European Society of Organ Transplantation (ESOT) Consensus Statement on Prehabilitation for Solid Organ Transplantation Candidates.

There is increasingly growing evidence and awareness that prehabilitation in waitlisted solid organ transplant candidates may benefit clinical transplant outcomes and improve the patient's overall health and quality of life. Lifestyle changes, consisting of physical training, dietary management, and psychosocial interventions, aim to optimize the patient's physical and mental health before undergoing surgery, so as to enhance their ability to overcome procedure-associated stress, reduce complications, and accelerate post-operative recovery. Clinical data are promising but few, and evidence-based recommendations are scarce. To address the need for clinical guidelines, The European Society of Organ Transplantation (ESOT) convened a dedicated Working Group "Prehabilitation in Solid Organ Transplant Candidates," comprising experts in physical exercise, nutrition and psychosocial interventions, to review the literature on prehabilitation in this population, and develop recommendations. These were discussed and voted upon during the Consensus Conference in Prague, 13-15 November 2022. A high degree of consensus existed amongst all stakeholders including transplant recipients and their representatives. Ten recommendations were formulated that are a balanced representation of current published evidence and real-world practice. The findings and recommendations of the Working Group on Prehabilitation for solid organ transplant candidates are presented in this article.

The Operation Rainbow Canada Technique for Unilateral Cleft Lip Revision.

BACKGROUND: Purpose of this article is to demonstrate the "Operation Rainbow Canada" cleft lip revision technique. This is a surgical technique used by Operation Rainbow Canada on volunteer surgical missions in developing nations. We show how to convert previous Millard or straight line cleft lip repairs to a Fisher anatomic subunit repair, placing a favourable scar along the philtrum. We show a case series of results and explain how this technique gives satisfying aesthetic results for patients seeking unilateral cleft lip revision. METHODS: This technique combines the principles of the anatomic subunit repair for primary cleft lip repair as described by Fisher and the correction of the cleft nose deformity as described by McComb. We apply these 2 techniques to unilateral cleft lip revision at the same operation. RESULTS: Patients for revision unilateral lip and nose deformities were treated with this technique over the course of several international surgical missions. There were over 90 cases of revisions performed by our group on previous repaired cleft lips. These procedures were done in India, China, and Cambodia. CONCLUSION: Previously repaired cleft lips can be improved by our revision procedure. We show how incorporating 2 triangular flaps to lengthen the cleft side of the repaired lip can be done in a revision setting. During lip revision, McCombs sutures can be placed to improve the aesthetic of the nose and correct the nasal alar dome.

HISTORIQUE: Le présent article vise à enseigner la technique de correction de la fente labiale d'Operation Rainbow Canada. L'organisme utilise cette technique lors des missions chirurgicales de volontaires dans les pays en développement. Les chercheurs démontrent comment convertir la technique de Millard et la technique en ligne droite en une réparation sous-unitaire anatomique de Fisher, pour former une cicatrice favorable le long du sillon sous-nasal. Ils présentent les observations d'une série de cas et expliquent que cette technique donne des résultats esthétiques pour les patients qui veulent faire corriger une fente palatine unilatérale. MÉTHODOLOGIE: La présente technique combine les principes des sous-unités anatomiques pour réparer les fentes palatines primaires décrites par Fisher et la correction de la fente palatine décrite par McComb. Les chercheurs appliquent ces deux techniques à la correction d'une fente labiale unilatérale lors de la même opération. RÉSULTATS: La technique a été utilisée auprès de patients qui devaient faire corriger une fente labiale et palatine unilatérale dans le cadre de plusieurs missions chirurgicales internationales. Le groupe a effectué plus de 90 corrections de fentes palatines déjà réparées en Inde, en Chine et au Cambodge. CONCLUSION: Les fentes labiales déjà réparées peuvent être améliorées grâce à une intervention de correction. Les auteurs démontrent comment intégrer deux lambeaux triangulaires pour allonger le côté réparé de la lèvre. Pendant cette correction de la lèvre, on peut utiliser des sutures de McCombs pour améliorer l'esthétique du nez et corriger les dômes des cartilages alaires nasaux.

