Impact of mastectomy flap necrosis on prepectoral reconstructive outcomes.

INTRODUCTION: As reconstructive surgeons have increasingly transitioned to the prepectoral plane for prosthetic breast reconstruction, the implications of mastectomy skin flap necrosis have become more concerning. Our goal was to evaluate the effect of skin flap necrosis on reconstructive outcomes in patients undergoing immediate prepectoral breast reconstruction. METHODS: A retrospective review was conducted of patients undergoing immediate two-stage prepectoral reconstruction at a single center with at least 3 months follow-up. Postoperative complications, reconstructive outcome, and time to final implant were compared between patients with and without mastectomy skin necrosis. RESULTS: A total of 301 patients underwent 509 prepectoral breast reconstructions. Forty-four patients (14.6%) experienced postoperative mastectomy skin flap necrosis. Demographic and reconstructive characteristics were similar between the necrosis and no necrosis cohorts. Patients with skin necrosis were more likely to undergo reoperation after tissue expander (64% vs 19%, p < 0.01) and undergo expander replacement (13.6% vs 3.5%, p = 0.02). However, rates of reconstructive failure (6.8% vs 6.2%), major infection (9.1% vs 9.0%), and minor infection (13.6% vs 17.5%) after expander placement were statistically similar. Patients with skin necrosis trended toward longer time before final implant placement, although the difference was not statistically significant (6.5 vs 5.0 months, p = 0.08). There was no difference in complication rates between the necrosis and no necrosis cohort after final implant placement. There was a higher rate of revision surgery after implant placement in the necrosis cohort (12.5% vs 4.1%, p = 0.047). CONCLUSIONS: Mastectomy skin flap necrosis is a concerning postoperative event, particularly in patients with prepectoral prostheses. We observed that patients with skin necrosis experience higher reoperation rates in the expander period, yet have similar infection rates and achieve similar final reconstructive outcomes compared to patients without necrosis.

Perioperative Pain Management in Cleft Lip and Palate Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Studies.

BACKGROUND: Developing effective strategies to manage perioperative pain remains a focus of cleft care. The present study's purpose was to systematically review perioperative pain control strategies for cleft lip and palate repair. METHODS: A systematic review and meta-analysis of randomized controlled trials was performed. Primary outcomes included pain scale scores and time to analgesia failure. Cohen d normalized effect size permitted comparison between studies, and a fixed-effects model was used for analysis. I2 and Q-statistic p values were calculated. RESULTS: Twenty-three studies were included: eight of 23 studies provided data for meta-analytic comparison. Meta-analyses evaluated the efficacy of intraoperative nerve blocks on postoperative pain management. Meta-analysis included a total of 475 treatment and control patients. Cleft lip studies demonstrated significantly improved pain control with a nerve block versus placebo by means of pain scale scores ( p < 0.001) and time to analgesia failure ( p < 0.001). Measurement of effect size over time demonstrated statistically significant pain relief with local anesthetic. Palatoplasty studies showed significantly improved time to analgesia failure ( p < 0.005) with maxillary and palatal nerve blocks. Multiple studies demonstrated an opioid-sparing effect with the use of local anesthetics and other nonopioid medications. Techniques for nerve blocks in cleft lip and palate surgery are reviewed. CONCLUSIONS: The present systematic review and meta-analysis of randomized controlled studies demonstrates that intraoperative nerve blocks for cleft lip and palate surgery provide effective pain control. Opioid-sparing effects were appreciated in multiple studies. Intraoperative nerve blocks should be considered in all cases of cleft lip and palate repair to improve postoperative pain management. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Treatment of Facial Fractures at Safety-Net Hospitals: A National Analysis of Inpatient Burden and Cost.

