Efficacy and Safety of Nerve Block for Postoperative Analgesia in Patients Undergoing Breast Cosmetic Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: To evaluate the postoperative analgesic efficacy and safety of nerve block (NB) in patients undergoing breast surgery for cosmetic purposes. METHODS: PubMed, Web of Science, Embase and Cochrane Libraries were searched from inception to September 2022, to identify all eligible randomized controlled trials (RCTs). Continuous data are presented as mean difference (MD) with 95% confidence intervals (CI), whereas dichotomous data are provided as odds ratios (OR) with 95% CI. This meta-analysis was performed in RevMan 5.4. RESULTS: A total of 10 RCTs with 565 patients were meta-analyzed. Compared to the control group, the pain score of the NB group was significantly lower at postoperative 2, 3-4, 6-8, 12-16 and 24 h. Opioid consumption in the first postoperative 24 h was significantly lower in the NB group (MD = - 9.02, 95% CI - 14.29 to - 3.75, P < 0.05), I2 = 95%). In addition, the NB group showed a prolonged time to first postoperative analgesic requirement (MD = 43.15, 95% CI 4.74-81.56, P < 0.05, I2 = 96%), decreased incidence of additional postoperative analgesia (OR 0.14, 95% CI 0.07-0.28, P < 0.05, I2 = 0%) and reduced incidence of postoperative nausea or vomiting (OR 0.33; 95% CI 0.22-0.48; P < 0.05; I2 = 0%). There was no significant difference in operation duration between the two groups. CONCLUSIONS: Nerve block is an effective and safe option for postoperative analgesia after breast cosmetic surgery. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Recurrence and Complications of Peri-operative Steroid Injection of Keloids: A Systematic Review and Meta-analysis.

Keloid scars are a particularly challenging fibroproliferative wound healing disorder with a variety of proposed management approaches including concurrent surgery and intralesional steroid injection. We aimed to identify the optimum time for triamcinolone injection of keloids, by comparing the recurrence and complication occurrence in patients who received pre-, intra- or post-operative injection. Studies reporting on the rate of recurrence and complication occurrence following treatment of keloid scarring with concurrent surgical excision and intralesional steroid injection were identified from the PubMed, Web of science and Embase databases. The I-squared (I2) statistic was used to quantify the variability in study estimates due to heterogeneity and to determine whether the fixed or random effect models will be employed. Publication bias was visualized through funnel plots and tested with the Egger's test. We found that the recurrence rate was significantly lower with post-operative injection compared to intra-operative injection (p < 0.001) and pre-operative injection (p = 0.009). A significant difference between intra-operative and pre-operative injection was not found (p = 0.46). In conclusion, post-operative steroid injection after surgical excision results in lower keloid recurrence compared to pre- and intra-operative injection.Level of Evidence IV "This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 ."

Blood Test Increases Colorectal Cancer Screening in Persons Who Declined Colonoscopy and Fecal Immunochemical Test: A Randomized Controlled Trial.

BACKGROUND & AIMS: The septin 9 blood test is indicated for colorectal cancer screening in individuals who decline first-line tests, but participation in this context is unclear. We conducted a randomized controlled trial to compare reoffering colonoscopy and fecal immunochemical test (FIT) alone versus also offering the blood test among individuals who declined colonoscopy and FIT. METHODS: Screen-eligible Veterans aged 50-75 years who declined colonoscopy and FIT within the previous 6 months were randomized to letter and telephone outreach to reoffer screening with colonoscopy/FIT only (control), or additionally offering the blood test as a second-line option (intervention). The primary outcome was completion of any screening test within 6 months. The secondary outcome was completion of a full screening strategy within 6 months, including colonoscopy for those with a positive noninvasive test. RESULTS: Of 359 participants who completed follow-up, 9.6% in the control group and 17.1% in the intervention group completed any screening (7.5% difference; P = .035). Uptake of colonoscopy and FIT was similar in the 2 groups. The full screening strategy was completed in 9.0% and 14.9% in the control and intervention groups, respectively (5.9% difference; P = .084). CONCLUSIONS: Among individuals who previously declined colonoscopy and FIT, offering a blood test as a secondary option increased screening by 7.5% without decreasing uptake of first-line screening options. However, completion of a full screening strategy did not increase. These findings indicate that a blood test is a promising method to improve colorectal cancer screening, but obtaining a timely colonoscopy after a positive noninvasive test remains a challenge (ClincialTrials.gov number, NCT03598166).

