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1.
Cleft Palate Craniofac J ; 60(6): 768-772, 2023 06.
Article in English | MEDLINE | ID: mdl-35195470

ABSTRACT

Despite a greater awareness of the differential diagnosis of head shape abnormalities among pediatricians, the effect of deformational forces on calvarial morphology can complicate the diagnosis of craniosynostosis. In this report, we describe 2 patients diagnosed with unicoronal craniosynostosis (UCS) in a delayed fashion due to the presence of concomitant posterior deformational plagiocephaly (PDP). In both cases, the severity of each patients' PDP obscured changes typically associated with UCS. This unique presentation underscores the importance of having a high index of suspicion for possible premature suture fusion despite the presence of concomitant PDP.


Subject(s)
Craniosynostoses , Jaw Abnormalities , Plagiocephaly, Nonsynostotic , Humans , Infant , Plagiocephaly, Nonsynostotic/diagnostic imaging , Craniosynostoses/complications , Craniosynostoses/diagnostic imaging , Facial Bones , Tomography, X-Ray Computed , Diagnosis, Differential
2.
Aesthetic Plast Surg ; 44(2): 595-603, 2020 04.
Article in English | MEDLINE | ID: mdl-31907588

ABSTRACT

BACKGROUND: The rates of opioid abuse and overdose in America have risen in parallel with the rates of opioid prescribing by physicians. As such, we sought to examine the prescribing practices among plastic surgery attendings and trainees to determine the need for more thorough education. METHODS: A survey was distributed to all ACGME-accredited plastic surgery residency programs and included questions regarding opioid-prescribing practices and self-rated ability pertaining to opioid management. Trends in prescribing practices based on prescriber position were analyzed using cumulative odds ordinal logistic regression with proportional odds and Chi-squared tests for ordinal and nominal variables, respectively. RESULTS: We received 78 responses with a wide geographical representation from plastic surgery residency programs: 59% of respondents were male and 39.7% female, 29.5% were attendings, 26.9% senior residents, 29.5% junior residents, and 14.1% interns. Compared with attendings, interns prescribe fewer pills (p < 0.05) and were significantly more likely to prescribe oxycodone (p < 0.03). Junior residents were 4.49 times more likely (p = 0.012) and senior residents 3.65 times more likely (p = 0.029) to prescribe additional opioids to avoid phone calls and follow-up visits. Interns and senior residents were significantly less comfortable than attendings in managing patients requesting additional opioids (p < 0.02). CONCLUSIONS: The results of this survey demonstrate that knowledge deficits do exist among trainees, and that trainees are significantly less comfortable than their attending counterparts with opioid prescribing and patient management. Therefore, the implementation of a thorough postoperative pain management education in residency may be a cogent strategy in mitigating the opioid crisis. 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.


Subject(s)
Internship and Residency , Surgery, Plastic , Analgesics, Opioid/therapeutic use , Drug Prescriptions , Female , Humans , Male , Pain, Postoperative/drug therapy , Pain, Postoperative/prevention & control , Practice Patterns, Physicians' , Surgery, Plastic/education
3.
Aesthetic Plast Surg ; 43(6): 1570-1574, 2019 12.
Article in English | MEDLINE | ID: mdl-31598767

ABSTRACT

BACKGROUND: The obese population has a higher incidence of mood disorders compared to individuals with normal body mass index (BMI). A better understanding of the unique psychosocial challenges faced by this patient population will allow physicians to better optimize patient psychosocial support systems perioperatively, as well as help the patient to maintain appropriate expectations. METHODS: A large, retrospective database of 1135 patients with greater than 50 pounds of weight loss was reviewed. Data were analyzed using a multinomial regression model to determine the influence of psychosocial factors on the incidence of depression and anxiety. RESULTS: Prior to massive weight loss, patients reported an overall incidence of depression and anxiety of 42.5% and 26.3%, respectively. Following massive weight loss, the incidence of depression decreased to 32.3% and the incidence of anxiety decreased to 22.0%. Patients with spousal support and with positive self-image were more likely to experience resolution of depression. Patients with positive self-image were likely to experience resolution of anxiety. Resolution of medical comorbidities correlated with a decrease in the rate of depression. CONCLUSION: Depression and anxiety are prevalent in the massive weight loss patient population undergoing body contouring surgery. Support systems are a vital resource for patients with psychological comorbidities undergoing massive weight loss. Patients who have a positive self-image of themselves are more likely to experience resolution of psychological comorbidities. Physicians should consider recommending support groups and/or counseling in patients who have poor support and negative self-image. 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.


