United States insurance coverage of immediate lymphatic reconstruction.

INTRODUCTION: Immediate Lymphatic Reconstruction (ILR) is a prophylactic microsurgical lymphovenous bypass technique developed to prevent breast cancer related lymphedema (BCRL). We investigated current coverage policies for ILR among the top insurance providers in the United States and compared it to our institutional experience with obtaining coverage for ILR. METHODS: The study analyzed the publicly available ILR coverage statements for American insurers with the largest market share and enrollment per state to assess coverage status. Institutional ILR coverage was retrospectively analyzed using deidentified claims data and categorizing denials based on payer reason codes. RESULTS: Of the 63 insurance companies queried, 42.9% did not have any publicly available policies regarding ILR coverage. Of the companies with a public policy, 75.0% deny coverage for ILR. In our institutional experience, $170,071.80 was charged for ILR and $166 118.99 (97.7%) was denied by insurance. CONCLUSIONS: Over half of America's major insurance providers currently deny coverage for ILR, which is consistent with our institutional experience. Randomized trials to evaluate the efficacy of ILR are underway and focus should be shifted towards sharing high level evidence to increase insurance coverage for BCRL prevention.

Breast cancer-related lymphedema: A comprehensive analysis of risk factors.

BACKGROUND: Breast cancer-related lymphedema is a devastating condition that negatively affects the quality of life of breast cancer survivors. We sought to identify risk factors that predicted the timing and development of lymphedema. METHODS: Women with breast cancer that underwent sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) at our institution between 2007 and 2022 were identified and sociodemographic and clinical information was extracted. We used logistic regression analysis to identify risk factors for lymphedema and performed cox-regression analysis to predict the timing of lymphedema presentation after surgery. RESULTS: We identified 1,223 patients, of which 161 (13.2%) developed lymphedema within 1.8 (mean, SD = 2.5) years postoperatively. Patients with SLNB had significantly lower odds for lymphedema development (vs. ALND, OR = 0.29 [0.14-0.57]). Patients between 40 and 49 years of age, and 50-59 (vs. <40 years, OR = 2.14 [1.00-4.60]; OR = 2.42, [1.13-5.16] respectively), African American patients (vs. Caucasian, OR = 1.86 [1.12-3.09]), patients with stage II, III, and IV disease (vs. stage 0, OR = 3.75 [1.36-10.33]; OR = 6.62 [2.14-20.51]; OR = 9.36 [2.94-29.81]), and patients with Medicaid (vs. private insurance, OR = 3.56 [1.73-7.28]) had higher rates of lymphedema. Cox-regression analysis showed that African American (HR = 1.71 [1.08-2.70]), higher BMI (HR = 1.03 [1.00-1.06]), higher stage (stage II, HR = 2.22 [1.05-7.09]; stage III, HR = 5.26 [1.86-14.88]; stage IV, HR = 6.13 [2.12-17.75]), and Medicaid patients (HR = 2.15 [1.12-3.80]) had higher hazards for lymphedema. Patients with SLNB had lower hazards for lymphedema (HR = 0.43 [0.87-2.11]). CONCLUSION: Lymphedema has identifiable risk factors that can reliably be used to predict the chances of lymphedema development and enable clinicians to educate patients better and formulate treatment plans accordingly. LEVEL OF EVIDENCE: III (Retrospective study).

Predicting Reduction Mammaplasty Total Resection Weight With Machine Learning.

