An Institutional Analysis of Early Postoperative Free Tissue Transfer Takeback Procedures.

BACKGROUND: Postoperative free tissue transfer reexploration procedures are relatively infrequent but associated with increased overall failure rates. This study examines the differences between flaps requiring takeback versus no takeback, as well as trends in reexploration techniques that may increase the odds of successful salvage. METHODS: A retrospective review was conducted on all free tissue transfers performed at our institution from 2011 to 2022. Patients who underwent flap reexploration within 30 days of the original procedure were compared with a randomly selected control group who underwent free flap procedures without reexploration (1:2 cases to controls). Univariate and multivariate logistic regression analyses were performed. RESULTS: From 1,213 free tissue transfers performed in the study period, 187 patients were included in the analysis. Of the total flaps performed, 62 (0.05%) required takeback, and 125 were randomly selected as a control group. Free flap indication, flap type, reconstruction location, and number of venous anastomoses differed significantly between the two groups. Among the reexplored flaps, 8 (4.3% of the total) had a subsequent failure while 54 (87.10%) were salvaged, with significant differences in cause of initial flap failure, affected vessel type, and salvage technique. CONCLUSION: Free tissue transfers least prone to reexploration involved breast reconstruction in patients without predisposition to hypercoagulability or reconstruction history. When takeback operations were required, salvage was more likely in those without microvascular compromise or with an isolated venous injury who required a single exploratory operation.

Evaluating the Mechanical Strength of Three Dimensionally (3D) Printed Implants in Septorhinoplasty through Finite Element Analysis (FEA).

BACKGROUND: Autologous nasoseptal cartilage grafts are used to correct nasal asymmetry and deviation in rhinoplasty, but patients who have undergone multiple surgeries may have limited autologous cartilage tissue available. 3D-printed L-strut implants may address these challenges in the future, but their mechanical strength is understudied. Silk fibroin-gelatin (SFG), polycaprolactone (PCL), and polylactide (PLA) are bio-inks known for their strength. We present Finite Element Analysis (FEA) models comparing the mechanical strength of 3D-printed SFG, PCL, and PLA implants with nasoseptal cartilage grafts when autologous or allografts are not available. METHODS: FEA models compared the stress and deformation responses of 3D-printed solid and scaffold implant replacements to cartilage. To simulate a daily force from overlying soft tissue, a unidirectional load was applied at the "keystone" region given its structural role and compared with native cartilaginous properties. RESULTS: 3D-printed solid SFG, PCL, and PLA and scaffold PCL and PLA models demonstrated lower deformations compared to cartilage. Solid SFG balanced strength and flexibility. The maximum stress was below all materials' yield stresses suggesting their deformations are unlikely permanent under a daily load. CONCLUSIONS: Our FEA models suggest that 3D-printed L-strut implants carry promising mechanical strength. Solid SFG's results mimicked cartilage's mechanical behavior. Thus, scaffold SFG merits further geometric optimization for potential use for cartilage substitution. 3D-printed septal cartilage replacement implants can potentially enhance surgical management of patients who lack available donor cartilage in select settings. CLINICAL RELEVANCE STATEMENT: Computational simulations can evaluate 3D-printed implant strength and their potential to replace septal cartilage in septorhinoplasty.

Comparing Collagenase and Tissue Subcision for Cellulite Treatment of the Buttock and Thigh Regions: A Systematic Review and Meta-analysis.

Background: In this systematic review, we assessed the therapeutic efficacy and safety of Clostridium histolyticum collagenase (CCH) and tissue subcision (TS) for treating cellulite, which ranges from subtle to pronounced lesions. Methods: A systematic review was performed following PRISMA guidelines for CCH and TS treatment to the thigh and gluteal regions. A proportion meta-analysis was then conducted using Stata statistical software. Results: A total of 14 studies were incorporated into the final analysis. Nine focused on TS and five on CCH injection, collectively reporting outcomes for 1254 patients. Of these, 465 received CCH injection and 789 underwent subcision. For bruising, rates were 89% [95% confidence interval (CI), 71%-96%] with CCH injection and 99% (95% CI, 85%-99%) for subcision; pain requiring analgesic was reported at 74% (95% CI, 55%-87%) for CCH and 60% (95% CI, 43%-76%) for subcision; both showed induration at 7% (95% CI, 5%-11% for CCH, 95% CI, 2%-25% for subcision), whereas skin discoloration was higher post-CCH injection at 16% (95% CI, 10%-26%) compared with 7% (95% CI, 5%-10%) postsubcision. Conclusions: Both CCH and TS seem effective treatments for cellulite. However, upon evaluating the adverse outcomes between the two modalities, subcision demonstrated a higher incidence of bruising, albeit similar rates of induration compared with CCH injection. Conversely, the CCH injection group manifested a higher propensity for pain requiring analgesia and notably exhibited increased instances of skin discoloration compared with their subcision patient group. Further standardized research is crucial for more informed cellulite treatment decisions and for comparing efficacy, safety, and cost-effectiveness between TS and CCH.