Subject(s)
Anxiety/complications , Anxiety/epidemiology , Depression/complications , Depression/epidemiology , Obesity, Morbid/complications , Weight Loss , Adolescent , Adult , Aged , Aged, 80 and over , Body Contouring/psychology , Databases, Factual , Female , Humans , Incidence , Male , Middle Aged , Obesity, Morbid/psychology , Retrospective Studies , Young Adult
5.
J Pediatr Orthop ; 36(5): 505-10, 2016.
Article in English | MEDLINE | ID: mdl-25929775

ABSTRACT

BACKGROUND: Although a plethora of literature exists on the impact of body mass index (BMI) in orthopaedic surgery, few have examined its implications in the pediatric cerebral palsy (CP) population. The aim of this study is to evaluate the effect of BMI class on 30-day complications after orthopaedic surgery on children with CP. METHODS: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric participant use files from 2012 to 2013 was conducted. Patients with a diagnosis of CP undergoing any orthopaedic procedure were included and subclassified according to BMI classes: underweight, normal weight, overweight, and obese. Multivariate logistic regressions were performed to evaluate the independent effect of BMI class on total, surgical site, and medical complications as well as unplanned reoperations. RESULTS: A total of 1746 patients were included in our study. These included 345 (19.8%) underweight, 952 (54.5%) normal weight, 209 (12.8%) overweight, and 240 (13.7%) obese children and adolescents. In hip and lower extremity osteotomies, underweight class was an independent risk factor for total complications (P=0.037) and medical complications (P=0.031). Similarly, underweight class was a risk factor for total complications (P=0.022) and medical complications (P=0.019) in spine procedures. Weight class was not independently associated with complications in tendon procedures. Overweight and obesity classes were not associated with any independent increased risk for complications. CONCLUSIONS: With respect to the pediatric CP population, underweight status was deemed an independent predictor of increased complications in osteotomies and spine surgery with no independent increased risk in the overweight or obese cohorts. This information can greatly aid providers with risk stratification, preoperative counseling, and postoperative monitoring as it relates to orthopaedic surgery. LEVEL OF EVIDENCE: Level III-Prognostic.


Subject(s)
Cerebral Palsy/epidemiology , Obesity/epidemiology , Orthopedic Procedures , Postoperative Complications/epidemiology , Thinness/epidemiology , Adolescent , Body Mass Index , Body Weight , Cerebral Palsy/surgery , Child , Comorbidity , Female , Humans , Logistic Models , Male , Middle Aged , Multivariate Analysis , Osteotomy , Overweight/epidemiology , Postoperative Period , Prognosis , Quality Improvement , Retrospective Studies , Risk Factors
6.
J Pediatr Orthop ; 36(2): 187-92, 2016 Mar.
Article in English | MEDLINE | ID: mdl-25730378

ABSTRACT

BACKGROUND: Pediatric scoliosis often requires operative treatment, yet few studies have examined readmission rates in this patient population. The purpose of this study is to examine the incidence, reasons, and independent risk factors for 30-day unplanned readmissions following scoliosis surgery. METHODS: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement-Pediatric database from 2012 to 2013 was performed. Patients undergoing spinal arthrodesis for progressive infantile scoliosis, idiopathic scoliosis, or scoliosis due to other medical conditions were identified and divided between 2 groups: patients with unplanned 30-day readmissions (Readmitted) and patients with no unplanned readmissions (Non-Readmitted). Multivariate logistic regression models were created to determine independent risk factors for readmissions. RESULTS: A total of 3482 children were identified, of which 120 (3.4%) had an unplanned readmission. A majority of patients had a readmission due to a surgical site complication regardless of scoliosis etiology. Risk factors for readmission included obesity (P<0.001) and posterior fusion of 13 or more vertebrae (P=0.029) for idiopathic scoliosis, impaired cognition (P=0.009) for progressive infantile scoliosis, and pelvic fixation (P=0.025) and American Society of Anesthesiologist ≥3 (P=0.048) for scoliosis due to other conditions. CONCLUSIONS: We present 30-day readmissions risk factors based on independent patient and procedural risk factors. This may be useful in the clinical management of patients following scoliosis surgery, specifically for the role of preoperative and predischarge risk stratification.


