Characterising differences between self-reported and wastewater-identified drug use at two consecutive years of an Australian music festival.

BACKGROUND: In the context of drug prohibition, potential adulteration and variable purity pose additional health risks for people who use drugs, with these risks often compounded by the outdoor music festival environment. Ahead of the imminent implementation of drug checking services in Queensland, Australia, this study aims to characterise this problem using triangulated survey and wastewater data to understand self-reported and detected drug use among attendees of a multi-day Queensland-based music festival in 2021 and 2022. METHODS: We administered an in-situ survey focusing on drug use at the festival to two convenience samples of 136 and 140 festival attendees in 2021 and 2022 respectively. We compared survey findings to wastewater collected concurrently from the festival's site-specific wastewater treatment plant, which was analysed using Liquid Chromatography Tandem Mass Spectrometry. RESULTS: Most survey respondents (82 % in 2021, 92 % in 2022) reported using or intending to use an illicit drug at the festival. Some respondents reported potentially risky drug use practices such as using drugs found on the ground (2 % in 2021, 4 % in 2022). Substances detected in wastewater but not surveys include MDEA, mephedrone, methylone, 3-MMC, alpha-D2PV, etizolam, eutylone, and N,N-dimethylpentylone. CONCLUSION: Many substances detected in wastewater but not self-reported in surveys likely represent substitutions or adulterants. These findings highlight the benefits of drug checking services to prevent harms from adulterants and provide education on safer drug use practices. These findings also provide useful information on socio-demographic characteristics and drug use patterns of potential users of Queensland's future drug checking service.

"They sent it away for testing and it was all bunk": Exploring perspectives on drug checking among steroid consumers in Queensland, Australia.

INTRODUCTION: Research supports the feasibility and acceptance of drug checking among nightlife and festival attendees. Interest in expanding drug checking to other groups of people who use drugs, including those who inject drugs, has grown. However, understanding the acceptability and feasibility of drug checking among specific cohorts, like anabolic-androgenic steroids (AAS) consumers, remains a research gap. This study explores AAS consumers' perspectives on drug checking and service preferences, aiding the preparation for drug checking delivery in Queensland, Australia. METHODS: A purposive sampling technique was used to recruit 15 AAS consumers (9 males, 6 females; Mage = 36.80 years, SD = 6.12) from Australia. One-on-one semi-structured qualitative interviews were conducted with questions exploring participants' views on drug checking/testing and their preferences for AAS analysis. Thematic analysis was conducted with final themes established through iterative consensus. RESULTS: Consumers expressed frustration with the prevailing stereotypes, social stigma, and the perception of criminality associated with the use of AAS. There was a strong dependence on personal connections and trusted suppliers, with coaches exerting significant influence. Participants expressed concerns about the widespread availability of counterfeit products and underground operations. The act of using unknown AAS was likened to a game of Russian roulette, underscoring the importance of obtaining accurate information and access to reliable drug checking services. Consumers expressed a preference for a web-based platform that enables individuals to access their own test results while contributing to a comprehensive database of brand-specific testing outcomes. DISCUSSION: AAS consumers recognise the significance of monitoring their AAS use and seek a service that can not only assist them in making informed decisions regarding AAS usage but also potentially contribute to the knowledge of the wider AAS-consuming community. These findings underscore the importance of tailored education, drug checking services, and harm reduction measures to address the diverse needs of AAS consumers.

Subpectoral Implant Repositioning With Partial Capsule Preservation: Treating the Long-Term Complications of Subglandular Breast Augmentation.

BACKGROUND: Patients with long-term complications associated with subglandular breast augmentation are being seen in increasing numbers in the Southern California community. Late deformities include a characteristic "slide-down" deformity as well as capsular contracture, implant wrinkling, and nipple-areola complex enlargement. Repositioning the implant to a subpectoral pocket is a recognized revisionary technique to treat this problem; however, technical details of how this is accomplished are lacking in the literature. OBJECTIVES: To review our technique for treating long-term complications associated with subglandular implants using subpectoral repositioning with partial capsule preservation and mastopexy, without the need for an acellular dermal matrix (ADM) or mesh. METHODS: A retrospective review of all patients undergoing subpectoral repositioning over the course of 6 years was performed. Patient data and long-term outcomes were assessed. A technique is presented utilizing a partial capsulectomy that preserves a portion of the capsule as an ADM/mesh equivalent, ensuring adequate implant coverage and preventing window shading of the pectoralis major muscle. RESULTS: Twenty-four patients with subglandular implants and slide-down deformity as well as other associated complications including capsular contracture, implant wrinkling, and enlarged areolas underwent revision surgery with a subpectoral site change. Often, patients presented many years after their initial augmentation (mean 18 years, range 4-38 years). The average patient follow-up was 3.1 years (range 1.0-6.8 years). Two patients required minor revisions with local anesthetic, while another 2 revisions required general anesthesia. CONCLUSIONS: Long-term deformities associated with subglandular breast augmentation can reliably be corrected by subpectoral repositioning, mastopexy, and utilization of residual breast capsule in the place of an ADM or mesh.