Temporal response of an injectable calcium phosphate material in a critical size defect.

BACKGROUND: Calcium phosphate-based bone graft substitutes are used to facilitate healing in bony defects caused by trauma or created during surgery. Here, we present an injectable calcium phosphate-based bone void filler that has been purposefully formulated with hyaluronic acid to offer a longer working time for ease of injection into bony defects that are difficult to access during minimally invasive surgery. METHODS: The bone substitute material deliverability and physical properties were characterized, and in vivo response was evaluated in a critical size distal femur defect in skeletally mature rabbits to 26 weeks. The interface with the host bone, implant degradation, and resorption were assessed with time. RESULTS: The calcium phosphate bone substitute material could be injected as a paste within the working time window of 7-18 min, and then self-cured at body temperature within 10 min. The material reached a maximum ultimate compressive strength of 8.20 ± 0.95 MPa, similar to trabecular bone. The material was found to be biocompatible and osteoconductive in vivo out to 26 weeks, with new bone formation and normal bone architecture observed at 6 weeks, as demonstrated by histological evaluation, microcomputed tomography, and radiographic evaluation. CONCLUSIONS: These findings show that the material properties and performance are well suited for minimally invasive percutaneous delivery applications.

WALANT Hand Surgery Does Not Require Postoperative Opioid Pain Management.

BACKGROUND: Currently, opioids are the standard of care for postoperative pain management. Avoiding unnecessary opioid exposure in patients is of current interest because of widespread abuse. METHODS: This is a prospective cohort study in which wide-awake, local anesthesia, no-tourniquet (WALANT) technique was used for 94 hand/upper extremity surgical patients and compared to patient cohorts undergoing similar procedures under monitored anesthesia care. Patients were not prescribed opioids postoperatively but were instead directed to use over-the-counter pain relievers. Pain scores on a visual analogue scale were collected from patients preoperatively, and on postoperative days 1 and 14. WALANT visual analogue scale scores were compared to those of the two patient cohorts who either did or did not receive postoperative opioids after undergoing similar procedures under monitored anesthesia care. Electronic medical records and New York State's prescription monitoring program, Internet System for Tracking Over-Prescribing, were used to assess prescription opioid-seeking. Information on sex, age, comorbidity burden, previous opioid exposure, and insurance coverage was also collected. RESULTS: Decreased pain was reported by WALANT patients 14 days postoperatively compared to preoperatively and 1 day postoperatively, with a total group mean pain score of 0.37. This is lower than mean scores of monitored anesthesia care patients with and without postoperative opioids. Only two WALANT patients (2.1 percent) sought opioid prescriptions from outside providers. There was little evidence suggesting factors including sex, age, comorbidity burden, previous opioid exposure, or insurance status alter these results. CONCLUSION: WALANT may be a beneficial technique hand surgeons may adopt to mitigate use of postoperative opioids and reduce risk of abuse in patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Augmentation Mastopexy with Surgical Excision of the Lower Pole to Avoid Waterfall Deformity: A Surgical Technique and Nipple Areolar Complex Case Series.

Purpose of this article is to demonstrate a way of avoiding the waterfall deformity in augmentation mastopexy patients. We will show a case series of results and explain how this technique gives satisfying aesthetic results for patients seeking breast augmentation who also require mastopexy. We will show how addressing the breast parenchyma on the lower pole via direct excision can give reliable results and avoids the waterfall deformity. The surgical technique used by the senior author combines the principles of breast augmentation, mastopexy, and breast reduction. We apply these principles during the initial single operation. Our goal is to achieve the best anatomical results for the patient. We describe 1538 consecutive patients whom underwent single-stage breast augmentation with mastopexy. All implants were submuscular with 12% being saline and 88% were silicone implants. Vertical mastopexies were performed in 8% and wise pattern incisions were used in 92%. There were no life-threatening complications such as deep vein thrombosis, pulmonary embolism, and so on. Tissue-related complications included wound infection (1%) and hematomas (1%). Implant-related complications included malposition or implant displacement 9% and capsular contracture 1%. Aesthetic complications included dystopia of NAC (4%) and volume asymmetries (10%). Revision surgery was tissue related (2%), implant related (3%), and aesthetic related (10%). There were no cases of waterfall deformity seen in the cohort. In conclusion, we believe that the technique detailed here is easy to do, uses principles already known of breast augmentation and reduction and gives consistent results with low reoperation rates.

