Combined Face and Whole Eye Transplantation: Cadaveric Rehearsals and Feasibility Assessment.

Background: In properly selected patients, combined face and whole eye transplantation (FWET) may offer a more optimal aesthetic and potentially functional outcome while avoiding the complications and stigma of enucleation and prosthetics. This study presents the most comprehensive cadaveric assessment for FWET to date, including rehearsal allograft procurement on a brain-dead donor. Methods: Over a 2-year period, 15 rehearsal dissections were performed on 21 cadavers and one brain-dead donor. After identification of a potential recipient, rehearsals assessed clinical feasibility and enabled operative planning, technical practice, refinement of personalized equipment, and improved communication among team members. Operative techniques are described. Results: Facial allograft procurement closely followed previously described face transplant techniques. Ophthalmic to superficial temporal (O-ST) vessel anastomosis for globe survival was assessed. Craniectomy allowed for maximal optic nerve and ophthalmic vessel pedicle length. Appropriate pedicle length and vessel caliber for O-ST anastomosis was seen. Research procurement demonstrated collateral blood flow to the orbit and surrounding structures from the external carotid system as well as confirmed the feasibility of timely O-ST anastomosis. Personalized cutting guides enabled highly accurate bony inset. Conclusions: This study formalizes an approach to FWET, which is feasible for clinical translation in judiciously selected patients. O-ST anastomosis seems to minimize retinal ischemia time and allow perfusion of the combined allograft on a single external carotid pedicle. Although restoration of vision likely remains out of reach, globe survival is possible.

Multifactorial Study on the Impact of Educational Level, Employment Status, and the Need for Extraordinary Care on the Economic Impact of Cancer Patients.

Cancer is one of the major socio-health problems in the world. The level of education, the profession and/or employment status of the patient and the family can influence the amount of household income, the additional expenditure, and the possible socio-economic impact of the disease. The main objective of the study is to analyse and evaluate the influence of the level of education, the employment status of the patient, and the need for care and how these factors influence the additional expenditure and the possible socio-economic impact. METHODS: descriptive cross-sectional randomised observational epidemiological study without replacement at the Hospital Universitario de Salamanca (CAUSA). RESULTS: total sample (n = 365) comprised 53.2% of patients with no education or primary education, 25.8% with secondary education and 21.1% with higher education. Overall, 36.4% of patients were employed, 10.1% were self-employed, 53.0% were not employed, and 38.9% were experiencing other conditions. Significant statistics were found for educational level, employment status of the patient and main caregivers in terms of financial expenditure. CONCLUSIONS: Oncology patients with more education spend more on home help and/or accompanying the patient and transfers to the hospital for treatment. Higher incomes are not synonymous with higher expenditure in the sample. The patient's main caregivers are a fundamental pillar of the patient's household income and additional spending on orthopaedic material.

Social support criteria in vascularized composite allotransplantation versus solid organ transplantation: Should the same ethical considerations apply?

The field of vascularized composite allotransplantation (VCA) is evolving, with some procedures poised to transition from highly experimental research toward standard of care. At present, the use of social support as an eligibility criterion for VCA candidacy is at the discretion of individual VCA programs, allowing VCA teams to consider the unique needs of each potential candidate. Yet this flexibility also creates potential for bias during the evaluation process which may disproportionately impact members of certain communities where social configurations may not resemble the model considered "optimal." We examine the extent to which ethical considerations for social support in solid organ transplantation (SOT) may be applied to or adapted for VCA, and the ethically meaningful ways in which VCA procedures differ from SOT. We conclude that VCA programs must retain some flexibility in determining criteria for candidacy at present; however, considerations of equity will become more pressing as VCA procedures evolve toward standard of care, and further empirical evidence will be needed to demonstrate the association between social support and post-operative success. The field of VCA has an opportunity to proactively address considerations of equity and justice and incorporate fair, inclusive practices into this innovative area of transplantation.

Study on the Socio-Economic Impact of Cancer Disease on Cancer Patients and Their Relatives.