PURPOSE: Safety-net hospitals (SNHs) are vital in the care of trauma populations, but little is known about the burden of facial trauma presenting to SNHs. The authors sought to characterize the presentation and treatment of facial fractures across SNHs and determine the association between SNH care and healthcare utilization in patients undergoing fracture repair. METHODS: Adult patients presenting with a facial fracture as their primary admitting diagnosis from the year 2012 to 2015 were identified in the National Inpatient Sample. The "safety-net burden" of each hospital was defined based on the proportion of Medicaid and self-pay discharges. Patient factors analyzed were sex, race, age, income level, insurance status, fracture location, and comorbidities. Hospital factors analyzed were safety-net burden, teaching status, geographic region, bed size, and ownership status. The main outcomes were length of stay (LOS), hospital costs, time to repair, and postoperative complications. RESULTS: Of 78,730 patients, 27,080 (34.4%) were treated at SNHs and 24,844 (31.6%) were treated at non-SNHs. Compared to non-SNHs, patients treated at SNHs were more likely to undergo operative repair at SNHs (65.8% versus 53.9%, P < 0.001). Overall mean LOS was comparable between non-SNH and SNH (3.43 versus 3.38 days, P = 0.611), as was mean hospital cost ($15,487 versus $15,169, P = 0.434). On multivariate linear regression, safety-net status was not a predictor of increased LOS, cost, or complications. However, safety-net status was significantly associated with lower odds of undergoing repair within 48 hours of admission (odds ratio 0.783, 95% confidence interval = 0.680-0.900, P = 0.001). CONCLUSIONS: Safety-net hospitals are able to treat facial trauma patients with greater injury burden and lower socioeconomic resources without increased healthcare utilization. Healthcare reform must address the financial challenges that endanger these institutions to ensure timely treatment of all patients.

The Efficacy of Schwann-Like Differentiated Muscle-Derived Stem Cells in Treating Rodent Upper Extremity Peripheral Nerve Injury.

BACKGROUND: There is a pressing need to identify alternative mesenchymal stem cell sources for Schwann cell cellular replacement therapy, to improve peripheral nerve regeneration. This study assessed the efficacy of Schwann cell-like cells (induced muscle-derived stem cells) differentiated from muscle-derived stem cells (MDSCs) in augmenting nerve regeneration and improving muscle function after nerve trauma. METHODS: The Schwann cell-like nature of induced MDSCs was characterized in vitro using immunofluorescence, flow cytometry, microarray, and reverse-transcription polymerase chain reaction. In vivo, four groups (n = 5 per group) of rats with median nerve injuries were examined: group 1 animals were treated with intraneural phosphate-buffered saline after cold and crush axonotmesis (negative control); group 2 animals were no-injury controls; group 3 animals were treated with intraneural green fluorescent protein-positive MDSCs; and group 4 animals were treated with green fluorescent protein-positive induced MDSCs. All animals underwent weekly upper extremity functional testing. Rats were euthanized 5 weeks after treatment. The median nerve and extrinsic finger flexors were harvested for nerve histomorphometry, myelination, muscle weight, and atrophy analyses. RESULTS: In vitro, induced MDSCs recapitulated native Schwann cell gene expression patterns and up-regulated pathways involved in neuronal growth/signaling. In vivo, green fluorescent protein-positive induced MDSCs remained stably transformed 5 weeks after injection. Induced MDSC therapy decreased muscle atrophy after median nerve injury (p = 0.0143). Induced MDSC- and MDSC-treated animals demonstrated greater functional muscle recovery when compared to untreated controls (hand grip after induced MDSC treatment: group 1, 0.91 N; group 4, 3.38 N); p < 0.0001) at 5 weeks after treatment. This may demonstrate the potential beneficial effects of MDSC therapy, regardless of differentiation stage. CONCLUSION: Both MDSCs and induced MDSCs decrease denervation muscle atrophy and improve subsequent functional outcomes after upper extremity nerve trauma in rodents.

Oral Flora and Perioperative Antimicrobial Interventions in Cleft Palate Surgery: A Review of the Literature.

BACKGROUND: The role of perioperative antibiotics in cleft palate remains a topic of debate. Advocates stress their importance in preventing local and systemic infections and decreasing the incidence of oronasal fistula formation. However, few studies to date have directly evaluated the role of antibiotics and other antimicrobial measures in cleft palate surgery. OBJECTIVE: The aim of this review is to evaluate the evidence surrounding the use of perioperative antibiotics and other antimicrobial interventions in cleft palate surgery. Additionally, we review the literature on the oral flora unique to the cleft palate patient population. METHODS: This was accomplished utilizing PubMed, Medline, and the Cochrane Library with MeSH and generic terms. Articles were selected based on predefined inclusion and exclusion criteria. RESULTS: This review highlights the lack of higher level evidence on perioperative antibiotic use and other antimicrobial interventions in cleft palatoplasty and calls for further research on the matter. CONCLUSIONS: The literature appears to support the use of preoperative antibiotics for cleft palatoplasty, but the benefits of prolonged postoperative antibiotic use remain questionable.

