Opioid-free Pain Management after Cleft Lip Repair.

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 [1.57 ±â€…1.18 nonopioid versus 1.76 ±â€…0.94 (SD) opioid; P = 0.46]. Average POD1 FLACC scores were significantly lower for the nonopioid group (0.73 ±â€…1.05 versus 1.35 ±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.

Race, ethnicity, and experienced racism are associated with adverse physical and mental health outcomes among cancer survivors.

INTRODUCTION: Survivors of cancer are at risk for adverse mental and physical health outcomes. It is not well understood, however, how these outcomes are differentially experienced according to an individual's exposure to racism. This study sought to evaluate associations of race/ethnicity, and experiences of racism, with adverse health outcomes in survivors of cancer. METHODS: Using the Behavioral Risk Factor Surveillance System database, data from 48,200 survivors between 2014 and 2020 were evaluated. Survey items included negative physical and emotional symptoms as a result of race-based treatment. Outcomes of interest included days of poor mental and physical health, activity limitations, depression, and inadequate sleep. Associations using prevalence ratios were evaluated. RESULTS: All historically marginalized racial/ethnic groups were more likely to experience at least one adverse health outcome compared with non-Hispanic White survivors. Those who physically experienced racism were 2.1 (95% CI, 1.64-2.69) times as likely to report poor physical health, 3.51 (95% CI, 2.61-4.71) times as likely to report poor mental health, 2.14 (95% CI, 1.77-2.58) times as likely to report inadequate sleep, 2.33 (95% CI: 1.91-2.83) times as likely to report depression, and 1.42 (95% CI, 1.04-1.93) times as likely to report activity limitations compared with those who have not experienced racism. Similar associations were observed for emotionally experienced racism. DISCUSSION: Racial inequities in health outcomes for survivors of cancer from marginalized racial/ethnic groups are well-established. Experienced racism contributes to adverse health outcomes and widens these disparities. Improving outcomes for survivors of cancer may require screening for experienced racism. PLAIN LANGUAGE SUMMARY: Survivors of cancer from marginalized racial/ethnic populations are more likely to have poor mental and physical health than their non-Hispanic White counterparts. Whether survivors from certain racial/ethnic populations of smaller size also have poorer health is less well understood. Generally, individuals who report experienced racism also report poor health, this association has not been studied in survivors of cancer. This study, from a national survey of survivors of cancer, describes disparities in health outcomes experienced by a variety of racial and ethnic populations. Our findings suggest racism is associated with poor mental and physical health in survivors of cancer.

A rapid review of end-of-life needs in the LGBTQ+ community and recommendations for clinicians.

BACKGROUND: Lesbian, gay, bisexual, transgender, and queer plus (LGBTQ+) adults face challenges accessing end-of-life care. Understanding the experiences of LGBTQ+ persons within the end-of-life context is crucial in addressing their needs and supporting equity at end of life. AIM: Review recent literature documenting the experiences of LGBTQ+ adults nearing end-of-life, identifying needs, barriers to care, and translating this into clinical recommendations. DESIGN: A rapid review design was chosen for prompt results. The process was streamlined by limiting the literature search to peer-reviewed articles, dissertations, theses, by date and language. Data collection used a predetermined set of items based on Meyer's Minority Stress and Bronfenbrenner's Ecological Models including participants' voices, needs, and barriers. Thematic analysis of collected data was conducted and presented results in a narrative summary. DATA SOURCES: We searched six electronic databases (PubMed, Medline, ProQuest Dissertations and Theses A&I, ProQuest Dissertations and Theses, Open Access Theses and Dissertations, CINAHL, and Google Scholar) for articles published from 2016 to 2020. RESULTS: We included and appraised for quality 33 articles. We uncovered three latent themes: systemic barriers, a lack of lived experience within the literature, and treatment of LGBTQ+ as one homogeneous group. CONCLUSIONS: The hybrid Meyer's Minority Stress and Bronfenbrenner Ecological model elucidated how stressors and social contexts may impact LGBTQ+ adults when accessing end-of-life care. Incorporating LGBTQ+ cultural competence training into continuing education and ensuring that LGBTQ+ individuals participate in the development of end-of-life care programming may better attend to the needs of this population.

VCP/p97 inhibitor CB-5083 modulates muscle pathology in a mouse model of VCP inclusion body myopathy.