BACKGROUND: Cancer is one of the most relevant social and health problems in the world. The disease entails additional costs for cancer patients and their families that are not covered by the public part of our welfare state, and which they assume themselves simply because they are ill. The main objective of this study is to identify and analyse the additional cost and socioeconomic impact of cancer disease on patients diagnosed with cancer disease and their families. METHODS: Descriptive cross-sectional randomised observational epidemiological study without replacement with prevalence of cancer disease in the study base, carried out in the Medical Oncology Service of the Complejo Asistencial Universitario de Salamanca (CAUSA), Spain. RESULTS: The study variable has been the additional cost of the cancer disease for cancer patients and their families that is not covered by our autonomous health system. CONCLUSIONS: Cancer disease entails an additional cost for the patient and family; more specifically, for 55% of the patients in the study sample, the diagnosis of cancer represents extra expenditure of between 8.38-9.67% of their annual income. Furthermore, the disability and dependence of patients does not represent an additional cost due to their levels of functionality, but it can have repercussions on the future cost of the evolution of the disease, in addition to the fact of having cancer.

Current Trends in Facial Feminization Surgery: An Assessment of Safety and Style.

BACKGROUND: Facial feminization surgery (FFS) plays an instrumental role in the process of gender affirmation. These procedures are becoming increasingly appreciated for their ability to improve patient satisfaction and gender identity in a way that alleviates gender dysphoria and improves the quality of life. Despite the recent surge in popularity across the US, the current literature lacks evidence on the safety profile of combined facial feminization procedures. Our goal was to determine the safety profile of facial feminization procedures registered on a national surgical database. METHODS: Patients with a primary diagnosis of gender dysphoria undergoing facial surgical procedures were identified from the National Surgical Quality Improvement Program database between the years 2013 and 2018. Demographic characteristics along with 30-day postoperative complications were recorded. Logistic regression models adjusted for confounders were used to determine the independent predictors of postoperative complications. RESULTS: A cohort of 77 patients who underwent a total of 220 procedures was identified. The number of patients undergoing surgery per year increased from three (3.9%) in 2013 to 41 (53.2%) in 2018, a 13.6-fold increase. The most commonly performed procedure was forehead contouring/frontal sinus setback, performed on 52 patients (67.5%), followed by orbital contouring (n = 37, 48%), rhinoplasty (n = 34, 44%), mandibuloplasty (n = 34, 44%), chondrolaryngoplasty (n = 27, 35.1%), genioplasty (n = 11, 14%), brow lift (n = 9, 11.7%), cheek augmentation (n = 9, 11.7%), and lip lift (n = 7, 9.1%). The number of patients who underwent 5 or more procedures in a single anesthetic event was 41 (53.2%). The complication rate was 3.9%. Univariate analysis suggested an association between older age and postoperative morbidity (P  < 0.02). However, this was not found to be an independent predictor on multivariate analysis adjusted for confounders (P < 0.083). Additionally, an increase in operative time and the number of procedures performed during a single anesthetic were not independent predictors of 30-day postoperative complications (P < 0.317 and P  < 0.19, respectively). CONCLUSIONS: FFS can be safely performed and has a low risk of postoperative morbidity. The number of patients seeking FFS surgery has risen exponentially, with the highest demand seen for the reconstruction of the upper facial third. These findings should guide expectations for patients seeking FFS, as well as for plastic surgeons looking to perform multiple procedures per anesthetic event.

Life cycle assessment of fish and seafood processed products - A review of methodologies and new challenges.

Life cycle assessment (LCA) has been widely applied in many different sectors, but the marine products and seafood segment have received relatively little attention in the past. In recent decades, global fish production experienced sustained growth and peaked at about 179 million tonnes in 2018. Consequently, increased interest in the environmental implications of fishery products along the supply chain, namely from capture to end of life, was recently experienced by society, industry and policy-makers. This timely review aims to describe the current framework of LCA and its application to the seafood sector that mainly focused on fish extraction and processing, but it also encompassed the remaining stages. An excess of 60 studies conducted over the last decade, along with some additional publications, were comprehensively reviewed; these focused on the main LCA methodological choices, including but not limited to, functional unit, system boundaries allocation methods and environmental indicators. The review identifies key recommendations on the progression of LCA for this increasingly important sustaining seafood sector. Specifically, these recommendations include (i) the need for specific indicators for fish-related activities, (ii) the target species and their geographical origin, (iii) knowledge and technology transfer and, (iv) the application and implementation of key recommendations from LCA research that will improve the accuracy of LCA models in this sector. Furthermore, the review comprises a section addressing previous and current challenges of the seafood sector. Wastewater treatment, ghost fishing or climate change, are also the objects of discussion together with advocating support for the water-energy-food nexus as a valuable tool to minimize environmental negativities and to frame successful synergies.

