ABSTRACT
Novel antiobesity medications, particularly glucagon-like peptide-1 receptor agonists (GLP-1RAs), have expanded weight loss (WL) options for kidney transplantation (KT) candidates with obesity beyond lifestyle modifications and bariatric surgery. However, varying effectiveness, risk profiles, and costs make strategy choices challenging. To aid decision-making, we used a Markov model to examine the cost-effectiveness of different WL strategies over a 10-year horizon. A target WL of 15% of total body weight was used for the base case scenario, and we compared these strategies to a "liberal" KT strategy of transplanting candidates with obesity. Outcomes included costs (2023 US dollars), quality-adjusted life years, and incremental cost-effectiveness ratios. In analysis, a liberal KT strategy was favored over lifestyle modifications and GLP-1RAs. Among WL strategies, bariatric surgery was the most effective and cost the least, whereas lifestyle modification had the highest cumulative costs and was the least effective. Compared to liberal KT, bariatric surgery costs $45 859 per quality-adjusted life year gained. GLP-1RAs were favored over bariatric surgery only when drug costs were below $5000 per year (base cost $12 077). In conclusion, for KT candidates with obesity, a liberal KT strategy and bariatric surgery are preferred over lifestyle modifications alone and GLP-1RAs based on outcomes and cost-effectiveness.
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INTRODUCTION: The reality of pilot health care avoidance behavior is often common knowledge to both pilots and aeromedical physicians, but the underlying factors leading to this behavior are less understood. In the current study, we conducted a qualitative assessment of a sample of U.S. Air Force (USAF) pilots to gather firsthand perceptions of the factors that encourage and discourage disclosure during aeromedical screening and use of mental and physical health care services, as well as recommendations to improve the USAF aeromedical health care system. MATERIALS AND METHODS: We conducted interviews with 21 USAF pilots on their perceptions of seeking medical care to identify factors that uniquely discourage or encourage disclosure and health care utilization to understand factors that aid the aeromedical provider/aviator relationship and to elicit interventions that could be prospectively researched. This work was reviewed by the Air Force Research Laboratory Institutional Review Board at Wright-Patterson Air Force Base and designated as exempt research, FWR20220103E. RESULTS: The most reported factors that discourage military pilot health care disclosure and health care utilization overall were medical revocation, stigma, and lack of trust in providers. Unit-embedded services, ease of access, and severity of condition were the most reported factors encouraging disclosure and utilization. Factor descriptions and exemplary quotes from pilots and pilot recommendations to encourage health care utilization and disclosure are provided. CONCLUSIONS: Results from firsthand interviews with pilots provide valuable information for flight surgeons to focus on building trust with their pilots to reduce health care avoidance.
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PURPOSE: Resection of sacral neoplasms such as chordoma and chondrosarcoma with subsequent reconstruction of large soft tissue defects is a complex multidisciplinary process. Radiotherapy and prior abdominal surgery play a role in reconstructive planning; however, there is no consensus on how to maximize outcomes. In this study, we present our institution's experience with the reconstructive surgical management of this unique patient population. METHODS: We conducted a retrospective review of patients who underwent reconstruction after resection of primary or recurrent pelvic chordoma or chondrosarcoma between 2002 and 2019. Surgical details, hospital stay, and postoperative outcomes were assessed. Patients were divided into 3 groups for comparison based on reconstruction technique: gluteal-based flaps, vertical rectus abdominus myocutaneous (VRAM) flaps, and locoregional fasciocutaneous flaps. RESULTS: Twenty-eight patients (17 males, 11 females), with mean age of 62 years (range, 34-86 years), were reviewed. Twenty-two patients (78.6%) received gluteal-based flaps, 3 patients (10.7%) received VRAM flaps, and 3 patients (10.7%) were reconstructed with locoregional fasciocutaneous flaps. Patients in the VRAM group were significantly more likely to have undergone total sacrectomy (P < 0.01) in a 2-stage operation (P < 0.01) compared with patients in the other 2 groups. Patients in the VRAM group also had a significantly greater average number of reoperations (2 ± 3.5, P = 0.04) and length of stay (29.7 ± 20.4 days, P = 0.01) compared with the 2 other groups. The overall minor and major wound complication rates were 17.9% and 42.9%, respectively, with 17.9% of patients experiencing at least 1 infection or seroma. There was no association between prior abdominal surgery, surgical stages, or radiation therapy and an increased risk of wound complications. CONCLUSIONS: Vertical rectus abdominus myocutaneous flaps are a more suitable option for patients with larger defects after total sacrectomy via 2-staged anteroposterior resections, whereas gluteal myocutaneous flaps are effective options for posterior-only resections. For patients with small- to moderate-sized defects, local fasciocutaneous flaps are a less invasive and effective option. Paraspinous flaps may be used in combination with other techniques to provide additional bulk and coverage for especially long postresection wounds. Furthermore, mesh is a useful adjunct for any reconstruction aimed at protecting against intra-abdominal complications.
