Postsurgical Pyoderma Gangrenosum After Penile Inversion Vaginoplasty: Case With Review of Diagnostic and Management Strategies.

Background: Postsurgical pyoderma gangrenosum (PSPG) is a highly uncommon and unpredictable wound healing complication. Rapid progression of ulcers at incisions can cause unfettered dehiscence. Most commonly, PSPG involves breast procedures; however, in this work, we detail a case of a patient who developed PSPG 10 days postoperatively after penile inversion vaginoplasty. Methods: The patient in this case underwent a penile inversion vaginoplasty with orchiectomy in the standard fashion. She had no risk factors for PSPG. Following an uncomplicated hospital stay, the patient developed difficulty with pain control and increasing serous drainage on the 10th postoperative day. On readmission, the patient was found to have developed large, mildly purulent ulcers throughout the perineal wound edges. On exam under anesthesia, the neovaginal canal was found to be patent and intact. The dehisced portions of the incisions were left open and redressed with occlusive bismuth-petrolatum dressing. Dermatology was promptly consulted with suspicion for PSPG. The patient was started on an 18-day prednisone taper with cyclosporine, along with doxycycline and ciprofloxacin. Results: After 5 days of immunosuppressive treatment, the ulcers visibly converted to healthy granulation tissue and were no longer actively purulent. Following another washout, the dehisced wound edges were reapproximated. At follow-up, the patient had no evidence of PSPG recurrence and continued dilating on schedule. Our patient recovered from PSPG without further complications and a satisfactory aesthetic result. Conclusions: This unique case highlights the importance of prompt dermatological consultation, immunosuppression, and avoidance of further pathergy in the setting of suspicion for PSPG.

Outcomes of Complex Abdominal Wall Reconstruction with Biologic Mesh in Patients with 8 Years of Follow-Up.

BACKGROUND: While many studies evaluated outcomes of abdominal wall reconstruction with biologic mesh, long-term data is lacking. In this study, we sought to analyze the outcomes of complex AWR with biologic mesh in a robust cohort of patients with a mean follow up of 8 years. METHODS: We conducted a longitudinal study of AWR patients from 2005 to 2019. Hernia recurrence was the primary outcome, and surgical site occurrence was the secondary outcome. Predictive/protective factors were identified using a Cox proportional hazards regression models. RESULTS: We identified 109 consecutive patients who met the inclusion criteria. Patient's mean (± SD) age was 57.5 ± 11.8 years, mean body mass index was 30.7 ± 7.2 kg/m2, and mean follow-up time was 96.2 ± 15.9 months. Fifty-six percent had clean defects, 34% had clean-contaminated defects, and 10% had contaminated/infected defects. Patients had a mean defect size of 261 ± 199.6 cm2 and mean mesh size of 391.3 ± 160.2 cm2. Nineteen patients (17.4%) developed HR at the final follow-up date. Obesity was independently associated with a four-fold higher risk of HR (hazard ratio, 3.98; 95%CI, 1.34 to 14.60, p = 0.02). SSOs were identified in 24.8% of patients. A prior hernia repair was associated with a three-fold higher risk of SSOs (Odds ratio, 3.13; 95%CI, 1.10 to 8.94, p = 0.03). No patient developed mesh infection. CONCLUSION: These longitudinal data demonstrate that complex AWR with biologic mesh provides long-term durable outcomes with acceptable HR and SSO rates despite high contamination levels, patients complexity, and large defect size.

It's Hip to Go Home: An Evaluation of Outpatient Alveolar Bone Grafting in Patients With Cleft Palate.

