitudinal study. However, -1.5 V P-ECLL produced a smaller spatial necrotic effect compared to 5 V V-ECLL. In addition, 5 V V-ECLL produced a comparable necrotic effect to that of -2.5 V and -3.5 V P-ECLL. CONCLUSIONS: V-ECLL and P-ECLL at the aforementioned dosimetry parameters both achieved fat necrosis by adipocyte membrane lysis and denuclearization. The -2.5 V and -3.5 V P-ECLL treatments created spatially similar fat necrotic effects when compared to the 5 V V-ECLL treatment. Quantitatively, total charge transfer between dosimetry parameters suggests that -2.5 V P-ECLL and 5 V V-ECLL produce comparable electrochemical reactions. Such findings suggest that a low-voltage closed-loop potentiostat-based system is capable of inducing fat necrosis to a similar extent compared to that of a higher voltage direct current system.

Electrosurgery Turbinate Reduction Revisited: Can Comparable Volumetric Heating be Achieved Without Feedback Control?

BACKGROUND AND OBJECTIVES: Temperature-controlled radiofrequency inferior turbinate ablation (TCRFA) uses a feedback system to control thermal injury and achieve precise volumetric heating to induce specific scar formation. However, it requires costly single-use proprietary consumables. Comparable volumetric tissue heating may be achieved for a fraction of the cost by adjusting the power settings on traditional monopolar electrosurgery devices that use low-cost needle tips. This pre-clinical study aims to determine the optimized power parameters to achieve electrosurgical coagulum volume similar to that of TCRFA. STUDY DESIGN/MATERIALS AND METHODS: An electrosurgery submucosal diathermy (SMD) system (cut mode, 4-32 W, 5-120 seconds) and a temperature-controlled radiofrequency ablation system (standard clinical parameters for treating inferior turbinate hypertrophy) were used to coagulate egg white and chicken breast. Coagulum major and minor axis were measured, and lesion volume was approximated as prolate spheroid. RESULTS: No significant difference in volume was found between the temperature-controlled system and the electrosurgery system at 8 W for 30 seconds, 8 W for 60 seconds, 16 W for 30 seconds, 32 W for 5 seconds, and 32 W for 15 seconds. The time to achieve equivalent lesion size was significantly less in the SMD system when compared to the temperature-controlled system (P < 0.05). CONCLUSION: Electrosurgery handpieces may achieve similar lesion volume effects as the temperature feedback-controlled, single-use handpieces when set to the optimized parameters. SMD handpieces are significantly more cost and time effective than proprietary devices, and they are easily used in the office. SMD devices may be a more affordable alternative to temperature-controlled systems with comparable lesion volume effect and may be valuable for office-based therapy. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Multiphoton Microscopy of Collagen Structure in Ex Vivo Human Skin Following Electrochemical Therapy.

OBJECTIVES: Injury to healthy dermis and the dermoepidermal junction initiates a robust healing process consisting of fibrous tissue overgrowth, collagen deposition, and scar formation. The conventional management of scars and other skin injuries has largely relied upon surgical soft tissue transfer to resurface and/or replace damaged and dysmorphic tissue with new skin. However, these strategies are invasive, expensive, and may further exacerbate integumentary injury. In this study, we examine the creation of in situ redox generated pH changes in fresh human skin. We believe this process of "electrochemical therapy" (ECT) leads to changes in collagen matrix structure. Our objective is to map local tissue pH landscapes and image changes in collagen structure of non-injured skin following ECT. STUDY DESIGN: Ex vivo human study involving ECT of human skin. METHODS: Remnant fresh ex vivo human facial skin from facelift operations was enveloped in saline-soaked gauze for a maximum of 2 hours prior to ECT and imaging. ECT was performed by inserting platinum-plated needle electrodes connected to a DC power supply. Voltage (4, 5, or 6 V) and time (3, 4, or 5 minutes) were varied systematically. High frequency ultrasound (25 MHz) was performed immediately after ECT on each sample. Treated samples were also imaged using multiphoton microscopy (MPM) with second harmonic generation (SHG) to specifically visualize collagen fibers in the dermis. The pH landscapes were mapped using indicator dyes in bisected specimens and the MPM images were compared with histologic findings. RESULTS: Above 4 V and 3 minutes, a profound reduction in dermal collagen SHG signal was observed at the anode. Although there was less blunting of SHG signal seen at the cathode, a decrease in the fluorescence of the dermoepidermal junction was observed. The pH application suggests ECT spatial selectivity and a direct relationship between voltage and application time. Ultrasound demonstrated gas formation between the anode and cathode, which is consistent with ECT's mechanism of action. Importantly, these electrochemical changes occurred without disrupting dermal and epidermal histologic architecture. CONCLUSION: ECT alters tissue pH leading to dermal collagen structural change. These results offer additional insight into the translational potential of ECT to locally remodel the soft-tissue matrix. Future directions aim to expand into a skin injury model to determine if similar collagen effects are observed in vivo. ECT is incredibly inexpensive (~$5) and may be a means to treat soft tissue injuries using simple needle-based devices and DC battery power supplies. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Reduced carboxylesterase 1 is associated with endothelial injury in methamphetamine-induced pulmonary arterial hypertension.