Le présent article vise à établir un moyen d'éviter les malformations en cascades chez les patientes ayant subi une mastopexie d'augmentation. Les auteurs présentent une série de cas et expliquent en quoi leur technique donne des résultats esthétiques satisfaisants pour les patientes qui veulent une augmentation mammaire et ont également besoin d'une mastopexie. Ils démontrent en quoi le traitement d'un parenchyme mammaire du pôle inférieur par excision directe peut donner des résultats fiables et éviter une malformation en cascades. La technique chirurgicale utilisée par l'auteur principal combine les principes d'augmentation mammaire, de mastopexie et de réduction mammaire. Les auteurs appliquent ces principes pendant l'opération initiale unique. Ils avaient l'objectif de réaliser les meilleurs résultats anatomiques pour les patients. Les auteurs ont décrit 1 538 patients consécutifs qui avaient subi une augmentation mammaire en une étape accompagnée d'une mastopexie. Tous les implants étaient sous-musculaires, 12 % étaient remplis de solution saline et 88 % étaient en silicone. Des mastopexies verticales ont été effectuées dans 8 % des cas, et des incisions en motifs prudents, dans 92 % des cas. Il n'y a pas eu de complications au potentiel mortel comme des thromboses veineuses profondes, des embolies pulmonaires, etc. Les complications tissulaires incluaient les infections des plaies (1 %) et les hématomes (1 %). Les complications liées aux implants incluaient une malposition ou un déplacement des implants dans 9 % des cas, et une contracture capsulaire dans 1% des cas. Les complications esthétiques incluaient la dystopie N-acétylcystéine (4 %) et l'asymétrie des volumes (10 %). Les opérations de révision étaient liées aux tissus (2 %), aux implants (3 %) et aux anesthésiques (10 %). Il n'y a pas eu de malformation en cascades dans la cohorte. Pour terminer, les auteurs sont d'avis que la technique est facile à effectuer, fait appel à des principes d'augmentation et de réduction mammaires déjà connus et donne des résultats uniformes liés à un faible taux de réopération.

Computed Tomographic Angiography Used for Localization of the Cutaneous Perforators and Selection of Anterolateral Thigh Flap "Bail-Out" Branches.

BACKGROUND: The purpose of this study was to evaluate the territory supplied by the lateral circumflex femoral artery for the consistency of a proximal perforator that could be used as an alternative pedicle for the anterolateral thigh flap if a tedious intramuscular course is encountered during elevation of the perforator used to develop the initial surgical plan. It is hypothesized that a consistent "bail-out" perforator supplying the proximal thigh would facilitate a simpler anterolateral thigh flap harvest, with minimal modification to flap design. METHODS: Computed tomographic images of 9 fresh cadavers were imported using Materialize's Interactive Medical Imaging Control System software to create surface-rendered 3-dimensional reconstructions of 15 lower limbs. Perforators emerging proximally and laterally to a 3-cm radius circle drawn at the midpoint of the anterior superior iliac spine and superolateral patella were considered potential bail-out perforators and evaluated for their number emerging diameter, length, course, and location relative to the anterior superior iliac spine. RESULTS: An average of 2.9 ± 1.8 perforators per limb were identified. Mean pedicle length was 111 ± 20 mm, measured from the origin in the lateral circumflex femoral artery to where the perforators emerged through the deep fascia directly overlying the thigh muscles. Average diameter at origin in the lateral circumflex femoral artery was 2.8 ± 0.8 mm, and that at emergence through the deep fascia was 1.1 ± 0.3 mm. Vessel course was predominantly musculocutaneous (90%). CONCLUSIONS: A significant bail-out perforator routinely supplies the proximal anterolateral thigh and may be used as an alternative vascular pedicle for an anterolateral thigh flap if a tedious intramuscular course is encountered during elevation of a perforator identified within the conventional landmarks (3-cm radius circle at the midpoint of the anterior superior iliac spine and superolateral patella).