Three-Dimensional Printing in Surgical Education: An Updated Systematic Review of the Literature.

INTRODUCTION: Three-dimensional printing (3DP) is being integrated into surgical practice at a significant pace, from preprocedural planning to procedure simulation. 3DP is especially useful in surgical education, where printed models are highly accurate and customizable. The aim of this study was to evaluate how 3DP is being integrated most recently into surgical residency training. METHODS: We performed a structured literature search of the OVID/MEDLINE, EMBASE, and PUBMED databases following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Articles published from 2016 to 2023 that met predefined inclusion and exclusion criteria were included. Data extracted included surgical subspecialty using 3DP, application of 3DP, and any reported satisfaction measures of trainees. A thorough analysis of pooled data was performed to evaluate satisfaction rates among studies. RESULTS: A total of 85 studies were included. The median number of participants was 18 (interquartile range 10-27). Fourteen surgical disciplines were represented, with ear, nose, and throat/otolaryngology having the highest recorded utilization of 3DP models among residents and medical students (22.0%), followed by neurosurgery (14.0%) and urology (12.0%). 3DP models were created most frequently to model soft tissue (35.3%), bone (24.7%), vessel (14.1%), mixed (16.4%), or whole organs (6.66%) (Fig.1). Feedback from trainees was overwhelmingly positive regarding the fidelity of the models and their support for integration into their training programs. Among trainees, the combined satisfaction rate with their use in the curriculum was 95% (95% confidence interval, 0.92-0.97), and the satisfaction rate with the model fidelity was 90% (95% confidence interval, 0.86-0.94). CONCLUSIONS: There is wide variation in the surgical specialties utilizing 3DP models in training. These models are effective in increasing trainee comfort with both common and rare scenarios and are associated with a high degree of resident support and satisfaction. Plastic surgery programs may benefit from the integration of this technology, potentially strengthening future surgical curricula. Objective evaluations of their pedagogic effects on residents are areas of future research.

The value of microvascular breast reconstruction: Cost equivalence of TRAM and DIEP flaps implications in the era of CMS reforms.

BACKGROUND: Recent CMS billing changes have raised concerns about insurance coverage for deep inferior epigastric perforator (DIEP) flap breast reconstruction. This study compared the costs and utilization of transverse rectus abdominis myocutaneous (TRAM), DIEP, and latissimus dorsi (LD) flaps in breast reconstruction. METHOD: The study utilized the National Inpatient Sample database to identify female patients who underwent DIEP, TRAM, and LD flap procedures from 2016 to 2019. Key data such as patient demographics, length of stay, complications, and costs (adjusted to 2021 USD) were analyzed, focusing on differences across the flap types. RESULTS: A total of 17,770 weighted patient encounters were identified, with the median age being 51. The majority underwent DIEP flaps (73.5%), followed by TRAM (14.2%) and LD (12.1%) flaps. The findings revealed that DIEP and TRAM flaps had a similar length of stay (LOS), while LD flaps typically had a shorter LOS. The total hospital charges to costs using cost-to-charge ratio were also comparable between DIEP and TRAM flaps, whereas LD flaps were significantly less expensive. Factors such as income quartile, primary payer of hospitalization, and geographic region significantly influenced flap choice. CONCLUSION: The study's results appear to contradict the prevailing notion that TRAM flaps are more cost-effective than DIEP flaps. The total hospital charges to costs using cost-to-charge ratio and hospital stays associated with TRAM and DIEP flaps were found to be similar. These findings suggest that changes in the insurance landscape, which may limit the use of DIEP flaps, could undermine patient autonomy while not necessarily reducing healthcare costs. Such policy shifts could favor less costly options like the LD flap, potentially altering the landscape of microvascular breast reconstruction.