Risk Factors and Complications in Reduction Mammaplasty: A Systematic Review and Meta-analysis.

BACKGROUND: Reduction mammaplasty (RM) has become established as the standard effective method for treating macromastia, but reports on the risk factors that predispose to postoperative complications have been conflicting. This meta-analysis aimed to pool the available data to identify predictors of complications following RM. METHODS: The PubMed, Web of Science, Embase, and Cochrane databases were screened from inception to 1 Jan 2022, and studies were included based on predefined criteria. The perioperative risk factors BMI, smoking, age, diabetes, radiation therapy, and tissue resection weight were extracted and their correlation with complications assessed. RESULTS: A total of 40 studies comprising of 5908 patients were included. BMI ≥ 30kg/m2 (OR = 1.65, 95% CI 1.35-2.02; p < 0.01) and ≥ 40 kg/m2 (OR = 1.97, 95% CI 1.26-3.08; p < 0.01), smoking (OR = 2.57, 95% CI 2.01-3.28; p < 0.01), diabetes (OR = 2.21, 95% CI 1.19-4.07; p < 0.05), a unilateral resection weight ≥ 1000 g (OR = 1.76, 95% CI 1.02-3.05; p < 0.05), and radiation therapy (OR = 11.11, 95% CI 2.01-3.28; p < 0.01) were associated with higher rates of postoperative complications. Obese patients (BMI ≥ 30 kg/m2) were more likely to experience fat necrosis (OR = 3.00, 95% CI 1.37-6.57; p < 0.01) and infection (OR = 1.66, 95% CI 1.15-2.40; p < 0.05). Smokers had a 2.03 times higher risk of infection (95% CI 1.24-3.31; p < 0.01) and 2.34 times higher risk of dehiscence (95% CI 1.38-3.98; p < 0.01). No association between complication occurrence and age 40 or 50 years or total tissue resection weight ≥ 1000 g was identified. CONCLUSIONS: This meta-analysis provides evidence that obesity, smoking, diabetes, unilateral resection weight ≥ 1000 g, and preoperative radiation therapy predispose to complication occurrence in RM. This information can optimize the ability of surgeons to provide preoperative patient education, perioperative assessment, and postoperative care planning. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Nonsurgical Chin Augmentation Using Hyaluronic Acid: A Systematic Review of Technique, Satisfaction, and Complications.

BACKGROUND: Nonsurgical chin augmentation using hyaluronic acid (HA) has become a common procedure in cosmetic practices. This is offered to patients that prefer a nonsurgical, temporary method to correcting underdeveloped or retruded chin and restoring the volume loss. This systematic review highlights the main HA injection technique and associated patient satisfaction and complications of chin augmentation to further guide practitioners. METHODS: A systematic review was performed according to PRISMA guidelines. PubMed, Embase, and Web of Science were searched using the appropriate keywords. Data collected from each study included patient satisfaction and complications, in addition to injection protocol and technique. RESULTS: A total of 1305 studies were found based on search criteria. After full-text screening for inclusion and exclusion criteria, 8 studies were included. A total of 917 patients underwent HA chin augmentation, with different injection protocols. Most patients were satisfied with the results, and there were only 2 relatively major complications reported. The most common adverse events were local responses at the injection sites (swelling, bruising, pain, redness, and itching). There were no reports of vascular complications. CONCLUSIONS: HA filler is an effective temporary method to correct chin retraction and absorption for chin augmentation, with a high degree of patient satisfaction and a low risk of severe complications. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Robotics in therapeutic endoscopy (with video).