Pulmonary arterial hypertension is a complication of methamphetamine use (METH-PAH), but the pathogenic mechanisms are unknown. Given that cytochrome P450 2D6 (CYP2D6) and carboxylesterase 1 (CES1) are involved in metabolism of METH and other amphetamine-like compounds, we postulated that loss of function variants could contribute to METH-PAH. Although no difference in CYP2D6 expression was seen by lung immunofluorescence, CES1 expression was significantly reduced in endothelium of METH-PAH microvessels. Mass spectrometry analysis showed that healthy pulmonary microvascular endothelial cells (PMVECs) have the capacity to both internalize and metabolize METH. Furthermore, whole exome sequencing data from 18 METH-PAH patients revealed that 94.4% of METH-PAH patients were heterozygous carriers of a single nucleotide variant (SNV; rs115629050) predicted to reduce CES1 activity. PMVECs transfected with this CES1 variant demonstrated significantly higher rates of METH-induced apoptosis. METH exposure results in increased formation of reactive oxygen species (ROS) and a compensatory autophagy response. Compared with healthy cells, CES1-deficient PMVECs lack a robust autophagy response despite higher ROS, which correlates with increased apoptosis. We propose that reduced CES1 expression/activity could promote development of METH-PAH by increasing PMVEC apoptosis and small vessel loss.

Assessing and Improving the Effectiveness of Online Patient Education Materials on Essential Vocal Tremor: A Comprehensive Evaluation.