Subject(s)
Patient Readmission/statistics & numerical data , Scoliosis/surgery , Spinal Fusion , Adolescent , Child , Child, Preschool , Cognitive Dysfunction/epidemiology , Databases, Factual , Disease Progression , Female , Humans , Length of Stay/statistics & numerical data , Male , Multivariate Analysis , Neuromuscular Diseases/epidemiology , Obesity/epidemiology , Operative Time , Pelvic Bones/surgery , Postoperative Complications/epidemiology , Respiration, Artificial/statistics & numerical data , Retrospective Studies , Risk Factors , Seizures/epidemiology , United States/epidemiology
7.
J Arthroplasty ; 30(4): 600-6, 2015 Apr.
Article in English | MEDLINE | ID: mdl-25680446

ABSTRACT

A prospective comparison of 148 hips in 139 consecutive patients treated with an off-the-shelf uncemented metaphyseal engaging (91-105 mm) stem and 69 hips in 61 patients treated with a custom uncemented metaphyseal engaging short stem was conducted to evaluate the mid-term clinical and radiographic results of an off-the-shelf metaphyseal-engaging short stem implant. All implants were radiographically stable with proximal bony in-growth. There was no significant difference in post-operative HHS (P <. 001) or WOMAC scores (P < .001) between cohorts. An off-the-shelf short femoral stem designed to fit and fill the metaphysis provides reliable fixation up to eight years with equivalent clinical and radiographic results to a customized implant.


Subject(s)
Arthroplasty, Replacement, Hip/instrumentation , Femur/surgery , Prosthesis Design , Adult , Aged , Arthroplasty, Replacement, Hip/methods , Bone Remodeling , Case-Control Studies , Equipment Design , Female , Follow-Up Studies , Hip Prosthesis , Humans , Male , Middle Aged , Prospective Studies , Treatment Outcome
8.
Plast Reconstr Surg ; 153(3): 584e-596e, 2024 Mar 01.
Article in English | MEDLINE | ID: mdl-37257128

ABSTRACT

BACKGROUND: The Boston Carpal Tunnel Questionnaire (BCTQ) is a validated measurement tool to assess the severity of carpal tunnel syndrome, and improvements in the BCTQ after carpal tunnel release (CTR) have been demonstrated to influence patient satisfaction. The authors hypothesized that patient-related factors influence response in BCTQ subscales, including the Symptom Severity Scale and the Functional Status Scale, after CTR. METHODS: Patients who underwent surgery with follow-up BCTQ were identified from a prospectively maintained database. Paired t tests were used to compare BCTQ subscales at each follow-up time point. Minimal clinically important differences were set. Patients below these thresholds were deemed as having failure to improve after CTR. Univariate analysis was used to identify risk factors for failure to improve after CTR. Multivariate logistic regression was used to identify independent predictors for failure to improve after CTR. RESULTS: A total of 106 patients met inclusion criteria. Patients demonstrated significant improvements at all follow-up time points. The factor most associated with improvement beyond the minimal clinically important differences was a more severe score in the respective domain assessed. Other independent factors that influenced outcome after CTR included race, concomitant cubital tunnel release, sex, and age. CONCLUSIONS: CTR results in significant improvements in BCTQ and its subscales, with improvements stabilizing after 6 weeks. In a select cohort of patients, failure to improve after CTR occurs with factors independently associated with a lower degree of improvement. Identification of patients with these risk factors will provide a basis for counseling and increased monitoring of patients at risk for a guarded prognosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.


Subject(s)
Carpal Tunnel Syndrome , Humans , Carpal Tunnel Syndrome/surgery , Carpal Tunnel Syndrome/complications , Logistic Models , Patient Satisfaction , Wrist , Surveys and Questionnaires
9.
J Neurol Surg B Skull Base ; 84(3): 225-231, 2023 Jun.
Article in English | MEDLINE | ID: mdl-37180865