The Keystone Flap-A Case Series Demonstrating Practical Design, Use, and Applications.

INTRODUCTION: The keystone design perforator island flap is a trapezoidal-shaped random perforator island flap with many advantages over primary closure, skin grafting, and other local flaps for soft tissue reconstruction commonly encountered with cancer excisions. METHODS: This case series of 39 keystone flaps in 37 patients reviews the practical design, use, and applications of the flap while highlighting certain important considerations. Keystone flaps were designed as in the original description, with a minor modification in the lower extremity where a higher flap to defect width ratio was used. RESULTS: Defects varying in size from 6 to 63 cm2 were reconstructed in 23 males and 14 females ranging in age from 49 to 89. In all 39 cases, there were 2 minor complications of partial flap dehiscence and no major complications such as partial or complete flap loss. CONCLUSION: The keystone flap is a versatile and reliable flap with applications almost anywhere on the body. A higher ratio of flap width to defect width up to 1:3 is more appropriate for the lower extremity where tension is higher.

INTRODUCTION: Le lambeau en clef de voûte perforateur en îlot est un lambeau perforateur trapézoïdal aléatoire qui comporte de nombreux avantages par rapport à la fermeture primaire, à la greffe cutanée et à d'autres lambeaux locaux pour la reconstruction des tissus mous souvent nécessaire après des excisions attribuables au cancer. MÉTHODOLOGIE: Cette série de 39 lambeaux en clef de voûte chez 37 patients vise à analyser la conception, l'utilisation et les applications pratiques du lambeau tout en explorant certains aspects importants. Les lambeaux en clef de voûte ont été conçus comme dans la description originale, à part une légère modification dans les membres inférieurs, où les plasticiens ont privilégié un ratio plus élevé entre la largeur du lambeau et la largeur de l'anomalie. RÉSULTATS: Les plasticiens ont reconstruit des anomalies de 6 cm2 à 63 cm2 chez 23 hommes et 14 femmes de 49 à 89 ans. Dans ces 39 cas, ils ont observé deux complications mineures de déhiscence partielle du lambeau et aucune complication majeure, telle que la perte partielle ou totale du lambeau. CONCLUSIONS: Le lambeau en clef de voûte, polyvalent et fiable, peut être utilisé pratiquement partout sur le corps. Un ratio plus élevé pouvant atteindre 1:3 entre la largeur du lambeau et la largeur de l'anomalie convient mieux aux membres inférieurs, où la tension est plus importante.

Aggressive Combined Medical and Surgical Management of Mucormycosis Results in Disease Eradication in 2 Pediatric Patients.

Rhinocerebral mucormycosis is an acute, rapidly fatal, fungal infection, classically involving the nasal mucosa and paranasal sinuses. It is an aggressive, opportunistic infection that frequently progresses to involve the orbit and cerebrum. Cerebral extension in immunocompromised patients is almost universally fatal. There are limited data on mucormycosis in pediatric immunocompromised patients in the literature, with only few reports on rhinocerebral involvement. The immunocompromised patients described in this report presented with suspected periorbital and nasal cellulitis, progressing rapidly to necrotic changes in nasal tissue and oral palatal mucosa. In these patients, the surgical resection of mucormycosis-infected tissue followed by flap reconstruction combined with medical treatment effectively treated the infection, allowed for the rapid resumption of chemotherapy and dramatically improved the quality of life for both the patient and their family.

