Pregnancy Reverses Abdominoplasty Aesthetic Outcome: Myth or Misconception? A Cross-Sectional Study.

BACKGROUND: The common recommendation for female abdominoplasty candidates is to conclude family planning before undergoing the procedure. However, no evidence demonstrates a correlation between aesthetic outcome compromise, risk for fetal complications, or risk for maternal complications when abdominoplasty is followed by pregnancy. OBJECTIVES: The aim of this study was to evaluate maternal, fetal, and aesthetic outcomes among pregnant females with a history of abdominoplasty. METHODS: The authors conducted an online survey among women who became pregnant after having an abdominoplasty. Participants were recruited via social media groups related to abdominoplasty. The survey included demographic-, aesthetic outcome-, and pregnancy-related questions utilizing a score from 1 (no effect) to 10 (worst effect) to assess abdominal aesthetic outcome compromise. RESULTS: Thirty-two participants completed the online survey, 15 (46.8%) of which reported their pregnancy was unplanned. Pregnancy-related findings included 5 (15.6%) late premature births (between gestational week 35 and 37), 1 miscarriage, and 1 emergency C-section. Compromised aesthetic outcomes following pregnancy included new abdominal stretch marks (50%, N = 16), widened abdominoplasty scar (28%, N = 9), abdominal skin excess (37.5%, N = 12), and abdominal bulge (25.8%, N = 8). A new hernia was reported by 2 participants (6.3%). The average abdominal aesthetic severity score was 2.7 (range, 1-8), and only 3 scores were above 5 (9.3%). Two women (6.2%) underwent abdominoplasty revision, and 18 (56.2%) stated they would recommend others to undergo abdominoplasty before pregnancy (56.3%). CONCLUSIONS: This survey shows there is room to reevaluate whether future pregnancy should be considered a relative contraindication for undergoing abdominoplasty.

Breast Implant-associated Anaplastic Large Cell Lymphoma Incidence: Determining an Accurate Risk.

OBJECTIVE: This study sought to estimate the incidence and incidence rate of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) at a high-volume single institution, which enables vigorous long-term follow-up and implant tracking for more accurate estimates. SUMMARY BACKGROUND DATA: The reported incidence of BIA-ALCL is highly variable, ranging from 1 in 355 to 1 in 30,000 patients, demonstrating a need for more accurate estimates. METHODS: All patients who underwent implant-based breast reconstruction from 1991 to 2017 were retrospectively identified. The incidence and incidence rate of BIA-ALCL were estimated per patient and per implant. A time-to-event analysis was performed using the Kaplan-Meier estimator and life table. RESULTS: During the 26-year study period, 9373 patients underwent reconstruction with 16,065 implants, of which 9589 (59.7%) were textured. Eleven patients were diagnosed with BIA-ALCL, all of whom had a history of textured implants. The overall incidence of BIA-ALCL was 1.79 per 1000 patients (1 in 559) with textured implants and 1.15 per 1000 textured implants (1 in 871), with a median time to diagnosis of 10.3 years (range, 6.4-15.5 yrs). Time-to-event analysis demonstrated a BIA-ALCL cumulative incidence of 0 at up to 6 years, increasing to 4.4 per 1000 patients at 10 to 12 years and 9.4 per 1000 patients at 14 to 16 years, although a sensitivity analysis showed loss to follow-up may have skewed these estimates. CONCLUSIONS: BIA-ALCL incidence and incidence rates may be higher than previous epidemiological estimates, with incidence increasing over time, particularly in patients exposed to textured implants for longer than 10 years.

Surgical Site Infection Risk Factor Analysis in Postbariatric Patients Undergoing Body Contouring Surgery: A Nested Case-Control Study.