BACKGROUND: Pathogenic gain of function variants in Valosin-containing protein (VCP) cause a unique disease characterized by inclusion body myopathy with early-onset Paget disease of bone and frontotemporal dementia (also known as Multisystem proteinopathy (MSP)). Previous studies in drosophila models of VCP disease indicate treatment with VCP inhibitors mitigates disease pathology. Earlier-generation VCP inhibitors display off-target effects and relatively low therapeutic potency. New generation of VCP inhibitors needs to be evaluated in a mouse model of VCP disease. In this study, we tested the safety and efficacy of a novel and potent VCP inhibitor, CB-5083 using VCP patient-derived myoblast cells and an animal model of VCP disease. METHODS: First, we analyzed the effect of CB-5083 in patient-derived myoblasts on the typical disease autophagy and TDP-43 profile by Western blot. Next, we determined the maximum tolerated dosage of CB-5083 in mice and treated the 2-month-old VCPR155H/R155H mice for 5 months with 15 mg/kg CB-5083. We analyzed motor function monthly by Rotarod; and we assessed the end-point blood toxicology, and the muscle and brain pathology, including autophagy and TDP-43 profile, using Western blot and immunohistochemistry. We also treated 12-month-old VCPR155H/+ mice for 6 months and performed similar analysis. Finally, we assessed the potential side effects of CB-5083 on retinal function, using electroretinography in chronically treated VCPR155H/155H mice. RESULTS: In vitro analyses using patient-derived myoblasts confirmed that CB-5083 can modulate expression of the proteins in the autophagy pathways. We found that chronic CB-5083 treatment is well tolerated in the homozygous mice harboring patient-specific VCP variant, R155H, and can ameliorate the muscle pathology characteristic of the disease. VCP-associated pathology biomarkers, such as elevated TDP-43 and p62 levels, were significantly reduced. Finally, to address the potential adverse effect of CB-5083 on visual function observed in a previous oncology clinical trial, we analyzed retinal function in mice treated with moderate doses of CB-5083 for 5 months and documented the absence of permanent ocular toxicity. CONCLUSIONS: Altogether, these findings suggest that long-term use of CB-5083 by moderate doses is safe and can improve VCP disease-associated muscle pathology. Our results provide translationally relevant evidence that VCP inhibitors could be beneficial in the treatment of VCP disease.

Systems of Care Implications in Hawai'i: Sexual and Gender Minorities.

Sexual and gender minorities (SGM) are diverse groups of people who do not identify as heterosexual or cisgender. SGM communities include Lesbian, Gay, Bisexual, and Transgender (LGBT) individuals as well as people of other sexual orientations and gender identities. SGM communities are disproportionately affected by substance use disorders, with differential use of specific substances among persons based on sexual or gender identity. As understood through the minority stress model, substance use and misuse among SGM people are tied to risk and resiliency factors at all levels of the social ecological paradigm. Despite the disproportionate burden of substance use disorders on SGM people in Hawai'i, very few resources or programs exist to ameliorate the impact of substance use on this community. Although some models of care could be useful for SGM people, community-specific interventions are scarce, especially in Hawai'i. To successfully meet the needs of SGM people in Hawai'i, multi-level transformation of the substance use prevention and treatment landscape must address: culturally appropriate service delivery; workforce recruitment and development; nimble and adequate financing; consistent data collection and reporting; and systems-level policy updates.

The Historical Role of the Plastic Surgeon in Spine Reconstruction.

Wound complications occur in up to 19% of patients undergoing complex spine surgery. The role of the plastic surgeon in complex and redo spine surgery is important and evolving. Classically, plastic surgeons have been involved in the management of patients who develop wound complications following surgery. This involves reconstruction of posterior trunk defects with locoregional fasciocutaneous, muscle, and free tissue transfers. There has also been an increasing role for plastic surgeons to become involved in prophylactic closures of complex and/or redo spine surgeries for high-risk populations. Identification of patients with comorbidities and likelihood for multiple reoperations who are prophylactically treated with complex closure with or without local muscle flaps could significantly decrease the postoperative wound complications.

Esthesioneuroblastoma with widespread distant metastasis: Case report and literature review.