La mucormycose rhinocérébrale est une infection fongique aiguë qui devient vite fatale et qui touche généralement les muqueuses nasales et les sinus paranasaux. C'est une infection agressive et opportuniste qui évolue souvent pour toucher l'orbite et le cerveau. Chez les patients immunodéprimés, l'atteinte cérébrale est presque toujours fatale. Les données sur la mucormycose chez les patients immunodéprimés d'âge pédiatrique sont limitées dans les publications, et seulement quelques articles traitent de l'atteinte rhinocérébrale. Les patients immunodéprimés décrits dans le présent rapport ont consulté à cause d'une présomption de cellulite périorbitale et nasale qui a évolué rapidement vers une nécrose des tissus nasaux et de la muqueuse oropalatine. Chez ces patients, la résection chirurgicale des tissus infectés par la mucormycose suivie d'une reconstruction par lambeau combinée à un traitement médical, a favorisé la résolution de l'infection, ce qui a permis une reprise rapide de la chimiothérapie et a considérablement amélioré la qualité de vie du patient et de sa famille.

Peritoneal Dialysis Access Revision in Children: Causes, Interventions, and Outcomes.

BACKGROUND AND OBJECTIVES: Little published information is available about access failure in children undergoing chronic peritoneal dialysis. Our objectives were to evaluate frequency, risk factors, interventions, and outcome of peritoneal dialysis access revision. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Data were derived from 824 incident and 1629 prevalent patients from 105 pediatric nephrology centers enrolled in the International Pediatric Peritoneal Dialysis Network Registry between 2007 and 2015. RESULTS: In total, 452 access revisions were recorded in 321 (13%) of 2453 patients over 3134 patient-years of follow-up, resulting in an overall access revision rate of 0.14 per treatment year. Among 824 incident patients, 186 (22.6%) underwent 188 access revisions over 1066 patient-years, yielding an access revision rate of 0.17 per treatment year; 83% of access revisions in incident patients were reported within the first year of peritoneal dialysis treatment. Catheter survival rates in incident patients were 84%, 80%, 77%, and 73% at 12, 24, 36, and 48 months, respectively. By multivariate logistic regression analysis, risk of access revision was associated with younger age (odds ratio, 0.93; 95% confidence interval, 0.92 to 0.95; P<0.001), diagnosis of congenital anomalies of the kidney and urinary tract (odds ratio, 1.28; 95% confidence interval, 1.03 to 1.59; P=0.02), coexisting ostomies (odds ratio, 1.42; 95% confidence interval, 1.07 to 1.87; P=0.01), presence of swan neck tunnel with curled intraperitoneal portion (odds ratio, 1.30; 95% confidence interval, 1.04 to 1.63; P=0.02), and high gross national income (odds ratio, 1.10; 95% confidence interval, 1.02 to 1.19; P=0.01). Main reasons for access revisions included mechanical malfunction (60%), peritonitis (16%), exit site infection (12%), and leakage (6%). Need for access revision increased the risk of peritoneal dialysis technique failure or death (hazard ratio, 1.35; 95% confidence interval, 1.10 to 1.65; P=0.003). Access dysfunction due to mechanical causes doubled the risk of technique failure compared with infectious causes (hazard ratio, 1.95; 95% confidence interval, 1.20 to 2.30; P=0.03). CONCLUSIONS: Peritoneal dialysis catheter revisions are common in pediatric patients on peritoneal dialysis and complicate provision of chronic peritoneal dialysis. Attention to potentially modifiable risk factors by pediatric nephrologists and pediatric surgeons should be encouraged.

Peritoneal-pericardial communication in an adolescent on peritoneal dialysis.

BACKGROUND: Dialysate leakage into the pericardium is a rare but potentially life-threatening complication of peritoneal dialysis (PD). There has been one reported pediatric case of spontaneous peritoneo-pericardial fistula in a 2-year-old boy with tissue fragility due to malnutrition and two reported adult cases in PD patients with a history of previous cardiac surgery and/or pericardiocentesis. CASE-DIAGNOSIS/TREATMENT: We describe a 15-year-old girl with end-stage renal disease secondary to granulomatosis with polyangiitis, with recurrent pericardial effusions secondary to a peritoneo-pericardial fistula while on continuous cycling peritoneal dialysis (CCPD). She had previously presented with chylous pericardial effusion that required pericardiocentesis and subsequently developed recurrent pericardial effusions when she was commenced on CCPD 9 months later. Pericardial fluid chemistry revealed a sterile, serous fluid containing 15.1 mmol/L of glucose and <0.11 mmol/L of triglycerides. Peritoneal scintigraphy with Tc-99m labeled sulfur colloid injected intra-peritoneally confirmed the presence of a peritoneo-pericardial fistula. The pericardial effusions resolved upon switching the patient to hemodialysis (HD). CONCLUSIONS: Our case of recurrent pericardial effusions in a child on PD secondary to a peritoneo-pericardial fistula highlights the need for close follow-up in patients with a history of previous pericardiocentesis who are commenced on PD.

