Reevaluating the Spatial Scale of Residential Segregation: Racial Change Within and Between Neighborhoods.

This study evaluates the extent to which metropolitan racial segregation occurs between neighborhoods-from tract to tract-and within neighborhoods-from block to block-and is framed theoretically by Putnam's (2007) "hunkering down" hypothesis. Analyses are based on complete-count block, tract, and metropolitan data from the last four U.S. decennial censuses. We document recent patterns of block-to-block segregation between Whites and racial and ethnic minorities (Blacks, Asians, and Hispanics) and between different minority pairs. For example, roughly 40% of all metro Black-White segregation is due to segregation from block to block within neighborhoods. Among Asians, the between-neighborhood component of metropolitan segregation has increased over time but was largely compensated by declines in the within-neighborhood (or block) component. Metropolitan fixed-effects models show that trends and racial and ethnic differences in segregation-overall and within and between neighborhoods-are broadly observed across metro areas but are most evident in the largest, oldest, and most highly segregated metro areas. The results are robust to alternative estimates that adjust for differential privacy, metropolitan reclassification, and neighborhood boundary changes. Analyses of neighborhood change in Atlanta, Georgia, further reinforce the generality of our multiscale approach.

Immediate Breast Reconstruction in Skin-Reducing Mastectomy with Prepectoral Polyuretane (Pu) Implant Covered with an Autologous Dermo-Adipose Flap.

BACKGROUND: The aim of this study was to present our new technique of immediate breast reconstruction with prepectoral Polyuretane (PU) Implants, covered with an autologous dermo-adipose flap, in skin-reducing mastectomy both for risk-reducing (prophylactic mastectomy) and therapeutic cases. METHODS: We performed a single-center, retrospective review of 21 patients (mean age 47 years), undergone skin-reducing mastectomy and immediate breast reconstruction with prepectoral Polyuretane (PU) Implants, covered with an autologous dermo-adipose flap, un the period January 2018-June 2021. All procedures were performed by the same surgeon. RESULTS: A total of 36 skin-reducing mastectomies (6 curative, 15 prophylactic) with one-stage prepectoral PU foam-coated implant and autologous dermo-adipose flap reconstruction were performed. All postoperative complications were collected. Quality of life (QoL) and satisfaction with reconstruction were evaluated through the BREAST-Q questionnaire, administered preoperatively and at 12 months after surgery. Independent Student's t tests were used to compare means of continuous variables and Chi-square test was used for ordinal variables. A p-value ≤0.05 was considered statistically significant. Uni- and multiple linear regression analyses were used to confirm all results. Out of 21 patients, we observed one small wound dehiscence and one partial Nipple-Areola Complex (NAC) necrosis. All cases of minor complications were managed conservatively and did not affect the quality of the final outcome. No implant loss was observed. No significant severe capsular contracture (grade III or IV) was detected at follow-up. Overall satisfaction with breasts, psychosocial, physical and sexual well-being all significantly increased, analyzing BRAST-Q data. Statistical analysis showed a significant influence of diabetes on the risk of complications. CONCLUSIONS: Our experience suggests that the procedure described is effective, feasible and cost-effective. It is easier to perform compared to similar and more demanding procedure, reduces operative time, and minimizes complications related to manipulation of the pectoralis major muscle, while also contributing to the containment of costs. Moreover, it appears to be oncologically safe, provides good esthetic results with low postoperative complication rate and leads to high level of patients' satisfaction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Development and validation of the canine visual function instrument.

OBJECTIVE: In this study, we created the Canine Visual Function Instrument (CVFI) and tested its validity and reliability for assessing the quality of vision of dogs. METHODS: We used Cronbach's alpha to test the strength of the consistency of the questions in the instrument and factor analysis to assess whether the questions achieved unidimensionality in the measurement of dogs' vision quality. RESULTS: Our analysis shows that the CVFI is a valid and reliable tool to seek self-reported observations about dogs' vision quality from owners. Our results also show that the vision quality scale has high empirical validity and therefore can be used to determine whether a dog has normal vision or moderate or serious visual impairments. CONCLUSION: The CVFI might have important practical applications in the field of veterinary ophthalmology in two important ways. First, it can be used to determine whether the treatment of dogs with visual impairment improves vision quality. Second, it can be used as a warning system to alert owners about their dogs' quality of vision.

