Reducing Chronic Opioid Use: Long-term Impacts of Enhanced Recovery after Mastectomy Protocols.

OBJECTIVE: This study investigates Enhanced Recovery After Surgery (ERAS®) protocols' impact on long-term opioid and sedative use following mastectomy with or without implant-based breast reconstruction (IBBR). SUMMARY BACKGROUND DATA: ERAS® protocols for patients undergoing mastectomy with or without IBBR are associated with decreased length of stay, increased rate of same-day discharge, decreased postoperative pain, and decreased postoperative opioid requirements. However, less is known about their effect on opioid and sedative use beyond 90 days after surgery. METHODS: A retrospective review of all patients undergoing mastectomy with or without IBBR at a single institution between January 2013 and December 2019. Mastectomy ERAS® protocols were implemented in February 2017, creating two groups: pre-ERAS® and ERAS®. Baseline characteristics and prevalence of chronic opioid and sedative use were compared. Univariable and multivariable logistic regression predicted factors associated with increased odds of chronic opioid and sedative use. RESULTS: 756 patients were evaluated: 405 pre-ERAS® and 351 ERAS®. Post-ERAS®, chronic opioid use decreased in opioid-naïve (40% vs. 30%, P=0.024) and opioid-tolerant patients (58% vs. 37%, P=0.002), with no increase in chronic sedative use. There were decreased odds of chronic opioid use for all ERAS® patients (OR=0.57, 95% CI: 0.42-0.76)), and of IBBR patients, those receiving subcutaneous implants (OR=0.31, 95% CI: 0.20-0.48). There was increased chronic opioid-use odds if undergoing bilateral surgery (OR=1.54, 95% CI: 1.14-2.08), two-stage reconstruction (OR=9.78, 95% CI: 5.94-16.09), and for patients with higher PACU pain scores (OR=1.09, 95% CI: 1.03-1.14) or >150 discharge OMEs (OR=2.63, 95% CI: 1.48-4.68). CONCLUSION: ERAS® protocols for mastectomy patients with or without IBR are associated with decreases in chronic opioid use, without concomitant increases in chronic sedative use.

Factors influencing quality of life and functional status in head and neck cancer patients.

OBJECTIVE: To assess the quality of life (QoL) and functional status factors of patients at various stages of treatment for head and neck cancer. STUDY DESIGN: Cross-sectional survey study. SETTING: Outpatient. METHODS: Patients over the age of 18 who received care at the Markey Head and Neck Cancer Center Clinic since 2015 were invited to complete the survey. Survey items included: demographic information, characteristics of the patient's disease and treatments, as well as an 18-item survey assessing quality of life and functional status. A follow-up for each factor asked patients to rate how important it was to them. RESULTS: Patients reported greatest difficulties with physical activity (2.18), sleep (2.20), stress (2.26), and fatigue (2.26). Patients indicated that information (3.00), medication management (2.67), and sleep (2.62) were the most important. Multimodal therapy, marital status, and education level were all found to have statistically significant associations with several QoL measures. CONCLUSION: Quality of life and functional status in patients who have undergone treatment for head and neck cancer are both affected by many factors, particularly multimodal treatment, partner support, and education level. Identifying patients who may be more affected by treatment and targeting them with additional support and resources may lead to improved QoL in patients and their caregivers. This study would suggest that efforts to support physical activity, sleep, and stress management could lead to the most significant impact.

Impact of early surgical complications on kidney transplant outcomes.

BACKGROUND: Kidney transplantation (KT) improves clinical outcomes of patients with end stage renal disease. Little has been reported on the impact of early post-operative surgical complications (SC) on long-term clinical outcomes following KT. We sought to determine the impact of vascular complications, urological complications, surgical site complications, and peri-graft collections within 30 days of transplantation on patient survival, graft function, and hospital readmissions. METHODS: We conducted a single-centre, observational cohort study examining adult patients (≥ 18 years) who received a kidney transplant from living and deceased donors between January 1st, 2005 and December 31st, 2015 with follow-up until December 31st, 2016 (n = 1,334). Univariable and multivariable analyses were performed with Cox proportional hazards models to analyze the outcomes of SC in the early post-operative period after KT. RESULTS: The cumulative probability of SC within 30 days of transplant was 25%, the most common SC being peri-graft collections (66.8%). Multivariable analyses showed significant relationships between Clavien Grade 1 SC and death with graft function (HR 1.78 [95% CI: 1.11, 2.86]), and between Clavien Grades 3 to 4 and hospital readmissions (HR 1.95 [95% CI: 1.37, 2.77]). CONCLUSIONS: Early SC following KT are common and have a significant influence on long-term patient outcomes.