BACKGROUND: Surgical site infections (SSIs) following body-contouring plastic surgery pose a significant burden on patients and caregivers, possibly leading to undesired surgical outcomes. Surgical site infection incidence following body-contouring plastic surgery ranges from 2% to 7%, but is estimated much higher among postbariatric massive weight loss (MWL) patients. OBJECTIVE: The aim of this study was to evaluate SSI rate, risk and protective factors among postbariatric MWL patients following body-contouring plastic surgery. METHODS: This was a nested case-control study of MWL patients who underwent body-contouring plastic surgery at the Department of Plastic Surgery at Assaf Harofeh Medical Center, between 2007 and 2014. Data were obtained from medical records. Surgical site infection was defined according to the Centers for Disease Control and Prevention criteria. Logistic regression was conducted to assess independent risk factors for SSIs. RESULTS: From a cohort of 172 patients, 86 were included in the study. Surgical site infection rate was 20% (n = 17). Significant SSI risk factors included lifetime maximal weight and lifetime maximal body mass index (P = 0.039 and P = 0.002, respectively), body mass index loss prior to surgery (P = 0.032), estimated blood loss during surgery (P = 0.002), and gynecomastia repair procedure (P = 0.038). Independent SSI-associated factors included thigh lift procedure (odds ratio, 4.66; 95% confidence interval, 1.13-19.28) and preoperative antimicrobial prophylaxis (odds ratio, 0.04; 95% confidence interval, 0.03-0.61). CONCLUSIONS: Although not required by current guidelines for body-contouring plastic surgery, preoperative antimicrobial prophylaxis in our study demonstrated a significant protective effect against SSIs. Further research may reveal its true contribution to SSI prevention in body-contouring plastic surgery.

Effect of Tight Glycemic Control Protocol on Hypoglycemia and Mortality in the Burn Unit: A Case-Control Study.

BACKGROUND: Burn injury pathophysiology is characterized by severe catabolic state and poor glycemic control. A tight glycemic control protocol using insulin for burn victims has yielded inconsistent mortality and morbidity outcomes. OBJECTIVES: To compare the effect of standard and tight glycemic control protocols on mortality and hypoglycemia events in critical care burn patients. METHODS: We conducted a case-control study of burn victims admitted to the burn intensive care unit between 2005 and 2011. Patients were assigned to either a standard or a tight glycemic control protocol. RESULTS: Of the 38 burn patients in the study, 28 were under a tight glycemic control protocol. No differences in glucose area-under-the-curve per day levels were observed between the groups (148.3 ± 16 vs. 157.8 ± 16 mg/dl in the standard and tight glycemic control protocol groups respectively, P < 0.12). The hypoglycemic event rate was higher in the tight glycemic control protocol group (46.4% vs. 0%, P < 0.008). No difference in mortality rate was noted (67.9% vs. 50%, P < 0.31). Mortality-independent risk factors found on multivariate analysis included total body surface area (adjusted hazard ratio [AHR] 1.039, 95% confidence interval  [95%CI] 1.02-1.06, P < 0.001), white blood cell count on admission (AHR 1.048, 95%CI 1.01-1.09, P < 0.02) and surgery during hospitalization (AHR 0.348, 95%CI 0.13-0.09, P < 0.03). CONCLUSIONS: The tight glycemic control protocol in burn patients was associated with higher rates of hypoglycemic events, and no association was found with improved survival in the acute setting of burn trauma care.

Poly Implants Prosthèse Breast Implants: A Case Series and Review of the Literature.

BACKGROUND: Silicone breast implants from the French manufacturer Poly Implants Prosthèse (PIP) were recalled from the European market after the French regulator has revealed the implants contain non-medical-grade silicone filler. In December 2011, following a large increase in reported rupture rate and a possible cancer risk, the French Ministry of Health recommended consideration of the PIP explantation, regardless of their condition. In 2012, the Israel Ministry of Health recommended to replace the implants only upon suspected implant rupture. OBJECTIVES: The aims of this study were to characterize breast-augmented Israeli patients with PIP implants, compare their outcomes with those of breast-augmented patients with different implant types, and review the current PIP literature. METHODS: Breast-augmented patients who underwent an elective breast implant exchange in Israel between January 2011 and January 2017 were included in the study. Data were collected from electronic and physical medical files. RESULTS: There were 73 breast-augmented female patients with 146 PIP breast implants included in this study. Average implant age was 6.7 ± 2.79 years. Mean implant size was 342.8 ± 52.9 mL. Fourteen women (19 implants [16%]) had a high-grade capsular contracture (Baker grade 3-4). During exchange, 28 implants were found to be ruptured (19.2%). CONCLUSIONS: Less than 10 years following breast augmentation, PIP implants demonstrated higher rupture rate compared with other implants. Our data are comparable to overall available rupture rate. Among patients with definitive rupture diagnosis, an elective implant removal should be recommended. In cases of undamaged implants, plastic surgeons should also seriously consider PIP implant explantation. When the patient does not desire to remove the implant, an annual physical examination and breast ultrasound are recommended, beginning a year after augmentation.