BACKGROUND: Machine learning (ML) is a form of artificial intelligence that has been used to create better predictive models in medicine. Using ML algorithms, we sought to create a predictive model for breast resection weight based on anthropometric measurements. METHODS: We analyzed 237 patients (474 individual breasts) who underwent reduction mammoplasty at our institution. Anthropometric variables included body surface area (BSA), body mass index, sternal notch-to-nipple (SN-N), and nipple-to-inframammary fold values. Four different ML algorithms (linear regression, ridge regression, support vector regression, and random forest regression) either including or excluding the Schnur Scale prediction for the same data were trained and tested on their ability to recognize the relationship between the anthropometric variables and total resection weights. Resection weight prediction accuracy for each model and the Schnur scale alone were evaluated based on using mean absolute error (MAE). RESULTS: In our cohort, mean age was 40.36 years. Most patients (71.61%) were African American. Mean BSA was 2.0 m 2 , mean body mass index was 33.045 kg/m 2 , mean SN-N was 35.0 cm, and mean nipple-to-inframammary fold was 16.0 cm. Mean SN-N was found to have the greatest variable importance. All 4 models made resection weight predictions with MAE lower than that of the Schnur Scale alone in both the training and testing datasets. Overall, the random forest regression model without Schnur scale weight had the lowest MAE at 186.20. CONCLUSION: Our ML resection weight prediction model represents an accurate and promising alternative to the Schnur Scale in the setting of reduction mammaplasty consultations.

A DIEP Dive into Patient Risk Factors for Hernia and Bulge Development: A Meta-regression.

BACKGROUND: This meta-regression aims to investigate risk factors for abdominal hernia and bulge in patients undergoing deep inferior epigastric perforator (DIEP) flaps and the effect of prophylactic mesh placement on postoperative complications. METHODS: A systematic search was conducted in July of 2022 in alignment with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Seventy-four studies published between 2000 and 2022 met the inclusion criteria. Sixty-four studies were included in the analysis for bulge and 71 studies were included in the analysis for hernia. Meta-regressions were run on the proportion of patients experiencing hernia or bulge to assess for patient risk factors and the role of prophylactic mesh placement. Proportions were transformed using the Freeman-Tukey double arcsine method. RESULTS: The average rates of hernia and bulge after DIEP flaps were found to be 0.18% and 1.26%, respectively. Increased age (ß = 0.0059, p = 0.0117), prior abdominal surgery (ß = 0.0008, p = 0.046), and pregnancy history (ß = -0.0015, p = 0.0001) were significantly associated with hernia. Active smoking (ß = 0.0032, p = 0.0262) and pregnancy history (ß = 0.0019, p < 0.0001) were significantly associated with bulge. Neither the perforator vessel laterality nor the number of perforator vessels harvested had any association with hernia or bulge. Prophylactic mesh placement was not associated with hernia or bulge. CONCLUSION: Understanding the comorbidities associated with hernia or bulge following DIEP flap breast reconstruction, such as advanced age, prior abdominal surgery, pregnancy history, and active smoking status, allows surgeons to proactively identify and educate high-risk patients. Future studies may further explore whether prophylactic mesh placement offers patients any benefit.

Trends of Medicare Reimbursement Rates for Lower Extremity Procedures.

BACKGROUND: Data collected across many surgical specialties suggest that Medicare reimbursement for physicians consistently lags inflation. Studies are needed that describe reimbursement rates for lower extremity procedures. Our goal is to analyze the trends in Medicare reimbursement rates from 2010 to 2021 for both lower extremity amputation and salvage surgeries. METHODS: The Physician Fee Schedule Look-Up Tool of the Centers for Medicare and Medicaid Services was assessed and Current Procedural Terminology codes for common lower extremity procedures were collected. Average reimbursement rates from 2010 to 2021 were analyzed and adjusted for inflation. The rates of work-, facility-, and malpractice-related relative value units (RVUs) were also collected. RESULTS: We found an overall increase in Medicare reimbursement of 4.73% over the study period for lower extremity surgery. However, after adjusting for inflation, the average reimbursement decreased by 13.19%. The adjusted relative difference was calculated to be (-)18.31 and (-)11.34% for lower extremity amputation and salvage procedures, respectively. We also found that physician work-related RVUs decreased by 0.27%, while facility-related and malpractice-related RVUs increased. CONCLUSION: Reimbursement for lower extremity amputation and salvage procedures has steadily declined from 2010 to 2021 after adjusting for inflation, with amputation procedures being devaluated at a greater rate than lower extremity salvage procedures. With the recent marked inflation, knowledge of these trends is crucial for surgeons, hospitals, and health care policymakers to ensure appropriate physician reimbursement. LEVEL OF EVIDENCE: IV (cross-sectional study).

