Residual cancer burden in two-stage nipple sparing mastectomy after first stage lumpectomy and devascularization of the nipple areolar complex.

PURPOSE: Ischemic complications after nipple-sparing mastectomy (NSM) can be ameliorated by 2-stage procedures wherein devascularization of the nipple-areolar complex (NAC) and lumpectomy with or without nodal staging surgery is performed first (1S), weeks prior to a completion NSM (2S). We report the time interval between procedures in relation to the presence of residual carcinoma at 2S NSM. METHODS: Women with breast cancer who received 2S NSM from 2015 to 2022 were identified. Both patient level and breast level analyses were conducted. Clinical staging at presentation, pathologic staging at 1S and residual disease at 2S pathology are noted. Residual disease was classified as microscopic (1-2 mm), minimal (3-10 mm), and moderate (> 10 mm). RESULTS: 59 patients (108 breasts) underwent 2S NSM. The median time interval between 1 and 2S for all patients was 34 days: 31 days for upfront surgery invasive cancer, 41 days for upfront DCIS surgery and 31 days for those receiving neoadjuvant therapy. Completion NSM was performed within 6 weeks for 72% of the breasts analyzed. Of the 53 breasts with invasive cancer on 1S pathology, 35% (19/53) had no residual invasive disease and 24.5% (13/53) had neither residual invasive nor in situ carcinoma on final 2S. Among the 50 women who had upfront surgery, 16 (32%) had residual invasive cancer found at 2S NSM, 9 of which had less than or equal to 1 cm disease. CONCLUSION: Invasive cancers were completely resected during 1S procedure in 65% of breasts. Residual disease was minimal and there was only one case of upstaging at 2S. Added time of two-stage surgery is offset by a reduction in ischemic mastectomy flap complications.

Ten-year experience with laparoscopic pedicled omental flap for cerebral revascularization in patients with Moyamoya disease.

BACKGROUND: The omental flap has numerous extraperitoneal applications in reconstruction and revascularization given its favorable immunologic and angiogenic properties. In patients with Moyamoya disease, cerebral revascularization using a pedicled omental flap has proven to be a viable option following direct revascularization procedures. Historically, harvesting omentum involved laparotomy with the associated risk of complications; herein we describe outcomes from a 10-year experience of laparoscopic harvesting of pedicled omental flap for cerebral revascularization in Moyamoya patients. METHODS: A retrospective chart review was performed of all patients with Moyamoya disease who underwent laparoscopic omental cerebral transposition between 2011 and 2021. Intraoperative and postoperative complications, length of stay (LOS), and outcomes at follow-up were analyzed. RESULTS: Twenty-one patients underwent the procedure during the study period. Three intraoperative complications occurred (one segmental transverse colectomy for mesenteric injury, one converted to omental free flap, and one requiring micro anastomosis). Average overall LOS was 6 ± 6 days, with 3 ± 3.5 days in the ICU (mean±SD). Following discharge, complications included epigastric incisional hernia at the graft fascial exit site, recurrent neck pain at subcutaneous tunneling site, and partial scalp necrosis. One patient required subsequent direct bypass seven months after the initial procedure owing to the progression of the disease. All other patients had partial or complete resolution of symptoms. CONCLUSION: Our retrospective observational study indicates that laparoscopic pedicled omental flap mobilization and transposition is a safe and effective method of indirect cerebral revascularization in patients with Moyamoya disease. LEVEL OF EVIDENCE: N/A.

Mental health outcomes in pediatric trauma patients: A 10 year real world analysis using a large database approach.

INTRODUCTION: Traumatic injury is the leading cause of morbidity and mortality among children in the United States. Single institution studies suggest an increased risk of poor mental health outcomes among these patients, but there are few population-based studies assessing this risk. METHODS: The IBMⓇ MarketScanⓇ private insurance claims database was used to identify children (6-17yo) with traumatic injuries between 2007 and 2016. Time-to-event analysis was performed to compare rates of PTSD, depression, anxiety, and adjustment disorder among children admitted to the hospital compared to children treated in the emergency department (ED), urgent care (UC), or in the outpatient setting, and to children admitted with uncomplicated appendicitis. RESULTS: Among children admitted for traumatic injury, 3.3% developed a subsequent mental health diagnosis, and 1.6% developed PTSD. Children admitted for traumatic injury were at increased risk of developing a mental health condition (HR 1.34, p < 0.001) compared to those admitted for appendicitis. Children treated in the ED or UC for traumatic injury and those treated in the outpatient setting were also at increased risk (HR 1.20 and 1.18, p = 0.006 and p = 0.012, respectively). Among those admitted to the hospital, the risk of subsequent mental health diagnosis increased by 1.5% per day; in the first 31 days of hospitalization, the risk of PTSD diagnosis increased by 13% per day. CONCLUSION: Children who sustain a traumatic injury are at increased risk of developing a mental health condition. PTSD rates found in our real world analysis are lower than those found in prospective studies, raising the possibility of under-recognition of PTSD in this population. LEVEL OF EVIDENCE: Level II.