Trends in the incidence and treatment of necrotizing soft tissue infections: an analysis of the National Hospital Discharge Survey.

Necrotizing soft tissue infections are a rare but potentially fatal condition of the soft tissues caused by virulent, toxin-producing bacteria. In the United States, there is an estimated annual incidence of 0.04 cases per 1000 annually, but previous estimates of the Centers for Disease Control and Prevention had the incidence at 500 to 1500 cases yearly. Early reports of mortality were variable with rates ranging from 46 to 76% but outcomes have been improving over time. The National Hospital Discharge Survey was analyzed to study current trends in the demographics, incidence, use, and mortality of patients diagnosed with necrotizing soft tissue infections. The authors analyzed the 1999, 2002, and 2007 National Hospital Discharge Survey by using a sampling weighting method. A total of 13,648 cases of necrotizing soft tissue infections were identified in 2007. This represents an increase from 12,153 cases in 2002 and 6612 cases in 1999. In the 9 years from 1999 to 2007 the gross incidence of necrotizing soft tissue infections more than doubled. Hospital stay was essentially unchanged within study years, at 16 days. Mean age increased from approximately 50 years in 1999 to 54 years in 2007. Further, mortality went from 10.45% in 1999 to 9.75% in the 2007 survey. The population-adjusted incidence rate increased 91% in the studied years. Rising use of immunosupression, exponential growth in the incidence of obesity, and type 2 diabetes could be a major contributing factor. The mortality rate is far below the rate in reports published from as early as 20 years ago, and at 9.75% compares with modern case series, but is a more accurate measure of mortality in this condition.

Trends in the surgical treatment of cubital tunnel syndrome: an analysis of the national survey of ambulatory surgery database.

PURPOSE: To ascertain trends in the surgical treatment of ulnar nerve compression at the elbow within the United States. METHODS: We analyzed the National Survey of Ambulatory Surgery to study trends in the treatment of cubital tunnel syndrome from 1994 to 2006. The National Survey of Ambulatory Surgery provides a comprehensive overview of ambulatory surgical procedures performed in the United States. Patients identified in the database with surgically treated cubital tunnel syndrome were verified by members of our research staff and compiled into these 3 groups: decompression, transposition, and other. The data were then statistically analyzed for trends in treatment, utilization, and demographics. RESULTS: A total of 52,133 surgical procedures were recorded in the National Survey of Ambulatory Surgery for the treatment of ulnar nerve compression in 2006. This represents an increase from 26,283 in 1994 and 35,406 in 1996. In the 11 years from 1996 to 2006, the total surgical procedures on the ulnar nerve increased by 47%. Transposition went from 49% of all cubital tunnel procedures in the 1990s to 38% in 2006. In 2006, women were much more likely to have a simple decompression (70%) than a transposition or other technique. Decompression had a mean surgical time of 48 minutes, and transposition had a mean surgical time of 59 minutes. CONCLUSIONS: The percentage of transpositions used in the treatment of cubital syndrome has decreased to 37% in the last survey. Possible reasons include expanded indications or changing surgical preferences. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

rhBMP-2 with a demineralized bone matrix scaffold versus autologous iliac crest bone graft for alveolar cleft reconstruction.