INTRODUCTION: Secondary alveolar bone grafting (ABG) is a common procedure performed at cleft care centers used to fill the alveolar cleft. The advent of techniques such as minimally invasive trephine drill harvest and placement of continuous-infusion pain pumps at the donor site has made outpatient ABG an increasingly feasible and cost-effective procedure. However, enhanced recovery after surgery protocols to maximize pain control and recovery times for this patient population have not been well established. METHODS: A retrospective single-institution review was conducted of pediatric patients with cleft palate who underwent iliac crest bone graft ABG at a large urban academic children's hospital from 2017 to 2022. Patient age, alveolar cleft repair laterality, pain scores, surgery duration, hospital LOS, readmissions, and re-operations within 30 days were examined. RESULTS: Fifty-four patients met our inclusion criteria. Fifty patients (92.6%) received a pain pump during the operation. The median duration of surgery and LOS in the post-anesthesia care unit were 1.28 and 1.75 hours, respectively. Fifty-two patients (96.3%) were discharged on the same day as their surgery whereas 2 patients (3.7%) stayed in the hospital overnight. The median pain score at the time of discharge was 0 (interquartile range 0, 0). There were 6 (11.1%) minor complications including 5 pain pump malfunctions and 1 recipient site wound breakdown. There was 1 readmission (1.9%) for development of a surgical site infection at the hip and no re-operations within 30 days of surgery. CONCLUSION: The described outpatient ABG protocol demonstrates effective postoperative pain control, short hospital LOS, and few complications requiring hospital readmission or reoperation.

Influence of TRPM4 rs8104571 genotype on intracranial pressure and outcomes in African Americans with traumatic brain injury.

The TRPM4 gene codes for a membrane ion channel subunit related to inflammation in the central nervous system. Recent investigation has identified an association between TRPM4 single nucleotide polymorphisms (SNPs) rs8104571 and rs150391806 and increased intracranial (ICP) pressure following traumatic brain injury (TBI). We assessed the influence of these genotypes on clinical outcomes and ICP in TBI patients. We included 292 trauma patients with TBI. DNA extraction and real-time PCR were used for TRPM4 rs8104571 and rs150391806 allele discrimination. Five participants were determined to have the rs8104571 homozygous variant genotype, and 20 participants were identified as heterozygotes; 24 of these 25 participants were African American. No participants had rs150391806 variant alleles, preventing further analysis of this SNP. Genotypes containing the rs8104571 variant allele were associated with decreased Glasgow outcome scale-extended (GOSE) score (P = 0.0231), which was also consistent within our African-American subpopulation (P = 0.0324). Regression analysis identified an association between rs8104571 variant homozygotes and mortality within our overall population (P = 0.0230) and among African Americans (P = 0.0244). Participants with rs8104571 variant genotypes exhibited an overall increase in ICP (P = 0.0077), although a greater frequency of ICP measurements > 25 mmHg was observed in wild-type participants (P = < 0.0001). We report an association between the TRPM4 rs8104571 variant allele and poor outcomes following TBI. These findings can potentially be translated into a precision medicine approach for African Americans following TBI utilizing TRPM4-specific pharmaceutical interventions. Validation through larger cohorts is warranted.

Comparison of Long-term Surgical Outcomes and Microsurgical Skills between Independent and Integrated Plastic Surgery Trainees.

We compared the surgical skills and outcomes of microsurgical fellows who completed an independent versus integrated plastic surgery residency. Methods: We reviewed outcomes of abdominal wall reconstructions performed autonomously by microsurgical fellows at our institution from March 2005 to June 2019; outcome measures included hernia recurrence, surgical site occurrence, surgical site infection, length of hospital stay, unplanned return to the operating room, and 30-day readmission. The microsurgical skills were prospectively evaluated using the validated Structured Assessment of Microsurgical Skills at the start and end of the fellowship, in an animal laboratory model and clinical microsurgical cases. Multivariable hierarchical models were constructed to evaluate study outcomes. Results: We identified 44 fellows and 118 consecutive patients (52% women) who met our inclusion criteria. Independent fellows performed 55% (n = 65) of cases, and 45% were performed by integrated fellows. We found no significant difference in hernia recurrence, surgical site occurrences, surgical site infections, 30-day readmission, unplanned return to the operating room, or length of stay between the two groups in adjusted models. Although laboratory scores were similar between the groups, integrated fellows demonstrated higher initial clinical scores (42.0 ± 4.9 versus 37.7 ± 5.0, P = 0.04); however, the final clinical scores were similar (50.8 ± 6.0 versus 48.9 ± 5.2, P = 0.45). Conclusions: Independent and integrated fellows demonstrated similar long-term patient outcomes. Although integrated fellows had better initial microsurgical skills, evaluation at the conclusion of fellowship revealed similar performance, indicating that fellowship training allows for further development of competent surgeons.