INTRODUCTION: Health literacy, a strong indicator of health outcomes, is an important aspect of good patient care. With an increasing reliance on the Internet for health information, online patient materials should be easily understood by the average reader. The American Medical Association (AMA) and National Institutes of Health (NIH) recommend that patient education materials be written at a sixth-grade level. Creating effective digital information requires careful consideration of not only word choice, but also many other factors including actionability, comprehensiveness, evidence, and visual organization. To support the creation of valuable online health content, the Office of Disease Prevention and Health Promotion (ODPHP) published Health Literacy Online, a research-based guide that discusses why and how to design digital health information tools.This study aims to assess the effectiveness of online patient education materials regarding vocal tremor, assess the effectiveness of patient education materials published by the American Laryngological Association, and to evaluate the usefulness of the Health Literacy Online guide in creating effective online patient education materials on laryngological diseases. METHODS: The first 50 unsponsored search results for the terms "vocal tremor" and "essential vocal tremor" were evaluated. Each website was analyzed using the Flesch Reading Ease Score (FRES) and Flesch-Kincaid Grade Level (FKGL) readability tests, the DISCERN instrument, and the Patient Education Materials Assessment Tool (PEMAT). The resources published by the American Laryngological Association were also evaluated in this manner. RESULTS: Of the 100 websites identified from the initial queries, 14 websites were included in this analysis. The average FRES and FKGL scores were 47.21 ± 10.47 and 10.96 ± 2.46, respectively, indicating that readers need a 11th-grade education to comprehend the materials. The average DISCERN score was 22.50 ± 9.76, indicating "very poor" quality with serious shortcomings and not appropriate sources of information about treatment choices. The average PEMAT understandability score was 68.43% ± 9.80% with an actionability score of 20.00% ± 23.53%, indicating the information was fairly difficult to process and do not help identify next steps. For the materials published by the American Laryngological Association (ALA), the average FRES and FKGL scores were 38.33 ± 12.81 and 12.56 ± 2.15, respectively, indicating a 12th-grade reading level. A DISCERN score of 27 was consistent across each item, indicating "very poor" quality. A PEMAT understandability score was 45% with an actionability score of 0%, indicating they are difficult to process and do not help identify next steps. After writing a revised sample of the information provided by the ALA based on the ODPHP's Health Literacy Online tool, the new FRES and FKGL score was 75.6 and 5.9, respectively. The new DISCERN score was 35. The new PEMAT understandability scores was 79% with actionability scores of 80%. CONCLUSION: This study found that most publicly available online patient education materials on essential vocal tremor and other laryngological diseases do not use plain language and require reading levels too advanced for the average reader to comprehend. In addition, most websites were of very poor quality readability, and were therefore less likely to benefit individuals in their decision-making. In an age where most people seek information on the Internet, the lack of easily understood online patient resources reduces the usefulness of these resources for many individuals. Professional organizations and societies like the American Laryngological Association may consider the use of the Health Literacy Online tool as a resource to provide both accurate and easily understandable patient education resources.

Long-range optical coherence tomography of pediatric airway during drug induced sleep endoscopy: A preliminary report.

OBJECTIVE: Drug induced sleep endoscopy (DISE) is often performed for pediatric obstructive sleep apnea (OSA) when initial diagnostic studies do not provide adequate information for therapy. However, DISE scoring is subjective and with limitations. This proof-of-concept study demonstrates the use of a novel long-range optical coherence tomography (LR-OCT) system during DISE of two pediatric patients. METHODS: LR-OCT was used to visualize the airway of pediatric patients during DISE. At the conclusion of DISE, the OCT probe was guided in the airway under endoscopic visual guidance, and cross-sectional images were acquired at the four VOTE locations. Data processing involved image resizing and alignment, followed by rendering of three-dimensional (3D) volumetric models of the airways. RESULTS: Two patients were included in this study. Patient one had 18.4%, 20.9%, 72.3%, and 97.3% maximal obstruction at velum, oropharynx, tongue base, and epiglottis, while patient two had 40.2%, 41.4%, 8.0%, and 17.5% maximal obstruction at these regions, respectively. Three-dimensional reconstructions of patients' airways were also constructed from the OCT images. CONCLUSION: This proof-of-concept study demonstrates the successful evaluation of pediatric airway during DISE using LR-OCT, which accurately identified sites and degrees of obstruction with respective 3D airway reconstruction.

How Variable are Patient Comorbidity Profiles Among Practicing Otolaryngologists?

OBJECTIVE: To determine whether certain groups of otolaryngologists (ORLs) are treating cohorts of patients with more comorbidities. STUDY DESIGN: Cross-sectional population-based analysis. SETTING: 2019 Medicare Provider Utilization and Payment Dataset. METHODS: Each ORL's average Medicare hierarchical condition category (HCC) risk score, a comorbidity index calculated from a patient's comorbidities, was collected. These were stratified and compared by various physician characteristics, including practice region and rurality, years in practice, gender, subspecialty, and setting (academic vs community). RESULTS: Among 8959 ORLs, the mean HCC risk score for Medicare patients was 1.35 ± 0.35. On univariate analysis, ORLs practicing in urban (compared to rural), ORLs in academic settings (compared to community), and early career ORLs all had a patient population with a higher HCC risk score (P < .001 for all). On multivariate analysis controlling for gender, rurality, graduation year, and region, rural setting was associated with decreased odds of having a high-risk patient population (odds ratio: 0.58 [95% confidence interval, CI: 0.48-0.71]; P < .001), while those more recently graduated has an increased risk (2000-2009: 1.41 [1.01-1.96], P = .046; 2010-2015: 2.30 [1.63-3.25], P < .001). In a separate subgroup analysis, subspecialty differences were seen and community setting was associated with decreased odds of having a high-risk patient population (0.36 [0.23-0.55]; P < .001). CONCLUSION: There is variability in patient comorbidity profiles among ORLs, with those in urban settings, those more recently graduated, and those in academic settings treating a group with more comorbidities. As the comorbidity burden may increase the cost of practice and complications, these findings may have important implications for health inequity.