Frequency of intra-abdominal organ injury is higher in patients with concomitant stab wounds to other anatomical areas.

BACKGROUND: Management of stable patients with abdominal stab wound remains controversial, particularly for those with no clear indications for explorative laparotomy. We evaluated the risk of intra-abdominal injury in stab wound victims concomitantly stabbed in other anatomical body areas. METHODS: We performed a retrospective cohort study of patients with abdominal stab wounds recorded in the Israeli National Trauma Registry from January 1st, 1997, to December 31st, 2013. Patients with an isolated abdominal stab wound were compared to those with concomitant stab wounds to other anatomical areas. Intra-abdominal organ injury was defined by imaging or surgery findings. Multivariate analysis using a logistic regression model was conducted to assess independent risk for intra-abdominal organ injury. RESULTS: The study included 3964 patients. After controlling for age, gender and hypotension on arrival, patients with multi-regional stab wounds had an increased risk of intra-abdominal injury (OR = 1.3, CI 95% 1.1-1.6, p < 0.001). These patients also had a higher rate of injury to the solid organs than patients with an isolated abdominal stab wound. CONCLUSIONS: Patients with multi-regional stab wounds have an increased risk of intra-abdominal injury. Worldwide accepted "clinical follow up" protocol may not be appropriate in management of patients with multi-regional stab wounds.

Motivational Factors in Women Seeking Augmentation Mammoplasty Across Different Age Groups: A Cross-Sectional Survey.

BACKGROUND: Augmentation mammoplasty is one of the most common esthetic procedures worldwide. A wide range of motivations leads women to undergo this procedure, among them socioeconomic status and age group. The aim of this study was to identify the motivation spectrum for augmentation mammoplasty through different age groups. METHODS: We conducted a cross-sectional prospective survey given to Israeli women seeking augmentation mammoplasty consults in a hospital and private clinic settings, using a 17-item Motivation for Augmentation questionnaire. Three motivation domains were examined: appearance, sexuality and social. Study participants were divided into three age groups: 18-29, 30-39 and over 40 years. RESULTS: A total of 101 women participated in the study. Motivations were rated similar among all age groups. Appearance and sexuality domains were rated significantly higher compared with the social domain throughout all age groups (3.28 ± 0.91 and 3.15 ± 1.03 vs. 1.88 ± 1.16, p < 0.001, respectively). CONCLUSIONS: Motivations in Israeli women seeking breast augmentation do not change with age. The desire to improve one's appearance and sexuality is more prominent than improving social and work status. 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 .

Outpatient Negative-Pressure Wound Therapy Following Surgical Debridement: Results and Complications.

OBJECTIVE: To present results and complications in a case series of outpatients with diabetic and neuropathic foot ulcers with exposed bone following surgical debridement treated with negative-pressure wound therapy (NPWT). METHODS: Retrospective data were obtained from digital medical records from the Maccabi Health Services High Risk Foot Clinic in Tel Aviv, Israel, between 2009 and 2014. Medical records examined were those of clinic outpatients with exposed bone following partial foot amputation or selective bone debridement (University of Texas grade III-A) treated with NPWT. MAIN OUTCOME MEASURES: Wound area, closure rate, and adverse events. MAIN RESULTS: There were 66 patients provided NPWT in a total of 77 treatment courses. Mean patient age was 62 ± 10 years, 82% were male, and mean diabetes mellitus duration was 14 ± 8 years. Mean HbA1C levels were 8.1% ± 1.7%. Mean treatment course duration was 16 days (range, 2-42 days). Wound area decreased significantly (from 11.3 ± 16.8 cm to 8.0 ± 13.3 cm, P < .0001). Ulcer curing was noted in 7% of the cases, and healing progression was noted in 54%. Seven serious adverse events were recorded. CONCLUSIONS: Outpatient NPWT is a relatively safe and effective adjuvant to surgical debridement of neuropathic foot ulcers. In an outpatient setting, one can expect serious adverse events to occur in 10% of cases, but this seems unavoidable in patients with diabetic foot ulcers when taking into account their comorbidities and patient resources. Strict protocols to promote early recognition of complications and appropriate response to minimize deterioration must be implemented.

When Should Abdominal Computed Tomography Be Considered in Patients with Lower Rib Fractures?