Since its inception, endoscopy has evolved from a solely diagnostic procedure to an expanding therapeutic field within gastroenterology. The incorporation of robotics in gastroenterology initially addressed shortcomings of flexible endoscopes in natural orifice transluminal endoscopy. Developing therapeutic endoscopic robotic platforms now offer operators improved ergonomics, visualization, dexterity, precision, and control and the possibility of increasing proficiency and standardization of complex endoscopic procedures including endoscopic submucosal dissection, endoscopic full-thickness resection, and endoscopic suturing. The following review discusses the history, potential applications, and tools currently available and in development for robotics in therapeutic endoscopy.

The molecular mechanism of GADD153 in apoptosis of keloid fibroblasts exposed to botulinum toxin type A.

Apoptosis plays a key role in keloids. Growth arrest and DNA damage-inducible gene 153 (GADD153) is regulated by apoptosis. Botulinum toxin type A (BTXA) can induce apoptosis in keloid fibroblasts. This research aimed to explore the hypothesis that GADD153 mediates apoptosis in keloid fibroblasts exposed to BTXA. BTXA significantly induced GADD153 protein and mRNA expression in keloid fibroblasts. Treatment with c-Jun N-terminal kinase (JNK) inhibitor SP600125, JNK small interfering RNA (siRNA) and tumour necrosis factor-alpha (TNF-α) antibodies reversed the BTXA-induced GADD153 expression. BTXA enhanced the transcriptional activity of GADD153, whereas the GADD153 mutant plasmid, JNK siRNA and anti-TNF-α antibody treatment abolished the BTXA-induced transcriptional activity of GADD153. The addition of TNF-α to keloid fibroblasts markedly increased GADD153 protein expression. The addition of GADD153 siRNA, SP600125 and anti-TNF-α antibodies reversed cell death and caspase 3 and 9 activity induced by BTXA.

Defining the origins of Ras/p53-mediated squamous cell carcinoma.

The precise identity of cancer cells of origin and the molecular events of tumor initiation in epidermal squamous cell carcinoma (SCC) are unknown. Here we show that malignancy potential is related to the developmental capacity of the initiating cancer cell in a genetically defined, intact, and inducible in vivo model. Specifically, these data demonstrate that SCCs can originate from inside the hair follicle stem cell (SC) niche or from immediate progenitors, whereas more developmentally restricted progeny, the transit amplifying (TA) cells, are unable to generate even benign tumors in the same genetic context. Using a temporal model of tumorigenesis in situ, we highlight the phenotypes of cancer progression from the hair follicle SC niche, including hyperplasia, epithelial to mesenchymal transition, and SCC formation. Furthermore, we provide insights into the inability of hair follicle TA cells to respond to tumorigenic stimuli.

Primary anastomosis closure after endoscopic ultrasound-directed transgastric intervention.

Background and study aims Endoscopic ultrasound-directed transgastric intervention (EDGI) is a technique that creates an anastomosis between the gastric pouch or jejunum to the excluded stomach in Roux-en-Y gastric bypass (RYGB) anatomy to allow access to the pancreaticobiliary system. Thus far, management of anastomosis closure at the time of lumen-apposing metal stent (LAMS) removal has varied widely. This study aimed to assess the efficacy of primary closure at the time of LAMS removal using a through-the-scope (TTS) tack-based suture system.  Patients and methods This was a two-center retrospective study of RYGB patients who underwent single-stage EDGI using a 20-mm LAMS and subsequent primary anastomosis closure with the X-tack system at the time of stent removal. Patient demographics, procedure details, clinical outcomes, and imaging findings are reported. Results Nineteen patients (median age 63 years, 84% female) underwent single-stage EDGI with a median follow-up of 31.5 months. Adverse events occurred in two patients (11%) who had abdominal pain requiring hospitalization. The median LAMS dwell time was 32 days (range 16-86). All patients (100%) who underwent follow-up studies after LAMS removal had confirmed anastomosis closure (n = 18). Most patients had documented weight loss at the time of LAMS removal and at last follow-up (68%, n = 13). Conclusions Single-stage EDGI is an effective approach to managing RYGB patients with pancreaticobiliary pathology. Thus far, endoscopic TTS tack-based suturing appears to have a high success rate in anastomosis closure after LAMS removal and should be considered as a primary method for preventing chronic fistulae.

