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The PD-L1/PD-1 signaling pathway is the gold standard for cancer immunotherapy. Therapeutic antibodies targeting PD-1, such as nivolumab (Opdivo) and pembrolizumab (Keytruda), and PD-L1, including atezolizumab (Tecentriq), durvalumab (Imfinzi), and avelumab (Bavencio) have received Food and Drug Administration approval and are currently being used to treat various cancers. Traditionally, PD-L1 is known as an immune checkpoint protein that binds to the PD-1 receptor on its surface to inhibit the activity of T cells, which are the primary effector cells in antitumor immunity. However, it also plays a role in cancer progression, which goes beyond traditional understanding. Here, we highlight the multifaceted mechanisms of action of PD-L1 in cancer cell proliferation, transcriptional regulation, and systemic immune suppression. Moreover, we consider the potential role of PD-L1 in the development and pathogenesis of diseases other than cancer, explore PD-L1-focused therapeutic approaches for these diseases, and assess their clinical relevance. Through this review, we hope to provide deeper insights into the PD-L1/PD-1 signaling pathway and present a broad perspective on potential therapeutic approaches for cancer and other diseases.
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BACKGROUND: Desmoid tumors occur throughout the body, presenting as aggressive, locally invasive lesions that can impede quality of life. Many controversies remain regarding the optimal surgical treatment of desmoid. This article presents a systematic review and meta-analysis on surgical management, focusing on risk of recurrence and the utility of reconstruction within this unique patient population. METHODS: A systematic review was conducted to search for articles. The clinical course of patients diagnosed with desmoid tumors and treated by our institution's multidisciplinary team was retrospectively reviewed over a 13-year period. Meta-analysis study findings were compared with our cohort. RESULTS: From the systematic review, 10 studies with level of evidence III were found, which resulted in 981 patients. Twenty patients from our institution met the inclusion criteria for our study. In both our study cohort and the pooled results, recurrence was significantly higher in patients with positive microscopic margin after resection. In our study cohort, patients with recurrence had higher rates of positive margins compared with those without recurrence (83.3% vs 7.1%, P = 0.004), whereas the pooled study showed a difference of margin positivity of 50% vs 40% ( P = 0.01). No patients who underwent reconstruction in our study cohort had a recurrence during the study period. CONCLUSION: In both our cohort and pooled results, recurrence was significantly higher in patients with positive margins after initial resection. Reconstruction was not found to be a risk factor for recurrence. Reconstruction following desmoid tumor resection should be considered a viable option if a large and aggressive resection is required to obtain negative margins.
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Fibromatose Agressiva , Humanos , Fibromatose Agressiva/cirurgia , Fibromatose Agressiva/patologia , Estudos Retrospectivos , Recidiva Local de Neoplasia/patologia , Qualidade de Vida , Fatores de RiscoRESUMO
PURPOSE: To assess the relief of dentin hypersensitivity of the new toothpaste with stabilized stannous fluoride (SnF2) versus a marketed standard fluoride toothpaste as a negative control and a marketed anhydrous SnF2 toothpaste as a positive control. METHODS: This was a single-centered, randomized, controlled, double blind, clinical trial. 96 participants with hypersensitivity were enrolled in this 4-week clinical study. Electrical stimulation and evaporative air tests were performed to evaluate the desensitization efficacy. Clinical assessments were made at baseline, and after 3 days, 1 week, 2 weeks and 4 weeks of twice-daily brushing. Additionally, the influence of Sn² ⺠species on desensitization was evaluated using bovine dentin specimens treated with toothpaste. RESULTS: All 96 enrolled participants were randomized. 96 participants completed all evaluations. Participants had an average age (SD) of 47.0 (10.5) years; 45% of participants were female. Both SnF2 toothpastes showed superior desensitization efficacy compared to the negative control toothpaste, the conventional sodium monofluorophosphate (SMFP) toothpaste, after a week. The new stabilized SnF2 toothpaste demonstrated improved electrical stimulation benefits compared to the negative control toothpaste, with increases of 15.1% after 3 days, 34.2% after 1 week, 66.3% after 2 weeks, and 111.6% after 4 weeks. Additionally, it showed relative verbal evaluation scale (VES) benefits of 14.2% after 3 days, 37.6% after 1 week, 28.9% after 2 weeks, and 37.4% after 4 weeks. The stabilized SnF2 toothpaste exhibited desensitization properties comparable to those of a commercial anhydrous SnF2 toothpaste, which typically produces undesirable side effects in the mouth. Toothpastes containing 0.454 % SnF2 exhibited perfect occlusion of dentin tubules. CLINICAL SIGNIFICANCE: The stabilized 0.454% SnF2 toothpaste exhibited significantly greater dentin hypersensitivity relief within only a week and comparable property to commercial anhydrous SnF2 toothpaste.