BACKGROUND: Lower rib fractures are considered as a marker of intra-abdominal organ injury. Abdominal computed tomography (CT) is the "gold standard" examination for patients with lower rib fractures. However, the reported incidence of concomitant intra-abdominal injuries (IAI) is 20%-40%. OBJECTIVE: The purpose of this study was to evaluate the incidence of intra-abdominal organ injuries in blunt trauma patients with lower rib fractures. METHODS: Medical charts and radiology reports of patients with lower rib (from the 8th to 12th rib) fractures admitted to our center during a 6-year period were retrospectively reviewed. Patients were divided into two groups. Group I included patients with intra-abdominal injury (IAI) diagnosed either by CT or on urgent laparotomy, and Group II included those with normal abdominal CT scans. Data included demographics, mechanism of injury, laboratory tests, radiology results including number and location of fractured ribs, and incidence of IAI. RESULTS: Overall 318 patients were included in the study. Fifty-seven patients (17.9%) had 71 IAIs compared with 265 (82.1%) patients with no IAI. Logistic regression identified age younger than 55 years (relative risk [RR] = 7.2; 95% confidence interval [CI] 3.1-16.8; p = 0.001), bilateral rib fractures (RR = 3.9; 95% CI 1.1-13.5; p = 0.03) and decreased levels of hematocrit (RR = 2.4; 95% CI 1.2-4.8; p = 0.016) as independent risk factors for the presence of IAI. CONCLUSIONS: Abdominal CT should be considered in blunt trauma patients with lower rib fractures who are younger than 55 years of age and have bilateral rib fractures and decreased levels of hematocrit on admission.

Rembrandt's Ocular Pathologies.

PURPOSE: This article aims to medically and artistically analyze various ophthalmological ailments documented in self-portraits of Rembrandt to determine if those ailments were medical conditions or stylistic and age-related changes. METHODS: A systematic literature review using Pub Med and Google Scholar found 232 results from a search of "Rembrandt" and more than 5,000 results for "Rembrandt Aging." After extensive review of the literature, the authors found 17 relevant sources. These sources were then supplemented with historical books on Rembrandt and the aging processes of artists. Analytical observations with proportional measurements of anthropometrical landmarks (from self-portraits of Rembrandt at various ages) were studied, measured, analyzed, and compared using a standardized technique via MB ruler graphic software to assess age- or medically related changes. RESULTS: The ophthalmological problems cited in the literature related to Rembrandt's periorbital structures were found by the authors to be false. Signs of inappropriate aging and ailments, such as hyperthyroidism were deemed inaccurate by the authors based on absence of classical disease progression. Ophthalmological problems cited in the literature on Rembrandt's visual acuity were found to be stylistic changes or considered normal aging. Finally, the authors found that ophthalmological problems relating to Rembrandt's eye and orbital adnexa are unfitting because these problems were not seen in subsequent paintings. CONCLUSIONS: The authors believe that all the physical changes seen in Rembrandt's portraits represent natural age-related or stylistic changes, and do not represent signs or symptoms of diseases in the master.

Head and Neck Cutaneous Squamous Cell Carcinoma Clinicopathological Risk Factors according to Age and Gender: A Population-based Study.

BACKGROUND: Clinicopathological risk factors for cutaneous squamous cell carcinoma of the head and neck (CSCCHN) are associated with local recurrence and metastasis. OBJECTIVES: To compare the incidence and risk factors of CSCCHN by age and gender in order to help refine the clinical evaluation and treatment process. METHODS: Clinical and pathological data of all patients diagnosed with CSCCHN during 2009-2011 were obtained from a central pathology laboratory in Israel. Estimated incidence rate calculation was standardized to the 2010 Israeli population. Independent risk factors for poorly differentiated CSCCHN were analyzed using logistic regression. RESULTS: CSCCHN was diagnosed in 621 patients. Mean age was 75.2 years; mean tumor horizontal diameter was 11.1 ± 6.8 mm. The overall estimated incidence rate in males was higher than in females (106.2 vs. 54.3 per 1,000,000, P 0.001). Twenty cases (3.2%) had poorly differentiated CSCCHN. Scalp and ear anatomic locations were observed more often in males than in females (22.1% vs. 6.1% and 20.3% vs. 3.3%, respectively, P < 0.001). Per 1 mm increment, tumor horizontal diameter increased the risk for poorly differentiated CSCCHN by 6.7% (95% CI 1.3-12.4%, P = 0.014). CONCLUSIONS: CSCCHN clinicopathological risk factors are not distributed evenly among different age and gender groups.