ABSTRACT

Objective The endoscopic endonasal approach (EEA) is commonly employed in skull base surgery for neoplasm resection. While nasal deformity following EEA is described, this study aimed to perform a detailed qualitative and quantitative assessment of the associated saddle nose deformity (SND) in particular. Setting/Participants This is a retrospective review of 20 adult patients with SND after EEA for resection of skull base tumors over a 5-year period at the University of Pittsburgh Medical Center. Main Outcome Measures Fifteen measurements related to SND were obtained on pre- and postoperative imaging. Statistical analyses were performed to evaluate differences between pre- and postoperative anatomies. Results The most common EEA was transsellar. Reconstruction techniques included nine free mucosal grafts alone, eight vascularized nasoseptal flaps (NSFs), one combined free mucosal graft/abdominal fat graft, and one combined NSF/fascia lata graft. Imaging analysis showed a trend toward loss of mean nasal height, nasal tip projection, and nasolabial angle postoperatively. Subgroup analysis showed that patients with NSF reconstruction had a significantly decreased nasal tip projection (1.2 mm, p = 0.039) and increased alar base width (1.2 mm, p = 0.046) postoperatively. Patients without functional pituitary microadenomas demonstrated significantly increased nasofrontal angle and decreased nasal tip projection on postoperative imaging, in contrast to those with functional adenomas who had no measurable significant changes. Conclusion Clinically evident SND does not always lead to significant radiographic changes. This analysis suggests that patients who undergo surgery for indications other than functional pituitary microadenomas or who receive NSF reconstruction develop more marked SND on standard imaging tests.

10.
Plast Reconstr Surg ; 152(2): 375-382, 2023 08 01.
Article in English | MEDLINE | ID: mdl-36912921

ABSTRACT

BACKGROUND: Basal joint arthritis is a common form of osteoarthritis. There is no consensus procedure for maintenance of trapezial height following trapeziectomy. Suture-only suspension arthroplasty (SSA) is a simple method for stabilizing the thumb metacarpal following trapeziectomy. METHODS: This single-institution, prospective, cohort study compares trapeziectomy followed by either ligament reconstruction with tendon interposition (LRTI) or SSA for the treatment of basal joint arthritis. Patients underwent LRTI or SSA from May of 2018 to December of 2019. Visual analogue scale pain scores; Disabilities of the Arm, Shoulder and Hand questionnaire functional scores; clinical thumb range of motion, pinch, and grip strength data; and patient-reported outcomes were recorded and analyzed preoperatively and at 6 weeks and 6 months postoperatively. RESULTS: Total number of study participants was 45 (LRTI, n = 26; SSA, n = 19). Mean ± SE age was 62.4 ± 1.5 years; 71% were female patients; and 51% underwent surgery on the dominant side. Visual analogue scale scores improved for LRTI and SSA ( P < 0.0001) over 6 months, with no differences between groups at any time point ( P > 0.3). Disabilities of the Arm, Shoulder and Hand questionnaire scores improved for LRTI and SSA over 6 months ( P < 0.0001), with no differences between groups at any time point ( P > 0.3). Following SSA, opposition improved ( P = 0.02), but not as well for LRTI ( P = 0.16). Grip and pinch strength decreased following LRTI and SSA at 6 weeks but recovered similarly for both groups over 6 months. Patient-reported outcomes were generally no different between groups at all time points. CONCLUSION: LRTI and SSA are similar procedures following trapeziectomy relative to pain, function, and strength recovery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.


Subject(s)
Carpometacarpal Joints , Osteoarthritis , Trapezium Bone , Humans , Female , Middle Aged , Male , Prospective Studies , Cohort Studies , Arthroplasty/methods , Osteoarthritis/surgery , Ligaments/surgery , Tendons/surgery , Thumb/surgery , Trapezium Bone/surgery , Sutures , Carpometacarpal Joints/surgery , Range of Motion, Articular
11.
Plast Reconstr Surg Glob Open ; 9(4): e3546, 2021 Apr.
Article in English | MEDLINE | ID: mdl-33912370

ABSTRACT

Bowel vaginoplasty is a well-described procedure utilizing a pedicled segment of large or small bowel. It has most commonly been used for vaginal agenesis, male-to-female gender affirmation surgery when the phallus skin is not sufficient, or a revision after failure of the primary reconstruction. Our case report describes the usage of a pedicled segment of large bowel to reconstruct the vagina after severe stricture of the original reconstruction. We were able to provide relief of the symptomatic Hartmann's pouch mucocele, urethral stricture, and provide a functional introitus and vaginal canal. This technique can provide a framework that can be used as a salvage plan in patients with previously irritated and inhospitable defects.

