Unique Idea: Using the KliniTray "Breast Board" for Immobilization of Digital Amputates During Replantation.

The KliniTray "breast board" used by many oncological breast surgeons is an innovative idea to succor microsurgical digital replantation. This piece of sterile equipment is readily available and provides excellent immobilization and retraction of the skin of digital amputates with minimal trauma. The fine metal pins are the key to its efficacy. They provide the flexibility to alter the position of the amputated part and alter the retraction of skin edges as many times as necessary. The construct acts as a tremor-free assistant for a single surgeon to efficiently prepare the amputated part of a digit, saving time including expensive theatre time.

The Ethics and Responsibilities of Social Media Usage by Plastic Surgeons: A Literature Review.

BACKGROUND AND OBJECTIVES: Social media has revolutionised how plastic surgeons advertise their work and promote their services, but concerns have been raised regarding the ethics of these practices. This review aims to identify said concerns and develop measures to address them. METHODS: PubMed, Cochrane and Medline were searched for studies assessing the ethics of social media use by plastic surgeons. Five search terms were used and 23 studies identified. Results were catalogued according to which principle of medical ethics was infringed. RESULTS: Autonomy: Patients must not be coerced into allowing their operative media to be shared and content anonymised by removing identifiable features and scrubbing metadata. Beneficence: It is difficult to balance the benefit to patients of posting photographs for educational purposes with the risk of identifiable features being present, particularly within craniofacial surgery. Non-maleficence: Taking operative media could be a distraction from the patient and lengthen the procedure which could lead to harm. Any content posted on social media should be adapted to avoid trivialisation or sexualisation. Justice: Surgeons should not entertain their audience to increase their following at the expense of patients. CONCLUSIONS: Greater oversight of social media use by plastic surgeons is required to avoid patient harm and tarnishing of the specialty's professional standing. Professional bodies should be tasked with devising a course dedicated to the responsible use of these platforms. This should ensure the public's trust in the specialty does not become eroded and patients are not harmed by unethical social media use. This review highlights the relevant shortfalls of SoMe use by plastic surgery Several proposals are made to reduce the incidence of these shortfalls and to ensure SoMe is used in a professional and responsible manner It also lists areas of the specialty where SoMe is underused and could be of help, such as academia 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 http://www.springer.com/00266 .

Efficacy of Citrullus colocynthis seed extract on Earias vittella, Fabricius, (Lepidoptera: Noctuidae): environment sustainable approach

Abstract Earias vittellaFabricius, 1794 (Noctuidae: Lepidoptera) is deliberated to be one of the most destructive pests of cotton and okra vegetation in the world including Asia. The pest has established resistance to various synthetic insecticides. The use of bio-pesticide is one of the unconventional approaches to develop a vigorous ecosystem without harming non- target pests and beneficial natural insect fauna. In the present study, the toxicity levels of Citrullus colocynthis seed extract have been evaluated against the populations of E. vittellaunder standardized laboratory conditions. The toxic effects of C. colocynthis on development periods, protein contents and esterase activity of the life stages of E. vittella were also evaluated. The toxicity levels of methanol, ethanol, hexane, water and profenofos were evaluated on the 1st instar larvae of E. vittella. LC30 and LC80 concentrations exhibited the effectiveness of methanol-based C. colocynthis seed extract against 1st instar larvae of E. vitella. The enhanced larval and pupal periods were revealed in treated samples during the comparison with untreated samples. The intrinsic rate of increase, net reproductive rate in the LC30 and LC80 concentrations exposed larvae remained less than the control treatment. Fecundity, the esterase activity and protein contents were declined in LC30 and LC80 treated samples as compared to the control. The present findings suggest that C. colosynthis extracts based botanical insecticides are beneficial, ecosystem sustainable and can be integrated with insect management programs from environment safety perspective.