Impact of Tissue Handling and Size Modification on Septal Chondrocyte Viability.

INTRODUCTION: The physical modification of cartilage grafts during rhinoplasty risks chondrocyte death at the margins where the tissue is cut. This study compares chondrocyte viability between diced, scaled, and pate samples in human models, and further computes percent chondrocyte viability as a function of sequential dicing size in a computational model. METHODS: Septal cartilage from 11 individuals was prepared as follows: diced (1 mm cubic), scaled (shaved to <1 mm thickness ~ translucent), pate (0.02 g of scraped cartilage surface), positive control (2 × 2 mm diced), and negative control (2 × 2 mm diced soaked in 70% EtOH). Viability analysis was performed using Live/Dead assay™ and confocal microscopy. Numerical simulation of cartilage dicing in 0.05 mm increments was performed using MATLAB assuming 250 chondrocytes/mm3 with each average chondrocyte size of 65 µm2. RESULTS: Chondrocyte viability was similar between 1 mm diced cartilage, scaled cartilage, and positive control samples (p > 0.05). Conversely, pate samples had significantly less viability compared to positive controls, diced samples, and scaled samples (all p < 0.01 after Bonferroni correction). Pate samples had similar chondrocyte viability compared to negative controls (p = 0.36). On computational modeling, cartilage viability decreased to 50% as the diced sample was cut from 1 mm edge length to 0.7-0.8 mm. Similarly, cartilage viability decreased to 26% at 0.55-0.65 mm, 11% at 0.4-0.5 mm, and <5% at <0.4 mm edge length. CONCLUSION: Modifying septal cartilage grafts into 1 mm diced or scaled samples maintains ideal chondrocyte viability whereas pate preparations result in significant chondrocyte death. According to computational analysis, chondrocyte viability sharply decreases as the cartilage is diced below 0.7-0.8 mm. LEVEL OF EVIDENCE: N/A Laryngoscope, 2024.

Severe unilateral refractory epistaxis arising from the septal branch of the anterior ethmoid artery.

KEY POINTS: The septal branch of the anterior ethmoid artery (sbAEA) is an underrecognized source of severe refractory epistaxis. Herein, we describe the presentation, predisposing factors, treatment strategies, and outcomes of a series of patients with this condition.

Medical Student Research Activity in Otolaryngology.

OBJECTIVE: To investigate medical student research productivity by institutions associated with otolaryngology residency programs and identify correlates of productivity. STUDY DESIGN: Retrospective review. SETTING: N/A. METHODS: A systematic search for articles indexed on PubMed published by 116 programs from January 1, 2016 to February 28, 2021 was conducted. Primary outcomes were number of faculty publications, first-author medical student publications and medical students from each institution. Secondary outcomes included geographic region, number of otolaryngology faculty members, and program rankings. RESULTS: Nationally, the mean number of faculty per institution was 21.7 at the time of search. Over a 5-year period, there was a mean 98.7 total publications and 15.8 medical student first-author publications per institution consisting of a mean of 10.03 distinct medical students. One-way analysis of variance showed no statistically significant difference in medical student productivity (P = .09) or department size (P = .12) between regions. Number of medical student first-author publications positively correlated to number of faculty (R = .43, P < .05) and number of faculty publications (R = .63, P < .05). The top 30 programs ranked by United States News & World Report or National Institute of Health for funding had a statistically significantly greater mean number of medical student first-author publications and distinct medical student first authors than all other programs (P < .05). CONCLUSION: Greater numbers of faculty members likely provide more mentorship and opportunities that allow medical students to engage in projects that lead to first-author publications. These findings allow institutions to reflect on efforts in medical student engagement and provide data to students for career planning.