A review on the fate of micro and nano plastics (MNPs) and their implication in regulating nutrient cycling in constructed wetland systems.

This review discusses the micro-nano plastics (MNPs) and their interaction with physical, chemical and biological processes in a constructed wetland (CW) system that is typically used as a nature-based tertiary wastewater treatment for municipal as well as industrial applications. Individual components of the CW system such as substrate, microorganisms and plants were considered to assess how MNPs influence the CW processes. One of the main functions of a CW system is removal of nutrients like nitrogen (N) and phosphorus (P) and here we highlight the pathways through which the MNPs influence CW's efficacy of nutrient removal. The presence of morphologically (size and shape) and chemically different MNPs influence the growth rate of microorganisms important in N and P cycling, invertebrates, decomposers, and the plants which affect the overall efficiency of a CW treatment system. Certain plant species take up the MNPs, and some toxicity has been observed. This review focuses on two significant aspects: (1) the presence of MNPs in a significant concentration affects the efficiency of N and P removal, and (2) the removal of MNPs. Because MNPs reduce the enzyme activities in abundance and overproduction of ROS oxidizes the enzyme active sites, resulting in the depletion of proteins, ultimately inhibiting nitrogen and phosphorus removal within the substrate layer. The review found that the majority of the studies used sand-activated carbon (SAC), granular-activated carbon (GAC), rice straw, granular limestone, and calcium carbonate, as a substrate for CW treatment systems. Common plant species used in the CW include Phragmites, Arabidopsis thaliana, Lepidium sativum, Thalia dealbata, and Canna indica, which were also found to be dominant in the uptake of the MNPs in the CWs. The MNPs were found to affect earthworms such as Eisenia fetida, Caenorhabditis elegans, and, Enchytraeus crypticus, whereas Metaphire vulgaris were found unaffected. Though various mechanisms take place during the removal process, adsorption and uptake mechanism effectively emphasize the removal of MNPs and nitrogen and phosphorus in CW. The MNPs characteristics (type, size, and concentration) play a crucial role in the removal efficiency of nano-plastics (NPs) and micro-plastics (MPs). The enhanced removal efficiency of NPs compared to MPs can be attributed to their smaller size, resulting in a faster reaction rate. However, NPs dose variation showed fluctuating removal efficiency, whereas MPs dose increment reduces removal efficiency. MP and NPs dose variation also affected toxicity to plants and earthworms as observed from data. Understanding the fate and removal of microplastics in wetland systems will help determine the reuse potential of wastewater and restrict the release of microplastics. This study provides information on various aspects and highlights future gaps and needs for MNP fate study in CW systems.

CXCR4 expression is elevated in TNBC patient derived samples and Z-guggulsterone abrogates tumor progression by targeting CXCL12/CXCR4 signaling axis in preclinical breast cancer model.