Resumo Earias vittella Fabricius, 1794 (Noctuidae: Lepidoptera) é considerada uma das pragas mais destrutivas de algodão e quiabo no mundo, incluindo a Ásia. Essa praga estabeleceu resistência a vários inseticidas sintéticos. O uso de biopesticidas é uma das abordagens não convencionais para desenvolver um ecossistema saudável sem prejudicar as pragas não alvo e a fauna natural benéfica de insetos. No presente estudo, os níveis de toxicidade do extrato de semente de Citrullus colocynthis foram avaliados nas populações de E. vittella em condições de laboratório padronizadas. Os efeitos tóxicos de C. colocynthis nos períodos de desenvolvimento, conteúdo de proteína e atividade esterase das fases de vida de E. vittella também foram avaliados. Os níveis de toxicidade de metanol, etanol, hexano, água e profenofós foram avaliados em larvas de 1º instar de E. vittella. As concentrações de LC30 e LC80 apresentaram eficácia do extrato de sementes de C. colocynthis à base de metanol contra larvas de 1º instar de E. vittella. Os períodos larval e pupal aumentados foram revelados nas amostras tratadas durante a comparação com as amostras não tratadas. A taxa intrínseca de aumento e a taxa reprodutiva líquida nas concentrações de larvas expostas LC30 e LC80 permaneceram menores do que o tratamento controle. A fecundidade, a atividade da esterase e o conteúdo de proteína diminuíram nas amostras tratadas com LC30 e LC80 em comparação com o controle. As presentes descobertas sugerem que os extratos de C. colocynthis à base de inseticidas botânicos são benéficos, sustentáveis para o ecossistema e podem ser integrados com programas de manejo de insetos do ponto de vista da segurança ambiental.

Efficacy of Citrullus colocynthis seed extract on Earias vittella, Fabricius, (Lepidoptera: Noctuidae): environment sustainable approach / Eficácia do extrato de semente de Citrullus colocynthis em Earias vittella Fabricius (Lepidoptera: Noctuidae): abordagem ambiental sustentável

Abstract Earias vittellaFabricius, 1794 (Noctuidae: Lepidoptera) is deliberated to be one of the most destructive pests of cotton and okra vegetation in the world including Asia. The pest has established resistance to various synthetic insecticides. The use of bio-pesticide is one of the unconventional approaches to develop a vigorous ecosystem without harming non- target pests and beneficial natural insect fauna. In the present study, the toxicity levels of Citrullus colocynthis seed extract have been evaluated against the populations of E. vittellaunder standardized laboratory conditions. The toxic effects of C. colocynthis on development periods, protein contents and esterase activity of the life stages of E. vittella were also evaluated. The toxicity levels of methanol, ethanol, hexane, water and profenofos were evaluated on the 1st instar larvae of E. vittella. LC30 and LC80 concentrations exhibited the effectiveness of methanol-based C. colocynthis seed extract against 1st instar larvae of E. vitella. The enhanced larval and pupal periods were revealed in treated samples during the comparison with untreated samples. The intrinsic rate of increase, net reproductive rate in the LC30 and LC80 concentrations exposed larvae remained less than the control treatment. Fecundity, the esterase activity and protein contents were declined in LC30 and LC80 treated samples as compared to the control. The present findings suggest that C. colosynthis extracts based botanical insecticides are beneficial, ecosystem sustainable and can be integrated with insect management programs from environment safety perspective.

Resumo Earias vittella Fabricius, 1794 (Noctuidae: Lepidoptera) é considerada uma das pragas mais destrutivas de algodão e quiabo no mundo, incluindo a Ásia. Essa praga estabeleceu resistência a vários inseticidas sintéticos. O uso de biopesticidas é uma das abordagens não convencionais para desenvolver um ecossistema saudável sem prejudicar as pragas não alvo e a fauna natural benéfica de insetos. No presente estudo, os níveis de toxicidade do extrato de semente de Citrullus colocynthis foram avaliados nas populações de E. vittella em condições de laboratório padronizadas. Os efeitos tóxicos de C. colocynthis nos períodos de desenvolvimento, conteúdo de proteína e atividade esterase das fases de vida de E. vittella também foram avaliados. Os níveis de toxicidade de metanol, etanol, hexano, água e profenofós foram avaliados em larvas de 1º instar de E. vittella. As concentrações de LC30 e LC80 apresentaram eficácia do extrato de sementes de C. colocynthis à base de metanol contra larvas de 1º instar de E. vittella. Os períodos larval e pupal aumentados foram revelados nas amostras tratadas durante a comparação com as amostras não tratadas. A taxa intrínseca de aumento e a taxa reprodutiva líquida nas concentrações de larvas expostas LC30 e LC80 permaneceram menores do que o tratamento controle. A fecundidade, a atividade da esterase e o conteúdo de proteína diminuíram nas amostras tratadas com LC30 e LC80 em comparação com o controle. As presentes descobertas sugerem que os extratos de C. colocynthis à base de inseticidas botânicos são benéficos, sustentáveis ​​para o ecossistema e podem ser integrados com programas de manejo de insetos do ponto de vista da segurança ambiental.