Electrochemical Lipolysis Induces Adipocyte Death and Fat Necrosis: In Vivo Pilot Study in Pigs.

BACKGROUND: Current minimally invasive fat reduction modalities use equipment that can cost thousands of U.S. dollars. Electrochemical lipolysis (ECLL), using low-cost battery and electrodes (approximately $10), creates acid/base within fat (width, approximately 3 mm), damaging adipocytes. Longitudinal effects of ECLL have not been studied. In this pilot study, the authors hypothesize that in vivo ECLL induces fat necrosis, decreases adipocyte number/viability, and forms lipid droplets. METHODS: Two female Yorkshire pigs (50 to 60 kg) received ECLL. In pig 1, 10 sites received ECLL, and 10 sites were untreated. In pig 2, 12 sites received ECLL and 12 sites were untreated. For ECLL, two electrodes were inserted into dorsal subcutaneous fat and direct current was applied for 5 minutes. Adverse effects of excessive pain, bleeding, infection, and agitation were monitored. Histology, live-dead (calcein, Hoechst, ethidium homodimer-1), and morphology (Bodipy and Hoechst) assays were performed on day 0 and postprocedure days 1, 2, 7, 14 (pig 1 and pig 2), and 28 (pig 2). Average particle area, fluorescence signal areas, and adipocytes and lipid droplet numbers were compared. RESULTS: No adverse effects occurred. Live-dead assays showed adipocyte death on the anode on days 0 to 7 and the cathode on days 1 to 2 (not significant). Bodipy showed significant adipocyte loss at all sites ( P < 0.001) and lipid droplet formation at the cathode site on day 2 ( P = 0.0046). Histology revealed fat necrosis with significant increases in average particle area at the anode and cathode sites by day 14 (+277.3% change compared with untreated, P < 0.0001; +143.4%, P < 0.0001) and day 28 (+498.6%, P < 0.0001; +354.5%, P < 0.0001). CONCLUSIONS: In vivo ECLL induces fat necrosis in pigs. Further studies are needed to evaluate volumetric fat reduction. CLINICAL RELEVANCE STATEMENT: In vivo ECLL induces adipocyte death and fat necrosis. ECLL has the potential to be utilized in body fat contouring.

Diagnosis and Management of Barosinusitis: A Systematic Review.

OBJECTIVE: To perform a systematic review to investigate the common presenting symptoms of barosinusitis, the incidence of those findings, the methods for diagnosis, as well as the medical and surgical treatment options. METHODS: A review of PubMed/MEDLINE, EMBASE, and Cochrane Library for articles published between 1967 and 2020 was conducted with the following search term: aerosinusitis OR "sinus squeeze" OR barosinusitis OR (barotrauma AND sinusitis) OR (barotrauma AND rhinosinusitis). Twenty-seven articles encompassing 232 patients met inclusion criteria and were queried for demographics, etiology, presentation, and medical and surgical treatments. RESULTS: Mean age of patients was 33.3 years, where 21.7% were females and 78.3% were males. Causes of barotrauma include diving (57.3%), airplane descent (26.7%), and general anesthesia (0.4%). The most common presentations were frontal pain (44.0%), epistaxis (25.4%), and maxillary pain (10.3%). Most patients received topical steroids (44.0%), oral steroids (28.4%), decongestants (20.7%), and antibiotics (15.5%). For surgical treatment, most patients received functional endoscopic sinus surgery (FESS) (49.6%). Adjunctive surgeries include middle meatal or maxillary antrostomy (20.7%), septoplasty (15.5%), and turbinate surgery (9.1%). The most efficacious medical treatments are as follows: 63.6% success rate with oral steroids (66 treated), 50.0% success rate with topical steroids (102 treated), and 50.0% success rate analgesics (10 treated). For surgical treatments received by greater than 10% of the sample, the most efficacious was FESS (91.5% success rate, 108 treated). CONCLUSION: Oral and topical steroids should be first line therapies. If refractory, then functional endoscopic sinus surgery is an effective treatment.