Environmental factors such as exposure to ionizing radiations, certain environmental pollutants, and toxic chemicals are considered as risk factors in the development of breast cancer. Triple-negative breast cancer (TNBC) is a molecular variant of breast cancer that lacks therapeutic targets such as progesterone receptor, estrogen receptor, and human epidermal growth factor receptor-2 which makes the targeted therapy ineffective in TNBC patients. Therefore, identification of new therapeutic targets for the treatment of TNBC and the discovery of new therapeutic agents is the need of the hour. In this study, CXCR4 was found to be highly expressed in majority of breast cancer tissues and metastatic lymph nodes derived from TNBC patients. CXCR4 expression is positively correlated with breast cancer metastasis and poor prognosis of TNBC patients suggesting that suppression of CXCR4 expression could be a good strategy in the treatment of TNBC patients. Therefore, the effect of Z-guggulsterone (ZGA) on the expression of CXCR4 in TNBC cells was examined. ZGA downregulated protein and mRNA expression of CXCR4 in TNBC cells and proteasome inhibition or lysosomal stabilization had no effect on the ZGA-induced CXCR4 reduction. CXCR4 is under the transcriptional control of NF-κB, whereas ZGA was found to downregulate transcriptional activity of NF-κB. Functionally, ZGA downmodulated the CXCL12-driven migration/invasion in TNBC cells. Additionally, the effect of ZGA on growth of tumor was investigated in the orthotopic TNBC mice model. ZGA presented good inhibition of tumor growth and liver/lung metastasis in this model. Western blotting and immunohistochemical analysis indicated a reduction of CXCR4, NF-κB, and Ki67 in tumor tissues. Computational analysis suggested PXR agonism and FXR antagonism as targets of ZGA. In conclusion, CXCR4 was found to be overexpressed in majority of patient-derived TNBC tissues and ZGA abrogated the growth of TNBC tumors by partly targeting the CXCL12/CXCR4 signaling axis.

The Effect of Segmentation Threshold on Computational Fluid Dynamic Analysis of Nasal Airflow.

BACKGROUND: The objective analysis of nasal airflow stands to benefit greatly from the adoption of computational fluid dynamic (CFD) methodologies. In this emerging field, no standards currently exist in regard to the ideal modeling parameters of the nasal airway. Such standards will be necessary for this tool to become clinically relevant. METHODS: Human nasal airways were modeled from a healthy control, segmented, and analyzed with an in-house immersed boundary method. The segmentation Hounsfield unit (HU) threshold was varied to measure its effect in relation to airflow velocity magnitude and pressure change. FINDINGS: Surface area and volume have a linear relationship to HU threshold, whereas CFD variables had a more complex relationship. INTERPRETATION: The HU threshold should be included in nasal airflow CFD analysis. Future work is required to determine the optimal segmentation threshold.

Photophysics of nanographenes: from polycyclic aromatic hydrocarbons to graphene nanoribbons.

Graphene quantum dots (GQDs) and nanoribbons (GNRs) are classes of nanographene molecules that exhibit highly tunable photophysical properties. There have been great strides in recent years to advance our understanding of nanographene photophysics and develop their use in light-harvesting systems, such as artificial photosynthesis. Here, we review the latest studies of GQDs and GNRs which have shed new light onto their photophysical underpinnings through computational and advanced spectroscopic techniques. We discuss how the size, symmetry, and shape of nanographenes influence their molecular orbital structures and, consequentially, their spectroscopic signatures. The scope of this review is to comprehensively lay out the general photophysics of nanographenes starting with benzene and building up to larger polycyclic aromatic hydrocarbons, GQDs, and GNRs. We also explore a collection of publications from recent years that build upon the current understanding of nanographene photophysics and their potential application in light-driven processes from display, lasing, and sensing technology to photocatalytic water splitting.

Development of a Novel Multiplex Bead-based Assay for Measuring Autoantibodies on Flow Cytometric Platform.

