Assessing the Quality of Reporting on Quality Improvement Initiatives in Breast Reconstruction: A Systematic Review.

BACKGROUND: There has been a recent increase in the number and complexity of quality improvement (QI) studies in breast reconstruction. To assist with the development of thorough QI reporting practices, with the goal of improving the transferability of these initiatives, the authors conducted a systematic review of studies describing the implementation of QI initiatives in breast reconstruction. The authors used the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guideline to appraise the quality of reporting of these initiatives. METHODS: English language articles published in Embase, MEDLINE, CINAHL, and the Cochrane databases were searched. Quantitative studies evaluating the implementation of QI initiatives in breast reconstruction were included. The primary endpoint of interest in this review was the distribution of studies according to SQUIRE 2.0 criteria scores in proportions. Abstracts and full-text screening, and data extraction were completed independently and in duplicate by the review team. RESULTS: The authors screened 1107 studies, of which 53 full texts were assessed and 35 met inclusion criteria. In our assessment, only three studies (9%) met all 18 SQUIRE 2.0 criteria. SQUIRE 2.0 criteria that were met most frequently were abstract, problem description, rationale, and analysis. The lowest SQUIRE 2.0 scores appeared in the interpretation criteria. CONCLUSIONS: Significant opportunity exists to improve QI reporting in breast reconstruction, especially in the realm of costs, strategic tradeoffs, ethical considerations, project sustainability, and potential for spread to other contexts. Improvements in these areas will help to further advance the transferability of QI initiatives in breast reconstruction.

Free Functional Muscle Transfer following Upper Extremity Sarcoma Resection: A Case Report.

Functional reconstruction of the upper extremity has traditionally involved tendon transfer or pedicled muscle transfer. The gracilis free functional muscle transfer remains as an excellent option for restoration of finger flexion. Here, we provide a case report of a 35-year-old man diagnosed with left forearm high-grade epithelioid sarcoma who underwent innervated free gracilis transfer and a secondary free flap, the profunda artery perforator flap, through a single donor-site incision to expand soft tissue coverage. Postoperatively, there were no complications reported. At 8-month follow-up, the patient had Musculoskeletal Tumor Score of 22/30, and a Quick Disabilities of the Arm, Shoulder, and Hand score of 34/100.

Preterm birth after recurrent pregnancy loss: a systematic review and meta-analysis.

OBJECTIVE: To evaluate the impact of recurrent pregnancy loss (RPL) on the risk of preterm birth (PTB) in subsequent pregnancies. DESIGN: Systematic review and meta-analysis. SETTING: Not applicable. PATIENT(S): Pregnant women with and without a history of RPL. INTERVENTION(S): PubMed, Embase, Google Scholar and Cochrane trial registry were used to identify relevant studies. MAIN OUTCOME MEASURE(S): The odds ratios (ORs) for the association between RPL and PTB across included studies were evaluated. Effect estimates were pooled using a DerSimonian and Laird random-effects meta-analysis model. RESULT(S): Eighteen studies met the inclusion criteria. A total of 58,766 women with a history of RPL and 2,949,222 women without a history of RPL were included. A pooled OR of 1.60 (95% confidence interval [CI], 1.45-1.78; 18 observational studies; I2 = 85.6%) was observed in our random-effects meta-analysis. A trend toward higher odds of PTB is observed with the increasing number of pregnancy losses: 2 RPLs (pooled OR, 1.31; 95% CI, 1.09-1.57; I2 = 88.9%); ≥2 RPLs (pooled OR, 1.58; 95% CI, 1.27-1.96; I2 = 71.7%); and ≥3 RPLs (pooled OR, 1.81; 95% CI, 1.58-2.07; I2 = 73.6%). The analysis of the risk of PTB for patients with unexplained RPL demonstrated a significantly heightened risk of PTB in this subgroup (pooled OR, 2.05; 95% CI, 1.46-2.89; I2 = 21.0%). Inconsistent adjustment for confounders and significant between-study heterogeneity were noted in this study. CONCLUSION(S): Despite significant heterogeneity among studies, we found that women with a history of RPL had significantly higher odds of delivering preterm infants in subsequent pregnancies. CLINICAL TRIAL REGISTRATION NUMBER: CRD 224763.

Trends and Outcomes of Cranioplasty Alone Versus Single-Stage Composite Scalp and Calvarial Reconstruction.