BACKGROUND: Secondary alveolar cleft reconstruction using autologous iliac crest bone graft is currently the standard treatment for alveolar clefts. Although effective, harvesting autologous bone may result in considerable donor-site morbidity, most commonly pain and the potential for long-term sensory disturbances. In an effort to decrease patient morbidity, a novel technique using recombinant human bone morphogenetic protein (rhBMP)-2 encased in a demineralized bone matrix scaffold was developed as an alternative to autografting for secondary alveolar cleft reconstruction. METHODS: A chart review was conducted for the 55 patients who underwent secondary alveolar cleft reconstruction over a 2-year period with a mean follow-up of 21 months. Of these, 36 patients received rhBMP-2/demineralized bone matrix scaffold (including 10 patients with previously failed repairs using iliac crest bone grafting) and 19 patients underwent iliac crest bone grafting. Postoperatively, bone stock was evaluated using occlusal radiographs rated according to the Bergland and Chelsea scales. RESULTS: Alveolar clefts repaired using rhBMP-2/demineralized bone matrix scaffold were 97.2 percent successful compared with 84.2 percent with iliac crest bone grafting. Radiographically, initial repairs with rhBMP-2/demineralized bone matrix scaffold were superior to iliac crest bone grafting according to both Bergland and Chelsea scales, and significantly more patients in the rhBMP-2/demineralized bone matrix scaffold group had coronal bridging. The postoperative intraoral infection rate following iliac crest bone grafting was significantly greater than for rhBMP-2/demineralized bone matrix scaffold. The cost of rhBMP-2/demineralized bone matrix scaffold products was offset by cost savings associated with a reduction in operative time averaging 102 minutes. CONCLUSIONS: rhBMP-2 encased in a demineralized bone matrix scaffold appears to be a viable alternative for secondary alveolar cleft repair. Patients are spared donor-site morbidity and achieve excellent results, decreasing operative time, and increasing operating room use. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Neural sheath tumors of the brachial plexus: a multidisciplinary team-based approach.

Peripheral tumors of the brachial plexus, although rare, provide an opportunity for the plastic surgeon to coordinate a multidisciplinary team and achieve excellent outcomes. Most of the case series are reported from the neurosurgical literature. We report on the experience of the Kaiser Permanente Brachial Plexus Clinic over a recent 2-year period. A retrospective review was conducted to examine the medical records, radiographic images, operative reports, and pathologic findings of 13 consecutive patients with peripheral nerve sheath tumors of brachial plexus origin. Of the 10 patients requiring surgical exploration, 90% had significant improvement or resolution of pain, with sensory and motor recovery showing mixed results. Average follow-up consisted of 2 years with occupational therapy beginning shortly after operative intervention. Our results are similar to or better than those published in the literature. The plastic surgeon with subspecialty training can safely and successfully treat tumors of the brachial plexus by implementing a multidisciplinary approach.

Scalp erosion in ankyloblepharon-ectodermal defect-cleft lip and/or palate (AEC syndrome): treatment with acellular dermal matrix.

Ankyloblepharon-ectodermal defect-cleft lip and/or palate (AEC syndrome, also known as Hay-Wells syndrome) is an autosomal dominant disease caused by mutation in the p63 gene that is primarily characterized by facial clefting, presence of ankyloblepharon, ectodermal dysplasia, and scalp erosion. Scalp erosion is perhaps the most debilitating manifestation of AEC due to its problematic treatment that is fraught with failure given the underlying pathology of the p63 mutation causing dysfunctional wound healing. Management is often targeted in a stepwise fashion, beginning with daily baths, light debridement, and emollients and progressing to extensive skin excision. Skin grafting has limited success and, inevitably, infections requiring aggressive debridement and antibiotic therapy result from dysfunctional healing. The use of acellular dermal matrix for treatment of scalp erosion is a novel approach attempted in a patient with severe scalp disease. Here we report her case and the failure of treatment, along with possible explanations and suggestions for future therapy.

A rare case of accessory maxilla and bilateral Tessier no. 7 clefts, a 10-year follow-up.

A Tessier no. 7 cleft is a lateral facial cleft which originates from the oral cavity and extends towards the tragus, involving both soft-tissue and skeletal components. A male patient presenting with both maxillary jaw duplication and bilateral Tessier no. 7 clefts, which has been reported only twice in the literature, is described. Bilateral facial clefts, macrostomia and chondro-cutaneous remnants were noted, which were repaired and resected. With further growth, facial asymmetry and asymmetric facial nerve dysfunction became apparent. Radiographic examination showed an accessory maxillary jaw and a flattened and hypoplastic right coronoid process. A maxillary alveolar cleft was also present between the left second bicuspid and the second permanent molar. This case may represent an under-recognized phenotype with an unusual combination of maxillary jaw duplication, macrostomia, Tessier no. 7 clefts, and chondro-cutaneous remnants. A long-term follow-up of these patients is recommended as they often develop craniofacial deformities later in life.

The variation in the absence of the palmaris longus in a multiethnic population of the United States: an epidemiological study.

