Firearm ownership among American veterans: findings from the 2015 National Firearm Survey.

BACKGROUND: While the majority of veteran suicides involve firearms, no contemporary data describing firearm ownership among US veterans are available. This study uses survey data to describe the prevalence of firearm ownership among a nationally representative sample of veterans, as well as veterans' reasons for firearm ownership. METHODS: A cross-sectional, nationally representative web-based survey conducted in 2015. RESULTS: Nearly half of all veterans own one or more firearms (44.9%, 95% CI 41.3-48.6%), with male veterans more commonly owning firearms than do female veterans (47.2%, 95% CI 43.4-51.0% versus 24.4%, 95%CI 15.6-36.1%). Most veteran firearm owners own both handguns and long guns (56.5%, 95% CI 51.1-61.8%); a majority cite protection as a primary reason for firearm ownership (63.1%, 95% CI 58.2-67.8%). CONCLUSIONS: The current study is the first to provide detailed, nationally representative information about firearm ownership among U.S. veterans. Better understanding firearm ownership among veterans can usefully inform ongoing suicide prevention efforts aiming to facilitate lethal means safety among vulnerable veterans during at-risk periods.

Reconstruction of Congenital Mandibular Hypoplasia With Microvascular Free Fibula Flaps in the Pediatric Population: A Paradigm Shift.

BACKGROUND: The microvascular free fibula flap has become the gold standard for reconstruction of complex mandibular defects since its description by Hidalgo in 1989. Prior studies have demonstrated its safety and efficacy in the pediatric population. However, this reconstructive method is often used only as a last resort for correction of congenital mandibular hypoplasia, after failure of bone grafting and distraction osteogenesis. The authors describe our experience using this technique, facilitated by virtual planning and prefabricated cutting jigs, for children with severe congenital mandibular hypoplasia. METHODS: All patients with mandibular reconstruction with a fibula flap in children with congenital mandibular hypoplasia between 2009 and 2014 by the senior authors were identified. Each patient underwent preoperative computed tomography scanning and virtual surgical planning to create custom cutting jigs for creation of the mandibular defect and fibular osteotomies. Preoperative, intraoperative, and postoperative medical records were examined in detail. RESULTS: Five patients age 10 to 18 with congenital mandibular hypoplasia and Pruzansky Grade III mandibles underwent microvascular free fibula flap for mandibular reconstruction during this period. Flap success rate was 100%. All patients underwent subsequent revision procedures to improve symmetry or for hardware removal. The 4 patients in our series who required dental implants were able to have them placed into their mandibular reconstruction. CONCLUSIONS: Preoperative virtual planning and prefabricated cutting jigs allow for precise complex fibula reconstruction of the mandible in the pediatric population. Additionally, virtual planning facilitates concomitant orthognathic procedures in patients with hemifacial microsomia. Our early success in this patient population leads us to suggest that while the free fibula can be safely and successfully used after multiple prior surgical interventions in the same anatomic region, it can also be a powerful tool for primary correction of congenital mandibular hypoplasia.

Roll, Spin, Wash, or Filter? Processing of Lipoaspirate for Autologous Fat Grafting: An Updated, Evidence-Based Review of the Literature.

BACKGROUND: The use of autologous adipose tissue harvested through liposuction techniques for soft-tissue augmentation has become commonplace among cosmetic and reconstructive surgeons alike. Despite its longstanding use in the plastic surgery community, substantial controversy remains regarding the optimal method of processing harvested lipoaspirate before grafting. This evidence-based review builds on prior examinations of the literature to evaluate both established and novel methods for lipoaspirate processing. METHODS: A comprehensive, systematic review of the literature was conducted using Ovid MEDLINE in January of 2015 to identify all relevant publications subsequent to the most recent review on this topic. Randomized controlled trials, clinical trials, and comparative studies comparing at least two of the following techniques were included: decanting, cotton gauze (Telfa) rolling, centrifugation, washing, filtration, and stromal vascular fraction isolation. RESULTS: Nine articles comparing various methods of processing human fat for autologous grafting were selected based on inclusion and exclusion criteria. Five compared established processing techniques (i.e., decanting, cotton gauze rolling, centrifugation, and washing) and four publications evaluated newer proprietary technologies, including washing, filtration, and/or methods to isolate stromal vascular fraction. CONCLUSIONS: The authors failed to find compelling evidence to advocate a single technique as the superior method for processing lipoaspirate in preparation for autologous fat grafting. A paucity of high-quality data continues to limit the clinician's ability to determine the optimal method for purifying harvested adipose tissue. Novel automated technologies hold promise, particularly for large-volume fat grafting; however, extensive additional research is required to understand their true utility and efficiency in clinical settings.