Equity in access to facial transplantation.

We examine ethical considerations in access to facial transplantation (FT), with implications for promoting health equity. As a form of vascularised composite allotransplantation, FT is still considered innovative with a relatively low volume of procedures performed to date by a small number of active FT programmes worldwide. However, as numbers continue to increase and institutions look to establish new FT programmes, we anticipate that attention will shift from feasibility towards ensuring the benefits of FT are equitably available to those in need. This manuscript assesses barriers to care and their ethical implications across a number of considerations, with the intent of mapping various factors relating to health equity and fair access to FT. Evidence is drawn from an evolving clinical experience as well as published scholarship addressing several dimensions of access to FT. We also explore novel concerns that have yet to be mentioned in the literature.

Guiding Strategies for the Future of Vascularized Composite Allotransplantation: A Systematic Review of Organ Donation Campaigns.

BACKGROUND: Since the 1990s, the field of vascularized composite allotransplantation has gained momentum, offering unprecedented solutions for patients with defects not amenable to autologous reconstruction. As with solid organ donation, the vascularized composite allotransplant donor pool remains limited. This systematic review identifies past successes and failures in organ donation campaigns to guide future strategies for expanding vascularized composite allotransplant donation. METHODS: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three databases (PubMed/MEDLINE, PsycINFO, and Embase) were searched through July 31, 2019. The study compiled solid organ and vascularized composite allotransplant campaigns that aimed to increase donor registration. Articles depicting the current state of vascularized composite allotransplant donation were also assessed. RESULTS: Of an initial 3318 articles identified, 40 were included. Six articles described direct mail or print interventions, 10 depicted Web-based interventions, 13 dealt with interpersonal interventions, and seven used multimodal interventions. Four articles described the current state of vascularized composite allotransplant donation. A qualitative synthesis was conducted. The authors found that social media campaigns can have a robust but fleeting effect on registration trends and that interpersonal interventions are effective at increasing registration rates. In addition, the opportunity for participants to immediately register as organ donors, by means of either return mail, in-person, or online, is vital to campaign success. CONCLUSIONS: Public organ donation campaigns have had success in increasing organ donor registration rates, particularly through the use of social media and interpersonal interventions that allow for immediate registration. Synthesizing this information, we propose a multimodal campaign to expand the vascularized composite allotransplant donor pool.

How to Integrate Lived Experience Into Quality-of-Life Assessment in Patients Considering Facial Transplantation.

Facial transplantation has gained increasing acceptance as a treatment option to improve quality of life (QoL) for persons suffering from severe facial disfigurement. Despite its growth, the field has yet to establish a consistent approach to assessing QoL in face transplant candidates and recipients that includes integration of meaningful patient-reported outcomes. The published literature suggests that face transplant programs currently use a wide variety of assessment tools and strategies. Moreover, confusion remains as to how best to weigh patients' lived experiences and incorporate them into QoL assessments. Qualitative research can illuminate the dimensions of QoL that are meaningful to face transplant candidates and recipients. Coupled with collaboration and data sharing across face transplant programs, qualitative research will help to bring conceptual clarity and transparency to the assessment process.

Comprehensive Assessment of Vascularized Composite Allotransplantation Patient-Oriented Online Resources.