Diagnostic Use of Endoscopic Retrograde Cholangiopancreatectography for Pancreatic Duct Injury in Trauma Patients.

BACKGROUND: Trauma patients diagnosed with pancreatic duct injury (PDI) have a high complication rate and prolonged hospital stay. The role of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of PDI remains unclear. During the last decade, our trauma unit incorporated ERCP into the management protocol for suspected PDI cases. OBJECTIVES: To determine whether ERCP is a sensitive tool to detect PDI. METHODS: This retrospective trauma patient series study assessed the diagnostic yield of ERCP in trauma cases with suspected PDI on computed tomography (CT) or intraoperatively. Between 1 January 2004 and 31 December 2011, 13 patients admitted to our medical center underwent ERCP for suspected PDI. Patient demographics, mechanism of injury, Injury Severity Score (ISS), time from injury to ERCP, and ERCP-related complications were documented and assessed. RESULTS: Of the 13 patients included in the analysis, 8 stable patients with suspected PDI on CT had no leak from the main pancreatic duct on ERCP. Two of them underwent surgery for suspected pancreatic transection. ERCP confirmed a main pancreatic duct leak in three patients. Two patients underwent ERCP for suspected PDI after "damage control" surgery. No leak from the pancreatic ducts was diagnosed. No pancreas-related complications or ERCP-related complications were observed. CONCLUSIONS: ERCP is a sensitive and relatively safe tool for the diagnosis of PDI, and its use might prevent unnecessary surgical interventions in selected trauma cases.

[The history of plastic surgery in Israel].

The medical institutions in the country have advanced together with the development of the state of Israel. Plastic surgery, which has progressed significantly during the 20th century, has also grown rapidly in the new state. The arrival of Jewish plastic surgeons from all over the world with the knowledge and experience gained in their countries of origin, as well as the need for reconstructive surgical treatment for many combat injured soldiers, also contributed to the development of plastic surgery. This review tells the story of plastic surgery in Israel, since its foundation until nowadays. This article reviews the work of the founders of plastic surgery in Israel, indicating significant milestones in its development, and clinical and scientific contribution to the international plastic surgery profession. Moreover, the article describes the current condition of the field of plastic surgery in Israel and presents the trends and the future challenges facing the next generation of plastic surgery in Israel.

Safety and tolerability of a focused ultrasound device for treatment of adipose tissue in subjects undergoing abdominoplasty: a placebo-control pilot study.

BACKGROUND: High-intensity focused ultrasound (HIFU) lipolysis is a noninvasive alternative to existing surgical body-sculpting methods. OBJECTIVE: To evaluate the safety, tolerability, and histologic outcome of HIFU lipolysis using a novel device in human subjects. METHODS AND MATERIALS: In a single-blind pilot study, six healthy subjects scheduled to undergo abdominoplasty within 4 weeks received HIFU lipolysis on one side of the umbilicus. An identical placebo treatment was given to the contralateral side. Patient evaluation of complications, blood tests, and urine analysis were performed 1, 3, 7, 14, and 28 days after treatment. Excised tissue from the treated areas was sent for histologic review. RESULTS: Treatment was well tolerated. Average visual analogue pain scale scores were 3.5 ± 2.3 (range 1-7) and 0.17 ± 0.41 (range 0-1). No major adverse events were documented, and laboratory analysis after HIFU lipolysis was normal. Fat necrosis with infiltration of lymphocytes and macrophages without adjacent tissue damage was documented on histology 2 to 4 weeks after HIFU lipolysis. Damage extent correlated with size of the area treated. No pathologic findings were found on the control side. CONCLUSIONS: High-intensity focused ultrasound treatment was well tolerated and safe. Focal damage to target tissue was documented, with adjacent tissues remaining intact.

Predicting early term complications of ORIF distal radius fracture in outpatient settings using NSQIP data.