BACKGROUND: Cranioplasty is a critical intervention to restore the calvarium using autologous or alloplastic materials with single-stage composite scalp and calvarial reconstruction reserved for complex cases. This study aims to identify 30-day outcomes in scalp and calvarial reconstruction using the American College of Surgeons National Surgical Quality Improvement Program database. METHODS: The authors conducted a retrospective analysis of the 2010 to 2018 American College of Surgeons National Surgical Quality Improvement Program database. Adult patients who underwent cranioplasty were identified using current procedural terminology coding and included by exposure type (autologous, alloplastic, composite, or other). Subjects with missing exposure or outcome data were excluded. Primary outcome was 30-day reoperation, whereas secondary outcomes were 30-day unplanned readmission and transfusion. Univariate analysis was completed to assess differences in demographics, comorbidities, and postoperative complications. Multivariable logistic regression was used to control for confounders. RESULTS: In total, 1719 patients underwent cranioplasty (mean age 54.7 ± 15.3 years, 43.5% male), including 169(9.8%) autologous, 1303(75.8%) alloplastic, 32(1.9%) composite, and 215(12.5%) other procedures. Cranioplasty procedures were associated with 30-day complication and mortality rate of 16.5% and 2.4%, respectively. Composite cranioplasty was associated with decreased 30-day reoperation (adjusted odds ratios 0.11, 95% confidence interval 0.014-0.94, P = 0.044). There was no statistically significant difference in readmission between cranioplasty groups. Alloplastic cranioplasty was associated with decreased odds of postoperative transfusion (adjusted odds ratios 0.47, 95% confidence interval 0.27â0.84, P = 0.01). CONCLUSIONS: Cranioplasty is an increasingly common procedure. Alloplastic cranioplasty is associated with decreased 30-day transfusion requirement, whereas single-stage composite reconstruction is a viable option and associated with decreased 30-day reoperation with no difference in readmission.

The effect of immediate breast reconstruction on adjuvant therapy delay, locoregional recurrence, and disease-free survival.

BACKGROUND: An important risk inherent to both alloplastic and autologous immediate breast reconstruction (IBR) is the higher incidence of postoperative complications and delays to adjuvant therapy. The main objective of this retrospective cohort study was to identify risk factors for locoregional recurrence after breast cancer mastectomy and IBR. METHODS: A 6-year retrospective study of breast cancer patients treated with mastectomy only (MO) or mastectomy and IBR (MIBR) was conducted from January 2013 to May 2019. The outcomes of interest included delay in adjuvant chemoradiotherapy, postoperative complications, and locoregional recurrence. Cox regression survival was used to estimate the risk of locoregional recurrence and time to adjuvant therapy. RESULTS: Of 1832 patients reviewed, 720 (38%) were included. The cohort consisted of 443 (62%) MO and 277 (38%) MIBR [140 (51%) direct-to-implant (MIBRi1), 96(35%) tissue expander to implant (MIBRi2), and 41(15%) autologous flap (MIBRf)]. MIBR had more delays to adjuvant therapy compared to MO [113 (70%) vs. 72 (80%) months, p = 0.022]. Kaplan-Meier analysis showed that MIBRi2 had significantly shorter DFS compared to MO [MIBRi2: 39.2 (15.6) vs MO: 41.7 (19.6) months, log-rank p-value = 0.01]. Cox regression indicated that MIBRi2 was associated with a 3.26-higher risk of locoregional recurrence compared to MO [HR: 3.26; 95% CI: 1.56, 9.24]. CONCLUSIONS: Cox regression showed MIBRi2 was significantly associated with increased risk of locoregional recurrence compared to MO. Neither delays nor postoperative complications were identified as significant risk factors for locoregional recurrence risk.

Detection of Circulating Tumor DNA in Patients with Thyroid Nodules.

OBJECTIVE: Detection of circulating tumor DNA (ctDNA) in cancer patients can potentially serve as a noninvasive, sensitive test of disease status. The purpose of this study was to determine the ability to detect BRAF (V600E) mutations in the plasma of patients with thyroid nodules, with the goal of distinguishing between benign and malignant nodules. METHODS: Consecutive patients with thyroid nodules who consented for surgery were recruited. Plasma samples were obtained preoperatively and one month postoperatively. Quantitative PCR was used to determine the levels of the BRAF (V600E) mutation preoperatively and postoperatively. RESULTS: A total of 109 patients were recruited. On final pathology, 38 (32.8%) patients had benign thyroid nodules, 45 (38.8%) had classical papillary thyroid cancer (PTC), 23 (19.8%) had nonclassical PTC, and 3 (2.6%) had follicular thyroid cancer. 15/109 patients had detectable BRAF (V600E) ctDNA in their preoperative samples-all of them having classical PTC. Higher T-stage and extrathyroidal extension in PTC were associated with positive BRAF (V600E) ctDNA (p < 0.05). Eighty-eight pairs of preoperative and postoperative plasma samples were collected and analyzed. Of these eighty-eight paired samples, a total of 13/88 (14.8%) patients had detectable BRAF (V600E) ctDNA in their preoperative samples-all of them having classical PTC. 12 of these 13 patients had no detectable BRAF (V600E) postoperatively, while one remaining patient had a significant decline in his levels (p < 0.05). CONCLUSION: BRAF (V600E) circulating thyroid tumor DNA can be detected in plasma and is correlated with a final diagnosis of the classical variant of PTC. Given that a postoperative drop in BRAF (V600E) ctDNA levels was observed in all cases suggests its utility as a tumor marker.