BACKGROUND: Autoantibodies (AAbs) are important biomarkers for the diagnosis of Autoimmune Diseases (ADs). The detection of AAbs performed by current methods (indirect immunofluorescence test (IIFT)/Immunoblot (dot/line)/enzyme-linked immunosorbent assay ELISA) which have limitations in terms of performing multiple assays to arrive at laboratory diagnosis. We validated a novel multiplex bead-based assay (NMBA) that could quantify five common antibodies, simultaneously, on a flow-cytometry platform. METHODS: A total of five recombinant antigens (SS-A Ro60, CENP B, RNP 70, Scl 70 and Histones) were covalently coupled onto beads and tested using known positive sera (positive for AAbs) and analyzed using flow cytometer. RESULTS: The sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were obtained for each antigen, analyzed by both assays (NMBA and IIFT). It showed comparable or higher values for the NMBA. The Spearman's rank correlation coefficient (Rho) were ≥ 0.97, (P < .05), indicating that multiplexing of the five autoantigens did not alter the results obtained when antigens were tested individually. The mean intra-assay precision measured by coefficient of variation (CV) was7.56 ± 1.6% and the mean inter-assay CV was 10.03 ± 1.34%. The time taken from sample receipt to reporting of results was 90 minutes in NMBA as compared to 150 minutes of IIFT. CONCLUSION: The NMBA could quantitatively measure antibodies against five autoantigens, simultaneously in patient's sera. The assay is faster, objective, reproducible, requires low sample volume, and stable. Moreover, the flow cytometer in diagnostic laboratory settings for hematological and transplant immunology tests, can also be used for testing AAbs.

Proton-Coupled Electron Transfer in a Ruthenium(II) Bipyrimidine Complex in Its Ground and Excited Electronic States.

Proton-coupled electron transfer (PCET) was studied for the ground and excited electronic states of a [Ru(terpy)(bpm)(OH2)(PF6)2] complex, Ru-bpm. Cyclic voltammetry measurements show that the Ru(II)-aqua moiety undergoes PCET to form a Ru(IV)-oxo moiety in the anodic region, while the bpm ligand undergoes PCET to form bpmH2 in the cathodic region. The photophysical behavior of Ru-bpm was studied using steady-state and femtosecond transient UV-vis absorption spectroscopy, coupled with density functional theory (DFT) calculations. The lowest-lying excited state of Ru-bpm is described as a (Ru → bpm) metal-to-ligand charge-transfer (MLCT) state, while the metal-centered (MC) excited state was found computationally to be close in energy to the lowest-energy bright MLCT state (MC state was 0.16 eV above the MLCT state). The excited-state kinetics of Ru-bpm were found via transient absorption spectroscopy to be short-lived and were fit well to a biexponential function with lifetimes τ1 = 4 ps and τ2 = 65 ps in aqueous solution. Kinetic isotope effects of 1.75 (τ1) and 1.61 (τ2) were observed for both decay components, indicating that the solvent plays an important role in the excited-state dynamics of Ru-bpm. Based on the pH-dependent studies and the results from prior studies of similar Ru-complexes, we hypothesize that the 3MLCT state forms an excited-state hydrogen-bond adduct with the solvent molecules and that this process occurs with a 4 ps lifetime. The formation of such a hydrogen-bond complex is consistent with the electronic density accumulation at the peripheral N atoms of the bpm moiety in the 3MLCT state. The hydrogen-bonded state 3MLCT decays to the ground state with a 65 ps lifetime. Such a short lifetime is likely associated with the efficient vibrational energy transfer from the 3MLCT state to the solvent.

Impact of Fellow Participation During Colonoscopy on Adenoma Detection Rates.

BACKGROUND: An endoscopist's adenoma detection rate (ADR) is inversely related to interval colorectal cancer risk and cancer mortality. Previous studies evaluating the impact of gastroenterology fellow participation in colonoscopy on ADR have generated conflicting results. AIMS: We aimed to determine the impact of fellow participation, duration of fellowship training, and physician sex on ADR and advanced ADR (AADR). METHODS: We retrospectively analyzed average-risk patients undergoing screening colonoscopy at Veterans Affairs New York Harbor Healthcare System Brooklyn Campus and Kings County Hospital Center. Review of colonoscopy and pathology reports were performed to obtain adenoma-specific details, including the presence of advanced adenoma and adenoma location (right vs. left colon). RESULTS: There were 893 colonoscopies performed by attending only and 502 performed with fellow participation. Fellow participation improved overall ADR (44.6% vs. 35.4%, p < 0.001), right-sided ADR (34.1% vs. 25.2%, p < 0.001), and AADR (15.3% vs. 8.3%, p < 0.001); however, these findings were institution-specific. Year of fellowship training did not impact overall ADR or overall AADR, but did significantly improve right-sided AADR (p-value for trend 0.03). Female attending physicians were associated with increased ADR (47.1% vs. 37.0%, p = 0.0037). Fellow sex did not impact ADR. CONCLUSIONS: Fellow participation in colonoscopy improved overall ADR and AADR, and female attending physicians were associated with improved ADR. Year of fellowship training did not impact overall ADR or AADR.

