The Efficacy of Pectoralis Nerve Blockade in Breast Reductions: A Prospective Randomized Trial.

BACKGROUND: Pectoralis nerve (Pecs) blocks have been shown to reduce perioperative opioid consumption in patients undergoing mastectomies, but the effectiveness of these blocks in breast reductions has not been established. This trial aims to evaluate the efficacy of Pecs blocks (I and II) on perioperative pain management in patients undergoing breast reductions. METHODS: Thirty-six patients were enrolled in the randomized controlled trial divided into 2 groups. The treatment group (n = 16) received general anesthesia plus postinduction ultrasound-guided Pecs blocks. The control group (n = 20) received general anesthesia alone. The primary outcomes measured were perioperative narcotic requirements, need for postoperative antiemetics, pain scores, and length of time in the operating room (OR). We measured patient and procedural risk factors including pedicle/skin excision patterns, concurrent liposuction, weight of resection, and additional local anesthesia. Risk factors as well as outcomes were analyzed using Fischer exact and t tests. RESULTS: No statistically significant difference was shown between the group receiving the Pecs blocks and the control with regard to narcotic requirements, pain scores, and need for antiemetics. Patients undergoing Pecs blocks had a significantly higher OR time before incision (P = 0.0073). Patient and procedural risk factors were well balanced (P > 0.41). CONCLUSIONS: Pectoralis nerve blocks may be a valuable component of a multimodality pain regimen; however, when performed as a solitary adjunct, they do not seem to decrease perioperative narcotic requirements, pain scores, or the need for antiemetic medication in patients undergoing breast reductions. In addition, postinduction Pecs blocks significantly increase OR times.

Appalachian Status Is a Negative Predictor of Breast Reconstruction Following Breast Cancer Resection.

BACKGROUND: Health care disparities in Appalachia are well documented. However, no previous studies have examined possible differences in the utilization of breast reconstruction (BR) in Appalachia. This study aims to determine if a disparity in BR utilization exists in women from Appalachia Kentucky. METHODS: A retrospective, population-based cohort study was conducted from January 1, 2006, to December 31, 2015. The Kentucky Cancer Registry was queried to identify population-level data for female patients diagnosed with breast cancer and treated with mastectomy. A multivariate logistic regression model controlling for patient, disease, and treatment characteristics was constructed to predict the likelihood of BR. RESULTS: Bivariate testing showed differences (P < 0.0001) in BR utilization between Appalachian and non-Appalachian women in Kentucky (15.0% and 26.3%, respectively). Multivariate analysis showed that women from Appalachia (odds ratio, 0.54; confidence interval (95), 0.48-0.61; P < 0.0001) were less likely to undergo BR than non-Appalachian women. Interestingly, the rate of BR increased over time in both Appalachian (r = 0.115; P < 0.0001) and non-Appalachian women (r = 0.148; P < 0.0001). CONCLUSIONS: Despite the benefits of BR, women from Appalachia undergo BR at lower rates and are less likely to receive BR than non-Appalachian Kentuckians. Although the rates of BR increased over time in both populations, access to comprehensive breast cancer care remains a challenge for women from Kentucky's Appalachian region.

Anatomic Implants in Breast Reconstruction: A Comparison of Outcomes and Aesthetic Results Compared to Smooth Round Silicone Implants.

BACKGROUND: Direct comparison studies of outcomes and aesthetic satisfaction of anatomic implants compared to other implants are scarce in the literature. OBJECTIVES: The objective of this study was to compare outcomes and aesthetic satisfaction of patients who underwent breast reconstruction with anatomic implants vs other implants (smooth round silicone). METHODS: A retrospective chart review was performed of patients who underwent implant-based breast reconstruction over 3 years. Outcomes including complications, number of surgeries, need for revisions, and aesthetic satisfaction of patients were tracked and compared. RESULTS: A total of 156 patients met inclusion criteria for this study. A total of 123 underwent reconstruction with a round implant, and 33 underwent reconstruction with an anatomic implant. Of the 156 patients, 38 underwent a 1-stage direct-to-implant reconstruction and the remainder underwent a 2-stage implant reconstruction. The round and anatomic implant groups did not differ with regards to number of surgeries, revisions, utilization of contralateral symmetry procedures, implant-related reoperations, complications, implant loss, infection, capsular contracture, and seroma. The Breast Q survey had a response rate of 27%. On all parameters, the round and anatomic implant groups did not significantly differ. CONCLUSIONS: There were no significant differences among round and shaped implants in regards to complications, revision surgeries, and overall outcomes. Furthermore, patients showed no differences regarding satisfaction and well-being when surveyed on the Breast Q survey. The decision of implant choice in breast reconstruction should be based on surgeon comfort and the patient's needs/body type.Level of Evidence: 4.