Impact of payer status and hospital volume on outcomes after head and neck oncologic reconstruction.

BACKGROUND: High-volume centers improve outcomes in head and neck cancer (HNCA) reconstruction, yet it is unknown whether patients of all payer status benefit equally. METHODS: We identified patients undergoing HNCA surgery between 2002 and 2015 using the National Inpatient Sample. Outcomes included receipt of care at high-volume centers, receipt of reconstruction, and post-operative complications. Multivariate regression analysis was stratified by payer status. RESULTS: 37,442 patients received reconstruction out of 101,204 patients who underwent HNCA surgery (37.0%). Privately-insured and Medicaid patients had similar odds of receiving high-volume care (OR = 0.99, 95% CI = 0.87-1.11) and undergoing reconstruction (OR = 0.96, 95% CI = 0.86-1.05). Medicaid beneficiaries had higher odds of complication (OR = 1.36, 95% CI = 1.22-1.51). The discrepancy in complication odds was significant at low-volume (OR = 1.44, 95% CI = 1.12-1.84) and high-volume centers (OR = 1.30, 95% CI = 1.15-1.47). CONCLUSIONS: Medicaid beneficiaries are as likely to receive care at high-volume centers and undergo reconstruction as privately-insured individuals. However, they have poorer outcomes than privately-insured individuals at both low- and high-volume centers.

Male breast cancer: a closer look at patient and tumor characteristics and factors that affect survival using the National Cancer Database.

OBJECTIVE: To comprehensively describe the tumor and clinical characteristics of breast cancer in a cohort of male patients and to assess the factors that affect survival. BACKGROUND: Much of the standard care of male breast cancer is based on the diagnosis and treatment strategies of female breast cancer. However, important clinical differences between the two have been elucidated, which suggests the need for unique attention to male breast cancer. METHODS: We evaluated the records of male patients who were diagnosed with breast cancer between 2004 and 2015 using the National Cancer Database (NCDB). Data obtained were demographic characteristics, clinical and tumor data, type of therapy, as well as survival data. We used descriptive statistics to characterize our study population. We then performed a survival and Cox proportional hazards analysis. RESULTS: We identified 16,498 patients (median age: 63 years). Several treatment modalities were used, of which surgery was the most common (14,882 [90.4%]). The total follow-up time was 13 years (156 months). Five-year survival was 77.7% (95% CI 76.9-78.4) and 10-year survival was 60.7%. In a Cox proportional hazards model, mastectomy was associated with the greatest survival (hazard ratio [HR] 0.49; p < 0.001). CONCLUSION: We report what is to our knowledge the largest national population-based cohort of male breast cancer patients. Importantly, our data suggests that similar to female patients, several treatment modalities are significantly associated with improved survival in male patients, particularly surgery. Increasing age, black race, government insurance, more comorbidities, and higher tumor stages are associated with decreased survival.

Infectious Complications After Open Cranial Vault Remodeling for Craniosynostosis.

BACKGROUND: Surgical site infection (SSI) after open cranial vault reconstruction (CVR), while relatively uncommon, has received little attention in the literature to date. Here, the authors report our institution's experience with the perioperative management of infectious complications following CVR for craniosynostosis and present the first systematic review of the literature on this topic. METHODS: The authors performed a retrospective chart review for patients with syndromic and nonsyndromic craniosynostosis who underwent open CVR between 1990 and 2015 at a single institution to determine predictors of SSIs and a systematic review of studies that evaluated for SSI after CVR to ascertain the pooled incidence of SSI, common infectious organisms, and prophylactic antibiotic protocols. RESULTS: Out of 548 primary and 163 secondary CVR cases at our institution, 6 primary reconstruction patients (1.09%) and 9 secondary reconstruction patients (5.52%) developed an SSI requiring extended hospital stay or readmission (P <0.001); overall infection rate was 2.11%. Streptococcus and Staphylococcus species were the most common organisms isolated. On multivariate analysis, syndromic status conferred more than 7 times greater odds of SSI (OR 7.7, P = 0.023). Pooled analysis of the literature yielded an overall SSI rate of 1.05% to 2.01%. In contrast to our institutional findings, the most common organisms reported were Candida species and Pseudomonas aeruginosa. The most common prophylactic antibiotic protocol was a first-generation cephalosporin for 24 to 72 hours post-operatively. CONCLUSIONS: Patients undergoing secondary reconstruction have higher infection rates after CVR, and syndromic status is an important predictor of infection when controlling for other patient factors. Our literature review reveals nosocomial organisms to be the most commonly reported source of infection, though this is contrary to our institutional findings of skin flora being most common. Antibiotic prophylaxis varies institutionally.