Epidural Nerve Blocks Increase Intraoperative Vasopressor Consumption and Delay Surgical Start Time in Deep Inferior Epigastric Perforator Free Flap Breast Reconstruction.

BACKGROUND: Epidural nerve blocks (EA) have been widely used in abdominal and thoracic surgery as an adjunct to general anesthesia (GA). The role for EA in microsurgical free flap breast reconstruction remains unclear with concerns regarding its impact on flap survival and operating room efficiency. The purpose of this study was to examine the effectiveness of epidural blocks in patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS: A retrospective analysis of patients undergoing DIEP breast reconstruction under GA alone was compared with those receiving EA/GA. Electronic records were analyzed for patient demographics, intraoperative data, and postoperative outcomes. The primary outcome was 48-hour narcotic usage and secondary outcomes were intraoperative vasopressor consumption, surgical delay, and safety profile. RESULTS: Sixty-one patients underwent DIEP reconstruction, 46 (75%) underwent EA/GA and 15 (25%) underwent GA alone. Epidural blocks were associated with a significant delay in operating room start time (67.8 min versus 45.6 min; P = 0.0004.) Patients in the EA/GA group also had a significant increase in vasopressor use (n = 38 versus n = 8; P = 0.037); however, there was no difference in flap complication rate [1 (2%) versus 2 (13%); P = 0.15]. Postoperatively, patients who received an epidural block had a reduced average pain score (1.1 versus 2.2; P = 0.0235), but there was no difference in 48-hour narcotic usage. CONCLUSIONS: Although epidural blocks reduce postoperative pain following DIEP flap breast reconstruction, they increase intraoperative vasopressor use and delay the start time of the case. Further studies are required to elucidate whether the benefits of improved pain control outweigh the potential risk for increased surgical complications and increased health care costs.

Navigating the new, transplanted self: how recipients manage the cognitive risks of organ transplantation.

The physiological risks of organ transplantation are well documented, but more poorly understood are the sociological ways in which organ recipients redefine themselves in reaction to physiological risks and social changes accompanying transplantation. This article analyses transplantation as a procedure that is not only physiologically risky but also poses risk to the social identity of the recipient, and explores how transplant recipients cognitively navigate transplantation surgery from waiting for to recovering after a transplant. It builds on previous sociological exploration of risk as a socially constructed process mediating experiences of health and illness with a focused contribution on explaining how individuals navigate risks posed to their social identities by major biophysical transformations. This article pointedly analyses narratives of fourteen organ recipients and the four dominant phases of identity management that emerged to create what we have coined as the new 'transplanted self', indicating the varied ways the individual social self emerges in response to the social risks of transplantation. We conclude that a better understanding of the recipient experience will contribute to improved care in the transplantation field.

Effect of DNase I treatment and neutrophil depletion on acute limb ischemia-reperfusion injury in mice.

OBJECTIVE: Extracellular traps (ETs) consisting of DNA-protein complexes formed after tissue injury contribute to the inflammatory and thrombosis cascades, thereby exacerbating injury. Exogenous DNase I has been suggested as a therapeutic strategy to limit injury in the brain and myocardium. These studies were designed to evaluate the effects of exogenous DNase I treatment on skeletal muscle injury after acute hindlimb ischemia-reperfusion (IR) injury in mice and to determine whether neutrophils are a major source of ETs in postischemic muscle tissue. METHODS: C57BL6 mice were subjected to 1.5 hours of tourniquet ischemia and 24 hours of reperfusion with and without human recombinant DNase I treatment. A separate set of mice was subjected to neutrophil depletion (ND), followed by the same intervals of IR. Laser Doppler imaging and tissue harvesting were done at 24 hours for assessment of limb perfusion, muscle fiber injury, adenosine triphosphate (ATP) level, markers of inflammation, thrombosis, and formation of ETs. RESULTS: DNase I treatment significantly reduced detection of ETs in postischemic muscle but did not alter skeletal muscle fiber injury, levels of proinflammatory molecules, or ATP level. DNase I treatment did enhance postischemic hindlimb perfusion, decreased infiltrating inflammatory cells, and reduced the expression of thrombin-antithrombin III. ND resulted in a significant yet small reduction in ETs in the postischemic muscle. ND did not alter skeletal muscle fiber injury, hindlimb perfusion, or ATP levels. CONCLUSIONS: These data suggest that neither DNase I treatment nor ND was protective against IR injury, even though both decreased detection of ETs in skeletal muscle after IR. Neutrophils are not the only source of ETs after IR.