Time Series and Spectral Analysis of Thermoacoustic Oscillations for Propane-Oxyfuel Combustion in a Swirl-Stabilized, Nonpremixed Combustor.

In this study, the time series data for sound pressure and heat release fluctuations were analyzed to establish the stability window of the propane-oxyflames under different operating conditions. The CO2 dilution level and the combustor power density were varied at a fixed global equivalence ratio to investigate the thermoacoustic instability of the flames. The phase difference between the fluctuations and the instantaneous Rayleigh index reveals whether the heat release and pressure fluctuations are coupled, which can result in the amplification of the sound pressure fluctuations. Results showed a negative Rayleigh index and uncoupled fluctuations at low (<40%) and high (>60%) CO2 dilution with coupled fluctuations and sound pressure amplification at intermediate CO2 dilution levels. A peak of varying magnitude appeared in the frequency domain at 465 Hz for both the heat release and pressure fluctuations in the coupled mode. The Strouhal number at different CO2 concentrations revealed a range of vortex-shedding frequencies (300-1000 Hz), suggesting that the coupled mode is vortex-induced. Phase space reconstruction for the sound pressure fluctuations was carried out and it is observed that although the pressure fluctuations are amplified in the coupled mode, limit cycle amplitudes have not been reached. The recorded coupling and uncoupling of the oscillations associated with flame-vortex interactions at certain CO2 concentrations provides a valuable insight on the combustor's dynamics and toward the development of nonpremixed-oxy-flames combustors.

Perioperative pain management in thoracic surgery: A survey of practices in Australia and New Zealand.

There are few data on current trends in pain management for thoracic surgery in Australia and New Zealand. Several new regional analgesia techniques have been introduced for these operations in the past few years. Our survey aimed to assess current practice and perceptions towards various modalities of pain management for thoracic surgery among anaesthetists in Australia and New Zealand. A 22-question electronic survey was developed and distributed in 2020 with the assistance of the Australian and New Zealand College of Anaesthetists Cardiac Thoracic Vascular and Perfusion Special Interest Group. The survey focused on four key domains-demographics, general pain management, operative technique, and postoperative approach. Of the 696 invitations, 165 complete responses were obtained, for a response rate of 24%. Most respondents reported a trend away from the historical standard of thoracic epidural analgesia, with a preference towards non-neuraxial regional analgesia techniques. If representative of anaesthetists in Australia and New Zealand more widely, this trend may result in less exposure of junior anaesthetists to the insertion and management of thoracic epidurals, potentially resulting in reduced familiarity and confidence in the technique. Furthermore, it demonstrates a notable reliance on surgically or intraoperatively placed paravertebral catheters as the primary analgesic modality, and suggests the need for future studies assessing the optimal method of catheter insertion and perioperative management. It also gives some insight into the current opinion and practice of the respondents with regard to formalised enhanced recovery after surgery pathways, acute pain services, opioid-free anaesthesia, and current medication selection.

Comparing the safety profiles of implants and autologous fat grafting in gluteal augmentation: A systematic review.

Gluteal augmentation has become a popular esthetic procedure since its inception. The main methods are augmentation using implants or autologous fat grafting, which is the harvesting and grafting of patients' own fat tissue. The last review comparing the safety of these methods was written 7 years ago, which warrants the writing of a new one. PubMed, Cochrane, and Medline were searched for studies focusing on the methods of gluteal augmentation listed previously. Five search terms were used and 15 studies fulfilled the criteria. The data were cataloged according to the method described and outcomes compared. Seven articles focused on gluteal implants and another seven assessed autologous fat grafting, whereas one detailed both. The most common complications in 524 implant procedures were wound dehiscence (9.16%), excessive implant palpability (5.92%), and seroma (3.82%), with an overall complication rate of 25%. The most common complications in 1788 gluteal fat augmentation procedures were seroma (6.9%), infection (3.0%), and transient sciatic paresthesia (1.0%), with an overall complication rate of 13%. Several articles listed satisfaction figures, but these were not assessed because this article was not powered to assess this outcome. Overall, gluteal augmentation using autologous fat grafting leads to fewer postoperative complications than implants and allows greater contouring of the buttocks and the surrounding areas. However, it can also be a far more dangerous procedure if certain recommendations are not followed.