Computer-Assisted Design and Manufacturing Assists Less Experienced Surgeons in Achieving Equivalent Outcomes in Cranial Vault Reconstruction.

PURPOSE: The purpose of this study was to assess whether long-term outcomes were equivalent between computer-assisted design and manufacturing (CAD/CAM) -assisted cranial vault reconstruction performed by an inexperienced surgeon, with fewer years of surgical experience, and traditional reconstruction performed by senior surgeons with many decades of experience. METHODS: An Institutional Review Board-approved retrospective cohort study was performed for all patients with nonsyndromic craniosynostosis between the ages of 1 month to 18 years who received primary, open calvarial vault reconstruction at the Johns Hopkins Hospital between 1990 and 2017. The primary outcome variable was the Whitaker category (I-IV) for level of required revision at the 2-year follow-up visit. Secondary outcomes included estimated blood loss, length of stay, operative time, and postoperative complications. CAD/CAM-assisted surgery was considered noninferior if the proportion of cases requiring any revision (Whitaker II, III, or IV) was no more than 10% greater than the proportion in the traditional surgery group with multivariate logistic regression analysis. t tests and fisher exact tests were used for secondary outcomes. RESULTS: A total of 335 patients were included, with 35 CAD/CAM-assisted reconstructions. CAD/CAM-assisted reconstruction was noninferior to traditional after accounting for patient demographics, type of surgery, and experience level of the plastic surgeon. The traditional group required revision more frequently at 29.0% compared to CAD/CAM at 14.3%. Secondary outcomes were not significantly different between groups, but CAD/CAM had significantly longer average operative times (5.7 hours for CAD/CAM, 4.3 hours for traditional, P < 0.01). CONCLUSION: CAD/CAM technology may lower the learning curve and assist less experienced plastic surgeons in achieving equivalent long-term outcomes in craniofacial reconstruction.

Poly(ε-Caprolactone) Nanofiber Wrap Improves Nerve Regeneration and Functional Outcomes after Delayed Nerve Repair.

BACKGROUND: The purpose of this study was to assess the efficacy of biodegradable, electrospun poly(ε-caprolactone) nanofiber nerve conduits in improving nerve regeneration. METHODS: The authors used a rat forelimb chronic denervation model to assess the effects of poly(ε-caprolactone) conduits on improving nerve regeneration and upper extremity function. Three groups of rats were examined: (1) negative-control animals (n = 5), which underwent 8 weeks of median nerve chronic denervation injury followed by repair with no conduit; (2) experimental animals (n = 5), which underwent 8 weeks of median nerve chronic denervation followed by repair and poly(ε-caprolactone) nerve conduit wrapping of the nerve coaptation site; and (3) positive-control animals (n = 5), which were naive controls. All animals underwent compound muscle action potential and functional testing. At 14 weeks after repair, the median nerve and flexor muscles were harvested for histologic analysis. RESULTS: Histomorphometric analysis of regenerating median nerves demonstrated augmented axonal regeneration in experimental versus negative control animals (total axon count, 1769 ± 672 versus 1072 ± 123.80; p = 0.0468). With regard to functional recovery, experimental and negative-control animals (1.67 ± 0.04 versus 0.97 ± 0.39; p = 0.036) had regained 34.9 percent and 25.4 percent, respectively, of baseline hand grip strength at 14 weeks after repair. Lastly, less collagen deposition at the nerve coaptation site of experimental animals was found when compared to control animals (p < 0.05). CONCLUSION: Biodegradable, poly(ε-caprolactone) nanofiber nerve conduits can improve nerve regeneration and subsequent physiologic extremity function in the setting of delayed nerve repair by decreasing the scar burden at nerve coaptation sites.