Virtual planning and navigational technology in reconstructive surgery.

Reconstructive technologies have expanded to include the use of virtual surgical planning (VSP) and computer-aided design and manufacturing (CAD-CAM), and 3-Dimensional printing. The advantages of VSP over traditional techniques are highlighted in many scenarios: (a) delayed reconstruction, (b) maxillary reconstruction, (c) placement of dental implants, and (d) precision guided oncology. Microsurgery is undergoing a paradigm shift with virtual planning at its foreground. Herein, we describe the versatile uses for CAD-CAM and key operative steps.

Characterization of Reversibly Immortalized Calvarial Mesenchymal Progenitor Cells.

BACKGROUND: Bone morphogenetic proteins (BMPs) play a sentinel role in osteoblastic differentiation, and their implementation into clinical practice can revolutionize cranial reconstruction. Preliminary data suggest a therapeutic role of adenoviral gene delivery of BMPs in murine calvarial defect healing. Poor transgene expression inherent in direct adenoviral therapy prompted investigation of cell-based strategies. OBJECTIVE: To isolate and immortalize calvarial cells as a potential progenitor source for osseous tissue engineering. MATERIALS AND METHODS: Cells were isolated from murine skulls, cultured, and transduced with a retroviral vector bearing the loxP-flanked SV40 large T antigen. Immortalized calvarial cells (iCALs) were evaluated via light microscopy, immunohistochemistry, and flow cytometry to determine whether the immortalization process altered cell morphology or progenitor cell profile. Immortalized calvarial cells were then infected with adenoviral vectors encoding BMP-2 or GFP and assessed for early and late stages of osteogenic differentiation. RESULTS: Immortalization of calvarial cells did not alter cell morphology as demonstrated by phase contrast microscopy. Mesenchymal progenitor cell markers CD166, CD73, CD44, and CD105 were detected at varying levels in both primary cells and iCALs. Significant elevations in alkaline phosphatase activity, osteocalcin mRNA transcription, and matrix mineralization were detected in BMP-2 treated iCALs compared with GFP-treated cells. Gross and histological analyses revealed ectopic bone production from treated cells compared with controls in an in vivo stem cell implantation assay. CONCLUSION: We have established an immortalized osteoprogenitor cell line from juvenile calvarial cells that retain a progenitor cell phenotype and can successfully undergo osteogenic differentiation upon BMP-2 stimulation. These cells provide a valuable platform to investigate the molecular mechanisms underlying intramembranous bone formation and to screen for factors/small molecules that can facilitate the healing of osseous defects in the craniofacial skeleton.

Gender-affirming DIEP Flap Breast Augmentation.

Implant-based techniques have been the mainstay of gender-affirming breast augmentation (GABA). Here we describe a novel autologous technique for GABA. We provide a single-patient case report of gender-affirming deep inferior epigastric artery perforator (DIEP) flap breast augmentation. World Professional Association for Transgender Health guidelines were followed according to Standards of Care, version 8. Prepectoral tissue expanders were placed at the time of the patient's facial feminization surgery. DIEP flaps were then used for bilateral breast augmentation. Planned revisions were made about 5 months later. Breast augmentation was performed successfully with DIEP flaps, and the patient was satisfied with her outcome. No complications occurred. Anatomic differences to cisgender women were noted, including relatively thick musculature of the abdominal wall and chest as well as tight anterior abdominal fascial closure. Advantages compared with implant-based GABA were also noted, including feminization of the abdomen and avoidance of potential implant related complications. We report a novel approach to GABA. Our approach borrows well-established techniques with demonstrated efficacy and high satisfaction in postmastectomy breast reconstruction and even cosmetic purposes. However, sex- and hormone-influenced anatomic differences required some modifications compared with postmastectomy DIEP flap reconstruction.

Chyle Leak Management in the Setting of Tissue Expander Breast Reconstruction with Acellular Dermal Matrix: Case Series and Literature Review.