Computer-Aided Rational Design Strategy to Improve the Thermal Stability of Alginate Lyase AlyMc.

Alginate lyase degrades alginate by the ß-elimination mechanism to produce unsaturated alginate oligosaccharides (UAOS), which have better bioactivities than saturated AOS. Enhancing the thermal stability of alginate lyases is crucial for their industrial applications. In this study, a feasible and efficient rational design strategy was proposed by combining the computer-aided ΔΔG value calculation with the B-factor analysis. Two thermal stability-enhanced mutants, Q246V and K249V, were obtained by site-directed mutagenesis. Particularly, the t1/2, 50 °C for mutants Q246V and K249V was increased from 2.36 to 3.85 and 3.65 h, respectively. Remarkably, the specific activities of Q246V and K249V were enhanced to 2.41- and 2.96-fold that of alginate lyase AlyMc, respectively. Structural analysis and molecular dynamics simulations suggested that mutations enhanced the hydrogen bond networks and the overall rigidity of the molecular structure. Notably, mutant Q246V exhibited excellent thermal stability among the PL-7 alginate lyase family, especially considering the heightened enzymatic activity. Moreover, the rational design strategy used in this study can effectively improve the thermal stability of enzymes and has important significance in advancing applications of alginate lyase.

Association between schizophrenia and psoriasis: A two-sample bidirectional Mendelian randomization study.

BACKGROUND: Observational studies have showed an association between schizophrenia and risk of psoriasis and vice versa. However, whether schizophrenia is causally associated with psoriasis is unclear. METHODS: A two-sample bidirectional Mendelian randomization (MR) analysis was performed with publicly available genome-wide association study data including schizophrenia (n = 77 096) and psoriasis (n = 462 933). The inverse-variance weighted method was performed as the main analysis, with a complementary with the other two analyses: MR-Egger and weighted median method. A series of sensitivity analyses were also conducted to evaluate the robustness of the results. RESULTS: MR analyses indicated that genetically predicted schizophrenia was significantly associated with an increased risk of psoriasis [OR: 1.001, 95% confidence interval (CI): 1.000-1.002, p = 0.012]. However, no causal effect of genetically predicted psoriasis on schizophrenia (OR: 0.221, 95% CI: 0.029-1.682, p = 0.145) was detected. No pleiotropy or heterogeneity was detected in sensitivity analysis (all p > 0.05). CONCLUSIONS: Our study provides genetic evidence for the causal association between schizophrenia and psoriasis.

Classification of gastrocnemius muscle hypertrophy for personalized botulinum toxin type A treatment.

BACKGROUND: Owing to its safety and convenience, botulinum toxin type A (BoNtA) has become a first-choice treatment for contouring calf muscle asymmetries or deformities. Different injection methods and dosages have been discussed in the literature, but a standardized BoNtA treatment remains unclear. AIMS: This study aimed to classify gastrocnemius muscle hypertrophy (GMH) through multiple measurements to provide a personalized BoNtA treatment protocol. METHODS: The measurements combining of gastrocnemius muscle (GM) contour, max leg circumference and GM thickness was applied to classify different type of GMH in a normal population. Based on these findings, a personalized BoNtA treatment protocol was determined and evaluated regarding max leg circumference, GM thickness, the position of max leg circumference, patient and doctor satisfaction rate, and complications. RESULTS: A total of 100 GMH were classified into two bulging types (bilateral-bulging type and unilateral-bulging type) and two categories (moderate GMH and severe GMH). 40 cases were treated with personalized BoNtA injection methods ("Even" or "Intense"method) and dosages (300 or 400 units). Follow-up examinations at 1, 3, and 6 months after treatment. Max leg circumference and GM thickness decreased significantly and the position of max leg circumference rose prominently during treatment (2.56 ± 1.93; p < 0.05). The overall patient satisfaction rate was 70%-100%. No serious complications occurred. CONCLUSIONS: We identify four groups of GMH through several measurements and outline a personalized BoNtA treatment for each type. This recommended protocol may improve the therapeutic outcomes and patient satisfaction after treatment.