Using Computer-Aided Design/Computer-Aided Manufacturing for Autogenous, Split Calvarial Bone Graft-based Cranioplasty: Optimizing Reconstruction of Large, Complex Skull Defects.

BACKGROUND: While autologous split calvarial bone is an ideal graft material in cranioplasty, selection of a donor site can be challenging and limited in the reconstruction of complicated cranial defects. Computer-aided design and manufacturing (CAD/CAM) may improve donor-site harvest and contouring and mitigate operative complications in split calvarial bone graft-based cranioplasty for complex patients, but has not previously been studied in this unique setting. METHODS: In this study, a retrospective review of patients who presented to the institution and underwent split-calvarial bone graft-based cranioplasty using CAD/CAM to optimize reconstruction of full-thickness cranial defects ≥30 cm was performed. Patient demographics, complications from past operations, intraoperative variables, and immediate and long-term postoperative outcomes were recorded. The CAD/CAM predicted and actual postoperative graft measurements were compared. RESULTS: Five patients were identified who fulfilled inclusion criteria. Mean age at operation was 43 years and mean size of cranial defect was 69 cm. Mean operative time was 443 minutes and mean estimated blood loss was 450 mL. There were no dural tears, sagittal sinus bleeds, or other intraoperative complications. There were no immediate postoperative complications requiring extended hospital stay or reoperation. The postoperative graft surface areas were on average within 2.1% of the planned graft and this difference was not statistically significant (P = 0.28). All patients expressed satisfaction with cranial contour postoperatively. CONCLUSION: Based on the early experience, the use of CAD/CAM enhances calvarial graft selection and improves contour accuracy in the reconstruction of complex skull defects with minimal complications.

Muscle-derived stem cells: important players in peripheral nerve repair.

INTRODUCTION: Stem cell therapy for peripheral nerve repair is a rapidly evolving field in regenerative medicine. Although most studies to date have investigated stem cells originating from bone marrow or adipose, skeletal muscle has recently been recognized as an abundant and easily accessible source of stem cells. Muscle-derived stem cells (MDSCs) are a diverse population of multipotent cells with pronounced antioxidant and regenerative capacity. Areas covered: The current literature on the various roles MDSCs serve within the micro- and macro-environment of nerve injury. Furthermore, the exciting new research that is establishing MDSC-cellular therapy as an important therapeutic modality to improve peripheral nerve regeneration. Expert opinion: MDSCs are a promising therapeutic agent for the repair of peripheral nerves; MDSCs not only undergo gliogenesis and angiogenesis, but they also orchestrate larger pro-regenerative host responses. However, the isolation, transformation, and in-vivo behavior of MDSCs require further evaluation prior to clinical application.

Pain Management for Nonsyndromic Craniosynostosis: Adequate Analgesia in a Pediatric Cohort?

BACKGROUND: Postoperative pain following open craniosynostosis repair has not been studied extensively and is sometimes thought to be inconsequential. The purpose of this study was to assess postoperative pain in this pediatric population. METHODS: We performed a retrospective chart review of patients (n = 54) undergoing primary open craniosynostosis repair from 2010 to 2016. Demographics, length of stay (LOS), pain scores, emesis events, and perioperative analgesics were reviewed. Multivariable regression models were designed to assess for independent predictors of LOS and emesis. RESULTS: A high proportion had moderate to severe pain on postoperative day 0 (56.5%) and day 1 (60.9%). Opioid administered in postoperative period was 1.40 mg/kg/d in morphine milligram equivalent (MME) (±1.07 mg/kg/d MME). Majority of patients transitioned to enteral opioids on postoperative day 1 (24.5%) or day 2 (49.1%). Ketorolac was administered to 11.1% (n = 6). Emesis was documented in 50% of patients. LOS revealed a positive association with age (P = 0.006), weight (P = 0.009), and day of transition to enteral opioids (P < 0.001); association with emesis was trending toward significance (P = 0.054). There was no association between overall LOS and amount of opioids administered postoperatively (P = 0.68). Postoperative emesis did not have any significant association with age, sex, weight, total amount of postoperative opioid administered, use of ketorolac, or intraoperative steroid use. CONCLUSION: Open craniosynostosis repair is associated with high levels of pain and low utilization of nonopioid analgesics. Strategies to improve pain, decrease emesis and LOS include implementation of multimodal analgesia period and avoidance of enteral medications in the first 24 hours after surgery.