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Sensibilidade da Dentina , Fluoretos de Estanho , Animais , Bovinos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sensibilidade da Dentina/tratamento farmacológico , Fluoretos/uso terapêutico , Fluoretos de Estanho/farmacologia , Fluoretos de Estanho/uso terapêutico , Cremes Dentais/farmacologia , Cremes Dentais/uso terapêuticoRESUMO
BACKGROUND: Despite the extensive use of various imaging modalities, there is limited literature on comparing the reliability between indocyanine green (ICG) lymphography, MR Lymphangiogram (MRL), and high frequency color Doppler ultrasound (HFCDU) to identify lymphatic vessels. METHOD: In this study of 124 patients, the correlation between preoperative image findings to the actual lymphatic vessel leading to lymphovenous anastomosis (LVA) was evaluated. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and simple detection were calculated. Subgroup analysis was also performed according to the severity of lymphedema. RESULTS: Total of 328 LVAs were performed. The HFCDU overall had significantly higher sensitivity for identifying lymphatic vessels (99%) over MRL (83.5%) and ICG lymphography (82.3%)(p < 0.0001). Both ICG lymphography and HFCDU had 100% specificity and PPV. The NPV was 3.6%, 6.5% and 57.1% respectively for MRL, ICG lymphography, and HFCDU. All modalities showed high sensitivity for early stage 2 lymphedema while HFCDU showed a significantly higher sensitivity for late stage 2 (MRL:79.7%, ICG:83.1%, HFCDU:97%) and stage 3 (MRL:79.7%, ICG:79.7%, HFCDU:100%) over the other two modalities (p < 0.0001). CONCLUSION: This study demonstrated while all three modalities are able to provide good information, the sensitivity may alter as the severity of lymphedema progresses. The HFCDU will provide the best detection for lymphatic vessels throughout all stages of lymphedema. However, as each modality provides different and unique information, combining and evaluating the data according to the stage of lymphedema will be able to maximize the chance for a successful surgical outcome.
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Vasos Linfáticos , Linfedema , Humanos , Verde de Indocianina , Linfografia/métodos , Reprodutibilidade dos Testes , Anastomose Cirúrgica/métodos , Vasos Linfáticos/diagnóstico por imagem , Vasos Linfáticos/cirurgia , Linfedema/diagnóstico por imagem , Linfedema/cirurgiaRESUMO
Primary biliary cholangitis (PBC) is an autoimmune disease that involves chronic inflammation and injury to biliary epithelial cells. To identify critical genetic factor(s) in PBC patients, we performed whole-exome sequencing of five female siblings, including one unaffected and four affected sisters, in a multi-PBC family, and identified 61 rare heterozygote variants that segregated only within the affected sisters. Among them, we were particularly interested in caspase-10, for although several caspases are involved in cell death, inflammation and autoimmunity, caspase-10 is little known from this perspective. We generated caspase-10 knockout macrophages, and then investigated the obtained phenotypes in comparison to those of its structurally similar protein, caspase-8. Unlike caspase-8, caspase-10 does not play a role during differentiation into macrophages, but after differentiation, it regulates the process of inflammatory cell deaths such as necroptosis and pyroptosis more strongly. Interestingly, caspase-10 displays better protease activity than caspase-8 in the process of RIPK1 cleavage, and an enhanced ability to form a complex with RIPK1 and FADD in human macrophages. Higher inflammatory cell death affected the fibrotic response of hepatic stellate cells; this effect could be recovered by treatment with UDCA and OCA, which are currently approved for PBC patients. Our findings strongly indicate that the defective roles of caspase-10 in macrophages contribute to the pathogenesis of PBC, thereby suggesting a new therapeutic strategy for PBC treatment.