PEG-Based Hydrogel Coatings: Design Tools for Biomedical Applications.

Device failure due to undesired biological responses remains a substantial roadblock in the development and translation of new devices into clinical care. Polyethylene glycol (PEG)-based hydrogel coatings can be used to confer antifouling properties to medical devices-enabling minimization of biological responses such as bacterial infection, thrombosis, and foreign body reactions. Application of hydrogel coatings to diverse substrates requires careful consideration of multiple material factors. Herein, we report a systematic investigation of two coating methods: (1) traditional photoinitiated hydrogel coatings; (2) diffusion-mediated, redox-initiated hydrogel coatings. The effects of method, substrate, and compositional variables on the resulting hydrogel coating thickness are presented. To expand the redox-based method to include high molecular weight macromers, a mechanistic investigation of the role of cure rate and macromer viscosity was necessary to balance solution infiltration and gelation. Overall, these structure-property relationships provide users with a toolbox for hydrogel coating design for a broad range of medical devices.

Total Reconstruction of Lower Lip and Chin Following Firework Injury Using Composite Bilateral Radial Forearm-Fascia Lata Flaps: A Case Report.

Background: Primary explosion injuries with fireworks can lead to devastating and geometrically complex facial traumas that present a challenge to the reconstructive surgeon. Our patient, a woman in her early thirties, was hit directly in her chin by a large artillery shell firework. This caused complete soft tissue loss of the lower lip and chin beyond the oral commissures, complicated further by a comminuted mandible fracture. Methods: After external fixation, our patient underwent a 2-stage reconstruction with a novel composite flap arrangement. Soft tissue coverage and lip reconstruction were performed with opposing bilateral radial forearm free flaps. The outer flap constituted the soft tissue of the new chin and outer lower lip, whereas the inner flap composed the intraoral lining. In the second stage, portions of the inner upper lip mucosa and superior orbicularis oris muscle were flipped down as a bipedicle, axial pattern "bucket-handle" type flap to the lower lip to reconstruct the vermilion. A graft of fascia lata was attached to the modioli of the orbicularis oris and interpositioned beneath the vermilion flap and the radial forearms to restore static and some dynamic sphincter control. One month later, the mandibular fractures underwent open reduction and internal fixation. Results: Two months after soft tissue reconstruction with no complications, our patient had satisfactory aesthetic outcomes, oral competence, and speech. Conclusions: This case has shown that use of bilateral, fascia lata-reinforced radial forearm flaps may be an effective choice for soft tissue reconstruction and oral competence restoration in cases of severe facial explosion trauma.

One-stage Flexor Reconstruction With Anterolateral Thigh and Fascia Lata Rolls After High-Voltage Trauma: A Case Report.

Background: Electrical injuries from high-voltage power lines are unique forms of trauma that can create challenging wounds for reconstructive surgeons. Our patients, a man in his late thirties (Patient 1) and a man in his early twenties (Patient 2), both sustained upper extremity injuries after contact with a high-voltage line. Methods: Despite minimal superficial damage, both patients required fasciotomies and debridement of the volar forearm, revealing segmental defects in most digital tendons as well as the distal median nerve. Free fasciocutaneous anterolateral thigh (ALT) flaps were harvested to ensure adequate wound coverage. Additionally, fascia lata grafts were taken from the free flap donor site and rolled into tubes to transfer available flexor digitorum superficialis proximal tendon stumps to the distal stumps of flexor digitorum profundus. The rolls were also used to bridge segmental tendon defects in flexor pollicis longus, while cadaveric nerve allografts were used to bridge the median nerve defects. Results: Nine months postoperatively, Patient 1 had premorbid function with activities of daily living (ADLs), and Patient 2 required only minimal assistance with instrumental ADLs. Within a year following reconstruction, Patient 1 mostly regained range of motion in his digits with some rigidity, and Patient 2 regained full range of motion in his digits with minimal rigidity. Conclusions: These cases have demonstrated that the use of an ALT free flap combined with rolled fascia lata graft tubes may be an effective choice for reconstruction and functional restoration in cases of severe high-voltage electrical trauma.