Septum-Enhanced Mammaplasty in Inferocentral Pedicled Breast Reduction for Macromastia and Gigantomastia Patients.

BACKGROUND: Inferior pedicle and free nipple grafting are commonly used as breast reduction techniques for patients with breast hypertrophy and gigantomastia. Limitations of these techniques are, respectively, possible vascular compromise and total/partial necrosis of the nipple-areola complex (NAC). The authors describe the innovative inferocentral pedicled reduction mammaplasty (ICPBR) enhanced by preservation of Würinger's septum for severe hypertrophic breasts. MATERIALS AND METHODS: Among 287 breast reductions performed between January 2001 and 2015, 83 (28.9%) macromastia and gigantomastia patients met the inclusion criteria (breast volume resection ≥400 g-sternal notch-to-nipple distance ≥33 cm) and were included in the study. Patients were stratified according to pedicle type: Group A (51 patients) underwent ICPBR with Würinger's septum preservation; group B (32 patients) underwent IPBR. Groups were compared for NAC vascular complications, surgical revisions, wound-healing period and patient satisfaction at a minimum 6-month follow-up assessed by a five-category questionnaire (breast size, shape, symmetry, texture and scars appearance), with five Likert subscales (1 = poor to 5 = excellent). Descriptive statistics were reported, and comparisons of performance endpoints between groups were performed using Chi-squared, Fisher's exact and Mann-Whitney U tests, with p value <0.05 considered significant. RESULTS: Group A and group B had, respectively, a mean age of 48.3 ± 12.4 and 50.1 ± 11.7 years, mean BMI of 23.8 and 24.6, mean weight resected of 560 ± 232 g and 590 ± 195 g, mean sternal notch-to-nipple distance of 35.1 and 34.3 cm, average nipple elevation of 9.7 and 9.5 cm. Among group A and group B, NAC complication rates were, respectively, 6.2 and 24.2% (p = 0.03), surgical revision rates were 33.3 and 60% (p = 1.00), healing time was 15.90 ± 3.2 and 19.03 ± 5.9 days (p = 0.002), and mean patient satisfaction scores were 19.9 ± 2.6 and 18.7 ± 3.4 (p = 0.07). CONCLUSIONS: The ICPBR technique enhanced by Würinger's septum preservation was found to be a reproducible and effective procedure for hypertrophic breasted and gigantomastia patients, improving the reliability of the vascular supply to the inferior-central pedicle. The authors do believe this procedure should be regarded as an innovative and safe option giving optimal aesthetic outcomes in this demanding group of patients. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Periareolar Access for Pectus Excavatum Correction with Silicone Implants: A New Method to Minimize Postoperative Scars-Review of the Literature, Considerations and Statistical Analysis of Clinical Outcomes.

BACKGROUND: Pectus excavatum (PE) is one of the most frequent thoracic malformations. Generally, the malformation is not associated with functional disorders and often constitutes an aesthetic alteration with significant psychological distress. OBJECTIVES: To reduce the visibility of the residual scarring produced by corrective surgery and to improve the aesthetic outcome, the authors propose a new prosthetic implant technique through a periareolar access. METHODS: From January 2005 to January 2015, 11 patients affected with PE underwent the surgical procedure with a sternal prosthesis implanted through a periareolar access with the help of a fiberscope. The preoperative evaluation of the perception of the malformation and postoperation results were made using different questionnaires. The data collected in our series were compared with that reported in 4 different papers where other forms of access were used: sternal, inframammary and transumbilical. RESULTS: No major complications or dislocation of the implants were reported. Among the complications, 6 postoperative seromas were reported. The patients' perception of improvement through the use of 2 questionnaires and an evaluation scale showed substantial improvement in all the aesthetic outcomes. CONCLUSIONS: The periareolar technique provides excellent cosmetic results compared to the sternal one. This access causes fewer complications and necessitates a shorter average hospital stay than the sternum access. To conclude, according to what is shown in the literature, periareolar access seems to be a quicker procedure, requiring a shorter stay in hospital, and results in scars that can more easily be hidden and are more accepted by patients. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Borderline Case in Reconstructive Plastic Surgery of the Lower Limb Treated with Bone Drilling and Use of Dermal Regeneration Template.