Exploring the Efficacy of Selected Allografts in Chronic Wound Healing: Evidence from Murine Models and Clinical Data for a Proposed Treatment Algorithm.

SIGNIFICANCE: Chronic wounds can lead to poor outcomes for patients, with risks including amputation and death. In the United States, chronic wounds affect 2.5% of the population and cost up to $28 billion per year in primary healthcare costs. RECENT ADVANCES: Allograft tissues (dermal, amnion, and amnion/chorion) have shown efficacy in improving healing of chronic, recalcitrant wounds in human patients, as evidenced by multiple clinical trials. Their mechanisms of actions have been relatively understudied, until recently. Research in murine models has shown dermal allografts promote re-epithelialization, amnion allografts promote granulation tissue formation and angiogenesis, and amnion/chorion allografts support all stages of wound healing. These findings not only confirm effectiveness, but they shed light on mechanisms of action responsible for their therapeutic utility in patients. CRITICAL ISSUES: Despite the promise of allografts in chronic wound care, a gap exists in understanding which allografts are most effective during each wound healing stage. The variable efficacy among each type of allograft suggests a mechanistic approach towards a proposed clinical treatment algorithm, based on wound characteristics and patient's needs, may be beneficial. FUTURE DIRECTIONS: Recent advances in allografts provide a framework for further investigations on how allograft selection can be based on specific needs of individual patients. This requires additional research to identify which allografts support the best outcomes during each stage of the wound healing process as well as utility in specific wound types. Longitudinal human studies investigating the long-term impacts of allografts, particularly in the remodeling phase, are also essential to developing a deeper understanding of their role in sustained wound repair and recovery.

Redefining Surgical Materials: Applications of Silk Fibroin in Osteofixation and Fracture Repair.

Silk and silk derivatives have emerged as a possible alternative in surgical device development, offering mechanical strength, biocompatibility, and environmental sustainability. Through a systematic review following PRISMA guidelines, this study evaluated silk fibroin's application across pre-clinical and clinical settings, focusing on its role as screws and plates for osteofixation. A comprehensive search yielded 245 studies, with 33 subjected to full-text review and 15 ultimately included for qualitative analysis. The findings underscore silk fibroin's superior properties, including its tunable degradation rates and ability to be functionalized with therapeutic agents. In vivo and in vitro studies demonstrated its efficacy in enhancing bone healing, offering improved outcomes in osteofixation, particularly for craniofacial defects. Silk fibroin's remarkable attributes in biodegradation and drug release capabilities underscore its potential to enhance patient care. Ultimately, silk fibroin's integration into surgical practices promises a revolution in patient outcomes and environmental sustainability. Its versatility, coupled with the continuous progress in fabrication techniques, signals a promising horizon for its widespread acceptance in the medical field, potentially establishing a new benchmark in surgical treatment. Further research is expected to solidify the transition of silk products from basic science to patient care, paving the way for widespread use in various surgical applications.

Management of Superficial and Deep Peroneal Nerve Neuromas with Targeted Muscle Reinnervation in Nonamputees: Operative Technique and Early Outcomes.

Background: Targeted muscle reinnervation (TMR), a surgical technique developed by the senior authors that coapts proximal ends of nerves to distal motor nerves of adjacent muscles, has demonstrated efficacy in the treatment and prevention of neuroma pain. The objective of this study is to describe the surgical technique for TMR of the superficial peroneal nerve (SPN) and deep peroneal nerve (DPN) in nonamputee patients and provide data on postoperative functional outcomes. Methods: A single-institution retrospective chart review was performed between March 2018 and April 2021. Patients were de-identified and included if they were nonamputees receiving TMR for pain in the peroneal nerve distribution. Data extracted included demographic information, symptoms before operation, relevant nerve coaptation, peri-, and postoperative complications, and long-term functional outcomes. Results: Of the 19 patients reviewed, 11 patients underwent TMR of the SPN alone: eight had complete resolution of their symptoms; two indicated partial improvement in pain; and one patient had no improvement. Four patients underwent TMR of the DPN alone: two patients had complete resolution of their pain, and two patients had partial improvement with pain. Four patients underwent TMR of both the SPN/DPN: two patients had complete resolution of their symptoms, and two patients were noted to have significant improvement but had persistent pain from prior foot operations. Average follow-up time was 260 days. Conclusions: TMR is a successful technique in the management of SPN and DPN neuroma pain. Our technique revealed excellent clinical outcomes, no procedure-specific complications, and improved subjective pain reports.