INTRODUCTION: Online resources have become a major source of medical information for the general public. To date, there has not been an assessment of patient-oriented online resources for face and upper extremity transplantation candidates and patients. The goal of this study is to perform a comprehensive assessment of these resources. METHODS: Our analysis relied on 2 dimensions: comprehensiveness and readability. Comprehensiveness was evaluated using 14 predetermined variables. Readability was evaluated using 8 different readability scales through the Readability Studio Professional Edition Software (Oleander Software, Ltd, Vandalia, Ohio). Data were also collected from solid organ transplantation (SOT), specifically kidney and liver, programs for comparison. RESULTS: Face and upper extremity transplantation programs were significantly more likely to list exclusion criteria (73.9% vs 41.2%; P = 0.02), the need for life-long immunosuppression (87.0% vs 58.8%; P = 0.02), and benefits of transplantation (91.3% vs 61.8%; P = 0.01) compared with SOT programs. The average readability level of online resources by all face and upper extremity transplantation programs exceeded the sixth grade reading level recommended by the National Institutes of Health and the American Medical Association. The average reading grade level of online resources by these programs was also significantly higher than those of SOT with both exceeding the recommended reading level (13.95 ± 1.55 vs 12.60 ± 1.65; P = 0.003). CONCLUSIONS: Future efforts in face and upper extremity transplantation should be directed toward developing standardized, comprehensive, and intelligible resources with high-quality content and simple language.

Three-Dimensional Analysis of Donor Masks for Facial Transplantation.

BACKGROUND: Face transplant teams have an ethical responsibility to restore the donor's likeness after allograft procurement. This has been achieved with masks constructed from facial impressions and three-dimensional printing. The authors compare the accuracy of conventional impression and three-dimensional printing technology. METHODS: For three subjects, a three-dimensionally-printed mask was created using advanced three-dimensional imaging and PolyJet technology. Three silicone masks were made using an impression technique; a mold requiring direct contact with each subject's face was reinforced by plaster bands and filled with silicone. Digital models of the face and both masks of each subject were acquired with Vectra H1 Imaging or Artec scanners. Each digital mask model was overlaid onto its corresponding digital face model using a seven-landmark coregistration; part comparison was performed. The absolute deviation between each digital mask and digital face model was compared with the Mann-Whitney U test. RESULTS: The absolute deviation (in millimeters) of each digitally printed mask model relative to the digital face model was significantly smaller than that of the digital silicone mask model (subject 1, 0.61 versus 1.29, p < 0.001; subject 2, 2.59 versus 2.87, p < 0.001; subject 3, 1.77 versus 4.20, p < 0.001). Mean cost and production times were $720 and 40.2 hours for three-dimensionally printed masks, and $735 and 11 hours for silicone masks. CONCLUSIONS: Surface analysis shows that three-dimensionally-printed masks offer greater surface accuracy than silicone masks. Greater donor resemblance without additional risk to the allograft may make three-dimensionally-printed masks the superior choice for face transplant teams. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Patient Representation in Medical Literature: Are We Appropriately Depicting Diversity?

BACKGROUND: Racial disparities exist in the accessibility, delivery, and quality of healthcare. Clinical images are central to plastic surgery, but choice of images in the literature is susceptible to implicit biases. The objective of this study was to determine if published images reflect the racial demographic of patients. METHODS: A search for color photographs and rendered graphics depicting human skin was completed in 6 plastic surgery journals and the New England Journal of Medicine Images in Clinical Medicine for each decade between 1992 and 2017. For each article, images were categorized as white or nonwhite based on Fitzpatrick Scale (1-3 versus 4-6). Additionally, the authors' geographic region was documented. Proportional data and average number of nonwhite images per article were compared. Regression analyses were performed to assess the correlation of time and geographic region on nonwhite images. RESULTS: In total, 24,209 color photographs and 1,671 color graphics were analyzed. In plastic surgery journals, 22% of photographs were nonwhite and the average number of photographs per article with white skin was 5.4 compared with 1.6 with nonwhite skin (P < 0.0001). There was a significant increase in nonwhite photographs over time (r = 0.086, P < 0.001) and association of nonwhite photographs with international authors (r = 0.12, P < 0.001). CONCLUSIONS: Roughly 60%-70% of the world population and 30% of US cosmetic patients are nonwhite. Images in plastic surgery literature reflect neither racial demographics by global region nor the patient population seeking surgery. To advance equitable care, images should better represent the racial composition of the populations served.

Racial Disparities in the Presentation and Treatment of Colorectal Cancer: A Statewide Cross-sectional Study.