Associative factors for tracheostomy in patients presenting with stridor or upper airway obstruction.

OBJECTIVE: This study aimed to identify associative factors for tracheostomy in patients presenting with airway obstruction. METHODS: Data from a tertiary hospital were reviewed to identify patients who presented with airway obstruction between 2009 and 2020. Patient demographics, causative pathology and treatments were analysed. RESULTS: The study identified 297 admitted patients. Of these, 66 underwent a tracheostomy and formed the 'tracheostomy' group and 231 formed the 'other intervention' group. The tracheostomy group had a higher mean age (p = 0.003), and higher percentages of males (p = 0.031) and smokers or ex-smokers (p = 0.020), compared to the other intervention group. The tracheostomy group also had a higher number of patients with a malignancy (p < 0.001) compared to the other intervention group. CONCLUSION: Being older, male, a previous or current smoker, or developing airway obstruction due to a malignancy were found to be the main associative factors for requiring a tracheostomy.

Melanoma predilection for the lower limbs of women compared with men.

The lower limb is a common site for melanoma in women, but the reason for this is not fully understood. To investigate this phenomenon in more detail, we assessed the specific subsites of primary melanoma occurring on the lower limbs of females compared with males across age groups. In a records-based study at an oncology hospital in north-west of England, among an unselected sample of patients with primary invasive melanoma treated between 2002-2015, information was collected on patient age at diagnosis, sex, and co-morbidities, and the tumor thickness and anatomical subsite (thigh, lower leg, foot for lower limb). Of a total sample of 1,522 patients, 316 (227, 72% female) had lower limb melanoma. The most common subsite was lower leg (142 cases with F:M ratio =3.74), followed by thigh (55 cases with F:M = 1.83) and feet (30 cases with F:M = 1.15). At ages <40 years the odds of thigh to foot melanoma was 20 times higher in females than in males (OR 20.0, 95% CI 2.6-152.6) and 7.5 times higher on the lower limb (OR 7.5, 95% CI 1.1-49.2). For ages 40+ years, the odds of females developing thigh melanoma compared to foot melanoma was similar in males versus females (OR 0.8), while the corresponding odds of lower leg melanoma in females versus males remained significantly increased at ages 40-59 and 60+ (OR 4.2 and 2.8 respectively). Our study demonstrates the female predilection for lower limb melanoma persists over most but not all subsites.However, there is heterogeneity in the female to male occurence of lower limb melanoma across subsites and at different ages, which may be linked to relative influence of genetic and environmental risk factors.

Management of a rare, giant multicompartmental lipoma of the hand: a case report and review of the literature.

Lipomas are the commonest benign tumour, made up exclusively of adipose tissue, and can arise anywhere in the body. However, giant lipomas of the hand, defined as >5 cm in diameter, are rare. They have the potential to invade into surrounding areas and cause a multitude of symptoms due to the compression and proximity of underlying structures. We describe a case of a 64-year-old woman who presents with a swelling of the left thenar eminence, associated with numbness and tingling in all fingers. Magnetic resonance imaging and nerve conduction studies confirmed the diagnosis of a lipoma causing median nerve compression. The patient underwent elective surgical excision with good postoperative recovery. The excised lesion, measuring 12 × 7 × 2.4 cm, is one of the largest giant lipomas of the hand reported in literature, and the first to demonstrate invasion from the mid palmar space into both the dorsal sub-aponeurotic space and carpal tunnel.

Efficacy of Citrullus colocynthis seed extract on Earias vittella, Fabricius, (Lepidoptera: Noctuidae): environment sustainable approach.