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Cirrose Hepática Biliar , Humanos , Feminino , Caspase 10 , Caspase 8/genética , Cirrose Hepática Biliar/genética , Morte Celular/genéticaRESUMO
BACKGROUND: Enhanced recovery after surgery (ERAS) protocols are effective in decreasing hospital length of stay and inpatient opioid consumption. Implementation of these protocols in abdominally based breast reconstruction has been successful. When a patient is a poor candidate for abdominally based flaps a popular secondary option is the profunda artery perforator (PAP) flap. We present our experience with implementation of our ERAS protocol in patients treated with PAP flaps for breast reconstruction. METHODS: Retrospective review of patients treated with autologous breast reconstruction using PAP flaps before and after ERAS implementation were performed. Patient characteristics, postoperative oral morphine equivalents (OMEs), and flap data were collected. RESULTS: A total of 87 patients were included in this study (58 patients in pre-ERAS and 29 patients in ERAS group). There was no statistical difference in patient age, comorbidities, smoking, and radiation between two groups. The ERAS group had statistically lower hospital length of stay (2.6 vs. 3.8 days), procedure time (315 vs. 433 minutes), postoperative day 0 (54.8 vs. 96.3), postoperative day 1 (29.9 vs. 57.7), and total opioid consumption (103.7 vs. 192.1). There was no statistical difference in average pain scores between two groups. Multivariate analysis revealed that procedure time significantly increased the amount of opioid consumption while ERAS implementation significantly reduced LOS and opioid consumption. CONCLUSION: Use of an ERAS protocol in PAP flap breast reconstruction has not been previously studied. Our work shows that ERAS implementation in PAP flap breast reconstruction significantly reduces inpatient opioid use and length of hospital stay.
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Recuperação Pós-Cirúrgica Melhorada , Mamoplastia , Retalho Perfurante , Analgésicos Opioides/uso terapêutico , Humanos , Tempo de Internação , Mamoplastia/métodos , Retalho Perfurante/irrigação sanguínea , Estudos Retrospectivos , Retalhos CirúrgicosRESUMO
INTRODUCTION: Firearm morbidity and mortality have been increasing in recent years, and with this, the demand for medical personnel firearm injury treatment knowledge. Extremities contribute to a majority of firearm injuries, with these injuries being particularly complex because of neurovascular proximity within a confined space. Knowledge of firearm mechanism of injury and treatment management options is important for any trauma hand surgeon. Many factors play vital roles in the treatment of complex upper extremity (UE) gunshot wounds (GSWs). The aim of our review and case illustrations is to provide hand surgeons with an up-to-date guide for initial emergent management, soft tissue, bony, and nerve repair and reconstruction. PATIENT AND METHODS: A literature review was conducted in the current management of UE GSW injuries, and 2 specific patient case examples were included. High-energy versus low-energy GSWs were documented and compared, as well as containment injures. Management including soft tissue, bony, and nerve injuries was explored along with patient outcome. Based on these findings, guidelines for GSW management were purposed. CONCLUSION: Gunshot wounds of the UE encompass a group of highly heterogeneous injuries. High-energy wounds are more extensive, and concomitant injuries to bone, vessel, nerve, muscle, and soft tissue are common. Early treatment with adequate debridement, skeletal fixation, and soft tissue coverage is indicated for complex injuries, and antibiotic treatment in the pre-, peri-, and postoperative period is indicated for operative injuries. Soft tissue coverage options include the entire reconstructive ladder, with pattern of injury and considerations of wound characteristics dictating reconstructive choice. There are arguments to using either external or internal bony fixation techniques for bone fracture management, with choice tailored to the patient. For management of nerve injuries, we advocate earlier nerve repair and a shorter duration of observation before secondary reconstruction in selective cases. If transected nerve endings cannot be brought together, nerve autografts of shorter length are recommended to bridge nerve ending gaps. A significant number of patients with GSW fail to make necessary follow-up appointments, which adds to challenges in treatment.