Neurovascular compromise due to true brachial artery aneurysm at the site of a previously ligated arteriovenous fistula: Case report and review of literature.

True arterial aneurysms of the upper extremity are rare. The case described is that of a 48-year-old man presenting with median neuropathy and distal vascular compromise 4 years after ligation of a brachiocephalic arteriovenous fistula. We describe our approach and present a review of the relevant literature.

Free flap lower extremity reconstruction in the obese population: does weight matter?

The obesity epidemic continues to grow, and we have observed greater numbers of obese individuals among patients seeking lower extremity reconstruction at our institution. These patients may present a greater reconstructive challenge, thus we sought to identify risk factors and differences in outcomes among patients undergoing lower extremity reconstruction.In this study we have performed a retrospective cohort analysis of patients undergoing lower extremity reconstruction with free tissue transfer at our institution from 2005 to 2012. Patients were classified using the World Health Organization criteria for obesity. Records were reviewed for patient characteristics, mechanism of injury, indications for reconstruction, and surgical technique, with a focus on intraoperative and early postoperative complications and outcomes.A total of 43 out of the 119 patients undergoing lower extremity reconstruction were obese (body mass index ≥ 30). Mechanism of injury, wound location, and the indications for reconstruction were similar in both cohorts. No significant differences were found in operative characteristics and techniques, including the type of flap utilized, operative time, or thrombotic events. No significant differences were seen in complication rates overall, however, obese patients more frequently needed second flaps (11.6 vs. 0%, p=0.005).This study concludes that successful lower extremity reconstruction can be performed in the obese population, with few differences in complication rates and outcomes relative to healthy weight patients.

Free tissue transfer for complex reconstruction of the lower extremity: experience of a young microsurgeon.

To examine the limb salvage experience of a young microsurgeon to determine risk factors for complications and demonstrate lessons learned through cases in practice. We performed a retrospective review of lower extremity (LE) reconstruction between 2007 and 2012 performed by the senior author. This analysis focused on medical comorbidities, mechanisms, indications, and perioperative complications. A total of 61 free tissue transfers were performed with a 95% LE salvage rate. The most common donor site was the anterolateral thigh (ALT) (n = 39). Infection (n = 25) and trauma (n = 25) were the most common indications for intervention. A total of 18 complications were reported, with 8 defined as major complications. Total flap loss occurred in three patients. Through increased utilization of the ALT and adherence to lessons learned over time, improvements in outcomes can occur, giving patients the best possible chance at limb salvage.

Abdominal wall reconstruction in the obese: an assessment of complications from the National Surgical Quality Improvement Program datasets.

BACKGROUND: This study utilizes the American College of Surgeons National Surgical Quality Improvement Program database to better understand the impact of obesity on perioperative surgical morbidity in abdominal wall reconstruction (AWR). METHODS: We reviewed the 2005 to 2010 American College of Surgeons National Surgical Quality Improvement Program databases, identifying cases of AWR and examining early complications in the context of obesity (body mass index > 30, World Health Organization classes 1 to 3). RESULTS: Of 1,695 patients undergoing AWR, 1,078 (63.2%) patients were obese (mean body mass index = 37.6 kg/m(2)). Major surgical complications (15.3% vs 10.1%, P = .003), wound complications (12.5% vs 8.1%, P = .006), medical complications (16.2% vs 11.2%, P = .005) and return to the operating room (9.1% vs 5.4%, P = .006) were significantly increased, while renal complications (1.9% vs .8%, P = .09) neared significance. On logistic regression, obesity only directly led to a significantly increased odds of having a renal complication (odds ratio = 4.4, P = .04). Complications were still noted to increase with World Health Organization classification, including a concerning incidence of venous thromboembolism. CONCLUSIONS: Although the incidence of complications increased with obesity, obesity itself does not appear to increase the odds of perioperative morbidity. Specific care should be given to VTE prophylaxis and to preventing renal complications.