Effect of obesity on outcomes after open laryngeal surgery including total laryngectomy: A NSQIP database analysis.

BACKGROUND: The impact of obesity on outcomes after open laryngeal surgery has not been well-described. METHODS: The NSQIP database was queried for all open laryngeal surgeries including total laryngectomies between 2005 and 2018. Outcomes of patients identified as obese or nonobese by BMI were compared. RESULTS: Of 1865 patients, 20.1% classified as obese. The most common operation performed was total laryngectomy with or without radical neck dissection (73.2%). Operation time and length of hospital stay were significantly less for obese patients. On multivariate analysis, obesity was associated with less bleeding transfusions occurrences (aOR, 0.395, p = 0.0052), surgical complications (aOR, 0.604, p < 0.001), and any complication (aOR, 0.730, p = 0.0019). CONCLUSION: Though there may be an inverse association of obesity with complications and bleeding transfusion occurrences, as well as decreased operation time and length of hospital stay, several confounders and bias may exist; therefore, it is difficult to conclude that the obesity paradox is present.

Mitochondrial Autoantibodies and the Role of Apoptosis in Pemphigus Vulgaris.

Pemphigus vulgaris (PV) is an IgG autoantibody-mediated, potentially fatal mucocutaneous disease manifested by progressive non-healing erosions and blisters. Beyond acting to inhibit adhesion molecules, PVIgGs elicit a unique process of programmed cell death and detachment of epidermal keratinocytes termed apoptolysis. Mitochondrial damage by antimitochondrial antibodies (AMA) has proven to be a critical link in this process. AMA act synergistically with other autoantibodies in the pathogenesis of PV. Importantly, absorption of AMA inhibits the ability of PVIgGs to induce blisters. Pharmacologic agents that protect mitochondrial function offer a new targeted approach to treating this severe immunoblistering disease.

Electrochemical treatment of ex vivo human abdominal skin and potential use in scar management: A pilot study.

INTRODUCTION: Scar treatments aim to address pathologic collagen deposition; however, they can be expensive or difficult to control. Electrochemical therapy (ECT) offers a simple alternative treatment. The purpose of this study is to examine the acid-base and histological changes in ex vivo human abdominal skin following ECT. METHODS: Forty-two ex vivo human panniculus tissue sections collected from six individuals were tumesced with normal saline. ECT was performed by inserting two platinum needle electrodes connected to a DC power supply into each specimen. Voltage was varied (3-6 V) and applied for 5 minutes. Each specimen was sectioned across both electrode insertion sites and immediately stained with pH sensitive dye. The width of dye color change for each dosimetry pair was calculated. Hematoxylin and eosin staining was used to evaluate samples. RESULTS AND DISCUSSION: ECT caused a spatially localised and dose-dependent increased area of acidic and basic pH around the anode and cathode, respectively. A significantly greater mean width of pH change was generated at the cathode compared to the anode in all treatment groups. Histological evaluation displayed broad condensation and hyalinisation of dermal collagen. CONCLUSION: ECT triggered dermal pH alterations and changed the underlying structural framework of the specimen. This technology may serve as a low-cost, minimally invasive local soft-tissue remodeling technique with potential application in scar management. LEVEL OF EVIDENCE: 5. LAY SUMMARY: Electrochemical therapy is a novel treatment that causes spatially selective dermal injury in areas of interest. This study measures the effects of electrochemical therapy when applied to abdominal skin. Electrochemical therapy appears to have beneficial effects by causing a highly localised reduction in collagen content or local softening of tissue, which is consistent with other studies on scar therapies, including chemexfoliation, radiofrequency technologies, and lasers. However, electrochemical therapy can be performed at a fraction of the costs of these aforementioned modalities.

Electrochemical Therapy of In Vivo Rabbit Cutaneous Tissue.