Earias vittellaFabricius, 1794 (Noctuidae: Lepidoptera) is deliberated to be one of the most destructive pests of cotton and okra vegetation in the world including Asia. The pest has established resistance to various synthetic insecticides. The use of bio-pesticide is one of the unconventional approaches to develop a vigorous ecosystem without harming non- target pests and beneficial natural insect fauna. In the present study, the toxicity levels of Citrullus colocynthis seed extract have been evaluated against the populations of E. vittellaunder standardized laboratory conditions. The toxic effects of C. colocynthis on development periods, protein contents and esterase activity of the life stages of E. vittella were also evaluated. The toxicity levels of methanol, ethanol, hexane, water and profenofos were evaluated on the 1st instar larvae of E. vittella. LC30 and LC80 concentrations exhibited the effectiveness of methanol-based C. colocynthis seed extract against 1st instar larvae of E. vitella. The enhanced larval and pupal periods were revealed in treated samples during the comparison with untreated samples. The intrinsic rate of increase, net reproductive rate in the LC30 and LC80 concentrations exposed larvae remained less than the control treatment. Fecundity, the esterase activity and protein contents were declined in LC30 and LC80 treated samples as compared to the control. The present findings suggest that C. colosynthis extracts based botanical insecticides are beneficial, ecosystem sustainable and can be integrated with insect management programs from environment safety perspective.

Tips and Tricks for Safe Retrieval of Tine-based Leadless Pacemakers.

As leadless pacing (LP) use is expected to increase, it becomes increasingly essential that operators become familiar with the tools and techniques needed to retrieve an LP successfully. The purpose of this review is to describe a stepwise approach for the successful retrieval of tine-based LP devices, including ways to minimize complications.

Subcutaneous cardiac rhythm monitors: state of the art review.

Introduction: Subcutaneous cardiac rhythm monitors (SCRMs) provide continuous ambulatory electrocardiographic monitoring for surveillance of known and identification of infrequent arrhythmias. SCRMs have proven to be helpful for the evaluation of unexplained symptoms and correlation with intermittent cardiac arrhythmias. Successful functioning of SCRM is dependent on accurate detection and successful transmission of the data to the device clinic. As the use of SCRM is steadily increasing, the amount of data that requires timely adjudication requires substantial resources. Newer algorithms for accurate detection and modified workflow systems have been proposed by physicians and the manufacturers to circumvent the issue of data deluge.Areas covered: This paper provides an overview of the various aspects of ambulatory rhythm monitoring with SCRMs including indications, implantation techniques, programming strategies, troubleshooting for issue of false positive and intermittent connectivity and strategies to circumvent data deluge.Expert opinion: SCRM is an invaluable technology for prolonged rhythm monitoring. The clinical benefits from SCRM hinge on accurate arrhythmia detection, reliable transmission of the data and timely adjudication for possible intervention. Further improvement in SCRM technology is needed to minimize false-positive detection, improve connectivity to the central web-based server, and devise strategies to minimize data deluge.

In-hospital outcomes and prevalence of comorbidities in patients with ST-elevation myocardial infarction with and without infective endocarditis: insight from the National Inpatient Sample (2013-2014).

In patients with infective endocarditis (IE), ST-elevation myocardial infarction (STEMI) is an uncommon phenomenon. Due to limited data, we intend to evaluate the clinical outcomes in hospitalized patients with STEMI with and without underlying IE. Mortality and morbidity are exponentially worse in STEMI with concomitant IE when compared with without IE. Patients with primary diagnosis of STEMI with and without IE were identified by querying the Healthcare Cost and Utilization Project database of the National Inpatient Sample for the years 2013 and 2014 based on International Classification of Diseases, Ninth Revision codes. During 2013 and 2014, a total of 117,386 patients were admitted with the principle diagnosis of STEMI, out of whom 305 had comorbid IE. There was a significantly increased in-hospital mortality (27.5% vs 10.8%), length of stay (LOS) (14 days vs 5 days), acute kidney injury (AKI; 44.9% vs 18.7%), stroke (23.6% vs 3%), aortic valve replacement (9.5% vs 0.3%), mitral valve replacement (0.2%-5.2%), sepsis (50% vs 6%) and acute respiratory failure (36.7% vs 16.7%) in patients with STEMI with IE when compared with patients with STEMI and without comorbid IE. STEMI without IE had a higher number of angiographies (58.7% vs 25.9%) and percutaneous coronary interventions (50.7% vs 14.4%) during the hospital course when compared with STEMI with IE. In conclusions, hospitalized patients with STEMI with a concurrent diagnosis of IE are at higher risk of in-hospital mortality, increased LOS, AKI, stroke, valve replacements, and acute respiratory failure.