Complications following reduction mammaplasty: a review of 3538 cases from the 2005-2010 NSQIP data sets.

BACKGROUND: Reduction mammaplasty is an established and effective technique to treat symptomatic macromastia. Variable rates of complications have been reported, and there is a continued need for better outcome assessment studies. OBJECTIVE: The authors investigate predictors of postoperative complications following reduction mammaplasty using the National Surgery Quality Improvement Program (NSQIP) data sets. METHODS: The 2005-2010 American College of Surgeons NSQIP databases were reviewed to identify primary encounters for reduction mammaplasty using Current Procedural Terminology code 19318. Two complication types were recorded: major complications (deep infection and return to operating room) and any complication (all surgical complications). Preoperative patient factors and comorbidities, as well as intraoperative variables, were assessed. A multivariate regression analysis was used to identify independent predictors of complications. RESULTS: A total of 3538 patients were identified with an average age of 43 years and body mass index of 31.6 kg/m(2). Most patients underwent outpatient surgery (80.5%) with an average operative time of 180 minutes. The incidence of overall surgical complications was 5.1%. The following factors were independently associated with any surgical complications: morbid obesity (odds ratio [OR], 2.1; P < .001), active smoking (OR, 1.7; P < .001), history of dyspnea (OR, 2.0; P < .001), and resident participation (OR, 1.8; P = .01). The incidence of major surgical complications was 2.1%. Factors associated with major complications included active smoking (OR, 2.7; P < .001), dyspnea (OR, 2.6; P < .001), resident participation (OR, 2.1; P < .001), and inpatient surgery (OR, 1.8; P = .01). CONCLUSIONS: This study demonstrates overall incidence of complications in 1 in 20 patients and a 1 in 50 incidence of a major surgical complication. Noteworthy findings include the identification of morbid obesity as a significant predictor of overall morbidity and active smoking as a strong predictor of major surgical morbidity. These data can assist surgeons in preoperative counseling and enhance perioperative decision making.

Breast reconstruction in the morbidly obese patient: assessment of 30-day complications using the 2005 to 2010 National Surgical Quality Improvement Program data sets.

BACKGROUND: The authors assess the risk and safety profiles of both implant and autologous breast reconstructions in the morbidly obese population using the National Surgical Quality Improvement Program data sets. METHODS: The authors reviewed the 2005 to 2010 National Surgical Quality Improvement Program databases, identifying encounters for Current Procedural Terminology codes including either implant-based reconstruction or autologous reconstruction. Patients were classified and compared based on World Health Organization obesity criteria. Complications were divided into three categories: major surgical complications, wound complications, and medical complications. RESULTS: During the study period, 15,937 breast reconstructions were identified. The incidence of obesity was 27.1 percent, with 4.0 percent defined as class III (morbidly) obese. Morbidly obese patients had significantly higher rates of almost all complications compared with nonobese patients, including major surgical complications (p < 0.001), medical complications (p < 0.001), respiratory complications (p = 0.015), venous thromboembolism (p = 0.001), and wound complications (p < 0.001). These patients also were more likely to require a return to the operating room both for any reason (p < 0.001) and specifically for prosthesis/flap failure (p < 0.001). Morbid obesity was found to be an independent predictor of wound complications (OR, 2.1; p < 0.001), surgical complications (OR, 1.6; p < 0.001), medical complications (OR, 1.6; p = 0.01), and return to the operating room (OR, 1.5; p < 0.001). There was no significant difference in the 30-day surgical complication rates between implant and autologous reconstructions in the morbidly obese (p = 0.23). CONCLUSION: Morbid obesity is associated with a significantly increased risk of perioperative complications that translates into progressive, higher rates of overall morbidity, regardless of reconstructive modality. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Optimizing the fascial closure: an analysis of 1261 abdominally based free flap reconstructions.