12.
Plast Reconstr Surg ; 144(5): 1150-1157, 2019 11.
Article in English | MEDLINE | ID: mdl-31688762

ABSTRACT

BACKGROUND: The present study examined risk factors associated with 30-day palatoplasty complications based on analysis of national data. METHODS: Primary palatoplasties were identified in the 2012 to 2015 Pediatric National Surgical Quality Improvement Program database. Cases were analyzed with multivariate regression to investigate predictors for wound healing complications, additional ventilation requirement, prolonged stay (>3 days), and readmission. RESULTS: In 3616 operations, mean age was 12.2 months and operative time was 135.4 minutes. The 30-day complication rate was 7.6 percent overall, including wound dehiscence/infection (3.4 percent), additional ventilation requirement (2.0 percent), and readmission (2.4 percent); 5.1 percent of patients required prolonged stays. Wound healing complications were not predicted by comorbidities. American Society of Anesthesiologists class 3 or greater (OR, 2.8; p = 0.033), neuromuscular disorder (OR, 3.5; p = 0.029), and nutritional support (OR, 2.9; p = 0.035) predicted additional ventilation requirement. Prolonged stays were predicted by requiring additional ventilation (OR, 14.7; p < 0.001) or American Society of Anesthesiologists class 3 or greater (OR, 1.8; p = 0.047), but preoperative ventilator dependence was protective (OR, 0.1; p = 0.012). Mean hospital stay was 1.6 days without an airway complication versus 5.0 days with. Readmissions were increased for patients requiring nutritional support (OR, 2.6; p = 0.025). CONCLUSIONS: This study represents one of the largest cohorts of palatoplasty patients analyzed to date. It identifies what can be learned from a nonspecific 30-day registry regarding cleft outcomes and, from its limitations, discusses what the future of cleft outcomes research might entail. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.


Subject(s)
Cleft Palate/surgery , Patient Readmission/statistics & numerical data , Plastic Surgery Procedures/adverse effects , Respiration, Artificial/methods , Surgical Wound Infection/diagnosis , Cleft Palate/diagnosis , Cohort Studies , Databases, Factual , Factor Analysis, Statistical , Female , Follow-Up Studies , Humans , Infant , Length of Stay , Logistic Models , Male , Multivariate Analysis , Palate, Hard/surgery , Palate, Soft/surgery , Plastic Surgery Procedures/methods , Reoperation/methods , Retrospective Studies , Risk Assessment , Surgical Wound Infection/therapy , Treatment Outcome
13.
Plast Reconstr Surg ; 143(2): 425e-432e, 2019 02.
Article in English | MEDLINE | ID: mdl-30531632

ABSTRACT

BACKGROUND: The Plastic Surgery Milestones Project was jointly conceived by the Accreditation Council for Graduate Medical Education and the American Board of Plastic Surgery as a tool to improve granularity in resident feedback. Resident self-evaluations were compared to attending clinical competency committee evaluations to gauge resident self-perceptions and understanding of the milestones framework. METHODS: Semiannual evaluations from June of 2014 to 2017 were analyzed and compared with corresponding resident self-evaluations from the 2015 to 2017 academic year at the University of Pittsburgh Medical Center. Evaluations were analyzed for overall trends in performance. The presence of systemic differences between each type of evaluation were determined using Student's t tests. Subgroup analysis using the chi-square test was performed to determine factors that may contribute to major assessment disparity (≥1). RESULTS: Six thousand two hundred seven milestones across 187 faculty evaluations and 3139 milestones across 106 resident self-evaluations were available for review. With the exception of postgraduate year-2 residents, residents rated themselves at a significantly lower level in the competencies of medical education and patient care. Postgraduate year, academic year timing, and Accreditation Council for Graduate Medical Education competency were associated with major assessment discrepancies. CONCLUSIONS: Overall, resident and faculty evaluations at the authors' program were concordant, which demonstrates that residents are capable of accurately assessing their own abilities and understanding the milestones framework. Areas of discordance between resident and faculty evaluations fostered discussion between residents and faculty and have led to multiple changes in the authors' program. The introduction of self-evaluation tools at other programs may provide them with similar benefits.


Subject(s)
Clinical Competence , Education, Medical, Graduate/organization & administration , Educational Measurement , Surgery, Plastic/education , Academic Medical Centers , Competency-Based Education/methods , Female , Humans , Internship and Residency/organization & administration , Male , Medical Staff, Hospital/organization & administration , Pennsylvania , Program Evaluation , Self-Assessment , Surgery, Plastic/organization & administration
14.
Plast Reconstr Surg ; 141(4): 892-901, 2018 04.
Article in English | MEDLINE | ID: mdl-29256998