Background: Chylous leakage is a rare surgical complication most frequently encountered following operations involving the neck and thorax. Even more rare are axillary chyle leaks secondary to breast cancer involving the axillary lymph nodes. Anatomic variability in the termination of the thoracic duct may play a role in the susceptibility some individuals may have to this type of leakage. There is no consensus on the definitive management of these complications, especially in the context of breast reconstruction. Methods: Here, we report our experience in the management of chylous leakage in three patients who underwent left axillary lymph node dissection and immediate breast reconstruction with the use of tissue expanders and acellular dermal matrix. Descriptions of each case are followed by a review of the relevant literature. We also present an original treatment algorithm. Results: Two of three patients with suspected chylous leakage secondary to intraoperative injury to the axillary region underwent definitive diagnosis by clinical examination and drain fluid triglyceride analysis, followed by conservative management with a low-fat diet. The third patient was diagnosed clinically with no fluid analysis. All leakages resolved through conservative means, with no need to return to the operating room for surgical exploration and repair. Conclusions: Based on our experience, we believe that patients with suspected chylous leakage secondary to axillary lymph node dissection in the context of breast reconstruction can be safely and effectively managed by conservative management in the acute postoperative period. If these measures are insufficient, surgical management may be necessary.

Trends of medicare reimbursement for breast cancer and reconstructive surgery.

This study evaluated trends in Medicare reimbursement for commonly performed breast oncologic and reconstructive procedures. Average national relative value units (RVUs) for physician-based work, facilities, and malpractice were collected along with the corresponding conversion factors for each year. From 2010 to 2021, there was an overall average decrease of 15% in Medicare reimbursement for both breast oncology (-11%) and reconstructive procedures (-16%). Based on these findings, breast and reconstructive surgeons should advocate for reimbursement that better reflects the costs of their practice.

RUNX2 quadruplication: additional evidence toward a new form of syndromic craniosynostosis.

The RUNX2 transcription factor regulates osteoblast differentiation. Its absence, as with cleidocranial dysplasia, results in deficient bone formation. However, its excess seems to follow a dose response of over ossification. RUNX2 duplications (3 copies) are exceedingly rare but have been reported to cause craniosynostosis. There are no existing reports of quadruplications (4 copies). We present a case study of a boy with an atypical skull deformity with pan-craniosynostosis whose microarray analysis revealed 4 copies of a 1.24-Mb region from 6p12.3 to 6p21.1 containing the RUNX2 gene. Further characterization of this osteogenic pathway may aid in our understanding of the pathogenesis and subsequent prevention and treatment of syndromic craniosynostosis.

Nationwide Bibliometric Analysis of Integrated Plastic Surgery Program Directors.

Studies have linked bibliometric indices with the academic level of plastic surgeons, but this relationship has not been explored with residency program directors (PDs). As teachers of the next generation, PDs' academic performance is an important component of residency program success. We sought to identify distinguishing characteristics of integrated plastic surgery programs, focusing on their PD bibliometric indices. Methods: We identified plastic surgery programs based on 2021 Doximity reputation and research output rankings, respectively, and then divided them into four quartiles (Q1-Q4). PD academic history and bibliometric indices (h-index, the number of publications, and citations) were collected through Doximity profiles and program websites: PubMed, Scopus, Google Scholar, American Society of Plastic Surgeons, and Accreditation Council for Graduate Medical Education. Results: Eighty-four programs were identified. There was a significant positive relationship between h-index, the number of publications, and type of research with reputation ranking (P < 0.05). After adjusting for years of experience post-training, h-index (OR = 1.24; P < 0.001) and the number of publications (OR = 1.05, P < 0.001) were significantly associated with reputation ranking. There was a statistically significant relationship between PD research fellowship completion and research output ranking (P < 0.01). After adjusting for years of experience post-training, h-index (OR = 1.05; P = 0.047) and the number of publications (OR = 1.01; P = 0.04) were significantly associated with research output ranking. Conclusion: Higher ranked programs tend to have PDs who have a strong record of scholarly activity, as evidenced by certain bibliometric indices.