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Traumatismos do Braço , Armas de Fogo , Ferimentos por Arma de Fogo , Traumatismos do Braço/etiologia , Traumatismos do Braço/cirurgia , Fixação de Fratura , Humanos , Estudos Retrospectivos , Extremidade Superior , Ferimentos por Arma de Fogo/cirurgiaRESUMO
Recent advancements in telecommunications and the tactile Internet have paved the way for studying human senses through haptic technology. Haptic technology enables tactile sensations and control using virtual reality (VR) over a network. Researchers are developing various haptic devices to allow for real-time tactile sensation, which can be used in various industries, telesurgery, and other mission-critical operations. One of the main criteria of such devices is extremely low latency, as low as 1 ms. Although researchers are attempting to develop haptic devices with low latency, there remains a need to improve latency and robustness to hand sizes. In this paper, a low-latency haptic open glove (LLHOG) based on a rotary position sensor and min-max scaling (MMS) filter is proposed to realize immersive VR interaction. The proposed device detects finger flexion/extension and adduction/abduction motions using two position sensors located in the metacarpophalangeal (MCP) joint. The sensor data are processed using an MMS filter to enable low latency and ensure high accuracy. Moreover, the MMS filter is used to process object handling control data to enable hand motion-tracking. Its performance is evaluated in terms of accuracy, latency, and robustness to finger length variations. We achieved a very low processing delay of 145.37 µs per finger and overall hand motion-tracking latency of 4 ms. Moreover, we tested the proposed glove with 10 subjects and achieved an average mean absolute error (MAE) of 3.091∘ for flexion/extension, and 2.068∘ for adduction/abduction. The proposed method is therefore superior to the existing methods in terms of the above factors for immersive VR interaction.
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Realidade Virtual , Dedos , Mãos , Humanos , Movimento , TatoRESUMO
BACKGROUND: Using a hemi-abdominal flap for unilateral breast reconstruction in patients may not be ideal due to paucity of abdominal tissue, presence of a lower abdominal midline scar, or a larger and/or ptotic contralateral native breast. Several algorithms exist to make these flaps successful, but all of them require an anastomosis sequence ultimately. In this study, we present our experience with the use of imaging to predict flap dominance and anastomosis sequence to make them consistently successful. METHODS: Seventy-five consecutive conjoined, bipedicled abdominal composite free flaps for unilateral breast reconstruction were performed. Preoperative computed tomographic angiography (CTA) was obtained to depict the pattern of perforators, flap dominance, and feasibility for intraflap anastomosis. Patient demographics, type/weights of flaps, number of anastomoses, location of perforators, length/type of pedicles, and flap-related complications were reviewed. RESULTS: Seventy-five patients underwent composite deep inferior epigastric perforator (DIEP) and/or superficial inferior epigastric artery (SIEA) flaps. There were 62 DIEP-DIEP flaps, 11 DIEP-SIEA flaps, and two SIEA-SIEA flaps. The mean age was 57 years with an average body mass index of 27 kg/m2 and flap weight of 1,054 g. Thirty-one patients underwent intraflap (41%) and 44 patients underwent crania/caudal anastomoses (59%). In comparison to bilateral DIEPs, the total number of perforators was significantly lower (2.9 vs. 3.8), and fat necrosis rate was lower (2.7 vs. 14.4%) as well. CONCLUSION: Guided by preoperative CTA imaging, we recommend the consistent use of these conjoined, bipedicled hemi-abdominal flaps for unilateral breast reconstruction, primarily those with delayed reconstruction and radiation deficits. Preoperative CTA imaging is crucial in directing perforator dissection to maximize overlapping perfusion zones and guide in performing anastomoses.