Reverse Radial Artery Flap Perforator Anatomy and Clinical Applications.

The pedicled reverse radial forearm flap is a well-known option for the treatment of a variety of soft tissue wounds including dorsal hand wounds. We document the number, emerging diameter, length from origin, course, and location of all perforators of the radial artery in a series of 6 fresh human cadavers after whole body lead oxide and gelatin injection to confirm and comprehensively document the anatomy of the radial artery perforators. This data provide an anatomic basis for a modification to the reversed radial forearm flap used to decrease venous congestion in the postoperative period. Two case reports are presented to provide clinical demonstration of the importance of this modification.

Canadian Society of Nephrology commentary on the 2012 KDIGO Clinical Practice Guideline for Anemia in CKD.

The KDIGO (Kidney Disease: Improving Global Outcomes) 2012 clinical practice guideline for anemia management in patients with chronic kidney disease provides the structural and evidence base for the Canadian Society of Nephrology commentary on this guideline's relevancy and application to the Canadian health care system. While in general agreement, we provide commentary on 11 of the 61 KDIGO guideline statements. Specifically, we agreed that a therapeutic trial of iron is appropriate in cases in which a reduction in erythropoiesis-stimulating agent (ESA) dosage or avoidance of ESA and transfusion is desired, transferrin saturations are >30%, and ferritin concentrations are >500 µg/L. However, we concluded that there is insufficient evidence to support an upper target or threshold for ferritin and transferrin saturation levels. We agree with the initiation of ESA treatment when hemoglobin (Hb) level is 90-100 g/L; however, we specifically state that an acceptable range for Hb level is 95-115 g/L, with a target of 100-110 g/L, and add caution to individualization above this range due to concerns regarding the safety of ESAs. We agree that ESAs should be used with considerable caution in patients with active malignancy, history of stroke, or history of malignancy, and we suggest initiating ESA therapy at Hb level of 90 g/L and to aim for a Hb level in the range of 90-105 g/L. The reader is encouraged to note the level of evidence and review the entire KDIGO anemia guideline to interpret the guideline statements and commentary appropriately.

Breast reduction scars: a prospective survey of patient preferences.

BACKGROUND: Studies have shown that scarring is a primary reason for patient dissatisfaction with reduction mammaplasty. OBJECTIVES: The authors prospectively evaluated patient preferences for the 3 most common breast reduction scar patterns: horizontal, vertical, and Wise. METHODS: Sixty-six patients were recruited for the study before receiving their reduction mammaplasty consultation. Each patient was shown line drawings and postoperative photographs of the 3 breast reduction techniques and scored the scars on a modified 10-point Likert scale (1 = unacceptable; 10 = acceptable). The survey responses had no impact on the patients' medical care. A nonparametric Friedman test was used to compare the mean scores, and univariate generalized linear regression analysis was performed to adjust for confounding factors. Post hoc analysis was performed using the Bonferroni method. Significance was set at P < .001. RESULTS: Sixty patients completed the study. The mean preference ranking was significantly higher for the horizontal scar pattern versus vertical and Wise (P < .001). The mean score difference between the horizontal and Wise patterns was 2.982. The mean difference between the horizontal and vertical patterns was 2.27. There was no significant difference in preference between the vertical and Wise patterns. Linear regression analysis showed that age, body mass index, and torso/bra size had no significant effect on preference. CONCLUSIONS: To our knowledge, this is the first study designed to prospectively evaluate patient preferences regarding postoperative scars. Results indicate that the horizontal technique is preferable with respect to scar placement.