BACKGROUND: Non-Hispanic blacks (NHB) and Hispanics often present with advanced colorectal cancer (CRC). The aim of the study was to characterize CRC differences among Hispanics, NHB, and non-Hispanic whites (NHW). METHODS: A cross-sectional analysis and logistic regression of 2009 Florida Agency for Healthcare Administration Hospital Admission Database data for CRC using the International Classification of Diseases, 9th Revision, Clinical Modification codes was performed. Outcomes included CRC location, frequency of metastasis and colectomy rates. Each minority group was compared with NHW. RESULTS: A total of 34,577 patients were NHW, 5190 were NHB, and 5033 were Hispanic. NHB had more proximal CRC [odds ratio (OR), 1.17; 95% confidence interval (CI), 1.09-1.25; P<0.0001]; Hispanics had more distal CRC (OR, 0.90; 95% CI, 0.83-0.96; P=0.0024). Hispanics had increased metastases (OR, 1.11; 95% CI, 1.02-1.22; P=0.04). NHB and Hispanics underwent fewer colectomies [(OR, 0.93; 95% CI, 0.86-0.99; P=0.03) and (OR, 0.9; 95% CI, 0.84-0.97; P=0.001), respectively]. CONCLUSIONS: Disparities in CRC metastases and colectomy rates exist among these racial groups in Florida. This work should serve as a foundation to study potential causes and to design culture-specific interventions.

A Semi-Quantitative Food Frequency Questionnaire Validated in Hispanic Infants and Toddlers Aged 0 to 24 Months.

BACKGROUND: There are limited validated food frequency questionnaires (FFQs) for infants and toddlers, most of which were evaluated in Europe or Oceania, and the ones available for use in the United States have important limitations. OBJECTIVE: Our aim was to assess the validity of an FFQ developed for infants and toddlers. DESIGN: A semi-quantitative FFQ was developed that included 52 food items, their sources, and portion sizes. The FFQ inquired about diets over the previous 7 days. Its validity was assessed in a cross-sectional study. Participants completed the FFQ, followed by a 24-hour recall on two occasions with 1 week between data collection. PARTICIPANTS/SETTING: A total of 296 caregivers of infants and toddlers aged 0 to 24 months enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children, Puerto Rico. MAIN OUTCOME MEASURES: Intake of nutrients and food groups were averaged for the two FFQs and the two 24-hour food recalls, and adjusted for energy intake. STATISTICAL ANALYSES PERFORMED: Spearman correlations were performed for intakes of energy, nutrients, and foods between administrations and between instruments. Correlation coefficients were de-attenuated to account for variation in the 24-hour recalls. RESULTS: A total of 241 participants completed the study. Intake of all nutrients and foods were significantly correlated between FFQs and 24-hour recalls and between the means of FFQs and 24-hour food recalls. The de-attenuated correlation for nutrients between the FFQs and 24-hour recalls ranged from 0.26 (folate) to 0.77 (energy), with a mean correlation of 0.53. The de-attenuated correlation for food groups between the FFQs and 24-hour recalls ranged from 0.28 (sweets) to 0.80 (breast milk), with a mean correlation of 0.55. When analyses were restricted to those consuming foods other than breast milk or formula (n=186), results were similar. CONCLUSIONS: This semi-quantitative FFQ is a tool that offers reasonably valid rankings for intake of energy, nutrients, foods, and food groups in this sample of infants and toddlers.

[Prevention and monitoring strategies on the use of illicit substances and accidents and costs in heavy load drivers in Mexico]. / Estrategias de prevención y vigilancia sobre el uso de sustancias ilícitas y su impacto en los costos de accidentes en conductores de carga pesada en México.

UNLABELLED: Road crashes are one of the largest public health problems in the world. Impacts affect Health, Economic and Social areas. This study focuses on heavy load drivers. The goal is to identify the costs of accidents to implement control strategies for licit and illicit substance consumption in heavy load drivers. METHOD: a retrospective correlation study was conducted, covering the period from 2004 to 2006. In the population covered by the program, the number of accidents decreased by 15% and cost for damage by collision by 24%. CONCLUSION: This type of studies are of great value and can be used as a basis for implementing programs designed to modify behavior and carefully monitor the health of professional drivers.