From Case Reports to Molecular Insight: Examining the Outcomes and Underlying Mechanisms of Squamous Cell Carcinoma in Breast Implant Patients-A Systematic Review.

There is extensive coverage in the existing literature on implant-associated lymphomas like anaplastic large-cell lymphoma, but breast implant-associated squamous cell carcinoma (BIA-SCC) has received limited scholarly attention since its first case in 1992. Thus, this study aims to conduct a qualitative synthesis focused on the underexplored association between breast implants and BIA-SCC. A systematic review was conducted utilizing the PubMed, Web of Science, and Cochrane databases to identify all currently reported cases of BIA-SCC. Additionally, a literature review was performed to identify potential biochemical mechanisms that could lead to BIA-SCC. Studies were vetted for quality using the NIH quality assessment tool. From an initial pool of 246 papers, 11 met the quality criteria for inclusion, examining a total of 14 patients aged between 40 and 81 years. BIA-SCC was found in a diverse range of implants, including those with smooth and textured surfaces, as well as those filled with saline and silicone. The condition notably manifested a proclivity for aggressive clinical progression, as evidenced by a mortality rate approximating 21.4% within a post-diagnostic interval of six months. Our literature review reveals that chronic inflammation, driven by various external factors such as pathogens and implants, can initiate carcinogenesis through epigenetic modifications and immune system alterations. This includes effects from exosomes and macrophage polarization, showcasing potential pathways for the pathogenesis of BIA-SCC. The study highlights the pressing need for further investigation into BIA-SCC, a subject hitherto inadequately addressed in the academic sphere. This necessitates the urgency for early screening and intervention to improve postoperative outcomes. While the review is confined by its reliance on case reports and series, it serves as a valuable reference for future research endeavors.

Utilization of patient-reported outcome measures in plastic surgery clinical trials: A systematic review.

BACKGROUND: Patient-reported outcomes (PROs) have evolved to validated questionnaires assessing health-related quality of life. This systematic review evaluates the utilization of PROs in United States plastic and reconstructive surgery (PRS) clinical trials (CTs). METHODS: A medical librarian conducted a search strategy for PRS CTs from 2012 to 2022. CTs were identified and assessed for PRO utilization. Summary statistics were performed, and Fisher's exact test was used for subgroup analysis. RESULTS: Of the 3609 studies initially identified, 154 were PRS CTs. Approximately half (80 studies) employed PROs, encompassing 13,190 participants, 95% (12,229) of whom were female. Among the CTs, 37 (48%) were in the field of reconstruction, while 25 (32%) were cosmetic. Pain (35%) and patient satisfaction (24%) were the most common primary outcomes. Validated PROs were the main outcome in 61% of these trials, with the visual analog scale (19%) and BREAST-Q (15%) as the top instruments. Funding was primarily private (34%) or not reported (49%). No significant trend in validated PRO usage was observed over the examined decade. CONCLUSIONS: The use of PROs is relevant for healthcare delivery and improvement as they provide insight into the efficacy of treatments from a patient-centered viewpoint. PROs are reported in just over half of PRS CTs, and within those CTs, the use of validated questionnaires is inconsistent. Therefore, emerging CTs should strive to incorporate PRO measures and utilize the existing validated tools to assess novel interventions and ensure that the data reported is objective.

"A Fifty-Year Review of Congressional Membership by Healthcare Professionals: Is Surgical Representation Adequate for Informed Legislation?"