Association of Changes in Antithrombin Activity Over Time With Responsiveness to Enoxaparin Prophylaxis and Risk of Trauma-Related Venous Thromboembolism.

Importance: Venous thromboembolism (VTE) affects 2% to 20% of recovering trauma patients, despite aggressive prophylaxis with enoxaparin. Antithrombin is a primary circulating anticoagulant and crucial component of enoxaparin thromboprophylaxis. Approximately 20% of trauma patients present with antithrombin deficiency (antithrombin activity <80%). Objective: To examine time-dependent changes in antithrombin activity, responsiveness to enoxaparin, as measured by anti-factor Xa (anti-FXa) levels, and incidence of VTE after severe trauma and to assess the association of ex vivo antithrombin supplementation with patients' sensitivity to enoxaparin prophylaxis. Design, Setting, and Participants: This single-center, prospective cohort study was performed at a level 1 trauma center between January 7, 2019, and February 28, 2020. Adult trauma patients admitted to the trauma service at high risk for VTE, based on injury pattern and severity, were screened and enrolled. Patients who were older than 70 years, were pregnant, had a known immunologic or coagulation disorder, or were receiving prehospital anticoagulants were excluded. Exposures: Blood samples were collected on emergency department arrival and daily for the first 8 days of hospitalization. Main Outcomes and Measures: Patients' antithrombin activity and anti-FXa levels were measured by a coagulation analyzer, and thrombin generation was measured by calibrated automated thrombography. Responsiveness to enoxaparin was assessed by measuring anti-FXa levels 4 to 6 hours after the first daily enoxaparin dose and compared between patients who developed VTE and who did not. In addition, the associations of ex vivo supplementation of antithrombin with plasma anti-FXa levels were assessed. Results: Among 150 patients enrolled (median [IQR] age, 35 [27-53] years; 37 [24.7%] female and 113 [75.3%] male; 5 [3.3%] Asian, 32 [21.3%] Black, and 113 [75.3%] White; and 51 [34.0%] of Hispanic ethnicity), 28 (18.7%) developed VTE. Patients with VTE had significantly lower antithrombin activity on admission compared with patients without VTE (median [IQR], 91% [79%-104%] vs 100% [88%-112%]; P = .04), as well as lower antithrombin activity on hospital days 5 (median (IQR), 90% [83%-99%] vs 114% [99%-130%]; P = .011), 6 (median [IQR], 97% [81%-109%] vs 123% [104%-134%]; P = .003), 7 (median [IQR], 82% [74%-89%] vs 123% [110%-140%]; P < .001), and 8 (median [IQR], 99% [85%-100%] vs 123% [109%-146%]; P = .011). Anti-FXa levels were significantly lower in patients with VTE vs those without VTE at hospital day 4 (median [IQR], 0.10 [0.05-0.14] IU/mL vs 0.18 [0.13-0.23] IU/mL; P = .006), day 6 (median [IQR], 0.12 [0.08-0.14] IU/mL vs 0.22 [0.13-0.28] IU/mL; P = .02), and day 7 (median [IQR], 0.11 [0.08-0.12] IU/mL vs 0.21 [0.13, 0.28] IU/mL; P = .002). Multivariable analyses found that for every 10% decrease in antithrombin activity during the first 3 days, the risk of VTE increased 1.5-fold. Conclusions and Relevance: The results of this cohort study suggest that after severe trauma, antithrombin deficiency is common and contributes to enoxaparin resistance and VTE. Interventional studies are necessary to determine the efficacy of antithrombin supplementation in the reduction of VTE incidence.