Subject(s)
Chordoma , Plastic Surgery Procedures , Sacrum , Humans , Male , Female , Middle Aged , Retrospective Studies , Plastic Surgery Procedures/methods , Aged , Adult , Aged, 80 and over , Chordoma/surgery , Sacrum/surgery , Chondrosarcoma/surgery , Surgical Flaps , San Francisco , Spinal Neoplasms/surgeryABSTRACT
BACKGROUND: Incisional negative pressure wound therapy (iNPWT) is an adjunctive treatment that uses constant negative pressure suction to facilitate healing. The utility of this treatment modality on vascular operations for critical limb-threatening ischemia (CLTI) has yet to be elucidated. This study compares the incidence of postoperative wound complications between the Prevena Incision Management System, a type of iNPWT, and standard wound dressings for vascular patients who also underwent plastic surgery closure of groin incisions for CLTI. METHOD: We performed a retrospective cohort study of 40 patients with CLTI who underwent 53 open vascular surgeries with subsequent sartorius muscle flap closure. Patient demographics, intraoperative details, and wound complications were measured from 2015 to 2018 at the University of California San Francisco. Two cohorts were generated based on the modality of postoperative wound management and compared on wound healing outcomes. RESULTS: Of the 53 groin incisions, 29 were managed with standard dressings, and 24 received iNPWT. Patient demographics, comorbidities, and operative characteristics were similar between the 2 groups. Patients who received iNPWT had a significantly lower rate of infection (8.33% vs 31.0%, P = 0.04) and dehiscence (0% vs 41.3%, P < 0.01). Furthermore, the iNPWT group had a significantly lower rate of reoperation (0% vs 17.2%, P = 0.03) for wound complications within 30 days compared with the control group and a moderately reduced rate of readmission (4.17% vs 20.7%, P = 0.08). CONCLUSIONS: Rates of infection, reoperation, and dehiscence were significantly reduced in patients whose groin incisions were managed with iNPWT compared with standard wound care. Readmission rates were also decreased, but this difference was not statistically significant. Our results suggest that implementing iNPWT for the management of groin incisions, particularly in patients undergoing vascular operations for CLTI, may significantly improve clinical outcomes.
Subject(s)
Groin , Ischemia , Negative-Pressure Wound Therapy , Wound Healing , Humans , Negative-Pressure Wound Therapy/methods , Male , Retrospective Studies , Female , Groin/surgery , Ischemia/surgery , Ischemia/etiology , Aged , Middle Aged , Vascular Surgical Procedures/methods , Cohort Studies , Postoperative Complications/epidemiologyABSTRACT
PURPOSE: The benefits of paraspinous flaps in adult complex spine surgery patients are established in the literature; however, their use in pediatric patients has not been well described. This study compares clinical outcomes with and without paraspinous muscle flap closure in pediatric patients who have undergone spine surgery. METHODS: We conducted a retrospective review of all pediatric spine surgeries at the University of California, San Francisco from 2011 to 2022. Patients were divided into 2 cohorts based on whether the plastic surgery service closed or did not close the wound with paraspinous muscle flaps. We matched patients by age, American Society of Anesthesiology classification, prior spinal surgical history, and diagnosis. Surgical outcomes were compared between the 2 cohorts. RESULTS: We identified 226 pediatric patients who underwent at least one spinal surgery, 14 of whom received paraspinous flap closure by plastic surgery. They were matched in a 1:4 ratio with controls (n = 56) that did not have plastic surgery closure. The most common indication for plastic surgery involvement was perceived complexity of disease by the spine surgeon with concern for inadequate healthy tissue coverage (78.6%), followed by infection (21.4%). Postoperative complications were similar between the two groups. The plastic surgery cohort had a higher rate of patients who were underweight (57.1% vs 14.3%, P < 0.01) and had positive preoperative wound cultures (28.6% vs 8.9%, P = 0.05), as well as a higher rate of postoperative antibiotic usage (78.6 vs 17.9%, P < 0.01). There was no difference in recorded postoperative outcomes. CONCLUSIONS: Spine surgeons requested paraspinous flap closure for patients with more complex disease, preoperative infections, history of chemotherapy, or if they were underweight. Patients with paraspinous flap coverage did not have increased postoperative complications despite their elevated risk profile. Our findings suggest that paraspinous muscle flaps should be considered in high-risk pediatric patients who undergo spine surgery.
