Role of Hashtags in Educating and Promoting the Field of Hand Surgery on Social Media.

Purpose: This study identifies the hand surgery content being posted on Instagram, how hashtags are being used, and those posting to determine what is reaching the public. Methods: Top hand surgery-related hashtags on Instagram from June 2020 to August 2020 were identified by searching "hand surgery" and sorting by relevance. Hashtags were quantified by number and qualitatively assessed. Posts without a clear relationship were excluded. Hashtags relevant to hand surgery were analyzed by educational merit, medical specialty, patient or nonpatient, and demographics. Results: The top 25 hashtags contained 325,400 posts. The 3 hashtags with the highest number of posts were #carpaltunnel (64,700), #handsurgery (50,500), and #handtherapy (48,300). Most posts were educational (53.2%). Nonsurgical fields (66.5%) posted the most, followed by orthopedic (25.9%), and plastic hand surgeons (7.7%). Nonpatients (68.8%) posted more than patients. The top 3 languages of the posts were English (67.7%), Russian (9.4%), and Spanish (7.1%). However, when looking at the hashtags with more than half of the posts being made by hand surgeons, we observed that most (62.9%) of the posts were noneducational in content. Conclusions: Instagram posts on hand surgery topics are largely posted by nonexperts and are educational in content. There is a major opportunity for hand surgeons to educate and market effectively using hand surgery-related hashtags. Given the number of hand surgeries performed annually, one would hope to see more representation by hand surgeons on social media. More active participation and provision of educational content by specialists is warranted. Clinical relevance: There is an opportunity for hand surgeons to educate those searching upper extremity conditions and seeking out expertise in a domain where information is largely driven by nonsurgeons and the quality of information is not vetted. This study identifies the need for more hand surgeon involvement to expand knowledge and communication efforts within the specialty and with the public through the evolving world of social media.

Utilization of a Chimeric Medial Femoral Condyle Free Flap for Mandibular Osteoradionecrosis.

Background: Primary options for oromandibular reconstruction with osteocutaneous free flaps are the vascularized fibula and iliac crest. Complications of mandible reconstruction are not uncommon and include osteomyelitis, malunion, and osteoradionecrosis (ORN) after radiation therapy. The medial femoral condyle (MFC) free flap is an established salvage option for carpal reconstruction in hand surgery, frequently used for scaphoid nonunion and avascular necrosis. We hypothesize that the MFC flap can be utilized to restore blood supply and reverse the negative effects of radiotherapy in patients who require mandibular reconstruction due to ORN. Methods: A retrospective chart review was conducted at Beaumont Health System, Royal Oak, for patients who underwent MFC free flap reconstruction for mandibular ORN between the years 2012 and 2018. Demographic data, operative details, complications, medical comorbidities, and patient outcomes were retrospectively gathered. Results: A total of four patients were isolated. Four patients developed ORN after resection of squamous cell carcinoma and adjuvant radiotherapy. No patients experienced donor site deficits. Revisions after MFC reconstruction were dependent on individual aesthetics and involvement of neighboring tissue. All four patients continue to be followed with no current issues to the osseous component of the MFC flap. Conclusion: Utilization of the MFC periosteal flap is a viable option in selected patients to salvage nonunion/resorption of mandible reconstruction and ORN of the mandible. Our experience found that the MFC is able to provide pain resolution and healing of intraoral soft tissue defects, and may halt the progression of ORN of the mandible.

Cervical Spine and Craniocervical Junction Reconstruction with a Vascularized Fibula Free Flap.

BACKGROUND: Long-term stabilization of the cervical spine after extensive multilevel tumor resection is difficult to achieve. The current standard approach of instrumentation combined with allograft or nonvascularized autograft is limited in settings of increased risk of nonunion or delayed union (i.e., prior radiation therapy or poorly vascularized wound beds). CASE DESCRIPTION: We report the first time to our knowledge that a vascularized fibular free flap has been used to reconstruct the cervical column across 5 vertebral levels, from the craniocervical junction to the lower cervical spine. We describe a transoral approach to the area and compare this method with other reconstructive options. CONCLUSIONS: Vascularized bone grafting is a viable alternative to achieve lasting stability because of hastened fusion time, limited reliance on osseous remodeling, and incorporation into the axial skeleton with strut strength.

Nursing Monitoring of Microsurgical Free Flaps: Identifying and Addressing Knowledge Gaps.