The traumatic pathology of the lower limb represents a very complex branch of medicine, which, despite the wide presence of guidelines, aimed at regulating the various therapeutic procedures, and is still greatly influenced by random variables and by the multiple responses to treatments. In this report, we present our experience with a borderline case, where the timing of the trauma and the patient's characteristics made it difficult to use the most recommended procedures in trauma management.

How affordances associated with a distractor object affect compatibility effects: a study with the computational model TRoPICALS.

Seeing an object activates both visual and action codes in the brain. Crucial evidence supporting this view is the observation of object to response compatibility effects: perception of an object can facilitate or interfere with the execution of an action (e.g., grasping) even when the viewer has no intention of interacting with the object. TRoPICALS is a computational model that proposes some general principles about the brain mechanisms underlying compatibility effects, in particular the idea that top-down bias from prefrontal cortex, and whether it conflicts or not with the actions afforded by an object, plays a key role in such phenomena. Experiments on compatibility effects using a target and a distractor object show the usual positive compatibility effect of the target, but also an interesting negative compatibility effect of the distractor: responding with a grip compatible with the distractor size produces slower reaction times than the incompatible case. Here, we present an enhanced version of TRoPICALS that reproduces and explains these new results. This explanation is based on the idea that the prefrontal cortex plays a double role in its top-down guidance of action selection producing: (a) a positive bias in favour of the action requested by the experimental task; (b) a negative bias directed to inhibiting the action evoked by the distractor. The model also provides testable predictions on the possible consequences of damage to volitional circuits such as in Parkinsonian patients.

The objective evaluation of triamcinolone acetonide efficacy in keloids management using Antera3D® imaging system.

Background: Keloids are pathological scars characterized by nodular fibrous tissue that extends beyond the border of initial damage. These lesions do not spontaneously regress and can cause cosmetic disfigurements and functional disabilities. IntraLesional Injection of Triamcinolone Acetonide (ILITA), alone or in combination with other therapy, is one of the first-line treatment modalities. In this study the authors evaluated the objective efficacy of ILITA treatment in keloids management using this new imaging system. Materials and Methods: 37 patients with 45 keloid scars were treated with intralesional injection of triamcinolone acetonide (TAC) 20 mg/ml at an interval of three weeks. Antera3D® camera took the images and dates of the treated area in each patient, before the treatment (T0) and at three weeks after the last injection (T1). The system processed the levels of color, elevations, melanin and hemoglobin expression. All the scars were also evaluated, at the same times, by validated Vancouver Scar Scale (VSS). Comparison of the variables was performed using a Wilcoxon signed-rank test with a p < 0.05. Results: At T0, mean VSS score was 8.67 ± 1.35 which reduced to 3.62 ± 1.72 at final follow up. Antera3D® scores were statistically significant differences in color (8.14 ± 2.41 vs 9.54 ± 1.81), protrusion (381.3 ± 15.6 vs 198.6 ± 21.3), melanin (0.53 ± 0.02 vs 0.62 ± 0.2) and hemoglobin (1.26 ± 0.41 vs 2.21 ± 0.41) expression levels after the treatment. Conclusions: In our clinical trial, the data results demonstrated that ILITA seems to be effective in reducing keloid dimensions and symptoms such as itching and pain, even if the treatment has local minimal adverse effects such as pain, telangiectasias and atrophy. Lay Summary: Keloids are pathological scars characterized by nodular fibrous tissue that extends beyond the border of initial damage. Large keloids can cause cosmetic disfigurements and functional disabilities that affect quality of life. In literature, several treatment approaches have been described but, to date, no single method is considered superior. The International Advisory Panel on Scar Management recommended the use of intralesional steroid injections for keloids treatment. The efficacy of treatment may be evaluated with subjective scale; as no one can guarantee an objective evaluation. To eliminate the observer and/or patient factors, and to obtain a reliable, consistent, feasible, valid and objective evaluation a skin analysis camera system called Antera3D® (Miravex, Dublin, Ireland) can be used.In this study the authors evaluated the objective efficacy of triamcinolone acetonide treatment in keloids management using this imaging system. In this series, for Antera3D® scores there were statistically significant differences in color, protrusion, melanin and hemoglobin expression levels before and after treatment. The device directly shows the treatment changes, measured objectively and accurately, without bias of traditional evaluation scoring scale.Antera3D® system guarantees an objective evaluation of effectiveness of scar treatment enabling clinicians to modulate the therapy according to the scores registered.