Subject(s)
Paraspinal Muscles , Plastic Surgery Procedures , Surgical Flaps , Humans , Retrospective Studies , Female , Male , Child , Adolescent , Plastic Surgery Procedures/methods , Surgical Flaps/transplantation , Child, Preschool , Postoperative Complications/epidemiology , Treatment Outcome , Spinal Diseases/surgeryABSTRACT
Facial feminization is a complex undertaking requiring skill in both craniofacial and aesthetic plastic surgery. As in aesthetic procedures, understanding the patient's goals and setting realistic expectations in light of an individual's anatomy is critical. Both soft tissue and bone must be addressed to adequately soften masculine facial features. This article delves into specific anatomic areas and delineates some of the pathways to successful outcomes.
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Plastic Surgery Procedures , Sex Reassignment Surgery , Surgery, Plastic , Humans , Esthetics, Dental , Face/surgery , Surgery, Plastic/methodsABSTRACT
INTRODUCTION: Work-related stress is common in pilots, with broad implications, including the potential development of mental health symptoms and sometimes even psychiatric disease. This commentary argues for the use of narrative as a tool to promote preventive health behaviors in pilots and combat misinformation about aeromedical certification related to mental health.Hoffman WR, McNeil M, Tvaryanas A. The untapped potential of narrative as a tool in aviation mental health and certification. Aerosp Med Hum Perform. 2024; 95(3):165-166.
Subject(s)
Accidents, Aviation , Aerospace Medicine , Aviation , Humans , Accidents, Aviation/prevention & control , Mental Health , CertificationABSTRACT
Background: Side effects of opioid pain management after surgical repair of cleft lips are numerous and affect postoperative course. We compared opioid versus opioid-free pain management regimens for infants who underwent cleft lip repair to evaluate the impact on postoperative recovery. Methods: Cleft lip repairs at our institution from December 2016 to February 2021 were retrospectively reviewed, comparing patients who received opioids to patients receiving a nonopioid pain control regimen. Data collected include length of stay, oral morphine equivalents (OME) received on day of surgery (DOS)/postoperative day (POD) 1, time to and volume of first oral feed, and Face/Legs/Activity/Cry/Consolability (FLACC) scores. Results: Seventy-three infants were included (47 opioid and 26 nonopioid). The opioid group received average 1.75 mg OME on DOS and 1.04 mg OME on POD1. Average DOS FLACC scores were similar between groups [1.57â ±â 1.18 nonopioid versus 1.76â ±â 0.94 (SD) opioid; P = 0.46]. Average POD1 FLACC scores were significantly lower for the nonopioid group (0.73â ±â 1.05 versus 1.35â ±â 1.06; P = 0.022). Median time to first PO (min) was similar [178 (interquartile range [IQR] 66-411) opioid versus 147 (IQR 93-351) nonopioid; P = 0.65]. Median volume of first feed (mL) was twice as high for the nonopioid group [90 (IQR 58-120) versus 45 (IQR 30-60); P = 0.003]. Conclusions: Nonopioid postoperative pain management was more effective than opioids for pain management in infants after cleft lip repair, as evidenced by FLACC scores and increased volume of the first oral feed.
Subject(s)
Craniocerebral Trauma , Skin Diseases , Infant, Newborn , Humans , Scalp/surgery , Autografts , Epidermis , Transplantation, AutologousABSTRACT
Facial feminization surgery (FFS), or gender-affirming facial surgery, is a common procedure for patients with gender dysphoria. One goal of FFS involves extensive contouring of the frontal and nasal bones to reduce supraorbital bossing. Ophthalmic complications after FFS have been rarely reported. We report 2 cases of superior oblique palsy after FFS producing persistent vertical and torsional diplopia. One case was successfully treated with prism spectacles; the other required surgical management. Both cases likely involved surgical trauma to or disinsertion of the trochlea during orbital bony reshaping.
