Optimizing Aesthetic Outcomes in Autologous Breast Reconstruction: 20 Pearls for Practice.

Autologous breast reconstruction with a deep inferior epigastric artery perforator (DIEP) flap is an excellent option for many patients proceeding with mastectomy for surgical management of their breast cancer. As microsurgical techniques and results improve and ensure consistent flap survival, optimizing aesthetic outcomes may become a primary focus. This article outlines 20 tips that can improve aesthetic results in DIEP flap breast reconstruction, based on our senior author's 8-year career in microsurgical breast reconstruction, with an emphasis on enhanced cosmesis. We highlight tips on preoperative planning, intraoperative, and revision stages of the reconstruction and provide a schematic for integrating the tips into a reader's microsurgical breast reconstruction practice.

Surgical management of advanced hidradenitis suppurativa via a one-stage procedure: A single-center experience.

BACKGROUND: Hidradenitis suppurativa (HS) is a debilitating skin condition; in severe forms it requires excision and skin grafting for cure. This is commonly performed as a multi-stage procedure; we explored single-stage operation as a more efficient alternative. METHODS: Retrospective review 2007-2018 evaluating outcomes of patients undergoing single-stage surgery. RESULTS: 139 one-stage procedures were performed: 35 excision and primary closure, 104 split-thickness skin grafting (STSG). Success rate was higher for STSG at 75% versus 60% with primary closure. Of failed primary closures, 57% required revision by grafting due to recurrence. Axilla procedures were most successful at 91% compared to 70%, 54%, and 50% for inguinal, gluteal, and perineal areas, respectively. Infection was the most common complication (17%), with 38% requiring readmission. CONCLUSION: Compared to prior literature on multi-stage HS treatment, one-stage operations are a feasible, cost-effective alternative. STSG should remain the procedure of choice, even when primary closure appears feasible.

False positive bronchoalveolar lavage galactomannan: Effect of host and cut-off value.

OBJECTIVES: Bronchoalveolar lavage galactomannan (BAL-GM) is a mycological criterion for diagnosis of probable invasive aspergillosis (IA) per European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORT-MSG) consensus criteria, but its real-world positive predictive value (PPV) has not been well-studied. Our aim was to estimate the PPV of BAL-GM in a contemporary cohort of patients with positive BAL-GM. METHODS: We identified consecutive patients with ≥1 positive BAL-GM value (index ≥ 0.5) at Brigham and Women's Hospital from 11/2009 to 3/2016. We classified patients as having no, possible, probable, or proven IA, excluding BAL-GM as mycological criterion. RESULTS: We studied 134 patients: 54% had hematologic malignancy (HM), and 10% were solid organ transplant (SOT) recipients. A total of 42% of positive (≥0.5) BAL-GM results were falsely positive (PPV 58%). The number of probable IA cases was increased by 23% using positive BAL-GM as mycologic criterion alone. PPV was higher in patients with HM or SOT (P < 0.001) and with use of higher thresholds for positivity (BAL-GM ≥ 1 vs 1-0.8 vs 0.8-0.5: P = 0.002). CONCLUSIONS: 42% of positive BAL-GM values were falsely positive. We propose a critical reassessment of BAL-GM cutoff values in different patient populations. Accurate noninvasive tests for diagnosis of IA are urgently needed.

Pruritic Rash in a Patient with Hodgkin's Lymphoma.

Bleomycin-induced flagellate erythema (FE), a skin finding associated with cutaneous deposition of bleomycin, is so called due to its characteristic pattern of whip-like, linear streaks. As bleomycin use in standard chemotherapeutic regimens has decreased, the clinical diagnosis has become increasingly rare. The authors present a case of a 43-year-old female patient with Hodgkin's lymphoma on her first cycle of adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD) treatment, who subsequently developed a diffuse rash classic for FE. This benign condition is important to recognize to avoid potentially unnecessary and harmful treatment for other dermatologic diagnoses for which it may be mistaken. In severe cases of FE, discontinuation of bleomycin should be considered.

Initial Treatment of Cancer Patients with Fluconazole-Susceptible Dose-Dependent Candida glabrata Fungemia: Better Outcome with an Echinocandin or Polyene Compared to an Azole?

The 28-day crude mortality rate in 68 cancer patients with fluconazole-susceptible dose-dependent Candida glabrata fungemia started on treatment (within 48 h after blood culture collection) with an echinocandin or liposomal amphotericin-B was better (30%) than those treated with azole monotherapy (52%) (P = 0.07). After adjusting for confounders, azole monotherapy also was associated with worse 28-day survival (hazard ratio, 3.8; P = 0.003).

The Effects of Double Gloving on Microsurgical Skills.

Objective To determine whether double gloving would negatively affect participants' ability to perform a simulated microsurgical task. Study Design Randomized single-blinded controlled crossover trial. Setting Temporal bone laboratory of an academic otolaryngology department. Subjects and Methods This study involved the simulated insertion of a stapes prosthesis into a model of the ossicular chain under microscopy. Forty-one participants were recruited from our medical and dental school and randomized into 2 groups. All groups began by performing the task without gloves, acting as their own control arm. The first group (A) then performed the task with a single pair of gloves while the second group (B) next performed the task with 2 pairs of gloves. The groups then switched gloving methods. The total time taken to perform the task was recorded for each participant and the results subjected to a series of statistical measures. Results This study found a statistically significant difference in the average time taken to complete the task between the "no-glove" arm of the study and both experimental groups but no difference between the 2 experimental groups. Likewise, no significant difference was found between the 2 experimental groups when comparing the rate at which they improved at performing the task. Conclusion These data suggest that wearing 2 pairs of surgical gloves does not negatively affect the speed at which a microsurgical procedure may be performed, lending support to the practice of double gloving, even in the setting of microsurgical fine motor tasks.

Plexin-B2 promotes invasive growth of malignant glioma.

Invasive growth is a major determinant of the high lethality of malignant gliomas. Plexin-B2, an axon guidance receptor important for mediating neural progenitor cell migration during development, is upregulated in gliomas, but its function therein remains poorly understood. Combining bioinformatic analyses, immunoblotting and immunohistochemistry of patient samples, we demonstrate that Plexin-B2 is consistently upregulated in all types of human gliomas and that its expression levels correlate with glioma grade and poor survival. Activation of Plexin-B2 by Sema4C ligand in glioblastoma cells induced actin-based cytoskeletal dynamics and invasive migration in vitro. This proinvasive effect was associated with activation of the cell motility mediators RhoA and Rac1. Furthermore, costimulation of Plexin-B2 and the receptor tyrosine kinase Met led to synergistic Met phosphorylation. In intracranial glioblastoma transplants, Plexin-B2 knockdown hindered invasive growth and perivascular spreading, and resulted in decreased tumor vascularity. Our results demonstrate that Plexin-B2 promotes glioma invasion and vascularization, and they identify Plexin-B2 as a potential novel prognostic marker for glioma malignancy. Targeting the Plexin-B2 pathway may represent a novel therapeutic approach to curtail invasive growth of glioblastoma.