A combined protocol for improving reconstruction of scrotal skin avulsions: The experience of the University Hospital Center of Foggia.

OBJECTIVE: Scrotal degloving injuries are rare and constitute a challenge for reconstructive surgeons. The authors describe their successful experience with a combined reconstruction protocol using an acellular dermal matrix (ADM), negative pressure wound therapy (NPWT) and a split-thickness skin graft (STSG), and the retrospective assessment of overall morbidity and esthetic outcomes. METHODS: Five consecutive patients underwent a wide excision of necrotic scrotal skin and a reconstruction procedure using a combined protocol with NPWT, Pelnac®, and STSG. The efficacy of this treatment was determined by assessing overall morbidity and esthetic outcomes with the Vancouver Scar Scale (VSS). RESULTS: The combined protocol made it possible to create an environment that promoted wound healing, improved graft intake, and gage the reconstructed site a more natural look. No significant problems were observed. Satisfactory cosmetic and functional results were obtained in all patients as shown by VSS scores obtained. CONCLUSIONS: We believe that this combined protocol is a reliable alternative to flaps and should be considered an excellent option in scrotal reconstruction, especially in critical patients.

Reduction of seroma and improvement of quality of life after early drain removal in immediate breast reconstruction with tissue expander. Preliminary report from a randomized controlled study.

Seroma is the most common complication of breast reconstruction with tissue expander (incidence 0.2-20%) with increased risk of infection and implant loss by 4-6 fold. About 90% of plastic surgeons routinely placed drains for its prevention. We theorized that early drain removal is a safe procedure that improves postoperative quality of life (QoL), reducing pain, length of hospital stay, and limitations on daily activities. We divided 49 patients operated on between September 2016 and March 2018 (follow-up: 9-26 months) into two groups: Group1 (output-based; drains removed when <30 ml/day); and Group2 (early-removal; at 3-4 days postop.). A study-specific questionnaire about the patient's QoL was conducted 3 weeks after surgery. We performed an intention-to-treat analysis. A comparison was performed using a Fisher test and a Mann-Whitney U test with p = 0.05. We observed lower production of wound fluid (641±49 ml vs 231±20 ml; p = 0.004), and a shorter time until wound healing (31.3±4.2 days vs 22±3.9 days; p = 0.031) for Group 2. The difference for infection (p = 0.36), impaired wound healing (p = 0.22), and the seroma formation period (p = 0.11) was not significant. Group 2 experienced less breast pain (8% vs 87.5%; p = 0.001), fewer limitations in daily activities (16% vs 50%; p = 0.002), in mobility (20% vs 83.3%; p = 0.001), and in social life (8% vs 91.7%; p < 0.001), and a better quality of sleep than Group 1 (36% vs 75%; p = 0.002). Group 2 did not require home care after hospital discharge (p < 0.001). The limitations of study are: its small sample size, the wound healing assessment, and the use of a non-validated questionnaire.