Esthesioneuroblastoma (ENB) is an uncommon sinonasal tract tumor, and it is even more uncommon among all neoplasms. Literature regarding the incidence and spread of the disease is limited. The prognosis of metastatic disease is poor. In this report, we present a case of recurrent ENB in a young woman involving metastasis to the neck, lungs, and ovary. Metastasis to the cervical lymph nodes is relatively common, but metastasis to the lungs is rare. Furthermore, to our knowledge, no cases of ovarian metastases of ENB have been reported. This case highlights the potential for widespread metastatic disease, suggesting the need for more frequent and thorough surveillance of patients diagnosed with recurrences of this tumor.

Craniosynostosis Surgery and the Impact of Tranexamic Acid Dosing.

Consensus does not exist regarding the best dosage regimen for using tranexamic acid (TXA) for patients undergoing open calvarial vault remodeling in craniosynostosis surgery. The purpose of this study was to evaluate 2 dosing protocols, as well as the cost of using TXA. Previously, the institutional protocol was to give patients undergoing open calvarial vault remodeling a loading infusion of TXA (10 mg/kg) at the start of their procedure, after which intravenous TXA (5 mg/kg/h) was given throughout surgery and for 24 hours postoperatively. In July 2015, the protocol changed to a reduced postoperative infusion time of 4 hours. A retrospective review was conducted of records of 30 patients who had surgery before the protocol change (24-hour group) and 23 patients whose surgery occurred after the protocol change (4-hour group). The following data were collected: blood volume transfused, hemoglobin levels, estimated blood loss, and intensive care days; and costs of TXA and blood transfusion. Results showed a 4-hour infusion was as effective as a 24-hour infusion for reducing blood loss in patients undergoing craniosynostosis. Transfusion requirements, hemoglobin and hematocrit levels, and estimated blood loss were not significantly different for the groups. The cost of TXA and transfusion in the 4-hour group was significantly less (P < 0.001) than in the 24-hour group. No significant difference in cost existed for patients who received blood transfusion alone versus patients who received the 4-hour TXA infusion.

Transabdominal robot-assisted diaphragmatic plication: a 3.5-year experience.

OBJECTIVES: Diaphragmatic paralysis, a known cause of dyspnoea, can drastically reduce breathing efficiency, diminishing quality of life. We report our 3.5-year experience with 22 consecutive patients who underwent transabdominal, robot-assisted diaphragmatic plication for diaphragmatic paralysis. METHODS: We retrospectively reviewed 22 consecutive patients who underwent this procedure by a single surgeon from 5 September 2012 to 12 May 2016. The primary outcome measure was change in dyspnoea severity, which was measured with the 5-point Medical Research Council dyspnoea scale (a score of 5 indicates breathlessness so severe, the individual is homebound). RESULTS: Of the 22 patients who underwent robotic diaphragmatic plication, 17 (77.3%) patients were male. Median body mass index was 30 kg/m2 (range 24.2-42.17 kg/m2). Most plications (13 of 22, 59.1%) were left sided; one (4.6%) was bilateral. Median operating time was 161 min (range 107-293 min), but this time was higher for the first 3 procedures (255 min, range 239-293 min). Median length of stay was 2 days, and median time to chest tube removal was 1 day. At follow-up, 20 of the 22 (91%) patients reported improved breathing and 2 reported no change. No patient reported worsened dyspnoea. The median Medical Research Council score changed from 4.0 preoperatively to 2.0 postoperatively (P = 0.001). CONCLUSIONS: Transabdominal robotic diaphragmatic plication involves small incisions but improves surgical dexterity. Surgical times are reasonable, and this surgical technique can be adopted with a quick but steep learning curve. Early results show good functional outcomes.

Textured Breast Implants: A Closer Look at the Surface Debris Under the Microscope.