Procedural Trends in Medicare Reimbursement and Utilization for Breast Reconstruction: 2000-2019.

PURPOSE: Development of appropriate reimbursement models for breast reconstruction in the United States requires an understanding of relevant economic trends. The purpose of this study is to evaluate longitudinal patterns in Medicare reimbursement for frequently performed breast reconstruction procedures between 2000 and 2019. METHODS: Reimbursement data for 15 commonly performed breast reconstruction procedures were analyzed using the Centers for Medicare & Medicaid Services Physician Fee Schedule Look-Up Tool for each Current Procedural Terminology code. By utilizing changes to the US consumer price index, monetary data were adjusted for inflation to 2019 US dollars. Inflation-adjusted trends were used to calculate average annual and total percentage changes in reimbursement over time. RESULTS: From 2000 to 2019, average adjusted reimbursement for all procedures fell by 13.32%. All procedures demonstrated a negative adjusted reimbursement rate other than immediate insertion of breast prosthesis, which increased by 55.37%. The largest mean decrease was observed in breast reconstruction with other technique (-28.63%), followed by single pedicle transverse rectus abdominis myocutaneous flap (-26.02%), single pedicle transverse rectus abdominis myocutaneous flap with microvascular anastomosis (-23.33%), latissimus dorsi flap (-19.65%), and free flap reconstruction (-19.36%). CONCLUSIONS: There has been a steady yet substantial decline in Medicare reimbursement for the majority of breast reconstruction procedures over the last 20 years. Given increasing medical costs and the financial uncertainty of the US health care system, an understanding of Medicare reimbursement trends is vital for policymakers, administrators, and physicians to develop agreeable reimbursement models that facilitate growth and economic vitality of breast reconstruction in the United States.

Facial Recognition Software Use on Surgically Altered Faces: A Systematic Review.

OBJECTIVE: Facial recognition software (FRS) is becoming pervasive in society for commercial use, security systems, and entertainment. Alteration of the facial appearance with surgery poses a challenge to these algorithms, but several methods are being studied to overcome this issue. This study systematically reviews methods used in facial recognition of surgically altered faces. MATERIALS AND METHODS: A systematic review was performed by searching PubMed and Institute of Electrical and Electronics Engineers (IEEE) databases to identify studies addressing FRS and surgery. On initial review, 178 manuscripts were identified relating to FRS and surgery and allowed division into multiple subgroups. The decision was made to focus on the recognition of surgically altered faces. RESULTS: Eligible studies included those reports in English on FRS of surgically altered faces, and 39 papers were included. Surgical procedures range from affecting skin surface, such as skin peeling, to altering facial features, such as rhinoplasty, mentoplasty, malar augmentation, brow lift, facelift, orthognathic surgery, facial reanimation, and facial feminization. Methods were classified into appearance-based, feature-based, and texture-based. Descriptive versus experimental protocols were characterized by different reporting outcomes and controls. Accuracy ranged from 19.1% to 85.35% using various analysis methods. CONCLUSIONS: Knowledge of available limitations and advantages can aid in counseling patients regarding personal technology use, security, and quell fears about surgery to evade authorities. Surgical knowledge can be utilized to improve FRS algorithms for postsurgical recognition.

The Use of Autologous and Cadaveric Grafts in Rhinoplasty: A Survey Study.