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Angiografia por Tomografia Computadorizada , Artérias Epigástricas/diagnóstico por imagem , Artérias Epigástricas/transplante , Mamoplastia/métodos , Retalho Perfurante/irrigação sanguínea , Algoritmos , Anastomose Cirúrgica , Tomada de Decisões , Feminino , Humanos , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND: Profunda artery perforator (PAP) flap breast reconstruction has emerged as a popular choice for patients who are not optimal candidates for autologous breast reconstruction using abdominal-based techniques such as the deep inferior epigastric perforator flap. Despite increased utilization of PAP flaps, there are no previous studies on the donor-site morbidity. In this study, we present risk factors, classification of thigh wounds, and our management of donor-site wounds. METHODS: Retrospective review of 69 patients who underwent PAP flap from 2013 to 2016 was performed. Demographic, patient characteristic, and flap data were collected. Postoperative photographs of donor sites were reviewed, and the wounds were classified into three types: type I-normal wound, type II-minor scab, and type III-dehiscence. RESULTS: Of the 69 patients (130 flaps), there were 13 patients (17 flaps) with wound dehiscence (13%), 8 patients with cellulitis (8.5%), 2 patients with seroma (3%), and 1 patient with hematoma (1.5%). The patients with wound dehiscence had statistically higher body mass index (BMI) (29.2 vs. 26.5) with p-value < 0.05 than the patients without wound complications. These patients had higher flap weight (514 vs. 439.7 g), were older (50.8 vs. 48.6 years old), and had a higher chance of being a diabetic (6 vs. 2%), but statistical significance was not achieved. The patients with dehiscence were managed with local wound care (63%), wound vacuum (26%), and operative intervention (11%). CONCLUSION: Our study shows that BMI plays a significant role in the development of postoperative thigh wounds, and all wounds occurred at the medial thigh. However, the majority of the study population did not require any intervention, and revision of scar using the posterior thigh advancement flaps can be used to improve the gluteal aesthetics. We believe findings from our study can help plastic surgeons to counsel and assist patients who will undergo breast reconstruction with a PAP flap.
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Mamoplastia , Retalho Perfurante , Artérias/cirurgia , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Coxa da Perna/cirurgiaRESUMO
BACKGROUND: With the technological advances, microsurgery has evolved to the era of supermicrosurgery since its inception. With the popularization of these flaps, proficiency in using tools such as color Doppler ultrasound (CDU) has become crucial. Despite the increased interest, studies regarding the role of ultrasound in microsurgical reconstruction are scarce. Therefore, in this study, we discussed currently available imaging modalities for reconstructive surgeons, types of ultrasound, and the role of ultrasound in microsurgical reconstruction, and made recommendations for ultrasound use in reconstructive surgery. METHODS: We performed a computerized search of ultrasound in reconstructive surgery using the MEDLINE database. Data regarding ultrasound indications, usage, and outcomes were collected. RESULTS: Of the 115 articles identified, the majority was written on nonreconstructive ultrasound uses (51.4%). For the reconstructive uses, mapping of perforators was the most common usage (39.1%), followed by flap monitoring and volume measurement. In addition, we found that there are a limited number of literature on the role of CDU in reconstructive surgery, especially on its intraoperative and postoperative use. CONCLUSION: CDU is a valuable and powerful tool for any reconstructive surgeons who are interested in performing microsurgery or supermicrosurgery. As the demand of customized flaps using superthin flaps, perforator-to-perforator anastomosis, and supermicrosurgery increases, understanding and becoming versatile in CDU will be critical. We hope our experience with using ultrasound and refinements that we made are helpful for those who would like to include it as a part of their armamentarium.
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Retalho Perfurante , Procedimentos de Cirurgia Plástica , Anastomose Cirúrgica , Humanos , Microcirurgia , Ultrassonografia Doppler em Cores , Ultrassonografia Doppler DuplaRESUMO
OBJECTIVE: The purpose of this study was to evaluate the mastication ability of elderly women by assessing the number of their remaining teeth, subjective mastication comfort, subjective chewing ability of five food items, relative occlusion balance and mastication performance involving in chewing gum. BACKGROUND: Korea has already entered an aged society, issues related to the elderly are also growing; for example, dementia is emerging as a social problem. In addition, oral health of the elderly is very important because it is directly related to nutrient intake. A total of 101 subjects aged ≥65 who attended senior citizen centres in Daegu city provided consent and were included in this study. MATERIALS AND METHODS: The Korean version of the Mini-Mental State Examination (MMSE-DS) was used to evaluate cognitive function. To assess the degree of objective mastication, we measured colour changes using a chewing gum and posterior occlusion force using a T-scan â ¢® system. RESULTS: There was an association between mastication ability and cognitive function, indicated by the colour changes in the chewing gum (P < .05). The participants with greater relative posterior occlusion forces had higher MMSE-DS scores than those with stronger relative anterior occlusion forces. There was a positive correlation between cognitive function and posterior occlusion force. CONCLUSION: The elderly having more occlusion force of posterior teeth rather than anterior teeth were associated with better cognitive ability. Therefore, it may be important for the elderly to restore the masticatory function for the posterior part to prevent against deterioration of cognitive function.