Management of anemia in children receiving chronic peritoneal dialysis.

Little information exists regarding the efficacy, modifiers, and outcomes of anemia management in children with CKD or ESRD. We assessed practices, effectors, and outcomes of anemia management in 1394 pediatric patients undergoing peritoneal dialysis (PD) who were prospectively followed in 30 countries. We noted that 25% of patients had hemoglobin levels below target (<10 g/dl or <9.5 g/dl in children older or younger than 2 years, respectively), with significant regional variation; levels were highest in North America and Europe and lowest in Asia and Turkey. Low hemoglobin levels were associated with low urine output, low serum albumin, high parathyroid hormone, high ferritin, and the use of bioincompatible PD fluid. Erythropoiesis-stimulating agents (ESAs) were prescribed to 92% of patients, and neither the type of ESA nor the dosing interval appeared to affect efficacy. The weekly ESA dose inversely correlated with age when scaled to weight but did not correlate with age when normalized to body surface area. ESA sensitivity was positively associated with residual diuresis and serum albumin and inversely associated with serum parathyroid hormone and ferritin. The prevalence of hypertension and left ventricular hypertrophy increased with the degree of anemia. Patient survival was positively associated with achieved hemoglobin and serum albumin and was inversely associated with ESA dose. In conclusion, control of anemia in children receiving long-term PD varies by region. ESA requirements are independent of age when dose is scaled to body surface area, and ESA resistance is associated with inflammation, fluid retention, and hyperparathyroidism. Anemia and high ESA dose requirements independently predict mortality.

Using phospho-motif antibodies to determine kinase substrates.

Phosphorylation of substrates by protein kinases regulates a myriad of cellular processes, ranging from proliferation and migration to autophagy, senescence, and apoptosis. Kinase substrate selectivity is largely dependent on the amino acid sequence surrounding the phosphorylation site; therefore, substrate-directed, phosphorylation-state-sensitive, motif-specific ("phospho-motif") antibodies represent powerful tools to identify novel kinase substrates and to investigate mechanisms of substrate phosphorylation in many signaling pathways typically associated with human malignancies. Phospho-motif antibodies are engineered to recognize proteins that contain a phosphorylated residue in the context of a specific motif. They are raised against a library of phospho-peptides comprising both the phosphorylated residue and the surrounding residues that determine kinase specificity, with degenerate residues taking up the remaining positions. Currently, several categories of phospho-motif antibody are commercially available, which may be used to specifically detect Ser, Thr, Ser/Thr, or Tyr residues phosphorylated by different protein kinase families. These antibodies are commonly used in immunoprecipitation and/or immunoblotting protocols to determine kinase-induced substrate phosphorylation. This unit describes the use of phospho-motif antibodies to elucidate the kinase(s) responsible for phosphorylating substrate proteins.

International plastic surgery missions: a framework for resident education using the CanMEDS competencies.

Residency education has shifted over the past decade in an attempt to graduate well-rounded physicians. There is a recognition that a physician's abilities must extend beyond medical knowledge. The Royal College of Physicians and Surgeons of Canada introduced the CanMEDS physician competency framework in 2005. The framework provides 7 areas of competencies that are aimed at providing improved patient care. These competencies are medical expert, communicator, collaborator, manager, health advocate, scholar, and professional. Teaching and evaluating many of these competencies is often challenging for residency training programs. We believe that international surgical missions provide a prime opportunity to teach and evaluate all CanMEDS' roles.Plastic surgery is a field with many different organizations involved in international surgery. Many plastic surgery training programs offer opportunities for residents to become involved in these international surgical missions. Through these trips, residents gain surgical experience, see a variety and volume of clinical cases, and have the opportunity to travel to a foreign country and experience different cultures. We believe that international plastic surgery surgical missions also provide an exceptional micro environment for the teaching of CanMEDS roles. Using examples from residents' personal experiences on international plastic surgery missions to China, Mali, and Cambodia, we describe the benefits of these missions in transferring the CanMEDS competencies to resident training.