SUMMARY: Whereas 100% of Congressional legislators vote on healthcare policy, only a minority have a background in healthcare. A review of the participation of healthcare professionals (HCPs) in Congress, highlighting participation by surgeons, is critical to the future policy-making endeavors in healthcare. This article seeks to better understand the characteristics of HCPs that engage in advocacy and describe the trends in their representation in Congress, with commentary on participation by surgeons and its impact on current health advocacy efforts.A search of Congress.gov and the Biographical Directory of the United States Congress was performed to identify professional healthcare history for each Congressperson, followed by review of official campaign websites for health advocacy work. Statistical analysis was performed using IBM® SPSS® Statistics Software for changes in representation of healthcare professionals, physicians, and surgeons in Congress over time.While there has been increasing representation of HCPs in Congress in the last 25 years, surgeons have the lowest increase in Congressional membership. For healthcare reform to optimally address high costs, variable insurance coverage and reimbursement rates, and equal access to care, more physicians must make healthcare advocacy efforts an integral part of their careers. Incorporation of education in areas of healthcare advocacy and/or reform into undergraduate and graduate medical education curricula may help address deficiencies in knowledge of current healthcare-related events to further encourage involvement in healthcare legislation.

12-Year Trends of Orofacial Clefts in the United States: Highlighting Racial/Ethnic Differences in Prevalence of Cleft Lip and Cleft Palate.

OBJECTIVE: Discrepancies in prevalence among infants with orofacial clefts are public health research priorities. Our objective was to calculate updated estimated prevalence of orofacial clefts in the United States, with sub-analyses by racial/ethnic group. DESIGN: The National Birth Defect Prevention Network database was used to evaluate trends in cases with orofacial cleft in the United States from 2006 to 2018. Cases with cleft lip with and without cleft palate (CL ± P) and cleft palate (CP) alone were sub-stratified by racial/ethnic category. Estimated prevalence was calculated using the total live births reported in each maternal racial/ethnic group. The odds ratio (OR) was calculated to measure the strength of association between racial/ethnic group and risk of orofacial clefts. RESULTS: Estimated prevalence rates show that maternally-reported Native American/Alaskan Native individuals were 43.8% (p < 0.0001) and 36.0% (p < 0.0001) more likely to have CL ± P and CP alone, respectively, compared to maternally-reported non-Hispanic White individuals. Estimated prevalence of CL ± P in maternally-reported non-Hispanic Black individuals (OR = 0.64) and maternally-reported Asians/Pacific Islander individuals were significantly lower than in maternally-reported non-Hispanic White individuals (OR = 0.63, p < 0.0001). Estimated prevalence of CP alone was significantly lower in maternally-reported non-Hispanic Black individuals (OR = 0.64, p < 0.0001), maternally-reported Asians/Pacific Islander individuals (OR = 0.69, p < 0.0001), and maternally-reported Hispanic individuals (OR = 0.81, p < 0.0001). CONCLUSIONS: Across the total population, there was no significant change in estimated orofacial cleft prevalence. However, there were significant disproportions in estimated orofacial cleft prevalence across racial/ethnic groups, which may guide further discussion among craniofacial health care providers and centers and their patients regarding differences in cleft risk factors.

Do Race and Socioeconomic Status Affect Date of Initial Presentation and Repair of Patients with Cleft lip ± Palate and Head Shape Conditions?

OBJECTIVE: To evaluate regarding the effect of race and socioeconomic status (SES) on the timing of cleft lip and/or palate (CL ± P), craniosynostosis, and plagiocephaly presentation to clinic and possible repair. DESIGN/METHODS: A retrospective review of patients with CL ± P and head shape conditions from Jan 2001 to Feb 2022 were included. Age at first plastic surgery clinic appointment, age at repair if applicable, gender, race, and zip code were collected. The Validated Child Opportunity Index (COI) scale was calculated based on zip code as a measure of SES. Kruskal-Wallis tests and Dunn's procedures were used for continuous variables and post hoc pairwise comparisons. RESULTS: 2733 patients with CL ± P, 9974 with plagiocephaly/brachycephaly, and 59 patients with craniosynostosis were included. Among patients with CL ± P, Black and Hispanic patients presented significantly later to both first plastic surgery clinic appointment and age at repair than White patients (P < .001). White patients and higher SES were associated with a significantly earlier date of initial presentation to plastic surgery clinic for head shape conditions (P < .001). CONCLUSIONS: Race and SES may play an important role in the delay of first presentation to plastic surgery clinic and subsequent repair for these patient populations. Further educational efforts must be provided to ensure equitable care. This single institutional study may serve to encourage other academic centers to analyze the timing of care for our pediatric patients.

Evaluating skin colour diversity in the validation of scar assessment tools.