BACKGROUND: Texturing of breast implants is done to decrease the risk of associated complications. Each manufacturer utilizes unique and at times proprietary techniques to texture the surface of their implants. Little is known about the integrity of this surface structure texturing or the propensity for the surfaces to shed particulate matter. This study aimed to determine the extent of surface particulate shedding from 3 textured implants approved by the US Food and Drug Administration (FDA), which are manufactured by Allergan, Mentor, and Sientra. METHODS: Control images of each of the 3 textured breast implants were obtained with scanning electron microscopy (SEM). A liquid adhesive, ethylene vinyl acetate (EVA) copolymer was then applied to the external shell of the implants, allowed to cool, and peeled from the surface. Images of the EVA copolymer were taken with SEM to qualitatively analyze displacement of surface particulate debris. Scanning electron microscopy imaging of the implants was repeated for qualitative comparisons with the control images. RESULTS: The peeled copolymer of the 3 implants exhibited surface shedding. Comparison of the 3 breast implants showed the shedding to be greatest for the Allergan implant. CONCLUSIONS: This study highlights the dynamic surface material properties of the 3 FDA-approved breast implants. Shedding of particulate matter from the implant surfaces can be precipitated by moderate adhesion. Our qualitative examination of SEM findings showed more debris shed from the Allergan breast implants than from the Mentor or Sientra implants.

HISTORIQUE: La texturation des implants mammaires vise à réduire le risque de complications. Pour ce faire, chaque fabricant utilise des techniques uniques et exclusives. On ne sait pas grand-chose sur l'intégrité de la structure après texturation de la surface ni sur sa propension à excréter des particules. La présente étude vsait à déterminer l'étendue de l'excrétion des particules de surface de trois implants texturés approuvés par la Food and Drug Administration (FDA) des États-Unis, fabriqués par Allergan, Mentor et Sientra. MÉTHODOLOGIE: Les chercheurs ont obtenu des images témoin de chacun des trois implants mammaires texturés au moyen la microscopie électronique à balayage (MÉB). Ils ont ensuite appliqué un copolymère d'éthylène-acétate de vinyle (EAV) adhésif liquide sur la coquille extérieure des implants, l'ont laissé refroidir, puis l'ont décollé de la surface. Ils ont pris des images du copolymère EAV par MÉB pour procéder à l'analyse qualitative des débris des particules de surface qui s'étaient détachés. Ils ont repris des images des implants par MÉB pour procéder à des comparaisons qualitatives par rapport aux images témoins. RÉSULTATS: La pelure de copolymère des trois implants contenait des particules de surface. La comparaison entre les trois implants a révélé que l'implant Allergan excrétait plus de particules. CONCLUSIONS: La présente étude fait ressortir les propriétés dynamiques des matières de surface des trois implants mammaires approuvés par la FDA. L'excrétion de particules à la surface des implants peut être précipitée par une adhésion modérée. L'examen qualitatif des résultats de la MÉB a démontré que les implants mammaires Allergan excrétaient plus de débris que les implants Mentor ou Sientra.

A decade of burn unit experience with Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis: Clinical pathological diagnosis and risk factor awareness.

Stevens-Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis (TEN) is a rare and often fatal spectrum of mucocutaneous diseases usually attributable to severe adverse drug reactions. Burn units are referral centers for patients at the most extreme end of the disease continuum. Our burn center admits a much higher percentage of TEN (>30% BSA) cases than reported in most prior reviews. The purpose of this study was to analyze the diagnostic and prognostic value of variables collected on referred SJS/TEN patients. We retrospectively analyzed 94 patients admitted to our unit with a presumptive SJS/TEN diagnosis made in most cases by the referring center. Most of the diagnoses were clinical. Fifty of the 94 patients underwent biopsy when the clinical diagnosis was questionable. Of the 50 patients who underwent biopsy, 18 (36%) received an alternative diagnosis. Analysis was therefore limited to 76 patients, i.e. 44 patients felt to have firm clinical diagnoses plus 32 patients with diagnoses confirmed by biopsy. Mean age was 54.3 years (17-93) and overall gender ratio was 43 F vs. 33 M (56.6% vs. 43.4%). Mean LOS was 15.2 days (1-48) and overall mortality was 23.7% (18/76). Univariate analysis revealed percent body surface area (%BSA) did not show statistically significant association with mortality. Histopathological correlation for diagnosis is not standardized across institutions worldwide. Due to challenges in the diagnosis of SJS/TEN and the high incidence of error in clinical diagnosis, it is recommended that all patients with presumed SJS/TEN receive skin biopsies with H&E and direct immunofluorescence. We propose a diagnostic approach in order to address this need. Lack of association between %BSA and mortality suggests that all biopsy-proven SJS/TEN cases belong in specialty centers due to the unstable nature of the disease and risk for rapid progression.