Subject(s)
Feminization , Trochlear Nerve Diseases , Male , Humans , Feminization/surgery , Eye , Trochlear Nerve Diseases/surgery , Diplopia/etiology , ParalysisABSTRACT
OBJECTIVE: Canadian pilots may avoid health care and report inaccurate medical information due to fear of medical invalidation. We sought to determine if health care avoidance due to fear of certificate loss exists. METHODS: We conducted an anonymous 24-item Internet survey of 1405 Canadian pilots between March and May 2021. Responses were collected using REDCap, and the survey was advertised through aviation magazines and social media groups. RESULTS: Seventy-two percent of respondents (n = 1007) have felt worried about seeking medical care because it may impact their career or hobby. Respondents participated in various health care avoidance behaviors with the most common being having actually avoided or delayed medical care for a symptom (46%, n = 647). CONCLUSION: Canadian pilots fear medical invalidation and consequently, avoid health care. This may be severely impacting aeromedical screening effectiveness.
Subject(s)
Aerospace Medicine , Humans , Cross-Sectional Studies , Canada , Fear , Surveys and Questionnaires , Delivery of Health CareSubject(s)
Sex Reassignment Surgery , Transsexualism , Humans , Face , Patient Reported Outcome MeasuresABSTRACT
Microtia is the term for congenital malformation of the ear in which the external and internal ear are absent or malformed. Surgical reconstruction is a common management approach and occasionally requires hair reduction of the newly constructed auricle. Few studies have investigated lasers for this purpose. We conducted a retrospective chart review of patients seen at a single institution between 2012 and 2021 who underwent laser hair reduction with long-pulsed neodymium-doped yttrium aluminum garnet laser (Nd:YAG). Efficacy ratings were done through review of clinical photographs. Twelve patients were identified with 14 total ears treated. The number of laser treatments varied from 1 to 9 sessions with an average of 5.1 treatments. The majority (8/12) had an "excellent" or "very good" response, one patient had a "good" response, and three were lost to follow-up. Other than pain, there were no side effects documented. Nd:YAG laser was both effective and safe in our pediatric cohort, without any cutaneous side effects in patients with darker skin.
Subject(s)
Congenital Microtia , Lasers, Solid-State , Humans , Child , Neodymium , Congenital Microtia/etiology , Retrospective Studies , Aluminum , Hair , Lasers, Solid-State/therapeutic use , Treatment OutcomeABSTRACT
Virtual crossmatch (VXM) is used as an alternative to or in conjunction with a cell-based physical crossmatch (PXM) for assessing HLA (human leukocyte antigen) compatibility prior to deceased donor kidney transplantation (DDKT). Data on practice patterns and perceptions regarding VXM use in the US are limited. We performed a survey of US HLA directors and transplant surgeons regarding HLA testing and crossmatch strategies. 53 (56 %) HLA directors and 68 surgeons (representing â¼ 23 % of US transplant centers) completed the survey. Both groups agreed that VXM could reduce cold ischemia time (CIT), costs and improve allocation efficiency. VXM use increased following the 2021 kidney allocation change. Reducing CIT was the primary reason for favoring VXM over PXM. Preference for VXM reduced as candidates' panel reactive antibodies increased. Regulations, program policies and limitations of HLA technology were cited as important reasons for preferring PXM over VXM. Surgeons reported similar perceptions, but findings are limited by the low response rate. Finally, half the labs reported lacking specific protocols for VXM use. In conclusion, improved HLA technology and protocols along with changes to institutional procedures and policy regulations are needed for safer expansion of VXM in DDKT.
Subject(s)
Kidney Transplantation , Humans , United States , Kidney Transplantation/methods , Blood Grouping and Crossmatching , Histocompatibility Testing/methods , Kidney , HLA Antigens , Histocompatibility , Graft RejectionABSTRACT
BACKGROUND: In March 2021, the United States implemented a new kidney allocation system (KAS250) for deceased donor kidney transplantation (DDKT), which eliminated the donation service area-based allocation and replaced it with a system on the basis of distance from donor hospital to transplant center within/outside a radius of 250 nautical miles. The effect of this policy on kidney discards and logistics is unknown. METHODS: We examined discards, donor-recipient characteristics, cold ischemia time (CIT), and delayed graft function (DGF) during the first 9 months of KAS250 compared with a pre-KAS250 cohort from the preceding 2 years. Changes in discards and CIT after the onset of COVID-19 and the implementation of KAS250 were evaluated using an interrupted time-series model. Changes in allocation practices (biopsy, machine perfusion, and virtual cross-match) were also evaluated. RESULTS: Post-KAS250 saw a two-fold increase in kidneys imported from nonlocal organ procurement organizations (OPO) and a higher proportion of recipients with calculated panel reactive antibody (cPRA) 81%-98% (12% versus 8%; P <0.001) and those with >5 years of pretransplant dialysis (35% versus 33%; P <0.001). CIT increased (mean 2 hours), including among local OPO kidneys. DGF was similar on adjusted analysis. Discards after KAS250 did not immediately change, but we observed a statistically significant increase over time that was independent of donor quality. Machine perfusion use decreased, whereas reliance on virtual cross-match increased, which was associated with shorter CIT. CONCLUSIONS: Early trends after KAS250 show an increase in transplant access to patients with cPRA>80% and those with longer dialysis duration, but this was accompanied by an increase in CIT and a suggestion of worsening kidney discards.