ABSTRACT

BACKGROUND: Combining liposuction and abdominoplasty is controversial because of concerns for increased complications and potential for vascular compromise of the abdominoplasty flap. Also, the lipoaspirate volume in abdominoplasty is regulated in some areas to as little as 500 ml when performed with abdominoplasty. This study measures abdominoplasty complication rates when performed with and without trunk liposuction, and evaluates the effect of lipoaspirate volume on complications. METHODS: Abdominoplasty and liposuction of the trunk procedures were identified in the Tracking Operations and Outcomes for Plastic Surgeons database. Multivariate regression models determined the effect of liposuction with abdominoplasty on complications compared with abdominoplasty alone and determined the effect of liposuction volume on complications. RESULTS: Eleven thousand one hundred ninety-one patients were identified: 9638 (86.1 percent) having abdominoplasty with truncal liposuction and 1553 (13.9 percent) having abdominoplasty alone. Overall complication rates were 10.5 percent and 13.0 percent, respectively. Combined liposuction and abdominoplasty was independently associated with a reduced risk of both overall complications (p = 0.046) and seroma (p = 0.030). Given existing laws limiting liposuction volume to 500 or 1000 ml in combination with abdominoplasty, each of these thresholds was evaluated, with no effect on complications. Surprisingly, increasing liposuction volume was not independently associated with an increased risk of any complication. CONCLUSIONS: When done by board-certified plastic surgeons, abdominoplasty with truncal liposuction is safe, with fewer complications than abdominoplasty alone. Regulations governing liposuction volumes in abdominoplasty are arbitrary and do not reflect valid thresholds for increased complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.


Subject(s)
Abdominoplasty/methods , Lipectomy/methods , Postoperative Complications/etiology , Abdominoplasty/adverse effects , Adult , Aged , Databases, Factual , Female , Humans , Lipectomy/adverse effects , Logistic Models , Male , Middle Aged , Postoperative Complications/epidemiology , Retrospective Studies , Risk Assessment , Risk Factors
15.
Plast Reconstr Surg ; 142(5): 1349-1352, 2018 11.
Article in English | MEDLINE | ID: mdl-30511990

ABSTRACT

Soft-tissue deficits in amputation stumps can lead to significant pain and disability. An emerging treatment option is stem cell-enriched fat grafting. This is the first study assessing the potential for this treatment modality in lower extremity amputation sites. In this prospective cohort study, five injured military personnel suffering from pain and limited function at amputation sites were recruited. Fat grafting enriched with stromal vascular fraction was performed at amputation sites to provide additional subcutaneous tissue padding over bony structures. Outcomes measures included complications, demographic data, physical examination, cellular subpopulations, cell viability, graft volume retention, pain, Lower Extremity Functional Scale, Functional Mobility Assessment, 36-Item Short-Form Health Survey, and rates of depression. Follow-up was 2 years. There were no significant complications. Volume retention was 61.5 ± 24.0 percent. Overall cell viability of the stromal vascular fraction was significantly correlated with volume retention (p = 0.016). There was no significant correlation between percentage of adipose-derived stem cells or number of cells in the stromal vascular fraction and volume retention. There was a nonsignificant trend toward improvement in pain scores (3.0 ± 2.5 to 1.2 ± 1.6; p = 0.180 at 2 years). There were no significant changes in disability indexes. Results from this pilot study demonstrate that stromal vascular fraction-enriched fat grafting is a safe, novel modality for the treatment of symptomatic soft-tissue defects in traumatic lower extremity amputations. Volume retention can be anticipated at slightly over 60 percent. Further studies are needed to assess efficacy. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.


Subject(s)
Adipose Tissue/transplantation , Soft Tissue Injuries/therapy , Stem Cell Transplantation/methods , Stromal Cells/transplantation , Adipocytes/transplantation , Amputation Stumps , Blast Injuries/surgery , Humans , Leg Injuries/surgery , Military Personnel , Operative Time , Pain, Postoperative/prevention & control , Pennsylvania , Pilot Projects , Prospective Studies
16.
Sci Transl Med ; 9(418)2017 Nov 29.
Article in English | MEDLINE | ID: mdl-29187641

ABSTRACT

Arginine vasopressin (AVP) made by hypothalamic neurons is released into the circulation to stimulate water resorption by the kidneys and restore water balance after blood loss. Patients who lack this antidiuretic hormone suffer from central diabetes insipidus. We observed that many of these patients were anemic and asked whether AVP might play a role in red blood cell (RBC) production. We found that all three AVP receptors are expressed in human and mouse hematopoietic stem and progenitor cells. The AVPR1B appears to play the most important role in regulating erythropoiesis in both human and mouse cells. AVP increases phosphorylation of signal transducer and activator of transcription 5, as erythropoietin (EPO) does. After sublethal irradiation, AVP-deficient Brattleboro rats showed delayed recovery of RBC numbers compared to control rats. In mouse models of anemia (induced by bleeding, irradiation, or increased destruction of circulating RBCs), AVP increased the number of circulating RBCs independently of EPO. In these models, AVP appears to jump-start peripheral blood cell replenishment until EPO can take over. We suggest that specific AVPR1B agonists might be used to induce fast RBC production after bleeding, drug toxicity, or chemotherapy.