Subcutaneous infection caused by Mycobacterium abscessus following botulinum toxin injections: A case report and literature review.

BACKGROUND: The rapid development of cosmetic injections has led to an increased incidence of nontuberculous mycobacterial (NTM) infection. PATIENTS AND METHODS: Here, we presented a case of cutaneous Mycobacterium abscessus infection subsequent to botulinum toxin injection for treating masseter hypertrophy, and reviewed the literature on skin and soft tissue infections caused by NTM after cosmetic injections. RESULTS AND CONCLUSIONS: The patient underwent surgical excision and regular antibiotic therapy and has had nearly 2 months of follow-up without any signs of infection. The diagnosis and treatment of NTM infection have always been challenging, and further research is needed to standardize and guide the treatment.

Rocking dizziness and headache: a two-way street.

BACKGROUND: Chronic rocking dizziness, often described as the feeling of being on a boat, is classically triggered by prolonged exposure to passive motion. Patients with this motion-triggered sensation of rocking, which is also known as MAL DE DEBARQUEMENT SYNDROME , often develop new onset headaches along with the dizziness. Chronic rocking dizziness has also been noted in vestibular migraine, occurring without a motion trigger. We sought to clarify the association between both motion-triggered (MT) and non-motion-triggered (non-MT) chronic rocking dizziness and headache history. METHODS: Our methods included questionnaire and interview study of subjects with either MT or non-MT chronic rocking dizziness. RESULTS: Onset of headaches was earlier in patients with non-MT rocking dizziness (median 26 years: MT; 16 years: non-MT). In MT subjects, there was a bimodal peak of age of onset of headache (20-29 years and 40-49 years). Most headache met criteria for migraine in both groups. By the time that chronic dizziness occurred, both groups had a comparable prevalence of migraine headache (41%: MT; 46%: non-MT). Pre-existing headache usually worsened after the onset of dizziness. DISCUSSION: Though rocking dizziness does not meet current criteria for vestibular migraine, migraine physiology may predispose to, develop in, or worsen with the onset of chronic rocking dizziness.

ERCP transpapillary nasogallbladder drainage: a last resort for endoscopic management of cholecystitis.

Video 1Clinical case for endoscopic management of cholecystitis.

Evolution of Pancreatic Endotherapy.

In the last half century, endotherapy for pancreatic diseases has changed considerably. Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) were introduced initially as diagnostic tools, they quickly evolved into therapeutic tools for preventing and managing complications of pancreatitis. More recently, therapeutic endoscopy has shown potential in palliation and cure of pancreatic neoplasms. This article discusses the changing landscape of pancreatic endotherapy as therapeutic ERCP and EUS were introduced and because they have evolved to treat different diseases.

The effect of calf subcutaneous fat thickness on patient satisfaction after calf contouring with botulinum toxin A.