In-hospital outcomes and prevalence of comorbidities in patients with infective endocarditis with and without heart blocks: Insight from the National Inpatient Sample.

Infective endocarditis (IE) complicated by heart block can have adverse outcomes and usually requires immediate surgical and cardiac interventions. Data on outcomes and trends in patients with IE with concurrent heart block are lacking. Patients with a primary diagnosis of IE with or without heart block were identified by querying the Healthcare Cost and Utilization Project database, specifically the National Inpatient Sample for the years 2013 and 2014, based on International Classification of Diseases Clinical Modification Ninth Revision codes. During 2013 and 2014, a total of 18,733 patients were admitted with a primary diagnosis of IE, including 867 with concurrent heart blocks. Increased in-hospital mortality (13% vs 10.3%), length of stay (19 vs 14 days), and cost of care ($282,573 vs $223,559) were found for patients with IE complicated by heart block. Additionally, these patients were more likely to develop cardiogenic shock (8.9% vs 3.2%), acute kidney injury (40.1% vs 32.6%), and hematologic complications (19.3% vs 15.2%), and require placement of a pacemaker (30.6% vs 0.9%). IE and concurrent heart block resulted in increased requirement for aortic (25.7% vs 6.1%) and mitral (17.3% vs 4.2%) valvular replacements. Conclusion was made that IE with concurrent heart block worsens in-hospital mortality, length of stay, and cost for patients. Our analysis demonstrates an increase in cardiac procedures, specifically aortic and/or mitral valve replacements, and Implantable Cardiovascular Defibrillator/Cardiac Resynchronization Therapy/ Permanent Pacemaker (ICD/CRT/PPM) placement in IE with concurrent heart block. A close telemonitoring system and prompt interventions may represent a significant mitigation strategy to avoid the adverse outcomes observed in this study.

Atezolizumab-Induced Bell's Palsy in a Patient With Small Cell Lung Cancer.

Immune checkpoint inhibitors are rapidly becoming popular therapeutic options for patients suffering from a number of malignancies. Atezolizumab is a programmed cell death ligand-1 inhibitor, and binding to this ligand decreases the ability of tumor cells to evade the immune system, resulting in self-tolerance. While inhibition of these molecules leads to increased T-cell destruction of tumor cells, it also may lead to autoimmune destruction of healthy cells. Neurotoxicity is a rare complication of immune checkpoint inhibitor therapy, and facial palsy as a complication of atezolizumab therapy has only been reported in one additional study. We present the case of a 68-year-old female with a history of small cell carcinoma of the lung presenting with sudden-onset facial palsy and numbness of the distal extremities in the setting of receiving atezolizumab immunotherapy. Our patient was managed with temporary cessation of her immunotherapy, oral prednisone, and supportive measures. Within 4 weeks, the patient had complete resolution of her facial palsy and was able to resume immunotherapy without further complication. Clinicians should be aware of this rare adverse effect in order to enact early management including temporary cessation of therapy to prevent morbidity in patients undergoing immunotherapy.

Paroxysmal Orthostatic Ventricular Tachycardia in a Patient With Supine Hypertension and Orthostatic Hypotension.

Supine orthostatic hypertension with orthostatic hypotension is an autonomic dysfunction where the patients present with hypertension when supine and with decrease in blood pressure while bearing an upright posture. We report on a 74-year-old male who was admitted with dizziness and was found to have profound orthostatic hypotension with supine hypertension. The patient also developed orthostatic paroxysmal premature ventricular beats as well as nonsustained ventricular tachycardia. In this report, we attempt to present the possible mechanism of orthostatic ventricular tachycardia in our patient and the overview of the treatment strategies used in management of patients with supine hypertension and orthostatic hypotension.