Small surgeries, big smiles: using virtual reality to reduce the need for sedation or general anesthesia during minor surgical procedures.

PURPOSE: Children often require anesthesia for simple diagnostic and therapeutic procedures. The aim of this study was to evaluate the feasibility of using virtual reality (VR) to reduce sedation in children undergoing minor surgical procedures. METHOD: In this prospective, non-randomized clinical trial, pediatric patients at a free-standing children's hospital undergoing hormone implant placement, removal, or exchange were recruited to use VR and local anesthesia instead of procedural sedation or general anesthesia (GA). Patients were enrolled between November 2017 and March 2020, and were compared to historic controls who underwent similar procedures without VR between April 2016 and February 2020. Primary outcome measure was successful procedure completion without sedation or GA. Secondary measures included assessments of pain, fear and anxiety, patient compliance, procedural and recovery times. RESULTS: Twenty-eight patients underwent 29 procedures with VR. Hormone implants (72%), removals (7%), or exchanges (21%) were completed without GA, sedation or IV placement. Procedure lengths and pain scores were similar between VR patients and historic controls, but recovery times were significantly shorter in VR patients (18 vs 65 min, p < 0.001). Participant satisfaction scores were high, with 95% recommending VR to others. CONCLUSIONS: VR is a feasible alternative to sedation or GA for select pediatric patients undergoing minor surgical procedures.

Two-Stage Versus One-Stage Nipple-Sparing Mastectomy: Timing of Surgery Prevents Nipple Loss.

BACKGROUND: Devascularization of the nipple-areola complex (NAC) before nipple-sparing mastectomy (NSM) enhances blood flow to the skin. This study analyzed the effect of the interval between stages in two-stage (2S) operations and compared the ischemic events with those of one-stage (1S) NSM. METHODS: Ischemic complications were defined as partial/reversible (PR) or full-thickness/irreversible (FI) skin necrosis of the NAC or flap. The latter encompassed limited areas of the NAC, resulting in loss of nipple height or areolar circumference without affecting the integrity or appearance of the NAC. Outcomes between the two groups were compared using chi-square and both uni- and multivariate analyses. RESULTS: From 2015 to 2019, 109 breasts underwent 2S NSM and 103 breasts underwent 1S NSM. Grade 2 or 3 breast ptosis was more common in the 2S group than in the 1S group (60.5% vs 30.5%; p < 0.01). The median time between devascularization and NSM was 30 days (range, 11-415 days). After devascularization, ischemic events occurred in 25.7% of the breasts. Nipple loss occurred in 7.8% of the 1S group and 0% of the 2S group. Both PR and FI NAC ischemic events were observed in 66.7% of the breasts when NSM took place fewer than 20 days (n = 9) after devascularization versus 15% when NSM took place 20 days or longer afterward (n = 100). Overall, NAC, flap ischemic complications, or both occurred in 35.9% of the 1S group versus 20.2% of the 2S group (p < 0.05). In the multivariate analysis, the odds ratio of ischemic complications in the 2S versus the 1S group was 0.38 (range, 0.19-0.75). CONCLUSIONS: Fewer ischemic complications and no nipple loss occurred in 2S NSM. Ischemic events are fewer when the interval between devascularization and NSM is 20 days or longer.

Financial burden of pediatric firearm-related injury admissions in the United States.

Pediatric firearm-related injuries pose a significant public health problem in the United States, yet the associated financial burden has not been well described. This is the first study examining national data on the cost of initial hospitalization for pediatric firearm-related injuries. In this retrospective review, the Healthcare Cost and Utilization Project Kids' Inpatient Database from the years 2003, 2006, 2009, and 2012 was used to identify all patients 18 years of age and under who were admitted with firearm-related injuries. We compared demographic and discharge-level data including injury severity score, hospital length of stay, income quartile, injury intent, and inflation-adjusted hospital costs across age groups (0-5, 6-9, 10-15, 16-18 years). There were approximately 4,753 pediatric firearm-related admissions each year, with a median hospitalization cost of $12,984 per patient. Annual initial hospitalization costs for pediatric firearm injuries were approximately $109 million during the study period. Pediatric firearm-related injuries predominately occured among older teenagers (74%, 16-18 years), males (89%), black individuals (55%), and those from the lowest income quartile (53%). We found significant cost variation based on patient race, income quartile, injury severity score, intent, hospital length of stay, disposition, and hospital region. Inflation-adjusted hospitalization costs have increased significantly over the study period (p < 0.001). Pediatric firearm-related injuries are a large financial burden to the United States healthcare system. There are significant variations in cost based on predictable factors like hospital length of stay and injury severity score; however, there are also substantial discrepancies based on hospital region, patient race, and income quartile that require further investigation.