Subject(s)
COVID-19 , Kidney Transplantation , Tissue and Organ Procurement , Humans , United States , Kidney , Tissue Donors , Antibodies , Graft Survival , Delayed Graft Function/epidemiologyABSTRACT
INTRODUCTION: U.S. military pilots are required to meet certain medical standards in order to maintain an active flying status. Military pilots face potential temporary or permanent loss of flying privileges in the setting of a new condition or symptom that does not meet required standards, which could result in negative social and occupational repercussions for the pilot. For this reason, it has been proposed that U.S. military pilots participate in health care avoidance behavior, but little evidence exists to characterize such a trend in this population. MATERIALS AND METHODS: We conducted a non-probabilistic Internet survey of the general population of U.S. pilots from November 1, 2019 through August 1, 2021. The current study is a sub-analysis of military pilots. RESULTS: A total of 4,320 pilots answered the informed consent question, and 264 selected one military pilot type and were included in this sub-analysis. There were 72% of military pilots who reported a history of health care avoidance behavior (n = 190), and no statistical difference was found between age groups, gender, and military pilot types. There were 55.5% of pilots who reported a history of seeking informal medical care (n = 147), 33.7% of pilots who have flown despite a new symptom they felt required medical evaluation, 42.5% of pilots who reported withholding information on aeromedical screening (n = 111), and 11.4% of pilots who reported a history of undisclosed prescription medication use (n = 30). CONCLUSIONS: U.S. military pilots may participate in health care avoidance behavior because of fear for loss of flying status.
Subject(s)
Aerospace Medicine , Military Personnel , Pilots , Humans , Self Report , Avoidance Learning , Fear , Delivery of Health CareABSTRACT
BACKGROUND: Perineal hernias can be secondarily acquired following abdominoperineal resection of the rectum. While transabdominal minimally invasive techniques have traditionally used laparoscopy, there are few studies published on the robotic platform, which has been gaining popularity for other types of hernia repairs. We review the existing literature, share a video vignette, and provide practical tips for surgeons interested in adopting this approach. METHODS: A literature search in Pubmed was performed to include all articles in English describing robotic repair of perineal hernias with identification of variables of interest related to repair. A case presentation with an accompanying video vignette and lessons learned from the experience are provided. RESULTS: Seven case reports (four containing video) published between 2019 and 2022 were included. Most articles (n = 5) utilized the Da Vinci Si or Xi, and most patients (n = 5) had undergone abdominoperineal resection with neoadjuvant chemotherapy to treat rectal cancer. Patients were positioned in Trendelenburg with rightward tilt (n = 2), modified lithotomy (n = 1), or a combination of the two (n = 1). All articles (n = 7) reported closing the defect and using mesh. Three articles describe placing five ports (one camera, three robotic, one assistant). There were no significant intraoperative or postoperative complications reported, and no recurrence noted at 3-27 months follow-up. Based on our experience, as shown in the video vignette, we recommend lithotomy positioning, using porous polypropylene mesh anchored to the periosteum of the sacrum and peritoneum overlying the bladder and side wall, and placing a drain above the mesh. CONCLUSIONS: A robotic transabdominal approach to perineal hernia repair is a viable alternate to laparoscopy based on low complication rates and lack of recurrence. Prospective and longer duration data are needed to compare the techniques.
Subject(s)
Hernia, Abdominal , Laparoscopy , Robotic Surgical Procedures , Humans , Prospective Studies , Hernia, Abdominal/surgery , Herniorrhaphy/methods , Surgical Mesh/adverse effectsABSTRACT
INTRODUCTION: It has been proposed that pilots face a perceived barrier to seeking medical care due to what a change in health status might mean to their status as a pilot. While this is often common knowledge to pilots and some physicians, this phenomenon has limited research or characterization in the medical literature. In this commentary, we propose a definition for the barrier pilots face in seeking healthcare in hopes of focusing future research efforts.Hoffman W, Bjerke E, Tvaryanas A. Breaking the pilot healthcare barrier. Aerosp Med Hum Perform. 2022; 93(8):649-650.