Subject(s)
Anemia/metabolism , Vasopressins/metabolism , Vasopressins/pharmacology , Animals , Cell Differentiation/drug effects , Cell Proliferation/drug effects , Erythrocytes/cytology , Erythrocytes/drug effects , Humans , Mice , Rats , Receptors, Vasopressin/metabolism
17.
Plast Reconstr Surg ; 138(3): 670-679, 2016 Sep.
Article in English | MEDLINE | ID: mdl-27556606

ABSTRACT

BACKGROUND: Cleft lip represents one of the most common birth defects in the world. Although the timing of cleft lip repair is contingent on a number of factors, the "rule of 10s" remains a frequently quoted safety benchmark. Initially reported by Wilhelmsen and Musgrave in 1966 and modified by Millard in 1976, this rule referred to performing surgery once patients had reached cutoffs in weight, hemoglobin, and age/leukocyte count. Despite significant advances in both surgical and anesthetic technique, the oft-quoted "rule of 10s" has not been systematically investigated since its inception. METHODS: Patients who underwent primary cleft lip repair were identified from the National Surgical Quality Improvement Program Pediatric database. Multivariate logistic regression models were used to determine the independent effect of each rule of 10 metric or violation of the rule of 10s as a whole on postoperative complications, and to determine independent risk factors for complications in cleft lip surgery. RESULTS: One thousand three hundred thirteen patients met inclusion criteria, with a 3.6 percent complication rate. Of the included patients, 151 (11.5 percent) violated at least one facet of the rule of 10s. Other than patient weight, neither the rule of 10s nor any individual metric was significantly predictive of postoperative complications. CONCLUSIONS: Since its introduction nearly a half century ago, the risks associated with performing surgery in patients who violate the rule of 10s has undergone dramatic reductions. This analysis highlights the need to continually validate and evaluate dogma as the field continues to advance. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.


Subject(s)
Cleft Lip/surgery , Female , Humans , Infant , Male , Postoperative Complications , Risk Factors
18.
Plast Reconstr Surg ; 136(6): 1249-1260, 2015 Dec.
Article in English | MEDLINE | ID: mdl-26267397

ABSTRACT

BACKGROUND: Most cranial vault remodeling for craniosynostosis is associated with substantial blood loss necessitating transfusion. The transfusion of over 25 ml/kg of red blood cells has long been considered an important safety threshold and has been proposed as a potential marker of health care quality, despite a lack of evidence. The authors sought to ascertain risk factors for transfusion in cranial vault remodeling and to quantify the effect of transfusion volume on postoperative complications. METHODS: Patients who underwent complex cranial vault remodeling for craniosynostosis were identified from the Pediatric National Surgical Quality Improvement Program database. Multivariate regression models were used to identify independent risk factors for transfusion and to assess its impact on subsequent outcomes. RESULTS: One thousand fifty-nine patients met inclusion criteria. Seven hundred seventy-seven patients (73.4 percent) required a transfusion and 520 patients (49.1 percent) required a transfusion in excess of 25 ml/kg. Neither transfusion nor transfusion volume in excess of 25 ml/kg had a significant effect on postoperative outcomes. Therefore, the authors sought to determine a more meaningful threshold. The top 20 percent of transfusion volumes were greater than or equal to 45.28 ml/kg. Recursive partitioning generated a threshold of 62.52 ml/kg, which independently predicted a greater number of complications and was associated with higher odds ratios than the quintile method. A threshold of 60 ml/kg was chosen for simplicity and was independently predictive of overall complications, medical complications, and increased length of stay. CONCLUSIONS: Transfusion is common in complex cranial vault remodeling. Currently described occurrence thresholds do not accurately convey postoperative risk. Transfusion in excess of 60 ml/kg significantly increases risk for complications and length of stay in cranial vault remodeling.


