Comparison of Complication Rates Between Subpectoral vs Prepectoral Techniques in Prosthetic Breast Reconstruction.

BACKGROUND: The location of tissue expanders in implant-based breast reconstruction remains controversial due to variation in surgical techniques and devices. OBJECTIVES: The aim of this study was to provide a comprehensive assessment of early and late complication rates between prepectoral and subpectoral placement of tissue expanders. METHODS: A retrospective cohort study was conducted of all adult female patients who had undergone 2-stage implant-based breast reconstruction between 2013 and 2019 in our institution. Early complication was defined as complications that occurred within 30 days after surgery. Time-to-event analyses were performed and Cox proportional hazard models were used to adjust for confounders. RESULTS: In total, 854 patients were included; 76% of patients underwent a subpectoral tissue expander placement. After the first-stage procedure, the early complication rate was 34% and the late complication rate was 36.4%. After the second-stage procedure, the early complication rate was 16.3% and the late complication rate was 16.1%. Location of the tissue expander did not predict either overall early or late complication rates, regardless of the stages of reconstruction, after adjusting for confounders. Tissue expanders placed in prepectoral plane were associated with a higher hazard ratio (HR) for developing early and late infection after the first stage of reconstruction (HR, 2.1 and 2.4, respectively) as well as late infection after the second stage of reconstruction (HR, 5.3; all P < .05). CONCLUSIONS: Location of tissue expanders did not predict risk of complication. However, the prepectoral group was associated with an increased risk of developing infection.

Clinical Observation or Further Excision: A Retrospective Review of Margin-positive Squamous and Basal Cell Carcinomas.

Background: Patients determined to have margin-positive nonmelanoma skin cancer (NMSC) after initial shave or punch biopsy performed by a primary care physician or dermatologist are commonly referred to extirpative surgeons for definitive removal. Not infrequently, the residual tumor is not appreciable, and the exact location of the lesion is indiscernible. The consulting surgeon must decide to excise the presumed lesion or clinically monitor for recurrence. Methods: This single-center, retrospective review examined patients with squamous and basal cell carcinomas referred over a 5-year period to two senior authors. Results: In total, 233 patients had a total of 312 lesions excised. Thirty-nine (12.5%) of these lesions (in 33 patients) demonstrated no residual tumor on pathologic examination. Twelve patients were managed nonoperatively (5.15%) and observed to have had no tumor recurrence with a mean observation period of 14.66 months (range 1-54 months). Thus, approximately 19.3% of all patients referred had no residual tumor. Conclusion: Based on our observations and low proclivity for metastases, nonoperative monitoring of NMSC may be a reasonable option for certain lesions less than 1 cm that are undiscernible at the time of referral.

Neurological Examination Frequency and Time-to-Delirium After Traumatic Brain Injury.

BACKGROUND: Frequent neurological examinations in patients with traumatic brain injury (TBI) disrupt sleep-wake cycles and potentially contribute to the development of delirium. OBJECTIVE: To evaluate the risk of delirium among patients with TBI with respect to their neuro-check frequencies. METHODS: A retrospective study of patients presenting with TBI at a single level I trauma center between January 2018 and December 2019. The primary exposure was the frequency of neurological examinations (neuro-checks) assigned at the time of admission. Patients admitted with hourly (Q1) neuro-check frequencies were compared with those who received examinations every 2 (Q2) or 4 (Q4) hours. The primary outcomes were delirium and time-to-delirium. The onset of delirium was defined as the first documented positive Confusion Assessment Method for the Intensive Care Unit score. RESULTS: Of 1552 patients with TBI, 458 (29.5%) patients experienced delirium during their hospital stay. The median time-to-delirium was 1.8 days (IQR: 1.1, 2.9). Kaplan-Meier analysis demonstrated that patients assigned Q1 neuro-checks had the greatest rate of delirium compared with the patients with Q2 and Q4 neuro-checks ( P < .001). Multivariable Cox regression modeling demonstrated that Q2 neuro-checks (hazard ratio: 0.439, 95% CI: 0.33-0.58) and Q4 neuro-checks (hazard ratio: 0.48, 95% CI: 0.34-0.68) were protective against the development of delirium compared with Q1. Other risk factors for developing delirium included pre-existing dementia, tobacco use, lower Glasgow Coma Scale score, higher injury severity score, and certain hemorrhage patterns. CONCLUSION: Patients with more frequent neuro-checks had a higher risk of developing delirium compared with those with less frequent neuro-checks.

Implementing arthritis clinical practice guidelines in primary care.