BACKGROUND: Donor-site morbidity continues to be a significant complication in patients undergoing abdominally based breast reconstruction. The purposes of our study were to critically examine abdominal donor-site morbidity and to present our algorithm for optimizing donor site closure to reduce these complications. METHODS: We performed a retrospective cohort study examining all patients undergoing abdominally based free tissue transfer for breast reconstruction from 2005 to 2011 at our institution. Data were analyzed for overall donor site morbidity, as defined by hernia/bulge or reoperation for debridement and/or mesh removal and for hernia/bulge alone. RESULTS: A total of 812 patients underwent 1261 free tissue transfers. Fifty-three patients (6.5%) experienced donor-site morbidity, including 27 hernias/bulges (3.3%). No significant difference in overall abdominal morbidity was found between unilateral and bilateral reconstructions (P = 0.39) or the use of muscle in the flap (P = 0.11 unilateral msfTRAM, P = 0.76 bilateral). Prior lower abdominal surgery was associated with higher rates of donor-site morbidity (P = 0.04); hypertension (P = 0.012) and multiple medical comorbidities (P < 0.001) were also significantly more common in these patients. Obesity was the only patient characteristic associated with higher rates of hernia/bulge (P = 0.04). Delayed abdominal would healing was associated with hernia/bulge (P < 0.001); these patients were significantly more likely to develop this complication (odds ratio = 6.3, P < 0.001). CONCLUSIONS: Particular attention must be provided to donor-site closure in obese patients and those with hypertension and multiple medical comorbidities. Low rates of abdominal wall morbidity result from meticulous fascial reconstruction and reinforcement and careful attention to tension-free soft tissue closure.

The virtual-patient pilot: testing a new tool for undergraduate surgical education and assessment.

BACKGROUND: The virtual patient (VP) is a web-based tool that allows students to test their clinical decision-making skills using simulated patients. METHODS: Three VP cases were developed using commercially available software to simulate common surgical scenarios. Surgical clerks volunteered to complete VP cases. Upon case completion, an individual performance score (IPS, 0-100) was generated and a 16-item survey was administered. Surgery shelf exam scores of clerks who completed VP cases were compared with a cohort of students who did not have exposure to VP cases. Descriptive statistics were performed to characterize survey results and mean IPS. RESULTS: Surgical clerks felt that the VP platform was simple to use, and both the content and images were well presented. They also felt that VPs enhanced learning and were helpful in understanding surgical concepts. Mean IPS at conclusion of the surgery clerkship was 69.2 (SD 26.5). Mean performance on the surgery shelf exam for the student cohort who had exposure to VPs was 86.5 (SD 7.4), whereas mean performance for the unexposed student cohort was 83.5 (SD 9). DISCUSSION: The VP platform represents a new educational tool that allows surgical clerks to direct case progression and receive feedback regarding clinical-management decisions. Its use as an assessment tool will require further validation.

Introducing health facility accreditation in Liberia.

In recent years, dozens of countries have introduced accreditation and other quality improvement initiatives. A great deal of information is available regarding best practices in high- and middle-income countries; however, little is available to guide developing nations seeking to introduce an accreditation programme. This paper describes the outputs and lessons learned in the first year of establishing an accreditation programme in Liberia, a developing nation in West Africa that in 2003 emerged from a brutal 14-year civil war. The Liberian experience of developing and implementing a government-sponsored, widespread accreditation programme may provide insight to other low-income and post-conflict countries seeking a way to drive rapid, system-wide reform in the health system, even with limited infrastructure and extremely challenging conditions.