Quorum-dependent mannopine-inducible conjugative transfer of an Agrobacterium opine-catabolic plasmid.

The Ti plasmid in Agrobacterium tumefaciens strain 15955 carries two alleles of traR that regulate conjugative transfer. The first is a functional allele, called traR, that is transcriptionally induced by the opine octopine. The second, trlR, is a nonfunctional, dominant-negative mutant located in an operon that is inducible by the opine mannopine (MOP). Based on these findings, we predicted that there exist wild-type agrobacterial strains harboring plasmids in which MOP induces a functional traR and, hence, conjugation. We analyzed 11 MOP-utilizing field isolates and found five where MOP induced transfer of the MOP-catabolic element and increased production of the acyl-homoserine lactone (acyl-HSL) quormone. The transmissible elements in these five strains represent a set of highly related plasmids. Sequence analysis of one such plasmid, pAoF64/95, revealed that the 176-kb element is not a Ti plasmid but carries genes for catabolism of MOP, mannopinic acid (MOA), agropinic acid (AGA), and the agrocinopines. The plasmid additionally carries all of the genes required for conjugative transfer, including the regulatory genes traR, traI, and traM. The traR gene, however, is not located in the MOP catabolism region. The gene, instead, is monocistronic and located within the tra-trb-rep gene cluster. A traR mutant failed to transfer the plasmid and produced little to no quormone even when grown with MOP, indicating that TraRpAoF64/95 is the activator of the tra regulon. A traM mutant was constitutive for transfer and acyl-HSL production, indicating that the anti-activator function of TraM is conserved.

Quorum-dependent transfer of the opine-catabolic plasmid pAoF64/95 is regulated by a novel mechanism involving inhibition of the TraR antiactivator TraM.

We previously described a plasmid of Agrobacterium spp., pAoF64/95, in which the quorum-sensing system that controls conjugative transfer is induced by the opine mannopine. We also showed that the quorum-sensing regulators TraR, TraM, and TraI function similarly to their counterparts in other repABC plasmids. However, traR, unlike its counterpart on Ti plasmids, is monocistronic and not located in an operon that is inducible by the conjugative opine. Here, we report that both traR and traM are expressed constitutively and not regulated by growth with mannopine. We report two additional regulatory genes, mrtR and tmsP, that are involved in a novel mechanism of control of TraR activity. Both genes are located in the distantly linked region of pAoF64/95 encoding mannopine utilization. MrtR, in the absence of mannopine, represses the four-gene mocC operon as well as tmsP, which is the distal gene of the eight-gene motA operon. As judged by a bacterial two-hybrid analysis, TmsP, which shows amino acid sequence relatedness with the TraM-binding domain of TraR, interacts with the antiactivator. We propose a model in which mannopine, acting through the repressor MrtR, induces expression of TmsP which then titrates the levels of TraM thereby freeing TraR to activate the tra regulon.

Longitudinal MRI and cognitive change in healthy elderly.

Cross-sectional studies of normal aging indicate an association between memory and hippocampal volume, and between executive functioning and subcortical-frontal circuits. Much less is known, however, about the relationship between longitudinal MRI changes and cognitive decline. The authors hypothesized that longitudinal change in memory would be best predicted by change in hippocampal volumes, whereas change in executive functioning would be best predicted by cortical atrophy and progression of MRI markers of cerebrovascular disease. For this study, 50 healthy elderly subjects underwent structural MRI and cognitive testing at baseline and again at follow-up, with a mean follow-up interval of 45 months. Volumetric MRI measures were hippocampus, cortical gray matter, white matter signal hyperintensity (WMSH), and lacunae. Neuropsychological measures were psychometrically robust composite scores of episodic memory (MEM) and executive functioning (EXEC). Hierarchical multiple regression indicated that a decrease in hippocampus was associated with a decline in MEM, whereas decreased cortical gray matter and increased WMSH were independently associated with a decline in EXEC. Results suggest that in normal aging, cognitive functioning declines as cortical gray matter and hippocampus decrease, and WMSH increases. The association between WMSH and EXEC further highlights the cognitive sequealae associated with cerebrovascular disease in normal elderly.