Pressure injuries in COVID-19 patients: A tertiary center experience.

Pressure ulcers continue to severely impact patient outcomes and increase health care costs. We aimed to examine the incidence and risk factors related to pressure ulcers among COVID-19 patients. A retrospective was conducted between March 2020-April 2021. Baseline differences were examined using chi-square and Fischer's exact test. Logistic regression was employed to examine the association of the collected variables to development of new pressure ulcers. 4608 patients were included, of which eighty-three acquired new pressure ulcers. Risk factors were increased age, peripheral artery disease, abnormal albumin levels, but not prone position.

Safety and Efficacy of Extended Postdischarge Venous Thromboembolism Prophylaxis in Microsurgical Breast Reconstruction.

Discharging patients on extended postoperative venous thromboembolism (VTE) prophylaxis is trending in microsurgical breast reconstruction (MBR). This study investigated contemporary bleeding and thromboembolic complications after MBR and reported postdischarge enoxaparin outcomes. Methods: The PearlDiver database was queried for MBR patients who did not receive postdischarge VTE prophylaxis (cohort 1) and MBR patients discharged with enoxaparin for at least 14 days (cohort 2), then queried for hematoma, deep venous thrombosis (DVT), and/or pulmonary embolism. Concurrently, a systematic review was undertaken to identify studies investigating VTE with postoperative chemoprophylaxis. Results: In total, 13,541 patients in cohort 1 and 786 patients in cohort 2 were identified. The incidence of hematoma, DVT, and pulmonary embolism were 3.51%, 1.01%, 0.55% in cohort 1, and 3.31%, 2.93%, and 1.78% in cohort 2, respectively. There was no significant difference in hematoma between these two cohorts (P = 0.767); however, a significantly lower rate of DVT (P < 0.001) and pulmonary embolism (P < 0.001) occurred in cohort 1. Ten studies met systematic review inclusion. Only three studies reported significantly lower VTE rates with postoperative chemoprophylaxis. Seven studies found no difference in bleeding risk. Conclusions: This is the first study utilizing a national database and a systematic review to investigate extended postoperative enoxaparin in MBR. Overall, rates of DVT/PE seem to be declining compared with previous literature. The results of this study suggest that there remains a lack of evidence supporting extended postoperative chemoprophylaxis, although the therapy appears safe in that it does not increase bleeding risk.

Clinical Outcomes Following Resection of Distal Lower Extremity Soft Tissue Sarcomas.

OBJECTIVE: Resection of soft tissue sarcoma (STS) in the distal lower extremity can result in large soft tissue defects that create difficult wounds to manage and significant risks for complications. Often, the anticipated or resultant tissue defect or loss of functional anatomy is an indication for amputation over limb salvage. Soft tissue reconstruction managed by plastic and reconstructive surgery (PRS) may help offer limb salvage as a therapeutic option with acceptable oncologic outcomes and wound complication rates. METHODS: This was a review of 52 patients who underwent resection of STS at the level of the knee or distal between 2010 and 2020. Plastic and reconstructive surgery soft tissue management was utilized in 40.4% (n = 21) of cases, most of whom would have otherwise been considered candidates for amputation. RESULTS: The overall rate of limb salvage was 76.9%. The overall rate of wound complications was 19.2%. The overall rate of negative margins of resection was 92.3%. The 1-, 5-, and 10-year overall survival probabilities were 92%, 85%, and 85%, respectively. Of the 40 limb salvage procedures, two required subsequent amputation, one for multiply recurrent disease and one for necrosis. The wound complication rate was 14.3% in the PRS management group and 22.6% in cases of wound closure managed by the primary surgeon. There were zero instances of total wound or flap loss in PRS- managed closures. When comparing patients with wound complications to those without, there was no difference in age (59.5 ± 21 vs. 51 ± 18 years, p = 0.42), body mass index (31.1 ± 4.8 vs. 26.1 ± 7.1 kg/m2 , p = 0.19), or tumor size (6.8 ± 5.0 vs. 6.4 ± 4.7 cm, p = 0.82). At final follow-up, 67% (n = 35) of patients were alive and disease-free. CONCLUSIONS: Wound complications are not uncommon after resection of distal lower extremity STS. Our experience has been successful in achieving limb salvage in these challenging cases. Without PRS soft tissue management, however, many patients may alternatively be candidates for amputation.