BACKGROUND: Multi-faceted interventions are among the strongest methods for changing provider behavior. AIMS: This paper reports the design, implementation and process evaluation of an educational program to disseminate clinical practice guidelines (CPGs) on the management of rheumatoid arthritis (RA) and osteoarthritis (OA) in primary care. METHODS: Organizations were invited to participate in inter-professional workshops on OA and RA followed by six months of activities to support the delivery of care in the community. Confidence in ability to manage arthritis was assessed at baseline using a 10 point numerical rating scale. Qualitative assessments were done immediately and 3-12 months post workshop. RESULTS: 646 multidisciplinary providers from 216 organizations attended one of 30 workshops. Providers (n = 584) reported moderate confidence in managing arthritis: family physicians: mean: SD = 7.46(1.42), n = 145; nurse practitioners: 6.10(1.84), n = 73; other health care professionals: 5.23(2.83), n = 389. Participants identified team learning, the opportunity to network and the involvement of trained patient educators as strong features of the workshops. At follow-up, participants indicated the greatest impact of the program was on collaborative care (83%) and patient self-management (79%). CONCLUSIONS: Qualitative results suggest that inter-professional learning may be a successful strategy for improving the delivery of collaborative arthritis care and supporting patient self-management.

Prebiotic condensation through wet-dry cycling regulated by deliquescence.

Wet-dry cycling is widely regarded as a means of driving condensation reactions under prebiotic conditions to generate mixtures of prospective biopolymers. A criticism of this model is its reliance on unpredictable rehydration events, like rainstorms. Here, we report the ability of deliquescent minerals to mediate the oligomerization of glycine during iterative wet-dry cycles. The reaction mixtures evaporate to dryness at high temperatures and spontaneously reacquire water vapor to form aqueous solutions at low temperatures. Deliquescent mixtures can foster yields of oligomerization over ten-fold higher than non-deliquescent controls. The deliquescent mixtures tightly regulate their moisture content, which is crucial, as too little water precludes dissolution of the reactants while too much water favors hydrolysis over condensation. The model also suggests a potential reason why life evolved to favor the enrichment of potassium: so living systems could acquire and retain sufficient water to serve as a solvent for biochemical reactions.

Bilateral endoscopic carpal tunnel releases: Simultaneous versus staged operative intervention.

PURPOSE: Open and endoscopic carpal tunnel release techniques have achieved excellent results for treatment of carpal tunnel syndrome. Symptoms frequently occur bilaterally but there are no reports of simultaneous operative intervention. The purpose of this study was to evaluate results in patients who underwent staged bilateral endoscopic carpal tunnel releases and in those who underwent simultaneous bilateral releases. TYPE OF STUDY: Retrospective review. METHODS: The efficacy of simultaneous and staged bilateral endoscopic carpal tunnel releases was evaluated using a retrospective chart review. This included patients who underwent these procedures during a 48-month period. Group A (48 patients) underwent staged procedures; group group B (48 patients) underwent simultaneous procedures. Inclusion criteria were a positive history and physical examination, positive electrical studies, and failure of conservative measures. Single-incision endoscopic releases were performed on an outpatient basis. Early rehabilitation with intermittent splinting was utilized. The analysis included complications, satisfaction, return to work, physician visits, physical therapy sessions, days to maximum medical improvement for all, and average percentage permanent partial impairment for Workers' Compensation patients. RESULTS: A decrease in return to work at regular duty was noted in the simultaneous group compared with the staged group for patients who had not filed Workers' Compensation claims (P =.0158). The simultaneous group had fewer physician visits than the staged group (P =.0002). Overall patient satisfaction was equal. CONCLUSIONS: Simultaneous bilateral endoscopic carpal tunnel releases are well tolerated with mild restrictions and a decrease in cost.

The synaptic cell adhesion molecule, SynCAM1, mediates astrocyte-to-astrocyte and astrocyte-to-GnRH neuron adhesiveness in the mouse hypothalamus.

We previously identified synaptic cell adhesion molecule 1 (SynCAM1) as a component of a genetic network involved in the hypothalamic control of female puberty. Although it is well established that SynCAM1 is a synaptic adhesion molecule, its contribution to hypothalamic function is unknown. Here we show that, in addition to the expected neuronal localization illustrated by its presence in GnRH neurons, SynCAM1 is expressed in hypothalamic astrocytes. Cell adhesion assays indicated that SynCAM is recognized by both GnRH neurons and astrocytes as an adhesive partner and promotes cell-cell adhesiveness via homophilic, extracellular domain-mediated interactions. Alternative splicing of the SynCAM1 primary mRNA transcript yields four mRNAs encoding membrane-spanning SynCAM1 isoforms. Variants 1 and 4 are predicted to be both N and O glycosylated. Hypothalamic astrocytes and GnRH-producing GT1-7 cells express mainly isoform 4 mRNA, and sequential N- and O-deglycosylation of proteins extracted from these cells yields progressively smaller SynCAM1 species, indicating that isoform 4 is the predominant SynCAM1 variant expressed in astrocytes and GT1-7 cells. Neither cell type expresses the products of two other SynCAM genes (SynCAM2 and SynCAM3), suggesting that SynCAM-mediated astrocyte-astrocyte and astrocyte-GnRH neuron adhesiveness is mostly mediated by SynCAM1 homophilic interactions. When erbB4 receptor function is disrupted in astrocytes, via transgenic expression of a dominant-negative erbB4 receptor form, SynCAM1-mediated adhesiveness is severely compromised. Conversely, SynCAM1 adhesive behavior is rapidly, but transiently, enhanced in astrocytes by ligand-dependent activation of erbB4 receptors, suggesting that erbB4-mediated events affecting SynCAM1 function contribute to regulate astrocyte adhesive communication.