Factors affecting the rise of treatment of resistant bacteria in skin and soft tissue infections in the United States: 1993-2012.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infections (SSTIs) prevalence has been steadily increasing for the past 40 years. The increase in such infections has contributed to a change in the treatment patterns of the patient. This study aimed to detail the factors determining prescription practices associated with MRSA-related skin and soft tissue infections. METHODS: The National Ambulatory Medical Care Survey (NAMCS) was searched for data from 1993 to 2012 regarding the factors associated with resistant vs. non-resistant-antibiotic prescription. RESULTS: Of all physician visits, 34.0% received resistant-antibiotic therapy and 66.0% received non-resistant-antibiotic therapy. Prescription of antibiotic-resistant therapy increased over the time period studied (Odds ratio (OR) = 1.07; 95% CI 1.05, 1.09; p < .0001). Logistic regression controlling for age, sex, race, region, metropolitan statistical area (MSA), infection type, physician specialty, number of medications and number of diagnoses found that region, infection type and physician specialty were factors in the prescription patterns of SSTIs. In the Northeast, patients were less likely to be prescribed resistant-antibiotics (OR = 0.25; 0.12, 0.53; p = .0003), non-primary care physicians were more likely to prescribe resistant-antibiotics (OR = 2.89; 1.75, 4.77; p < .0001), and patients presenting with folliculitis were more likely to be prescribed resistant antibiotics (OR = 3.03; 1.30, 7.05; p = .01). CONCLUSIONS: With the increasing prevalence of MRSA-related SSTIs, the treatment of these infections is changing. Understanding of the factors contributing to the prescription of resistant antibiotics could aid in the selection of appropriate treatment of SSTIs, and hopefully, avoidance of development of additionally resistant organisms.

A Review of the Use of Secukinumab for Psoriatic Arthritis.

Psoriatic arthritis (PsA) is a chronic, seronegative spondyloarthropathy associated with psoriasis (PsO). Treatment options range from non-pharmacologic measures to NSAIDS, DMARDs, and biologics, depending on patient presentation. Secukinumab (Cosentyx©) is a new biologic treatment option that was approved for use in treating adult patients with PsA in October 2016. Our paper explores the clinical trial evidence available for secukinumab to examine its safety and efficacy as a therapeutic agent for the treatment of PsA. While indirect comparisons of indicate that secukinumab is as effective as other treatment options, further studies directly comparing available treatments will be necessary to establish its place in treatment guidelines. As these and other trials are conducted, the evidence produced will further elucidate the clinical potential of secukinumab as a treatment option for patients with rheumatologic disease.

The repABC Plasmids with Quorum-Regulated Transfer Systems in Members of the Rhizobiales Divide into Two Structurally and Separately Evolving Groups.

The large repABC plasmids of the order Rhizobiales with Class I quorum-regulated conjugative transfer systems often define the nature of the bacterium that harbors them. These otherwise diverse plasmids contain a core of highly conserved genes for replication and conjugation raising the question of their evolutionary relationships. In an analysis of 18 such plasmids these elements fall into two organizational classes, Group I and Group II, based on the sites at which cargo DNA is located. Cladograms constructed from proteins of the transfer and quorum-sensing components indicated that those of the Group I plasmids, while coevolving, have diverged from those coevolving proteins of the Group II plasmids. Moreover, within these groups the phylogenies of the proteins usually occupy similar, if not identical, tree topologies. Remarkably, such relationships were not seen among proteins of the replication system; although RepA and RepB coevolve, RepC does not. Nor do the replication proteins coevolve with the proteins of the transfer and quorum-sensing systems. Functional analysis was mostly consistent with phylogenies. TraR activated promoters from plasmids within its group, but not between groups and dimerized with TraR proteins from within but not between groups. However, oriT sequences, which are highly conserved, were processed by the transfer system of plasmids regardless of group. We conclude that these plasmids diverged into two classes based on the locations at which cargo DNA is inserted, that the quorum-sensing and transfer functions are coevolving within but not between the two groups, and that this divergent evolution extends to function.

Cognitive and neuroimaging predictors of instrumental activities of daily living.

Impaired ability to conduct daily activities is a diagnostic criterion for dementia and a determinant of healthcare services utilization and caregiver burden. What predicts decline in instrumental activities of daily living (IADLs) is not well understood. This study examined measures of episodic memory, executive function, and MRI brain volumes in relation to baseline IADLs and as predictors of rate of IADL change. Participants were 124 elderly persons with cognitive function between normal and moderate dementia both with and without significant small vessel cerebrovascular disease. Random effects modeling showed that baseline memory and executive function (EXEC) were associated with baseline IADL scores, but only EXEC was independently associated with rate of change in IADLs. Whereas hippocampal and cortical gray matter volumes were significantly associated with baseline IADL scores, only hippocampal volume was associated with IADL change. In a model including cognitive and neuroimaging predictors, only EXEC independently predicted rate of decline in IADL scores. These findings indicate that greater executive dysfunction at initial assessment is associated with more rapid decline in IADLs. Perhaps executive function is particularly important with respect to maintaining IADLs. Alternatively, executive dysfunction may be a sentinel event indicating widespread cortical involvement and poor prognosis.