OBJECTIVES: To examine the acid-base and histological changes in in vivo rabbit cutaneous tissue after electrochemical therapy. STUDY DESIGN: In vivo rabbit tissue study. METHODS: The shaved skin on the backs of female Oryctolagus cuniculi were assigned to treatments with or without tumescence with normal saline. Two platinum-needle electrodes were inserted into each treatment area and connected to a direct current (DC) power supply. Voltage (3-5 V) was varied and applied for 5 minutes. The wound-healing process was monitored via digital photography and ultrasonography until euthanasia at day 29. Treatment areas were biopsied, and specimens were sectioned through a sagittal midline across both electrode insertion sites. Samples were then evaluated utilizing light microscopy (hematoxylin and eosin, Masson's Trichrome, and Picrosirius red). RESULTS: Treatment sites developed mild inflammation that dissipated at lower voltages or became scabs at higher voltages. Ultrasonography demonstrated acoustic shadowing with spatial spread that increased with increasing voltage application. The 4- and 5-V sites treated with saline had localized areas of increased tissue density at day 29. Although specimens treated with 3 V did not look significantly different from control tissue, 4- and 5-V samples with and without saline tumescence had finer, less-organized collagen fibers and increased presence of fibrocytes and inflammatory infiltrates. CONCLUSIONS: Electrochemical therapy caused localized injury to in vivo rabbit cutaneous tissue, prompting regenerative wound repair. With future development, this technology may offer precise, low-cost rejuvenation to restore the functionality and appearance of dermal scars and keloids. LEVEL OF EVIDENCE: NA Laryngoscope, 131:E2196-E2203, 2021.

Coupling Pressure Sensing with Optical Coherence Tomography to Evaluate the Internal Nasal Valve.

PURPOSE: To evaluate endoscopic long-range optical coherence tomography system combined with a pressure sensor to concurrently measure internal nasal valve cross-sectional area and intraluminal pressure. METHODS: A pressure sensor was constructed using an Arduino platform and calibrated using a limiter-controlled vacuum system and industrial absolute pressure gauge. Long-range optical coherence tomography imaging and pressure transduction were performed concurrently in the naris of eight healthy adult subjects during normal respiration and forced inspiration. The internal nasal valve was manually segmented using Mimics software and cross-sectional area was measured. Internal nasal valve cross-sectional area measurements were correlated with pressure recordings. RESULTS: Mean cross-sectional area during forced inspiration was 6.49 mm2. The mean change in pressure between normal respiration and forceful inspiration was 12.27 mmHg. The direct correlation between pressure and cross-sectional area as measured by our proposed system was reproducible among subjects. CONCLUSIONS: Our results demonstrate a direct correlation between internal nasal valve cross-sectional area and nasal airflow during inspiration cycles. Endoscopic long-range optical coherence tomography coupled with a pressure sensor serves as a useful tool to quantify the dynamic behavior of the internal nasal valve.

Video Standards for Rhinoplasty Education: A Review and Recommended Guidelines.

Importance: Intraoperative videography is widely used to record rhinoplasty procedures, yet little is known about the optimal surgical vantage points at critical procedural steps. Objective: To assess commonly used camera angles in public and proprietary intraoperative rhinoplasty videos and discuss approaches to obtaining these viewing angles. Design: Public and propriety rhinoplasty videos were reviewed and categorized based on procedure type, specific area(s) of focus, and camera angles utilized at a series of critical operative steps. The most commonly used camera angles were recorded and assessed based on surgical field visualization and the authors' personal recording experiences. Results: Of the 114 videos that met inclusion criteria, 49 were full-length open rhinoplasty procedures, 20 full-length endonasal rhinoplasty procedures, 17 tip techniques, 8 opening techniques, 7 fashioning grafts, 7 osteotomies, and 6 cartilage harvests. With respective to footage acquisition, the upward camera angle was most frequently used for recording, and endoscopic view was least frequently used. Conclusions and Relevance: These findings demonstrate that there is extensive variability in camera angles between surgical films. Moreover, many of these camera angles are insufficient due to obstruction by surgical staff, inability to visualize deep structures, and difficulty capturing the three-dimensional nasal framework. A guide indicating the best viewing angles for different aspects of the procedure would be useful to optimize educational videos.