Functional return after implant-based breast reconstruction: A prospective study of objective and patient-reported outcomes.

BACKGROUND: There is sparse literature studying the functional morbidity of subpectoral implant- based breast reconstruction. We aimed to prospectively investigate this technique's impact on objective upper extremity function and patient-reported outcomes. METHODS: Women undergoing mastectomy and immediate subpectoral tissue expander insertion with ADM sling were enrolled from November 2014 to August 2016. Preoperative evaluation of shoulder range of motion, pectoralis major strength, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Breast-Q surveys were conducted before surgery and at 1 month and 6 months postoperatively, or until return to baseline pectoralis major strength. RESULTS: Eighteen women (mean age, 51 years, SD 9.6, range 35-72 years) comprising 26 breast reconstructions completed postoperative follow-up. The average follow-up length was 9 months (range, 3 -18 months; SD, 144 days). At 1-month follow-up, there was a statistically significant decrease in lower and non dominant upper fiber pectoralis strength from preoperative baseline (p < 0.05). At final postoperative follow-up, 24 reconstructions (92.3%) recovered to at least 80% of preoperative strength in upper and lower fibers. From preoperative to final postoperative follow-up, QuickDASH scores showed a statistically significant (p = 0.008) increase from 4.1 (range 0-20.5, SD 6.1) to 18.7 (range 0-45.5, SD 13.4). Physical well-being: The chest was the only Breast-Q domain in which the average score significantly decreased (p = 0.02) between preoperative assessment and final follow-up. CONCLUSIONS: After implant-based breast reconstruction, patients achieve the return of objective upper extremity function, but patient-reported outcomes do not return to baseline as shown by increased QuickDASH scores. Thus, pectoralis-sparing reconstructive strategies such as prepectoral implant insertion should be pursued.

The Evolution of Iliac Bone Graft Donor Site Analgesia in Cleft Patients: Transversus Abdominis Plane Block Is Safe and Efficacious.

BACKGROUND: The transversus abdominis plane (TAP) block has been increasingly used as a means of abdominal wall analgesia. This study aims to determine if TAP block analgesia provides a benefit in cleft patients undergoing alveolar bone grafting with iliac crest cancellous bone graft. METHODS: Two groups of 20 consecutive patients undergoing alveolar bone grafting with iliac crest cancellous bone with either TAP block or indwelling catheter pain pump were examined in a retrospective fashion. Demographic data, pharmacologic use, and hospital length of stay were examined. RESULTS: Mean lengths of stay were identical between both groups. Patients in both groups received similar cumulative doses of morphine equivalents, codeine, ibuprofen, and ondansetron at 6 and 24 hours postoperatively. Transversus abdominis plane block patients received greater amounts of Tylenol at both 6 and 24 hours (P = 0.0015 and P = 0.0106). Pain scores did not differ significantly across our groups at 6 or 24 hours postoperatively. No adverse events were reported with the TAP block procedure. CONCLUSIONS: Patients undergoing TAP blocks receive the benefit of a single stage procedure without an indwelling catheter and similar 6- and 24-hour morphine usage. Given the safety profile of the procedure, its effectiveness and comfort without indwelling catheter, we advocate for TAP block analgesia as an adjunct therapy in the management of postoperative pain in this population.

Redefining the Rectus Sheath: Implications for Abdominal Wall Repair.

BACKGROUND: The abdominal wall is frequently manipulated in a variety of reconstructive procedures, and its anatomy is well described. The authors' clinical observations, however, contradict the standard depiction of the components of the abdominal wall at various levels-particularly regarding the course of the transversus abdominis muscle. Therefore, the authors sought to characterize the components of the rectus sheath at various surgical landmarks to define anatomic points important to abdominal wall repair. METHODS: The authors analyzed the abdominal computed tomographic studies of 100 healthy, young (age, 18 to 35 years; body mass index, 20 to 40 kg/m) patients with suspected renal calculi. Coordinates of key landmarks were recorded at vertebral levels T12 to L5 using a specially designed computer program that scaled all values and calculated distances between various points. RESULTS: All subjects had significant presence of the transversus abdominis within the rectus sheath (the overlap between the abdominis rectus and transversus abdominis muscles) at the costal margin plane (T12-L1, 4.2 cm). Ninety-nine percent had transversus abdominis presence within the rectus sheath at L1-L2 (3.2 cm), 86 percent at the level of the twelfth rib (L2-L3, 1.4 cm), 36 percent at the umbilicus (L3-L4), and 2 percent slightly above the posterosuperior iliac spine (L5-S1). CONCLUSIONS: These findings contradict classic teachings of abdominal wall structure and highlight the need for a cautious revisiting of the various permutations of component separation, particularly posterior component release. Furthermore, these anatomical landmarks may help predict the development or recurrence of ventral hernias, thus guiding patient selection and informing surgical technique.

Emergency medical practice: advancing cultural competence and reducing health care disparities.

In an increasingly diverse patient population, language differences, socioeconomic circumstances, religious values, and cultural practices may present barriers to the delivery of quality care. These obstacles contribute to the health care disparities observed in all areas of medical care. Increasing cultural competence has been cited as part of the solution to reduce disparities. The emergency department (ED) is an environment where cultural sensitivity is particularly needed, as it is often a primary source of health care for the underserved and ethnic and racial minorities and a place where high patient volume and acuity place the provider under demanding time pressures, yet the emergency medicine (EM) literature on health care disparities and cultural competence is limited. The authors present three clinical scenarios highlighting challenges in providing equitable emergency care to minority populations. Using these cases as illustrations, three processes are proposed that may improve the quality of care delivered to minority populations: 1) increase cultural awareness and reduce provider biases, enabling providers to interact more effectively with different patient populations; 2) accommodate patient preferences and needs in medical settings through practice adjustments and cultural modifications; and 3) increase provider diversity to raise levels of tolerance, awareness, and understanding for other cultures and create more racially and/or ethnically concordant patient-physician relationships.