BACKGROUND: Microsurgical free flaps require careful monitoring to detect early signs of compromise. At many hospitals, nursing staff provides the majority of postoperative monitoring of free flap patients and it lies within their responsibility to alert physicians of a failing free flap. The aim of this study is to identify knowledge gaps in the monitoring of microvascular free tissue transfer in both novice and experienced nurses and to provide appropriate education to address these gaps. METHODS: This was a pre- and postintervention study. An initial pilot survey was administered to identify knowledge deficiencies. A nursing educational session on free flap physiology and monitoring was then designed to address these deficiencies. An 18-question multiple choice quiz was administered before and after the educational session. Pre- and post-test scores were compared based on nursing experience. At 6 months, the participating nurses completed a survey rating their confidence with free flap patient care as a result of the educational session. RESULTS: A total of 72 nurses completed the in-service training course and quiz. The average quiz score increased from 61.9 to 89.3% after the in-service (p < 0.001). There was no correlation between precurriculum test scores and nursing experience as referenced by total number of years in the profession (r s = -0.038, p = 0.754). The follow-up survey showed that prior to the course 38% of respondents reported little or no confidence caring for free flap patients, decreasing to 6% after the course (p < 0.05). CONCLUSION: Based on the results of this study, nursing knowledge of capillary refill, venous congestion, and basic microsurgical free flap physiology is inadequate. With implementation of a teaching in-service curriculum highlighting these key areas of deficiencies, nurses improved both their understanding and confidence levels, regardless of their level of experience.

Enhancement of Viable Adipose-Derived Stem Cells in Lipoaspirate by Buffering Tumescent with Sodium Bicarbonate.

BACKGROUND: Fat grafting is a growing field within plastic surgery. Adipose-derived stem cells (ASCs) and stromal vascular fracture (SVF) may have a role in fat graft survival. Our group previously demonstrated a detrimental effect on ASC survival by the lidocaine used in tumescent solution. Sodium bicarbonate (SB) buffers the acidity of lidocaine. The purpose of this study was to determine whether SB buffering is a practical method to reduce ASC and SVF apoptosis and necrosis seen with common lidocaine-containing tumescent solution. METHODS: Human patients undergoing bilateral liposuction for any indication were included in this study. An internally controlled, split-body design was utilized. Tumescent liposuction on one side of the body was conducted with tumescent containing lidocaine. On the opposite side, liposuction was conducted by adding SB to the tumescent. Tumescent solution and lipoaspirate pH were measured. Lipoaspirate from each side was processed for SVF isolation and ASC culture. The number of viable ASCs was counted and SVF apoptosis/necrosis was examined. RESULTS: The pH of the SB-buffered tumescent was significantly higher than that of the standard tumescent, an effect also seen in the lipoaspirate. Adipose-derived stem cell survival in the SB-buffered lipoaspirate was approximately 53% higher. However, there was no significant difference in SVF apoptosis and necrosis between the groups. CONCLUSIONS: The acidic standard tumescent solution commonly used in liposuction diminishes ASC viability from lipoaspirates. Sodium bicarbonate buffering tumescent solution can enhance ASC viability, but does not affect SVF apoptosis and necrosis. We recommend buffering tumescent with SB to potentially improve fat graft take. Our findings advocate for further research investigating mechanisms and optimal harvest techniques that maximize SVF/ASC survival and the clinical effect on overall fat graft viability.

Ahead of the Curve: Tracking Progress in Novice Microsurgeons.

BACKGROUND: The purpose of this study was to evaluate learning curves for an existing microsurgical training model. We compared efficiency and amount of training needed to achieve proficiency between novice microsurgeons without operative experience versus those who had completed a surgical internship. METHODS: Ten novice microsurgeons anastomosed a silastic tube model. Time to perform each anastomosis, luminal diameter, and number of errors were recorded. RESULTS: First year residents improved up to a brief plateau at 10 repetitions, followed by continued improvement. Second year residents improved up to a plateau at 10 repetitions with no further improvement thereafter. There was no significant difference in luminal area or errors between groups. CONCLUSION: Residents with no operative experience can benefit from early exposure to microsurgical training. These interns continue to improve with additional repetitions while second year residents achieve proficiency with fewer repetitions.

Tumescent Liposuction without Lidocaine.