Estrategias de prevención y vigilancia sobre el uso de sustancias ilícitas y su impacto en los costos de accidentes en conductores de carga pesada en México / Estratégia de prevenção e vigilância sobre o consumo de sustâncias ilícitas e os custos dos acidentes em motoristas de carga pesada, no México / Prevention and monitoring strategies on the use of illicit substances and accidents and costs in heavy load drivers in Mexico

Las colisiones de tránsito son uno de los grandes problemas de Salud Pública en el mundo, los impactos afectan áreas de la salud, económica y social. Los conductores de carga pesada fueron el objeto de este estudio. Se tuvo por objetivo identificar los costos de accidentes después de aplicar estrategias de control de consumo de sustancias lícitas e ilícitas en conductores de transporte de carga pesada. Se realizó un estudio correlacional retrospectivo de 2004 a 2006. La población a la que se aplicó el programa disminuyó el número de accidentes en 15 por ciento, y el costo por daños por colisión en 24 por ciento. Se concluye que estudios de esta naturaleza son importantes para implantación de programas orientados a modificar la conducta cuidado y seguimiento de la salud de los conductores profesionales.

Os acidentes de trânsito constituem um dos maiores problemas de saúde pública no mundo, e seus impactos afetam as áreas de saúde, econômica e social. O motorista de carga pesada é o objeto do presente estudo. O objetivo foi identificar os custos de acidentes ao aplicar estratégias de controle, frente ao uso de drogas lícitas e ilícitas, em motoristas de carga pesada. Como metodologia deste estudo foi usada a pesquisa retrospectiva correlacional, conduzida de 2004 a 2006. Com base no censo, na população participante do programa houve diminuição do número de acidentes de 15 por cento e dos custos por danos causados por colisão de 24 por cento. Conclui-se que estudos dessa natureza são importantes para implantação de programas direcionados à modificação de comportamentos e monitorização do cuidado de saúde a motoristas profissionais.

Road crashes are one of the largest public health problems in the world. Impacts affect Health, Economic and Social areas. This study focuses on heavy load drivers. The goal is to identify the costs of accidents to implement control strategies for licit and illicit substance consumption in heavy load drivers. Method: a retrospective correlation study was conducted, covering the period from 2004 to 2006. In the population covered by the program, the number of accidents decreased by 15 percent and cost for damage by collision by 24 percent. Conclusion: This type of studies are of great value and can be used as a basis for implementing programs designed to modify behavior and carefully monitor the health of professional drivers.

Prevalencia de retinopatía diabética en comunas dependientes del Servicio de Salud Metropolitano Occidente (SSMOC) / Prevalence of diabetic retinopathy in districts of the Servicio de Salud Metropolitano Occidente (SSMOC)

La retinopatía diabética (RD) es una microangiopatía progresiva que se caracteriza por lesiones y oclusión de vasos retinales pequeños en personas con diabetes mellitus. En relación a su prevalencia en Chile, contamos con pocos trabajos descritos en la literatura, cabe mencionar que en el trabajo de Verdaguer en el año 2001 se encontró una prevalencia de 28,5 por ciento durante la campaña "Día de la diabetes". Presentamos un estudio retrospectivo de prevalencia, cuyo objetivo es determinar la prevalencia de la RD y sus tipos en la población diabética en 10 comunas del Servicio de Salud Metropolitano Occidente (SSMOC). La muestra consiste en el análisis de los resultados de fotografías retinales tomadas a 4600 pacientes diabéticos. Se encuentra una prevalencia de RD de 20 por ciento de los pacientes diabéticos estudiados, 17 por ciento tenía hallazgos compatibles con una RDNP leve a moderada y 3 por ciento presentaba características de RDNP severa y RDP.

Diabetic retinopathy (DR) is a progressive microangiopathy characterized by lesions and occlusion of small retinal vessels in people with diabetes mellitus. In relation to their prevalence in Chile, we have few studies reported in the literature, it is noteworthy that in the work of Verdaguer in 2001 found a prevalence of 28.5 percent during the "Day of diabetes". A retrospective study of prevalence, which aims to determine the prevalence of diabetic retinopathy and their rates in the diabetic population in 10 districts of the Western Metropolitan Health Service (SSMOc). The sample consists of the analysis of the results of retinal photographs taken in 4600 diabetic patients. Is a DR prevalence of 20 percent of diabetic patients studied. 17 percent had findings consistent with a mild to moderate no proliferative DR and 3 percent had features of severe no proliferative DR and proliferative DR.