Role of a new acellular dermal matrix in a multistep combined treatment of dermatofibrosarcoma protuberans of the lumbar region: a case report.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is a rare skin fibroblastic tumor, with a high rate of recurrence. The treatment of DFSP is generally surgical, and wide local excision is the mainstay of surgical treatment. Therefore, complete assessment of all surgical margins is fundamental before definitive reconstruction. The reconstruction is a challenge for plastic surgeons, especially in particular anatomical areas (for aesthetic or functional problems) or in patients who are not candidates for more complex surgical treatments. We describe an alternative approach for reconstructive treatment of the lumbar area after wide excision of DFSP (without fresh-frozen sections) in a young obese woman with a history of smoking, using a new type of acellular dermal matrix (ADM) in a combined management protocol. The benefits of ADM are numerous: immediate wound closure and prevention of infections and excessive drying; minimal donor site morbidity; and good functional and aesthetic outcomes. Moreover, it is a temporary cover while the anatomical specimen is histologically analyzed, without donor site morbidity or prevention of any future surgery (if the margins are not tumor-free) or radiotherapy. CASE PRESENTATION: In October 2019, a 34-year old obese Caucasian Woman with a history of smoking came to our institute for a multinodular growing polypoid mass in her lumbar region. An incisional biopsy diagnosed DFSP. The patient underwent proper staging. A wide local excision with 3 cm clinically healthy tissue margins down to the muscle fascia was performed and the defect was repaired using a combined approach with a new artificial bilaminar dermal template (Pelnac®, Gunze Ltd., Osaka, Japan) and a negative-pressure wound therapy system (V.A.C.®, KCI, San Antonio, USA). After the final histological examination revealed tumor-free margins, a split-thickness graft was harvested from the right gluteus and fixed to the new derma with negative-pressure wound therapy. Postoperative radiotherapy was not necessary. After 15 days, the wound had healed without complications, with satisfactory aesthetic outcome and with no limitation of back motion or pain. After 6 months of follow-up, the patient was free from disease. CONCLUSIONS: This is the first reported case of Pelnac® use in DFSP reconstruction of the lumbar region. We believe that the multistep approach described herein may be a good alternative approach in selected patients with wide resections in particular anatomical areas, especially when frozen sections (with Mohs micrographic surgery) are not available.

Release of pseudosyndactyly in recessive dystrophic epidermolysis bullosa using a dermal regeneration template glove: the Foggia experience.

BACKGROUND: Epidermolysis bullosa (EB) comprises a heterogeneous group of rare genetic diseases associated with skin blistering caused by minimal trauma. A major and common EB subtype, recessive dystrophic EB (RDEB), is characterized by altered wound healing, inflammatory dysbalance and fibrotic changes associated with reduced to absent collagen VII. Because of its exposed position and its continued use in daily activities, the hand is constantly at risk of microtrauma and is therefore one of the organs most affected by the disease with highly disabling deformities that represent a challenging field in hand surgery practice. METHODS: The authors present their experience in the microsurgical treatment of pseudosyndactylies comparing the classic dressing with vaseline gauze with an innovative "glove protocol" using Integra® dermal regeneration template. The endpoints analyzed were: healing times, hospital stay time, discomfort for the patient, free-recurrence interval, follow-up range and major complications. RESULTS: A total of 34 procedures were performed on 24 RDEB patients with hand deformities. Compared with the dressing with vaseline gauze, microsurgery followed by application of dermal regeneration template gloves allowed a significant reduction of hospital stay, healing time, and dressing pain as well as an increased recurrence-free interval. CONCLUSIONS: The microsurgical approach followed by our new protocol described in the study has been beneficial in providing consistent and successful long-term results for these patients.

Cling Wrap Technique: An Inexpensive and Simple Way to Seal Negative Pressure Wound Therapy on External Fixation Devices.

SUMMARY: Negative pressure therapy is often applied to treat limb traumas with or without bone exposure. However, sealing a negative pressure dressing in the presence of an external fixation device may be complicated and time consuming. In this technique, we attempted to maintain vacuum conditions by preventing air leakage around the screws using plastic drape and cling wrap as the final layer over the external fixation device. To prevent rupturing of the wrap, the prominences of the pins and rods were covered using cotton wool roll. This novel solution is also effective for complex and extended wounds, with no need for additional dressing changes and no occurrence of complications for approximately 4 days. Furthermore, it is an inexpensive, quick, and readily available technique requiring minimal training to perform. It is also adaptable to any anatomical region, allowing the inspection of the limb when required.