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Demência , Centros Comunitários para Idosos , Idoso , Goma de Mascar , Feminino , Humanos , Mastigação , Prevalência , República da CoreiaRESUMO
OBJECTIVES: To evaluate the efficacy of a brush-off patch containing 3.0% hydrogen peroxide, which is a new over-the-counter (OTC) product for tooth whitening, and determine the optimal protocol for use. MATERIALS AND METHODS: We performed an in vitro study using hydroxyapatite specimens and a clinical trial involving 140 volunteers. The brush-off patch was applied to the specimens (in vitro) or the maxillary anterior teeth (in vivo; 14 days) for 10 min twice daily (case 10 group) or 30 min once daily (case 30 group). We also included control groups in both experiments. Lightness (L*), redness (a*), and yellowness (b*) values were measured using a colorimeter. In the in vivo study, color changes were measured at baseline and 7 and 14 days after the start of patch application. The overall color change (ΔE) was statistically analyzed. RESULTS: In the in vitro study, the color change (ΔE*) after the experiment was significantly different between the two case groups and the control group (p < 0.001). In the in vivo study, the case groups showed color changes at both 7 and 14 days after patch application. In particular, the change in the case 30 group was significantly more prominent on day 14 than on day 7 (p < 0.05). CONCLUSION: Our findings suggest that brush-off patches containing 3.0% hydrogen peroxide are effective OTC products for tooth whitening. CLINICAL RELEVANCE: For best results, brush-off patches containing 3.0% hydrogen peroxide can be applied once daily for 30 min.
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Peróxido de Hidrogênio/administração & dosagem , Clareadores Dentários/administração & dosagem , Clareamento Dental , Descoloração de Dente , Adulto , Cor , Feminino , Humanos , Resultado do TratamentoRESUMO
OBJECTIVE: Chewing ability may reflect the overall oral health, which affects the general health of the elderly. Therefore, we assessed the association between subjective chewing ability and health-related quality of life (HRQOL) among the elderly. METHODS: We analysed the data of 3034 elderly people aged ≥65 years from the Korean National Health and Nutrition Examination Survey that was conducted by the Korean government from 2013 to 2015 (KNHANES-VI). Subjective chewing ability was evaluated using a questionnaire, and HRQOL was assessed using EuroQol 5-dimension (EQ-5D) instrument by trained examiners. Covariates, such as socio-demographic, oral health-related and general health-related variables, were investigated. RESULTS: Logistic regression analysis showed that chewing ability was significantly associated with HRQOL in both crude and adjusted model for covariates such as age, gender, economic activity, residence, education, smoking, alcohol, hypertension, diabetes, remaining teeth, denture, CPI, tooth brushing and oral hygiene (crude OR, 2.67; 95% CI, 2.23-3.20) (adjusted OR, 2.36; 95% CI, 1.95-2.86). Chewing ability was also significantly associated with most dimensions of EQ-5D, such as motor ability, self-care, daily activities, pain and discomfort, and anxiety and depression (P < 0.05). CONCLUSION: Chewing ability was significantly associated with HRQOL, suggesting that elderly people with low chewing ability are more likely to have poor health-related quality of life.