PURPOSE: There is no consensus on which risk factors are most predictive for complications following open reduction internal fixation of distal radius fractures (ORIF-DRF) in an outpatient setting. This study is a complication risk analysis for ORIF-DRF in outpatient settings based on data obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). METHODS: A nested, case-control study, was conducted in ORIF-DRF cases performed in outpatient settings from 2013 to 2019 obtained from the ACS-NSQIP database. Cases with documented local or systemic complications were age and gender-matched in a 1:3 ratio. The association between patient and procedure-dependent risk factors for systemic and local complications in general and for different subpopulations was examined. Bivariate and multivariable analyses were performed to evaluate the association between risk factors and complications. RESULTS: From a total of 18,324 ORIF-DRF, 349 cases with complications were identified and matched to 1047 Controls. Independent patient-related risk factors included a history of smoking, the American Society of Anesthesiologists (ASA) Physical Status Classification 3 and 4, and bleeding disorder. The intra-articular fracture with three or more fragments was found to be an independent risk factor of all procedure-related risk factors. History of smoking was found to be an independent risk factor for all gender populations, as well as for patients younger the 65 years old. For older patients (age ≥65) bleeding disorder was found to be an independent risk factor. CONCLUSION: Complications of ORIF-DRF in outpatient settings have many risk factors. This study provides surgeons with specific risk factors for possible complications following ORIF-DRF.

Silicone breast implant rupture is more prevalent in the dominant limb side: A retrospective cohort study.

BACKGROUND: Breast implant rupture is associated with multiple risk factors such as implant age, manufacturer, and a history of trauma to the breast. However, the exact mechanism of breast implant rupture remains unclear. We hypothesize that repetitive minor mechanical forces on the implant collectively play a significant role in the cascade that eventually leads to its rupture. Therefore, we expect a more significant cumulative effect on the breast implant in the dominant upper limb side. Thus, we aim to ascertain whether laterality in silicone breast implant rupture is associated with the dominant upper limb. METHODS: A retrospective cohort study was performed on patients with silicone breast implants who underwent an elective breast implant removal or exchange. All patients had breast augmentations for cosmetic reasons. We collected data on implant rupture laterality and limb dominance together with known risk factors like patient age, implant age, implant pocket, and implant volume. RESULTS: A total of 154 patients with unilateral implant rupture were included in the study. Among patients with a dominant right limb (n = 133), an ipsilateral rupture was found in 77 patients (58%) (p = 0.036), while in patients with a left dominant limb (n = 21), an ipsilateral rupture was found in 14 patients (67%), (p = 0.036). CONCLUSIONS: The dominant limb was a significant risk factor for ipsilateral breast implant rupture. The prevailing theory that cyclic envelope movement carries an increased rupture risk is reinforced in this study. Extensive prospective studies are needed to clarify risk factors for implant rupture further.

Alternative immunological markers to document successful multiple smallpox revaccinations.

BACKGROUND: Successful smallpox vaccination is traditionally defined by clinical response ("take"). Nevertheless, only 60% of subjects in the 2002 Israeli smallpox revaccination campaign developed clinical take. More sensitive immunological markers are needed to document successful revaccination. We compared the level of vaccinia-specific immune markers among subjects who did or did not develop clinical take following revaccination. METHODS: Forty subjects who participated in 2002 smallpox revaccination campaign and developed clinical take were individually matched for age, sex, and smallpox vaccinations with subjects who did not develop clinical take ("no-take"). Vaccinia immunity markers were examined prior to and 14 days and 2 years after revaccination. RESULTS: Higher levels of total immunoglobulin (Ig) G, IgG1, and neutralizing antibodies (highest dilution of serum that inhibited the cytopathic effect by at least 50% [PRNT50]) were observed in the no-take group before vaccination (166 vs 94.3 ELISAU/mL [P<.05], 53.2 vs 34.5 ELISAU/mL [ P<.05], and 30% vs 19.7% [P<.05], respectively). The mean time since last smallpox vaccination was longer in the take group than in the no-take group. Total IgG, IgG subclasses, avidity index, and PRNT50 levels were higher among "take" than "no-take" volunteers 14 days after revaccination. The no-take group was not inferior to the take group in all vaccinia immune marker levels measured 24 months after vaccination. Moreover, mean interferon-γ secretion and the percentage of serum samples with PRNT50 levels ≥1:32 were significantly higher in the No-take group than in the take group (677.5 vs 282.7 pg/mL [P < .05] and 95% vs 80% [P<.05], respectively). CONCLUSIONS: The overwhelming majority of subjects in the no-take group were successfully revaccinated against smallpox. Under circumstances of emergent smallpox mass immunization, there is no need for revaccination success assessment among individuals who have received multiple previous smallpox vaccinations.

Triage in mass-casualty events: the Haitian experience.