Treating children with achalasia using per-oral endoscopic myotomy (POEM): Twenty-one cases in review.

BACKGROUND: Per-oral endoscopic myotomy (POEM), a modern treatment for achalasia, has only recently emerged as an option for pediatric patients. Here we describe and characterize the success of POEM in children with achalasia. METHODS: A single-institution prospective cohort study was performed of patients <18 years old who underwent POEM from 2014 to 2019. Main outcomes were success at one year (Eckardt ≤3), procedure duration, complications, reintervention. RESULTS: The median age of patients (n = 21) was 13 years (range 2-17). Median procedure duration was 92 min (range 52-259) with case duration plateau of 87.4 min and learning rate of 15.5 cases. Intraoperative complications included capnoperitoneum requiring needle decompression and mucosotomy requiring additional clips. One patient experienced chest pain with small capnoperitoneum seen on chest radiography, and three patients had extraluminal carbon dioxide found incidentally on routine radiography. All were managed with observation. Pre- versus 1-month postprocedure Eckardt scores were significantly improved (7 ±â€¯2 versus 1 ±â€¯2, p < 0.0001, and median ±â€¯SD) with 100% symptomatic relief at one year. To achieve this, 13 patients required further dilation(s), one required laparoscopic Heller myotomy, and two required repeat POEM. CONCLUSIONS: POEM is a viable and safe treatment for pediatric patients with achalasia. We demonstrate improvement in symptoms and procedure proficiency with minimal intra- and postoperative complications. TYPE OF STUDY: Prospective cohort study. LEVEL OF EVIDENCE: Level II.

Dilemma in management of hemorrhagic myositis in dermatomyositis.

Dermatomyositis (DM) is a rare inflammatory disorder affecting the muscle and skin. DM patients can present with spontaneous muscle hemorrhage, a potentially fatal complication. The best practice for management of hemorrhagic myositis in these patients remains unclear. Here we discuss the case of a patient who presented with progressive muscle weakness and intermittent rash that was diagnosed with dermatomyositis. During admission, she developed spontaneous hemorrhagic myositis of the right pectoralis major treated with surgical evacuation. She also developed a spontaneous left anterior thigh hematoma which was treated conservatively. She recovered and showed no evidence of recurrent bleeding at either location. We performed a literature review and identified ten cases of spontaneous hemorrhage in DM patients, with a 60% mortality rate among reported cases. Given the high mortality rate associated with spontaneous hemorrhage in DM patients, it is important for physicians to be aware of the diagnosis, workup, and management strategies.

Correction to: Delayed appearance of mature ganglia in an infant with an atypical presentation of total colonic and small bowel aganglionosis: a case report.

Following publication of the original article [1], the authors reported error on the images/figures used which also resulted in un-sequential order. The updated figures and captions are provided below.

Delayed appearance of mature ganglia in an infant with an atypical presentation of total colonic and small bowel aganglionosis: a case report.

BACKGROUND: Total colonic and small bowel aganglionosis (TCSA) occurs in less than 1% of all Hirschsprung's disease patients. Currently, the mainstay of treatment is surgery. However, in patients with TCSA, functional outcomes are often poor. A characteristic transition zone in TCSA can be difficult to identify which may complicate surgery and may often require multiple operations. CASE PRESENTATION: We present the case of a male infant who was diagnosed with biopsy-proven total colonic aganglionosis with extensive small bowel involvement as a neonate. The patient was diverted at one month of age based on leveling biopsies at 10 cm from the Ligament of Treitz. At 7 months of age, during stoma revision for a prolapsed stoma, intra-operative peristalsis was observed in nearly the entire length of the previously aganglionic bowel, and subsequent biopsies demonstrated the appearance of mature ganglion cells in a previously aganglionic segment. CONCLUSIONS: TCSA remains a major challenge for pediatric surgeons. Our case introduces new controversy to our understanding of aganglionosis. Our observations warrant further research into the possibility of post-natal ganglion maturation and encourage surgeons to consider a more conservative surgical approach.

Firearm Legislation Stringency and Firearm-Related Fatalities among Children in the US.