Subject(s)
Blood Loss, Surgical/statistics & numerical data , Blood Transfusion/statistics & numerical data , Craniosynostoses/surgery , Skull/surgery , Child, Preschool , Female , Humans , Infant , Male , Models, Statistical , Quality Improvement , Retrospective Studies , Risk Assessment , Risk Factors , Time Factors
19.
Spine (Phila Pa 1976) ; 40(18): 1422-30, 2015 Sep 15.
Article in English | MEDLINE | ID: mdl-26076438

ABSTRACT

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine predictors of and 30-day complications associated with blood transfusion volume after posterior spinal fusion for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Posterior arthrodesis is a common procedure performed for AIS, and patients frequently require perioperative blood transfusions. Few studies, however, have examined the rates and potential complications associated with blood transfusion volume. METHODS: Patients undergoing posterior arthrodesis for AIS were selected from the National Surgical Quality Improvement Program pediatric database from 2012 to 2013. Patients were stratified on the basis of blood transfusion volume and patient demographics and comorbidities, operative characteristics, and 30-day complications were recorded. Multivariate analyses were performed to determine predictors of transfusion as well as the effect of transfusion volume on 30-day complication rates. RESULTS: A total of 1691 patients were included. Male sex (P = 0.010), esophageal or gastrointestinal disease (P = 0.016), cardiac risk factors (P = 0.037), preoperative inotrope requirement (P = 0.031), total operative time of 300 minutes or more (P < 0.001), and posterior arthrodesis of 13 or more vertebral segments (P < 0.001) were independent risk factors for requiring blood transfusion. Total transfusion volume of 20 mL/kg or more was the minimum volume independently associated with increased rates of total complications (P = 0.018), with a complication rate of 5.9%. CONCLUSION: We present the first large, comprehensive analysis of complications related to blood transfusion events and transfusion volume on short-term postoperative complications after posterior arthrodesis for AIS. Although transfusion in general is not associated with 30-day adverse events, a volume of 20 mL/kg was associated with higher complication rates. LEVEL OF EVIDENCE: 4.


Subject(s)
Blood Loss, Surgical/prevention & control , Scoliosis/surgery , Spinal Fusion/adverse effects , Transfusion Reaction , Adolescent , Age Factors , Blood Loss, Surgical/mortality , Blood Transfusion/mortality , Chi-Square Distribution , Child , Databases, Factual , Female , Humans , Male , Multivariate Analysis , Odds Ratio , Retrospective Studies , Risk Factors , Scoliosis/diagnosis , Scoliosis/mortality , Scoliosis/physiopathology , Spinal Fusion/mortality , Time Factors , Treatment Outcome , United States
20.
Breast Dis ; 35(4): 221-31, 2015.
Article in English | MEDLINE | ID: mdl-26397768

ABSTRACT

BACKGROUND: Recent healthcare legislation has made unplanned hospital readmission an important metric of health care quality, and current efforts center on reducing this complication in order to avoid fiduciary penalties. OBJECTIVE: There is currently a paucity of data delineating risk factors for readmission following mastectomy. To this end, we sought to develop a predictive model of unplanned readmissions following mastectomy. METHODS: The 2011 and 2012 National Surgical Quality Improvement Program (NSQIP) datasets were retrospectively queried to identify patients who underwent mastectomy. Multivariate logistic regression modeling was used to identify risk factors for readmission. RESULTS: Of 21,271 patients meeting inclusion criteria, 1,190 (5.59%) were readmitted. The most commonly cited reasons for readmission included surgical site complications (32.85%), infection not localized to the surgical site (2.72%), and venous thromboembolism (4.39%). Independent predictors of readmission included BMI, active smoking status, and skin-sparing mastectomy. Significantly, concurrent breast reconstruction and bilateral mastectomy were not independent predictors of readmission. CONCLUSIONS: This is the first study of readmission rates after mastectomy. Awareness of specific risk factors for readmission, particularly those that are modifiable, may serve to identify and manage high risk patients, aid in the development of pre- and postoperative clinical care guidelines, and ultimately improve patient care.


Subject(s)
Mastectomy/adverse effects , Mastectomy/statistics & numerical data , Patient Readmission/statistics & numerical data , Surgical Wound Infection/etiology , Venous Thromboembolism/etiology , Adult , Aged , Area Under Curve , Body Mass Index , Female , Forecasting/methods , Humans , Logistic Models , Middle Aged , Multivariate Analysis , Organ Sparing Treatments/adverse effects , Organ Sparing Treatments/statistics & numerical data , ROC Curve , Retrospective Studies , Risk Factors , Smoking , Time Factors
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