INTRODUCTION: Mass-casualty triage is implemented when available resources are insufficient to meet the needs of all patients in a disaster situation. The basic principle is to do the maximum good for the most casualties with the least amount of resources. There are limited data to support the applicability of this principle in massive disasters such as the January 2010 earthquake in Haiti, in which the number of patients seeking medical attention overwhelmed the local resources. OBJECTIVE: To analyze the application of a triage system developed for use in a mass-casualty setting with limited resources. The system was designed to admit only those patients who had medical conditions requiring urgent treatment that were within the capabilities of the hospital and had a good chance of survival after discharge. Priority was given to those whose treatment could be administered within a short hospital stay. METHOD: A retrospective, observational review of computerized registration forms of Haitian earthquake victims who sought medical care at a 72-bed field hospital within four to 14 days after the event. An analysis of the efficacy of the triage protocol that was used followed, using length of hospital stay to measure consumption of resources. RESULTS: A total of 1,111 patients were triaged for treatment in the field hospital within 14 days of the earthquake. The median length of stay for all patients for whom data was available was 16 hours (mean = 29.7 hours). The majority of patients (n = 620, 65%) were discharged within 24 hours. Two hundred five patients underwent surgery and were discharged within a median of 39 hours (mean = 52.6 hours); of these, 124 (62%) were discharged within 48 hours. The total mortality of the treated patients was 1.5% (n = 17). CONCLUSIONS: Currently accepted triage principles for the most part are appropriate for efficiently providing medical care in a disaster area with extremely limited resources, but require extensive adaptation to local conditions.

Immunosuppressive treatments reduce long-term immunity to smallpox among patients with breast cancer.

BACKGROUND: Mass vaccination is the principal preventive measure against a smallpox outbreak after an act of bioterrorism. Vaccination of subjects who received immunosuppressive therapies is problematic because of smallpox vaccine reactogenicity. Moreover, long-term immunity to vaccinia might be affected. OBJECTIVE: The objective of the study was to examine the effect of cytotoxic chemotherapy on long-term immunity to vaccinia. METHODS: In a case-control study, 67 patients with breast cancer who received cytotoxic chemotherapy and who were disease free for at least 1 year were matched with healthy controls according to age, sex, and the number of smallpox vaccinations received. Markers of immunity to smallpox were examined. Forty-one patients with breast cancer who did not receive chemotherapy were used to assess the affect of cancer and radiotherapy on immunity to smallpox. RESULTS: Patients with breast cancer who received chemotherapy had lower levels of vaccinia total immunoglobulin G and immunoglobulin G1 (expressed as enzyme-linked immunosorbent assay units per milliliter), neutralizing antibodies, vaccinia:memory B cell ratio (expressed as a percentage), and interferon-gamma level (expressed as picograms per milliliter), compared with healthy control individuals. CONCLUSIONS: Immunity to smallpox is reduced after receipt of chemotherapy for breast cancer. This finding should be considered when planning smallpox vaccination campaigns. The effect of immunosuppressive treatments on persistence of immunity should be tested with respect to additional vaccines or natural infections.

Smooth versus Textured Implant Breast Reconstruction: Patient-Reported Outcomes and Complications.

BACKGROUND: The association between textured surface breast implants and breast implant-associated anaplastic large cell lymphoma has led to an increase in surgical procedures to exchange textured devices to smooth surface implants. Because patient satisfaction is an integral part of breast reconstruction, the purpose of this study was to compare patient-reported outcomes between smooth and textured implant recipients. METHODS: Patients aged 18 years or older who underwent implant-based postmastectomy breast reconstruction with either smooth or textured devices from 2009 to 2017 and completed the BREAST-Q patient-reported outcome measure following reconstruction were included in this analysis. The primary outcomes of interest were mean and median BREAST-Q scores and postoperative complications. RESULTS: Overall, 1077 patients were included-785 who underwent breast reconstruction with smooth implants and 292 who underwent breast reconstruction with textured implants. No statistical differences were observed between the textured and smooth implant groups for any of the BREAST-Q domain scores at any of the early (3-month) to late (2-year) postoperative time points. Smooth implant recipients reported significantly more rippling (p = 0.003) than textured implant recipients. In contrast, textured implant recipients had a higher rate of cellulitis than smooth implant recipients (p = 0.016). CONCLUSIONS: These data suggest that postoperative satisfaction with breasts or health-related quality of life following immediate postmastectomy implant-based breast reconstruction is likely independent of implant surface type. However, smooth breast implants may result in more rippling. The authors' findings represent an important aid in counseling patients who have questions about the risks and benefits of replacing their textured implants with smooth surface devices. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.