BACKGROUND: Firearm-related injuries are the second leading cause of pediatric deaths in the US. We sought to evaluate the effectiveness of both state child access prevention (CAP) laws and gun regulations on pediatric firearm mortality. We hypothesized that states with more stringent firearm legislation had lower pediatric firearm mortality. STUDY DESIGN: We used 2014-2015 firearm mortality data from the Web-Based Injury Statistics Query and Reporting System, 2014 Brady scores (used to quantify stringency of state gun regulations) and CAP laws. State-level covariates were obtained from government sources, including the Bureau of Labor Statistics and the Department of Education. Spearman rank correlations and linear regression were used to determine the relationship between overall pediatric firearm mortality and gun regulations. We also examined the relationship between gun regulations and firearm-related homicides and suicides. RESULTS: Annually, there were approximately 2,715 pediatric firearm fatalities among children; 62.1% were homicides and 31.4% suicides. There was a moderate negative correlation between states' firearm legislation stringency and overall pediatric firearm mortality (ρ = -0.66; p < 0.001), and between CAP laws and firearm suicide rates (ρ = -0.56; p < 0.001). After controlling for poverty, unemployment, substance abuse, and the number of registered firearms, the association between firearm legislation stringency and overall pediatric firearm mortality remained significant (p = 0.04). The association between CAP laws and firearm suicide rate remained significant after controlling for socioeconomic factors, registered firearms, and other firearm legislation (p = 0.04). CONCLUSIONS: Strict gun legislation and CAP laws are associated with fewer pediatric firearm fatalities and firearm suicides, respectively, though no such association was identified with pediatric firearm homicides. Although more studies are needed to determine causality, state-level legislation could play an important role in reducing pediatric firearm-related deaths.

Yellow nail syndrome with chylothorax after coronary artery bypass grafting.

BACKGROUND: Yellow nail syndrome is a rare condition considered secondary to functional anomalies of lymphatic drainage. Yellow nail syndrome is diagnosed through the triad of intrathoracic findings (30% being pleural effusions), nail discoloration, and lymphedema, with any two features sufficient for diagnosis. We report the second case of post-operative yellow nail syndrome. CASE PRESENTATION: After coronary artery bypass grafting, our patient presented with chylothorax on post-operative day 13 and yellow toenail discoloration on post-operative day 28, diagnosing yellow nail syndrome. Initial conservative management with pigtail catheter drainage and low-fat diet with medium-chain triglycerides reduced chylous drainage from 350 mL/day on post-operative day 14 to < 100 mL/day on post-operative day 17. However, by post-operative day 18, drainage returned to 350 mL/day that persisted despite attempts to readjust the catheter position, replacement of catheter with chest tube, and transition to total parenteral nutrition and octreotide while nil per os. Lymphangiogram on post-operative day 32 did not identify the thoracic duct or cisterna chyli, precluding embolization. Talc and doxycycline pleurodeses performed on post-operative days 33 and 38, respectively, resolved his chylothorax and nail discoloration. CONCLUSIONS: Both yellow nail syndrome and chylothorax as a complication of coronary artery bypass grafting are rare entities. The proposed mechanism of post-operative chylothorax is iatrogenic injury to thoracic duct or collateral lymphatic vessels. Diagnosing yellow nail syndrome in patients with post-operative chylothorax (through co-existing yellow nail discoloration and/or lymphedema) may suggest predisposition to impaired lymphatic drainage, portending a difficult recovery and potentially indicating need for surgical management.

Twenty years of ecosystem response after clearcutting and slashburning in conifer forests of central British Columbia, Canada.

Forests are being clearcut over extensive areas of western North America, but plant community response to harvesting and slashburning under varying climatic conditions in central British Columbia, Canada is still largely unknown. Evaluation of resilience is hampered by the short history of logging, lack of long-term experiments and methodological limitations. To test the effect of clearcut logging, prescribed burning and reforestation on forest resilience, we recorded vascular plant cover repeatedly after treatment between 1981 and 2008 in 16 permanent research installations in three biogeoclimatic zones: Engelmann Spruce-Subalpine Fir, Interior Cedar-Hemlock and Sub-Boreal Spruce. We created a plant-trait dataset for the 181 recorded species to define plant functional types representing groups of plants that behave in similar ways and/or produce similar ecological outcomes. These plant functional types, along with taxonomic analysis of diagnostic and indicator species, were then used to evaluate plant community response to disturbance. Twenty years post-treatment, species diversity increased in all zones and plant abundance was greatest in the Interior Cedar-Hemlock. Cover of understory plant functional types associated with mature conifer forests increased in all zones, constituting a significant proportion (> 40%) of the vegetation community by year 20. Response patterns varied by zone and with time. Understory species diagnostic of mature forests were present in all zones by year 20, but we identified indicator species sensitive to slashburning or requiring more time for recovery, including white-flowered rhododendron (Rhododendron albiflorum) and devil's club (Oplopanax horridus). Overall, loss of compositional or functional diversity following harvest and site remediation was not detected, suggesting that montane and subalpine forests in British Columbia are resilient to this treatment. However, because these forests can be slow to recover from disturbance, the post-disturbance assessment window of this study may not have been long enough to detect diminishment of ecosystem resilience.