BACKGROUND: Our previous study demonstrated that lidocaine has a negative impact on adipose-derived stem cell (ASC) survival. Currently for large-volume liposuction, patients often undergo general anesthesia; therefore, lidocaine subcutaneous anesthesia is nonessential. We hypothesized that removing lidocaine from tumescent might improve stromal vascular fraction (SVF) and ASC survival from the standard tumescent with lidocaine. Ropivacaine is also a commonly used local anesthetic. The effect of ropivacaine on ASC survival was examined. METHODS: Adults who underwent liposuction on bilateral body areas were included (n = 10). Under general anesthesia, liposuction on 1 area was conducted under standard tumescent with lidocaine. On the contralateral side, liposuction was conducted under the modified tumescent without lidocaine. Five milliliters of lipoaspirate were processed for the isolation of SVF. The adherent ASCs were counted after 24 hours of SVF culture. Apoptosis and necrosis of SVF cells were examined by Annexin/propidium iodide staining and analyzed by flow cytometry. RESULTS: Average percentage of live SVF cells was 68.0% ± 4.0% (28.5% ± 3.8% of apoptosis and 3.4% ± 1.0% of necrosis) in lidocaine group compared with 86.7% ± 3.7% (11.5% ± 3.1% of apoptosis and 1.8% ± 0.7% of necrosis) in no-lidocaine group (P = 0.002). Average number of viable ASC was also significantly lower (367,000 ± 107) in lidocaine group compared with that (500,000 ± 152) in no-lidocaine group (P = 0.04). No significant difference was found between lidocaine and ropivacaine on ASC cytotoxicity. CONCLUSIONS: Removing lidocaine from tumescent significantly reduced SVF and ASC apoptosis in the lipoaspirate. We recommend tumescent liposuction without lidocaine, particularly if patient's lipoaspirate will be used for fat grafting.

Recombinant interferon-α may retard progression of early primary myelofibrosis: a preliminary report.

The limited effects of current treatments of primary myelofibrosis (PM) led us to prospectively evaluate recombinant interferon-α (rIFNα) in "early" PM patients with residual hematopoiesis and only grade 1 or 2 myelofibrosis. Seventeen patients meeting World Health Organization PM diagnostic criteria received either rIFNα-2b 500 000 to 3 million units 3 times weekly, or pegylated rIFNα-2a 45 or 90 µg weekly. International Working Group for Myelofibrosis Research and Treatment criteria for prognosis and response were used. Eleven patients were women and 6 were men. Their median age at diagnosis was 57 years. Eleven patients were low risk and 6 were intermediate-1 risk. Two achieved complete remission, 7 partial, 1 clinical improvement, 4 stable disease, and 3 had progressive disease. Thus, more than 80% derived clinical benefit or stability. Improvement in marrow morphology occurred in 4. Toxicity was acceptable. These results, with documented marrow reversion because of interferon treatment, warrant expanded evaluation.

Tissue-specific homing and expansion of donor NK cells in allogeneic bone marrow transplantation.

NK cells have potential therapeutic impact in suppressing graft-versus-host disease (GVHD) and enhancing antitumor effects as a cellular therapy for hematologic malignancies. However, few studies have addressed the trafficking and in vivo behavior of NK cells in murine models of bone marrow transplantation (BMT). We investigated NK cell trafficking and survival following allogeneic and syngeneic BMT using a novel bioluminescence-based imaging strategy. Transplantation of luciferase-expressing NK cells revealed CD62L-mediated trafficking to lymphoid organs and trafficking to GVHD target tissues, as evidenced by in vivo and ex vivo bioluminescence imaging. The NK cells persisted for approximately 4 wk after transplantation in allogeneic recipients, but were not detectable in syngeneic recipients. CFSE-labeling studies showed extensive NK cell proliferation in vivo. Transplanted NK cells up-regulated molecules necessary for homing to the lymph nodes, gastrointestinal tract, and skin, yet did not cause clinical GVHD. This expansion and tissue-specific homing was not solely due to the conditioning regimen, as NK cells proliferated and reached lymphoid and GVHD target tissue in unconditioned allogeneic RAG2(-/-) gamma-chain(-/-) recipients. IL-2 enhanced expansion and antitumor activity of NK cells. These results provide significant insight into the behavior and potential therapeutic impact of NK cells in BMT.

Synthesis of 2,3,4-Trisubstituted Thiochromanes using an Organocatalytic Enantioselective Tandem Michael-Henry Reaction.

Enantioenriched 2,3,4-trisubstituted thiochromanes have been synthesized by using a cupreine-catalyzed tandem Michael addition-Henry reaction between 2-mercaptobenzaldehydes and ß-nitrostyrenes. Good diastereoselectivities and enantioselectivities were obtained for the title compounds, which may be further improved through a single recrystallization (up to 98% de and> 99% ee).