BACKGROUND: Both autologous and cadaveric grafts are often used during rhinoplasty to create volume and provide support. Despite discussion in the literature comparing the efficacy, cost-effectiveness, and complication rates between grafting options, it remains unclear which is the superior choice when considering availability, donor site morbidity, and cost. There is a little description of the current use of these materials amongst facial plastic surgeons. METHODS: A 12 question survey was created, and IRB approval was obtained. The survey was distributed to practicing members of the AAFPRS via their membership listserv. RESULTS: 178 respondents completed the survey for an overall response rate of 17.5%. The most common rhinoplasty graft types used by respondents were autologous septal cartilage (96.6%), autologous auricular grafts (93.8%), autologous rib graft (ARG) (75.8%), and cadaveric rib graft (CRG) (56.7%). Patient comorbidities and performing more than 50 rhinoplasties per year were positively correlated with use of CRG grafts and concerns about complications and cost were negatively correlated. CONCLUSIONS: While autologous septal and auricular cartilage remain the most common graft choices amongst surveyed facial plastic surgeons, a majority utilize cadaveric rib grafts in their practice. Patient comorbidities, surgery volume, concerns about graft complications, and cost were the chief factors associated with use of cadaveric grafts amongst survey respondents. LEVEL OF EVIDENCE V: 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 .

Risk Factors Associated with Complications in Rhinoplasty Using Polydioxanone Plates.

OBJECTIVE: Polydioxanone (PDS) plates are utilized in septorhinoplasty to reconstruct the nasal septum. Our goal was to analyze factors affecting short- and long-term complications in patients undergoing septorhinoplasty using PDS plates with a particular focus on smoking and diabetes. METHODS: This is a retrospective review of patients undergoing septorhinoplasty with PDS plates analyzing risk factors and outcomes. Early complications included infection, hematoma, extrusion, and septal thickening. Late complications included septal perforation, obstruction, revision, and infection. Complication rate was assessed as a function of demographics, diabetes, smoking, autoimmune disease, cancer, and trauma. Multivariate analyses assessed the contributions of these variables, and Chi-square analyses specifically addressed smoking and diabetes. RESULTS: A total of 119 patients were included. In multivariate analysis, current smoking had a large negative effect on late outcomes (OR 2.00, 95% CI 0.59-6.55), while diabetes did not show any significant difference. Targeted Chi-squared analysis showed a statistically significant effect of current smoking on increased early complications (OR 3.65, 95% CI 1.67-7.63) and a large but not statistically significant increase in long-term complications (OR 4.20, 95% CI 0.72-22.74). In both models, diabetes was not shown to have an effect on early or late complications. CONCLUSION: Current smokers undergoing septorhinoplasty with a PDS plate showed a statistically significant association with early complications and large but not statistically significant association with late complications. Diabetic patients were not found to have an increased complication risk. 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 .

Observer Gaze Patterns of Patient Photographs Before and After Facial Feminization.

BACKGROUND: Human interaction begins with visual evaluation of others, and this often centers on the face. Objective measurement of this evaluation gives clues to social perception. OBJECTIVES: The objective of this study was to use eye-tracking technology to evaluate if there are scanpath differences when observers view faces of cisgender men, cisgender women, and transgender women before and after facial feminization surgery (FFS) including when assigning tasks assessing femininity, attractiveness, and likability. METHODS: Undergraduate psychology students were prospectively recruited as observers at a single institution. Their eye movements were recorded by eye-tracking technology when they were presented with frontal photographs of prototypical male, prototypical female, and pre- and post-FFS faces in a random order and then with prompting to assess femininity, attractiveness, and likability. RESULTS: Twenty-seven observers performed the tasks. Participants focused their attention more on the central triangle of post-FFS and prototypical female images and on the forehead of pre-FFS and prototypical male images. Higher femininity ratings were associated with longer proportional fixations to the central triangle and lower proportional fixations to the forehead. CONCLUSIONS: This preliminary study implies the scanpath for viewing a post-FFS face is closer to that for viewing a prototypical female than a prototypical male based on differences viewing the forehead and brow vs the central triangle.

Early postoperative acute myocardial infarction in kidney transplant recipients: A nested case-control study.