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Mastigação , Qualidade de Vida , Idoso , Estudos Transversais , Nível de Saúde , Humanos , Inquéritos Nutricionais , Saúde Bucal , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: Differentiating synostotic and nonsynostotic plagiocephaly can be challenging, and many providers routinely obtain screening skull radiographs when evaluating an infant with plagiocephaly. However, the diagnostic yield of radiographs has not been studied in this clinical setting. DESIGN: This study was a retrospective chart review. SETTING: The study took place in a tertiary care center. PATIENTS: We retrospectively reviewed the records of all patients referred to Children's Medical Center (Dallas, TX) between the years 2010 to 2012 with a diagnosis of plagiocephaly. After an initial evaluation, skull radiographs were obtained to rule out craniosynostosis. We reviewed clinical and demographic data and radiographic findings to determine the diagnostic yield of routine screening radiographs in infants presenting with plagiocephaly. RESULTS: There were 1219 patients in total, and 1213 of these patients received screening four-view conventional skull radiographs. Six had computed tomography without prior radiographs. Of the patients in the skull radiograph group, 24% (289 of 1213) had abnormal radiographic findings, and 7.6% of this group (22 of 289) had findings that were indicative of craniosynostosis. Of these 22 patients, 12 obtained follow-up studies, and only three patients (0.2% of skull group) had true craniosynostosis. In comparison, 50% (three of six) in the group of patients who underwent computed tomography without prior conventional screening radiographs had true craniosynostosis. CONCLUSIONS: Routine screening skull radiographs have a low diagnostic yield in differentiating between synostotic and nonsynostotic plagiocephaly in patients presenting to a tertiary care deformational plagiocephaly clinic. Considering the costs and radiation exposure, the benefit of the routine use of skull radiographs in patients with deformational plagiocephaly is questionable.
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Plagiocefalia/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Diagnóstico Diferencial , Feminino , Humanos , Lactente , Masculino , Plagiocefalia não Sinostótica/diagnóstico por imagem , Estudos RetrospectivosRESUMO
The approach to bony craniofacial reconstruction has been significantly enhanced with the development of patient-specific, computer-aided designed and manufactured (CAD/CAM) implants. This technology, however, has not yet been widely employed for soft tissue reconstruction. While algorithmic approaches based on the size, location, and etiology of the defect are effective in most cases, a patient-specific CAD/CAM approach has benefits in complex reconstructive problems. In this study, we present a patient-specific approach to preoperative flap planning: using three-dimensional (3D) printing and liquid latex to create a flexible model of a flap, and demonstrate its application in planning a complex scalp reconstruction.
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Traumatismos Craniocerebrais/cirurgia , Látex , Procedimentos de Cirurgia Plástica , Impressão Tridimensional , Retalhos Cirúrgicos , Craniotomia , Feminino , Humanos , Lactente , Modelos Anatômicos , Falha de TratamentoRESUMO
An understanding of radiation dose and the anticipated risk to the patient is an important aspect of ordering radiological imaging studies responsibly. It is especially true for the pediatric practitioner because children are more vulnerable to the biological effects of radiation, such as radiosensitivity, longer lifetime years, and higher cellular mitotic activity. The use of fluoroscopy and computed tomography is commonplace in the practice of craniofacial surgery, but often dose reports from varied investigations are not directly comparable, and the risk of patient harm from the investigation is unclear. This article presents the fundamentals of radiation, dose, and risk as it applies to radiological imaging and also introduces our low dose craniofacial computed tomography protocol.