Temporal Changes in Extracellular Vesicle Hemostatic Protein Composition Predict Favourable Left Ventricular Remodeling after Acute Myocardial Infarction.

The subset of plasma extracellular vesicles (EVs) that coprecipitate with low-density lipoprotein (LDL-EVs) carry coagulation and fibrinolysis pathway proteins as cargo. We investigated the association between LDL-EV hemostatic/fibrinolysis protein ratios and post-acute myocardial infarction (post-AMI) left ventricular (LV) remodeling which precedes heart failure. Protein concentrations of von Willebrand factor (VWF), SerpinC1 and plasminogen were determined in LDL-EVs extracted from plasma samples obtained at baseline (within 72 h post-AMI), 1 month and 6 months post-AMI from 198 patients. Patients were categorized as exhibiting adverse (n = 98) or reverse (n = 100) LV remodeling based on changes in LV end-systolic volume (increased or decreased ≥15) over a 6-month period. Multiple level longitudinal data analysis with structural equation (ML-SEM) model was used to assess predictive value for LV remodeling independent of baseline differences. At baseline, protein levels of VWF, SerpinC1 and plasminogen in LDL-EVs did not differ between patients with adverse versus reverse LV remodeling. At 1 month post-AMI, protein levels of VWF and SerpinC1 decreased whilst plasminogen increased in patients with adverse LV remodeling. In contrast, VWF and plasminogen decreased whilst SerpinC1 remained unchanged in patients with reverse LV remodeling. Overall, compared with patients with adverse LV remodeling, higher levels of SerpinC1 and VWF but lower levels of plasminogen resulted in higher ratios of VWF:Plasminogen and SerpinC1:Plasminogen at both 1 month and 6 months post-AMI in patients with reverse LV remodeling. More importantly, ratios VWF:Plasminogen (AUC = 0.674) and SerpinC1:Plasminogen (AUC = 0.712) displayed markedly better prognostic power than NT-proBNP (AUC = 0.384), troponin-I (AUC = 0.467) or troponin-T (AUC = 0.389) (p < 0.001) to predict reverse LV remodeling post-AMI. Temporal changes in the ratios of coagulation to fibrinolysis pathway proteins in LDL-EVs outperform current standard plasma biomarkers in predicting post-AMI reverse LV remodeling. Our findings may provide clinical cues to uncover the cellular mechanisms underpinning post-AMI reverse LV remodeling.

Bioactive hydrogel coatings of complex substrates using diffusion-mediated redox initiation.

Hydrogels have long been established as materials with tunable stiffness and chemistry that enable controlled cellular interactions. When applied as coatings, hydrogels can be used to introduce biofunctionality to medical devices with minimal effect on bulk properties. However, it remains challenging to uniformly apply hydrogel coatings to three dimensional geometries without substantially changing the manufacturing process and potentially affecting device function. Herein, we report a new redox-based crosslinking method for applying conformable hydrogel coatings with tunable thickness and chemistry. This new diffusion-mediated strategy of redox initiation and hydrogel crosslinking enabled coating of a variety of three dimensional substrates without changing the primary fabrication process. Following adsorption of the reducing agent to the construct, hydrogel coating thickness was readily controlled by immersion time with desorption and diffusion of the reducing agent initiating hydrogel crosslinking from the surface. The process was used to generate a range of hydrogel properties by varying the macromer molecular weight and concentration. In addition, we demonstrated that these coatings can be applied sequentially to generate multilayered constructs with distinct features. Finally, incorporation of proteins into the bulk of the hydrogel coating or as a final surface layer permitted the controlled introduction of bioactivity that supported cell attachment. This work provides a versatile method for assembling bioactive coatings with a simple post-fabrication process that is amenable to diverse geometric substrates and chemistries.