INTRODUCTION: The epidemiology of early acute myocardial infarctions after kidney transplantation has not been well characterized. This study sought to examine the incidence, risk factors, and clinical outcomes of early acute myocardial infarctions or EAMI in kidney transplant recipients. METHODS: A total of 1976 patients who underwent kidney transplantation at our center from Jan 1, 2000, to Sept 30, 2016, were included. A nested case-control design was used to study EAMI risk factors using a conditional logistic regression model. A Cox proportional hazards model was used to assess the association of EAMI with death-censored graft failure, death with graft function, and total graft failure. RESULTS: Seventy four patients had an EAMI within 3 months post-transplant. Based on univariable analyses, risk factors for EAMI included age and recipient history of diabetes mellitus or coronary artery disease. After adjustment, recipient history of coronary artery disease was the only independent predictor for EAMI (OR 3.76, p < .001). Patients who experienced EAMI were more likely to experience death-censored graft failure, death with graft function, and total graft failure. CONCLUSION: While the incidence of EAMI in kidney transplant recipients is relatively low, these data show that EAMI has profound long-term effects on morbidity and mortality.

Analysis of 20-Year Trends in Medicare Reimbursement for Reconstructive Microsurgery.

BACKGROUND: Microsurgery is being increasingly utilized across surgical specialties, including plastic surgery. Microsurgical techniques require greater time and financial investment compared with traditional methods. This study aimed to evaluate 20-year trends in Medicare reimbursement and utilization for commonly billed reconstructive microsurgery procedures from 2000 to 2019. METHODS: Microsurgical procedures commonly billed by plastic surgeons were identified. Reimbursement data were extracted from The Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid Services for each current procedural terminology (CPT) code. All monetary data were adjusted for inflation to 2019 U.S. dollars. The average annual and total percentage changes in reimbursement were calculated based on these adjusted trends. To assess utilization trends, CMS physician/supplier procedure summary files were queried for the number of procedures billed by plastic surgeons from 2010 to 2018. RESULTS: After adjusting for inflation, the average reimbursement for all procedures decreased by 26.92% from 2000 to 2019. The greatest mean decrease was observed in CPT 20969 free osteocutaneous flaps with microvascular anastomosis (-36.93%). The smallest mean decrease was observed in repair of blood vessels with vein graft (-9.28%). None of the included procedures saw an increase in reimbursement rate over the study period. From 2000 to 2019, the adjusted reimbursement rate for all procedures decreased by an average of 1.35% annually. Meanwhile, the number of services billed to Medicare by plastic surgeons across the included CPT codes increased by 42.17% from 2010 to 2018. CONCLUSION: This is the first study evaluating 20-year trends in inflation-adjusted Medicare reimbursement and utilization in reconstructive microsurgery. Reimbursement for all included procedures decreased over 20% during the study period, while number of services increased. Increased consideration of these trends will be important for U.S. policymakers, hospitals, and surgeons to assure continued access and reconstructive options for patients.

Pyoderma Gangrenosum: A Rare Disease With Dire Consequences in Facial Aesthetic Surgery Patients.

Pyoderma gangrenosum (PG) is a rare, inflammatory dermatologic condition characterized by painful cutaneous ulcerations. Herein, we describe the third documented case of PG arising in an elective plastic surgery patient who had undergone an otherwise uncomplicated facelift. We describe the course of her diagnosis and management of PG, which involved her face and neck and then progressed to her lower extremities. Although the etiology remains unknown, PG often arises in a host with another autoimmune disease. In the case described, the patient was diagnosed with an immunoglobulin A gammopathy shortly after she developed PG. Following the case report, the pathogenesis, diagnosis, and treatment strategy of PG is briefly reviewed. Level of Evidence: 5.

RiboD: a comprehensive database for prokaryotic riboswitches.

SUMMARY: Riboswitches are cis-regulatory non-coding genomic segments that control the expression of downstream genes by undergoing conformational change upon ligand binding. We present a comprehensive database of prokaryotic riboswitches that allows the user to search for riboswitches using multiple criteria, extract information about riboswitch location and gene/operon it regulates. RiboD provides a very useful resource that can be utilized for the better understanding of riboswitch-based gene regulation in bacteria and archaea. AVAILABILITY AND IMPLEMENTATION: RiboD can be freely accessed on the web at http://ribod.iiserkol.ac.in/.