Optimization of the Wound Scratch Assay to Detect Changes in Murine Mesenchymal Stromal Cell Migration After Damage by Soluble Cigarette Smoke Extract.

Cell migration is vital to many physiological and pathological processes including tissue development, repair, and regeneration, cancer metastasis, and inflammatory responses. Given the current interest in the role of mesenchymal stromal cells in mediating tissue repair, we are interested in quantifying the migratory capacity of these cells, and understanding how migratory capacity may be altered after damage. Optimization of a rigorously quantitative migration assay that is both easy to customize and cost-effective to perform is key to answering questions concerning alterations in cell migration in response to various stimuli. Current methods for quantifying cell migration, including scratch assays, trans-well migration assays (Boyden chambers), micropillar arrays, and cell exclusion zone assays, possess a range of limitations in reproducibility, customizability, quantification, and cost-effectiveness. Despite its prominent use, the scratch assay is confounded by issues with reproducibility related to damage of the cell microenvironment, impediments to cell migration, influence of neighboring senescent cells, and cell proliferation, as well as lack of rigorous quantification. The optimized scratch assay described here demonstrates robust outcomes, quantifiable and image-based analysis capabilities, cost-effectiveness, and adaptability to other applications.

Hind limb ischemia-reperfusion injury in diet-induced obese mice.

BACKGROUND: Obesity is a major risk factor for the development of diabetes. Limb ischemia-reperfusion injury (IR) is a common clinical problem in diabetics who have compromised lower extremity perfusion. This study compared the histologic, metabolic, and functional outcomes after hind limb IR in diet-induced obese (DIO) and non-diabetic (ND) mice during the acute and the regenerative phases of IR. METHODS: DIO and ND mice were subjected to 1.5 h unilateral hind limb ischemia followed by 1- or 28-d IR. Muscle morphology, metabolic, and genomic stress were evaluated at days 1 and 28 IR; Acute inflammation and thrombosis were only measured at day-1 IR. At day 28, IR, skeletal muscle contractility, and maturation were also assessed. RESULTS: At day-1 IR, similar levels of acute muscle fiber necrosis were seen in both groups. DIO mice demonstrated substantially greater inflammatory, prothrombotic, and genomic stress responses, which were also associated with a greater reduction in energy substrates and Akt phosphorylation. At 28d, there was no difference in the peak forces generated in the hind limbs for the two groups. DIO mice had reduced fatigue resistance compared with ND and larger areas of fat accumulation although there was no significant difference in muscle fiber maturation. CONCLUSIONS: DIO mice had an exacerbated acute response to IR with enhanced metabolic deficit, fat accumulation, and defective functional recovery during the regenerative phase of IR. These changes in fatigue resistance reflect compromised functional recovery after IR injury and have relevance for the functional recovery of patients with metabolic syndrome and insulin resistance.

Besting vitamin E: sidechain substitution is key to the reactivity of naphthyridinol antioxidants in lipid bilayers.

A series of naphthyridinol analogs of α-tocopherol (α-TOH, right) with varying sidechain substitution was synthesized to determine how systematic changes in the lipophilicity of these potent antioxidants impact their radical-trapping activities in lipid bilayers, regenerability by water-soluble reductants, and binding to human tocopherol transport protein (TTP). The activities of the naphthyridinols were assayed in phosphatidylcholine unilamellar liposomes using a recently developed high-throughput assay that employs a boron dipyrromethene conjugate of α-TOH (H(2)B-PMHC) that undergoes fluorescence enhancement upon oxidation. The naphthyridinols afforded a dose-dependent protection of H(2)B-PMHC consistent with unprecedented peroxyl radical-trapping activity in lipid bilayers. While sidechain length and/or branching had no effect on their apparent reactivity, it dramatically impacted reaction stoichiometry, with more lipophilic compounds trapping two peroxyl radicals and more hydrophilic compounds trapping significantly less than one. It is suggested that the less lipophilic compounds autoxidize rapidly in the aqueous phase and that preferential partitioning of the more lipophilic compounds to the bilayer protects them from autoxidation. The cooperativity of a lipophilic naphthyridinol with water-soluble reducing agents was also studied in liposomes using H(2)B-PMHC and revealed superior regenerability by each of ascorbate, N-acetylcysteine, and urate when compared to α-TOH. Binding assays with human TTP, a key determinant of the bioavailability of the tocopherols, reveal that the naphthyiridinols can be very good ligands for the protein. In fact, naphthyridinols with sidechains of eight or more carbons had affinities for TTP which were similar to, and in one case 10-fold better than, α-TOH.