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Anormalidades Craniofaciais/diagnóstico por imagem , Anormalidades Craniofaciais/cirurgia , Doses de Radiação , Fluoroscopia , Humanos , Segurança do Paciente , Lesões por Radiação/prevenção & controle , Radiação Ionizante , Medição de Risco , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: The American Society of Anesthesiologists Physical Status (ASA-PS) classification is a ranking system that quantifies patient health before anesthesia and surgery. Some surgical disciplines apply the ASA-PS to gauge a patient's likelihood of developing postoperative complications. OBJECTIVE: In this study, the authors analyze whether ASA-PS scores can successfully predict risk for postoperative complications in plastic and reconstructive operations. METHODS: The authors retrospectively reviewed the charts of 1801 patient procedures and selected for inclusion 1794 complex plastic and reconstructive operations that took place at 1 of several academic medical institutions between January 2008 and January 2012. ASA-PS scores, patient comorbidities, and postoperative complications were analyzed. Percentile data were treated with tests for proportions. Nonpercentile data were analyzed through comparison of means (t test). Low-risk (ASA 1-2) and high-risk (ASA 3+) groups were compared with simple odds ratios. RESULTS: For the 1430 women and 364 men in the patient cohort (average age, 49.5 years), the overall complication rate was 27.7%. When patients with complications were compared to those without, body mass index, operation time, recent major surgery, diabetes, hypertension, renal disease, cancer, and oral contraceptive use were statistically significant. After high-risk (n = 398) and low-risk (n = 1396) groups were identified, infection, delayed wound healing, deep vein thrombosis, and overall complications had significantly increased incidence in the high risk group. Notably, deep vein thrombosis displayed the highest odds ratio (4.17) and a complication rate increase from 0.93% to 3.77%. CONCLUSIONS: ASA-PS scores can be used either as substitutes for or as adjuncts to questionnaire-based risk assessment methods in plastic surgery. In addition to deducing significant findings for deep vein thrombosis incidence, ASA-PS scores hold important predictive associations for multiple non-venous thromboembolism complications, providing a broader measurement for postoperative complication risks. LEVEL OF EVIDENCE: 4.
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Procedimentos de Cirurgia Plástica/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Procedimentos de Cirurgia Plástica/métodos , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Adulto JovemRESUMO
BACKGROUND: Reconstruction of the midface after maxillectomy is extremely challenging due to the need to reestablish the contour of the midface, maintain oronasal separation, support the orbit, and to restore the dentition. In this study, we present our specific technique, surgical and functional outcomes, and pitfalls to avoid for reconstruction of the midface with the fibula osteocutaneous free flap. METHODS: A retrospective review of patients who underwent maxillary reconstruction with a fibula osteocutaneous free flap was performed. RESULTS: Eighty-five flaps were performed in 73 patients (61 patients received a fibula flap only; 12 patients received an additional soft tissue free flap). Reconstructions were performed for 82.2% Cordeiro type 2 and 18.8 % Cordeiro type 3a defects. Osseointegrated dental implants were placed in 95.9% of patients, 13.7% of whom underwent immediate implant placement. Concurrent orbital floor reconstruction was performed in 16.2% of patients. The rate of operative takeback was 18.9%, and total flap loss occurred in 2.7%. Hardware exposure occurred in 11.0% at a mean of 4.4 years postoperatively and palatal fistulae occurred in 5.5%, usually within the first 3 weeks following reconstruction. Functionally, 79.5% demonstrated excellent speech and 80.9% had unrestricted diet postoperatively. The mean follow-up period was 3.4 years. CONCLUSIONS: The present study shows that maxillary reconstruction with free fibula flap provides reliable reconstruction that restores dental, orbital, and midfacial support. Modifications and nuances to the reconstructive technique learned over time to avoid complications and improve outcomes are described herein.
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INTRODUCTION: The use of tissue expanders (TE) in post-mastectomy breast reconstruction is a widely accepted practice, especially in patients desiring implant-based breast reconstruction. It has become the standard of care to perform a two-staged breast reconstruction using tissue expanders for the past 50 years due to its reliability, safety, cost-effectiveness, and versatility. Due to its popularity, there are numerous types and features of breast tissue expanders and various surgical approaches available for plastic surgeons. AREAS COVERED: In this article, we will review the role of tissue expanders in breast reconstruction, the types and features of breast tissue expanders, and technical considerations. EXPERT OPINION: The use of tissue expanders in breast reconstruction offers significant advantages of preserving the breast skin envelope and reestablishing the breast mound. With evolving approaches to breast reconstruction, tissue expander design, and application underwent several refinements and modifications. Due to these advances, studies on its long-term efficacy and safety profile typically fall behind and more studies with higher levels of evidence are needed to better evaluate the efficacy and safety profile of tissue expanders. With increased understanding, reconstructive surgeons can minimize complications and maximize reconstructive, aesthetic outcomes with high patient satisfaction.