Optimizing delivery of breast conservation therapy: a multidisciplinary approach to oncoplastic surgery.

BACKGROUND: For patients with small breasts relative to tumor size and for those with tumors in the central or inferior poles, lumpectomy can be aesthetically devastating. The field of oncoplastic surgery has developed to offset the aesthetic pitfalls of breast conservation. Questions remain regarding oncologic safety, potential complications, and patient selection. In this study, we report our institutional, multidisciplinary experience with oncoplastic surgery. METHODS: A retrospective review was performed including all patients at our institution undergoing oncoplastic breast surgery between 2003 and September 2009 at an academic medical center. Mean follow-up period was 38 months. All patients were referred by the institutional multidisciplinary breast team. RESULTS: Forty-five female patients underwent 46 oncoplastic breast reconstructions. Immediate reconstruction was performed in 21 patients, early (within 9 to 73 days of final tumor resection) in 18, and delayed (following completion of radiation) in 6. Three patients (14%) who underwent immediate oncoplastic reconstruction had positive margins on final pathology and proceeded to completion mastectomy. No local cancer recurrence was seen. Two patients developed distant metastatic disease. Twelve complications occurred in 11 patients; by group, 2 (10%) in immediate, 7 (39%) in delayed-immediate group, and 2 (33%) in delayed. Immediate oncoplastic reconstruction, performed as a single-stage procedure, inversely correlated with complication risk (P = 0.059). No other risk factor correlated with complications. CONCLUSIONS: Our review suggests this multidisciplinary approach to oncoplastic surgery is safe. Interestingly, women undergoing immediate oncoplastic reconstruction trended toward a lower rate of complications. The benefit of immediate reconstruction must be balanced by risk of positive tumor margin and subsequent necessity for completion mastectomy. This risk-benefit balance may be best delivered by a multidisciplinary team focused on all aspects of breast cancer care.

Differentiation of osteoprogenitor cells is induced by high-frequency pulsed electromagnetic fields.

UNLABELLED: Craniofacial defect repair is often limited by a finite supply of available autologous tissue (ie, bone) and less than ideal alternatives. Therefore, other methods to produce bony healing must be explored. Several studies have demonstrated that low-frequency pulsed electromagnetic field (PEMF) stimulation (ie, 5-30 Hz) of osteoblasts enhances bone formation. The current study was designed to investigate whether a Food and Drug Administration-approved, high-frequency PEMF-emitting device is capable of inducing osteogenic differentiation of osteoprogenitor cells. Osteoprogenitor cells (commercially available C3H10T1/2 and mouse calvarial) in complete Dulbecco modified Eagle medium were continuously exposed to PEMF stimulation delivered by the ActiPatch at a frequency of 27.1 MHz. Markers of cellular proliferation and early, intermediate, and terminal osteogenic differentiation were measured and compared with unstimulated controls. All experiments were performed in triplicate. High-frequency PEMF stimulation increases alkaline phosphatase activity in both cell lines. In addition, high-frequency PEMF stimulation augments osteopontin and osteocalcin expression as well as mineral nodule formation in C3H10T1/2 cells, indicating late and terminal osteogenic differentiation, respectively. Cellular proliferation, however, was unaffected by high-frequency PEMF stimulation. Mechanistically, high-frequency PEMF-stimulated osteogenic differentiation is associated with elevated mRNA expression levels of osteogenic bone morphogenetic proteins in C3H10T1/2 cells. Our findings suggest that high-frequency PEMF stimulation of osteoprogenitor cells may be explored as an effective tissue engineering strategy to treat critical-size osseous defects of the craniofacial and axial skeleton. ABBREVIATIONS: ALP, alkaline phosphatase; BMP, bone morphogenetic protein; ERK-1, extracellular signal-regulated kinase 1; iCALs, immortalized calvarial cells; IHC, immunohistochemical; MAP, mitogen-activated protein; MSC, mesenchymal stem cell; OCN, osteocalcin; OPN, osteopontin; p38α, p38-reactivating kinase; PBS, phosphate-buffered saline; PEMF, pulsed electromagnetic field.