The absence of the palmaris longus (PL) has been shown to vary based on body side, gender, and ethnicity. In prior studies, homogenous ethnic populations have been shown to have differences in rates of absence. However, no study thus far has analyzed the differences in palmaris longus prevalence in a multiethnic population. We prospectively collected data on 516 patients visiting the outpatient hand clinics at LAC+USC Medical Center and Keck Medical Center. Analysis of the data was then performed for variables including ethnicity, laterality, and gender. There were no differences in the absence of the PL based on laterality or gender. Ethnically, there was no difference between white (non-Hispanic) and white (Hispanic) patients, with prevalence of 14.9% and 13.1%, respectively. However, African American (4.5%) and Asian (2.9%) patients had significantly fewer absences of the PL than the Caucasian, Hispanic reference group (P = 0.005 and P = 0.008, resp.). African Americans and Asians have a decreased prevalence of an absent PL. The Caucasian population has a relatively greater prevalence of an absence of the PL. This epidemiological study demonstrates the anatomic variation in this tendon and may be taken into account when planning an operation using tendon grafts.

Endoscopic delivery of calcium phosphate cement for secondary craniofacial reconstruction.

Contour defects are common following primary craniofacial procedures including cranial vault remodeling, fronto-orbital and midface advancements, and complex posttraumatic reconstructions. When onlayed as fast-setting pastes, calcium phosphate cements (CPCs) have been used to effectively correct contour defects in open secondary reconstruction procedures. Here, we describe an endoscopic procedure using an injectable CPC and compare surgical outcomes with the open technique. A retrospective review was conducted for 36 consecutive patients aged 3.0-28.9 years (mean, 10.1 years) who underwent secondary craniofacial reconstruction over a 3-year period. Patients were stratified into endoscopic or open groups depending on the surgical approach utilized. Mean operative time was significantly shorter (P < 0.001) for the endoscopic group (64 minutes) than for the open group (131 minutes). Similarly, hospital stay was significantly shorter (P = 0.005) in the endoscopic group than in the open group. There was also a significant difference with respect to cost (P < 0.001), with the endoscopic approach resulting in a per-patient cost savings of $2208.05. In conclusion, endoscopic delivery of CPC appears to be a safe, efficacious, and cost-effective method of performing secondary craniofacial reconstruction, with the additional benefits of decreased operative time and shorter postoperative hospital stay when compared with an open procedure.

Vector control in internal midface distraction using temporary anchorage devices.

Le Fort III and monobloc distraction osteogenesis serve as the primary surgical treatment for children with severe midface hypoplasia. The orbital retrusion and class III malocclusion of patients with midface hypoplasia is best addressed with bodily advancement of the midface segment parallel to the cephalometric Frankfort horizontal plane. Use of internal distraction devices allows for advancement of the midface without extensive external hardware but comes at the cost of less vectorial control, resulting in a distraction vector that can cause a clockwise rotation of the entire midface or frontofacial component creating hollow appearing orbits. To counteract this clockwise rotation, we have developed a technique using orthodontic microimplants to anchor interarch class III relationship elastics. We report our experiences with this technique on a cadaveric model and as a case series of 17 patients who underwent midface distraction. A Le Fort III distraction procedure was carried out on a cadaver, and the orbital height was measured at 0-, 10-, and 20-mm distraction advancement with and without elastics in a class III relationship. Improvement of both subjective hollow appearance of the orbits and objective measurement of the orbital height with class III relationship elastics demonstrated the efficacy of class III relationship elastics in counteracting the clockwise rotation of the midface segment. A review of 17 patients with midface or frontofacial hypoplasia treated with Le Fort III or monobloc distraction with simultaneous microimplant anchored class III relationship elastics revealed correction of malocclusion and improved midface projection without significant increase in vertical height of the orbits.

Multifocal lipoblastoma of the face.

Lipoblastoma is a rare benign neoplasm found exclusively in the pediatric population that can occur anywhere in the body, most commonly seen in the extremities but also found in the face. We report an 8-month-old female subject who presented with multifocal soft tissue masses of the face. The diagnosis of lipoblastoma was made in 2 separate locations after surgical resection. Subsequent surgery was performed at the cheek site in an attempt to remove further mass, resulting in discovery of 2 other discrete tumors found to be lipoblastomas. Although the literature reports recurrence rates ranging from 14% to 27%, to our knowledge, aside from a case of Proteus syndrome, there are no known reports of multiple lipoblastomas in the literature. Presentation of the case, review of pertinent literature, and consideration of congenital infiltrative lipomatosis of the face follow.

Hypertrophic scarring in cleft lip repair: a comparison of incidence among ethnic groups.