Across scar studies, there is a lack of dark-skinned individuals, who have a predisposition for keloid formation, altered pigmentation and poorer quality of life (QOL). There is a need for patients of colour to be included in scar scale development and validation. In this study, we evaluate the racial diversity of patients included in the validation of scar assessment scales. A systematic review was conducted for articles reporting on the validation of a scar assessment tool. Racial, ethnic and Fitzpatrick skin type (FST) data were extracted. Fifteen scar scale validation studies were included. Nine of the studies did not mention FST, race or ethnicity of the patients. Two of the studies that reported FST or race information only included White patients or included no FST V/VI patients: mapping assessment of scars (MAPS) and University of North Carolina '4P'. Only four studies included non-White patients or dark-skinned patients in the validation of their scar scale: the modified Vancouver Scar Scale (VSS), modified Patient and Observer Scar Assessment Scale (POSAS), acne QOL and SCAR-Q scales. The patients included in the modified VSS validation were 7% and 13% FST V/VI, 14% African in the modified POSAS and 4.5% FST V/VI in the SCAR-Q. We highlight the severe lack of diversity in scar scale validation, with only 4 out of 15 studies including dark-skinned patients. Given the susceptibility of darker-skinned individuals to have poorer scarring outcomes, it is critical to include patients of colour in the very assessment tools that determine their scar prognosis. Inclusion of patients of colour in scar scale development will improve scar assessment and clinical decision-making.

Targeted muscle reinnervation in above knee amputation: surgical technique.

In the United States, an estimated 185,000 individuals undergo amputation of their upper or lower limb. This results in residual limb pain in up to 85% of cases. Targeted muscle reinnervation (TMR) is a technique that has been shown to prevent symptomatic neuroma formation. In this video, the authors demonstrate their technique utilizing TMR at the time of above-the-knee amputation. Coaptations are made to provide motor targets for branches of the saphenous, tibial, and peroneal sensory nerves. At the featured patient's most recent follow-up visit 3 months postoperatively, she reported no stump pain or phantom limb pain. The video can be found here: https://stream.cadmore.media/r10.3171/2022.10.FOCVID2293.

Incidental Bystander or Essential Culprit: A Systematic Review of Bacterial Significance in the Pathogenesis of Breast Implant-Associated Anaplastic Large Cell Lymphoma.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a distinct subtype of T-cell non-Hodgkin lymphoma that arises in the context of prolonged exposure to textured breast implants. The intent of this manuscript is to explore whether the bacterial presence in biofilms on these implants is a mere incidental finding or plays a pivotal role in the pathogenesis of BIA-ALCL. Our goal is to delineate the extent of bacterial involvement, offering insights into potential underlying mechanisms, and establishing future research priorities aimed at resolving the remaining uncertainties surrounding this complex association. A comprehensive systematic review of several databases was performed. The search strategy was designed and conducted by an experienced librarian using controlled vocabulary with keywords. The electronic search identified 442 publications. After evaluation, six studies from 2015 to 2021 were included, encompassing 201 female patients aged 23 to 75. The diagnosis span post-implantation ranged from 53 to 135.6 months. Studies consistently found bacteria near breast implants in both BIA-ALCL cases and controls, with varied microbial findings. Both BIA-ALCL cases and controls exhibited the presence of specific bacteria, including Pseudomonas aeruginosa, Klebsiella oxytoca, Staphylococcus aureus, and Ralstonia spp., without any statistically significant differences between groups. The use of antiseptic and antimicrobial agents during implant insertion did not demonstrate any impact on reducing or altering the risk of developing BIA-ALCL. Our systematic review reveals that the current evidence is inadequate to link bacterial etiology as a central factor in the development of BIA-ALCL. The limitations in the existing data prevent a complete dismissal of the role of biofilms in its pathogenesis. The observed gap in knowledge underscores the need for more focused and comprehensive research, which should be structured in a multi-faceted approach. Initially, this involves the utilization of sophisticated genomic and proteomic methods. Following this, it is crucial to delve into the study of immunological reactions specifically induced by biofilms. Finally, this research should incorporate extended observational studies, meticulously tracking the evolution of biofilm development and its correlation with the emergence of BIA-ALCL. In light of the inconclusive nature of current findings, further investigation is not only justified but urgently needed to clarify these unresolved issues.