Trends in Skin Melanoma Burden: Findings From the Global Burden of Disease Study.

Background: Melanoma is the third most common skin cancer and the leading cause of skin cancer mortality. This study sought to investigate trends in melanoma incidence, mortality, and burden of disease. Methods: The authors assessed the records of the Global Burden of Disease Study 2017 to extract information about the incidence, mortality, and disability adjusted life years (DALY) related to melanoma during 1990-2017 in the US and other countries based on their socio-demographic index (SDI). Results: Melanoma incidence in the US increased 1.6 times, although the difference was not statistically significant. For patients over the age of 60, the incidence was significantly increased by 1.72 to 164.6 times. Mortality was relatively stable during the study period; however, it was increased for patients over 65 years of age (range: 1.03 to 70 times), although not statistically significant. Mortality-to-incidence ratio was decreased, but the difference was not statistically significant. For patients over 75 years of age, DALYs were statistically significantly increased by 1.34 to 1.71 times. Conclusions: This study highlights differences in melanoma incidence and mortality from 1990-2017. Physicians involved in melanoma care should be aware of these changes in order to anticipate care needs.

Burden of Pressure Injuries: Findings From the Global Burden of Disease Study.

Background: Pressure injuries remain among the most common problems faced by plastic surgeons and comprise a large portion of wound clinic practice. However, little is known about the overall morbidity related to the disease. This research sought to identify the burden related to the diagnosis of pressure injuries. Methods: We used the Global Burden of Disease Study 2017 to extract information about incidence and disability-adjusted life years (DALYs) related to pressure injuries from 1990 to 2017. Descriptive statistics were used to identify changes in the outcomes of interest. Results: A relative though not statistically significantly decrease in the incidence and burden of pressure injuries was observed between 1990 and 2017. Rates of incidence in the US appear higher than other higher socio-demographic index countries. No clinically and statistically significant changes were observed based on age or sex. Conclusions: Pressure injury incidence and burden have remained relatively stable between 1990 and 2017 with no significant improvement noted. There is room for improvement on a national performance level, and further research is needed regarding inconsistencies in regional outcomes.

Role of RANK-RANKL-OPG axis in cranial suture homeostasis.

Craniosynostosis is a significant disorder affecting 1 in 2500 live births worldwide. Although a large body of work has focused on dural regulation and the contributions of molecular mediators such as fibroblast growth factor, bone morphogenetic protein, and transforming growth factor ß, minimal attention has been directed toward osteoclast function in cranial suture biology. Receptor activator of nuclear factor κB (RANK) is an essential mediator of osteoclastogenesis and osteoclast activation. In this study, physiologic fusion of posterior frontal sutures in murine development correlated with decreasing protein expression of RANK in comparison to age-matched coronal and sagittal sutures via immunohistochemical survey. However, RANK mRNA did not exhibit a similar pattern suggesting that RANK is regulated at the protein level. Fused cranial sutures in nonsyndromic craniosynostotic children also showed decreased levels of RANK staining in immunohistochemistry in comparison to patent sutures from the same patients. Immunohistochemistry with a RANK ligand antibody did not show differences in fused or patent sutures. Moreover, RANK knockdown in calvarial strip suture cultures displayed increased bone density specifically in the suture line after infection with small interfering RANK viruses. Cranial suture biology, similar to bone biology in general, likely depends on a complex interplay between osteoblasts and osteoclasts. We now report a temporospatial correlation between RANK expression and suture morphology that suggests that osteoclast activity is important in maintenance of cranial suture patency in normal physiology and disease. Furthermore, RANK downregulation promoted suture fusion establishing a causal relationship between the presence of RANK and patency.