BACKGROUND: As a minimally invasive therapy, botulinum toxin A (BTXA) treatment effectively reduces the hypertrophy of the gastrocnemius muscle (GM). Patient satisfaction is, however, reported to be low after treatment with a possible correlation between high satisfaction and thinner subcutaneous fat. The goal of this study was to classify the subcutaneous fat of calves to understand the relation between fat thickness and patient satisfaction after BTXA treatment. METHODS: The maximal leg circumference was measured and B-mode ultrasound was used to measure the thickness of the medial head of the GM and of the subcutaneous fat. Patients were followed up at one and six months post-BTXA treatment. RESULTS: A total of 50 cases were classified into three levels of fat thickness, slim (< 0.55 cm), moderate (0.55 cm to 0.85 cm) and bulge (> 0.85 cm). All patients were treated with 300 units of BTXA (HengLi, China). Patients in the slim and bulge groups reported higher satisfaction rate than patients in the moderate group, with patients in the slim and bulge groups reporting complete satisfaction (100%) with calf contour at the 6-month follow-up. The satisfaction rate with the improvement in total leg circumference was low in all three groups. No severe complications were encountered in this study. CONCLUSIONS: This study identified a U-shaped correlation between calf subcutaneous fat thickness and patient satisfaction rate after treatment. Our results provide a theoretical basis for BTXA treatment and suggest the importance of pre-procedure conversations in GM hypertrophy treatment.

[Restoration of partial penile defect by scrotal skin flap in combination with penile lengthening].

OBJECTIVE: To evaluate the feasibility and clinical efficacy of a scrotal skin flap in combination with penile lengthening for repairing penile defects. METHODS: From 1999 to 2008, 7 cases (19 to 42 years old) of penile defects were treated by scrotal skin flap in combination with penile lengthening. The average preoperative length of stubbed penis was 2.1 cm in flaccid (range: 1.0 to 3.0 cm) and 4.8 cm in erection (range: 3.0 to 5.5 cm). All cases were treated with penile elongation. And a bilateral scrotal skin flap supplied by anterior scrotal artery (n = 3) or whole anterior scrotum flap (n = 4) was used to cover the exposed penile shaft. The scrotal incision was sutured directly. RESULTS: There was no need for urethra reconstruction. It was simple to obtain the scrotal skin flap. And the operation might be quickly performed with a lesser hemorrhage as compared with penile reconstruction. The scrotal flaps survived without any necrosis and all wounds healed primarily with an excellent contour and erectile function. When followed up for 1 - 5 years, the average preoperative penile length was 6.4 cm in flaccid (range: 5.0 to 7.5 cm) and 9.5 cm in erection (range: 8.0 to 10.5 cm). All cases had normal functions of urination, erection and gonobolia. Five cases had satisfied sexual life and one experienced a sexual life. CONCLUSIONS: The method of restoring partial penile defect with scrotal skin flaps is both simple and efficacious. Reasonable appearance and penile length are restored in most cases with better sensory and erectile functions.

The Role of Endoscopic Ultrasound-Guided Ki67 in the Management of Non-Functioning Pancreatic Neuroendocrine Tumors.

BACKGROUND/AIMS: The management of small, incidentally discovered nonfunctioning pancreatic neuroendocrine tumors (NF-PNETs) has been a matter of debate. Endoscopic ultrasound with fine-needle aspiration (EUS-FNA) is a tool used to identify and risk-stratify PNETs. This study investigates the concordance rate of Ki67 grading between EUS-FNA and surgical pathology specimens in NFPNETs and whether certain NF-PNET characteristics are associated with disease recurrence and disease-related death. METHODS: We retrospectively reviewed the clinical history, imaging, endoscopic findings, and pathology records of 37 cases of NFPNETs that underwent pre-operative EUS-FNA and surgical resection at a single academic medical center. RESULTS: There was 73% concordance between Ki67 obtained from EUS-FNA cytology and surgical pathology specimens; concordance was the highest for low- and high-grade NF-PNETs. High-grade Ki67 NF-PNETs based on cytology (p=0.028) and histology (p=0.028) were associated with disease recurrence and disease-related death. Additionally, tumors with high-grade mitotic rate (p=0.005), tumor size >22.5 mm (p=0.104), and lymphovascular invasion (p=0.103) were more likely to have poor prognosis. CONCLUSION: NF-PNETs with high-grade Ki67 on EUS-FNA have poor prognosis despite surgical resection. NF-PNETs with intermediate-grade Ki67 on EUS-FNA should be strongly considered for surgical resection. NF-PNETs with low-grade Ki67 on EUSFNA can be monitored without surgical intervention, up to tumor size 20 mm.