BACKGROUND: Although hypertrophic scar (HTS) formation following cleft lip repair is relatively common, published rates vary widely, from 1% to nearly 50%. The risk factors associated with HTS formation in cleft patients are not well characterized. The primary aim of this retrospective study of 180 cleft lip repairs is to evaluate the frequency of postoperative HTS among various ethnic groups following cleft lip repair. METHODS: A retrospective chart view of patients undergoing primary cleft lip repair over a 16-year period (1990-2005) by the senior surgeon was performed. The primary outcome was the presence of HTS at 1 year postoperatively. Bivariate analysis and multivariable logistic regression were used to evaluate potential risk factors for HTS, including ethnicity, type and laterality of cleft, and gender. RESULTS: One hundred and eighty patients who underwent cleft lip repair were included in the study. The overall rate of postoperative HTS formation was 25%. Ethnicity alone was found to be an independent predictor of HTS formation. Caucasian patients had the lowest rate of HTS formation (11.8%) and were used as the reference group. HTS rates were significantly higher in the other ethnicities, 32.2% in Hispanic patients (odds ratio [OR]: 3.51; 95% confidence interval [CI]: 1.53-8.85), and 36.3% for Asian patients (OR 4.27; 95% CI: 1.36-13.70). Sex, cleft type, and cleft laterality were not associated with increased rates of HTS. CONCLUSIONS: Differences in ethnic makeup of respective patient populations may be a major factor influencing the wide variability of reported HTS rates. Consideration should be given to potential prophylactic treatments for HTS in susceptible ethnic populations.

Neonatal and infant mandibular distraction as an alternative to tracheostomy in severe obstructive sleep apnea.

CONTEXT: Surgical management for severe obstructive sleep apnea has been tracheostomy, which has significant morbidity. OBJECTIVE: To determine the efficacy of internal mandibular distraction in treating severe obstructive sleep apnea in infants and neonates. DESIGN: Retrospective review of medical records of 29 patients who underwent internal mandibular distraction for obstructive sleep apnea secondary to micrognathia. SETTING: Nonprofit, academic, pediatric medical center. PATIENTS: A total of 29 infants with obstructive sleep apnea were studied. Nine were included in the respiratory failure group requiring intubation prior to distraction surgery. The other 20 were included in the respiratory distress group and underwent preoperative polysomnography that assessed the severity of obstructive sleep apnea as measured by the apnea-hypopnea index. One patient expired following surgery; the remaining 28 underwent postoperative polysomnography determining their postoperative apnea-hypopnea index. INTERVENTIONS: Bilateral mandibular distraction with internal microdistractors. MAIN OUTCOME MEASURE: Improvement in the apnea-hypopnea index or extubation. RESULTS: The nine respiratory failure patients avoided tracheostomy and were successfully extubated postdistraction. Eight in this group had postoperative polysomnographies showing a mean apnea-hypopnea index of 3.13 (range, 0 to 13.9). All 20 patients in the respiratory distress group underwent polysomnography and showed improved apnea-hypopnea indices (p < .001). The mean pre-op apnea-hypopnea index was 39.7 (range, 4.5 to 177), and the mean post-op apnea-hypopnea index was 5.8 (range, 0 to 34). Average improvement in the apnea-hypopnea index was 33.9. The mean follow-up period was 18.7 months (1.6 to 45.2 months). CONCLUSIONS: Infants with micrognathia and obstructive sleep apnea may avoid tracheostomy and its inherent risks and complications by undergoing internal mandibular distraction, which is a viable alternative to tracheostomy.

Nasofrontal heterotopic ossification following lymphangioma resection.

Heterotopic ossification (HO) is the formation of mature lamellar bone in soft tissues. Heterotopic ossification can occur locally following surgical trauma, most commonly after total hip arthroplasty. Periosteal stripping, organizing hematoma, and extensive soft tissue dissection have been associated with subsequent HO. Craniomaxillofacial HO is rare and almost always associated with injury to the muscles of mastication. We present a report of biopsy-established HO of the cranium. An 18-month-old boy presented with a soft, compressible mass in the forehead midline, which did not extend intracranially on computed tomography scan. Surgical exploration revealed a poorly marginated lymphangioma infiltrating the periosteum of the nasofrontal region. This was debulked to restore nasofrontal contour. Two months postoperatively, after minor accidental trauma, the patient developed a subperiosteal hematoma that was evacuated in the clinic. Eight months postoperatively, the patient returned with a visible nasofrontal prominence overlying a firm immobile mass. Computed tomography scan revealed a 3-cm horn-like osseous structure extending inferiorly from the frontal bone across the nasofrontal junction. The bony mass was resected via a coronal approach and confirmed as HO with hematopoietically active marrow.