Resection of the Posterior, Middle, and Anterior Superior Alveolar Nerves and Infraorbital Nerve Neurolysis for Refractory Maxillary Pain.

Trigeminal injury can cause intractable facial pain. However, surgical approaches to the superior alveolar nerves have not been widely described. We report resection of the anterior superior alveolar nerve (ASAN), middle superior alveolar nerve (MSAN), and posterior superior alveolar nerve (PSAN) in a patient with refractory facial pain and outline an algorithmic approach to the treatment of trigeminal nerve injury. A 56-year-old woman presented with a 3-year history of refractory facial pain in the distribution of the right superior alveolar nerves after dental trauma. As a comorbidity, central sensitization developed in the patient, manifesting in the uninjured oral areas being painful. After several temporary nerve blocks and medical management, the patient underwent resection of the ASAN, MSAN, and PSAN, as well as neurolysis of the infraorbital nerve, through a Caldwell-Luc approach. One week postoperatively, she reported substantial improvement in pain symptoms, including burning and temperature sensitivity, in the right maxilla. These findings were maintained at 7 months, without any maxillary sinus complications. Central sensitization caused continued intraoral symptoms. The ASAN, MSAN, and PSAN can be surgically resected within the maxillary sinus to treat refractory neuropathic pain. An etiology-based approach can guide successful treatment of trigeminal neuropathy. Central sensitization as a comorbidity must be addressed medically.

Design of Small Molecules That Compete with Nucleotide Binding to an Engineered Oncogenic KRAS Allele.

RAS mutations are found in 30% of all human cancers, with KRAS the most frequently mutated among the three RAS isoforms (KRAS, NRAS, and HRAS). However, directly targeting oncogenic KRAS with small molecules in the nucleotide-binding site has been difficult because of the high affinity of KRAS for GDP and GTP. We designed an engineered allele of KRAS and a covalent inhibitor that competes for GTP and GDP. This ligand-receptor combination demonstrates that the high affinity of GTP and GDP for RAS proteins can be overcome with a covalent inhibitor and a suitably engineered binding site. The covalent inhibitor irreversibly modifies the protein at the engineered nucleotide-binding site and is able to compete with GDP and GTP. This provides a new tool for studying KRAS function and suggests strategies for targeting the nucleotide-binding site of oncogenic RAS proteins.

Use of computer-assisted design and manufacturing to localize dural venous sinuses during reconstructive surgery for craniosynostosis.

OBJECTIVE: Cranial vault remodeling surgery for craniosynostosis carries the potential risk of dural venous sinus injury given the extensive bony exposure. Identification of the dural venous sinuses can be challenging in patients with craniosynostosis given the lack of accurate surface-localizing landmarks. Computer-aided design and manufacturing (CAD/CAM) has allowed surgeons to pre-operatively plan these complex procedures in an effort to increase reconstructive efficiency. An added benefit of this technology is the ability to intraoperatively map the dural venous sinuses based on pre-operative imaging. We utilized CAD/CAM technology to intraoperatively map the dural venous sinuses for patients undergoing reconstructive surgery for craniosynostosis in an effort to prevent sinus injury, increase operative efficiency, and enhance patient safety. Here, we describe our experience utilizing this intraoperative technology in pediatric patients with craniosynostosis. METHODS: We retrospectively reviewed the charts of children undergoing reconstructive surgery for craniosynostosis using CAD/CAM surgical planning guides at our institution between 2012 and 2016. Data collected included the following: age, gender, type of craniosynostosis, estimated blood loss, sagittal sinus deviation from the sagittal suture, peri-operative outcomes, and hospital length of stay. RESULTS: Thirty-two patients underwent reconstructive cranial surgery for craniosynostosis, with a median age of 11 months (range, 7-160). Types of synostosis included metopic (6), unicoronal (6), sagittal (15), lambdoid (1), and multiple suture (4). Sagittal sinus deviation from the sagittal suture was maximal in unicoronal synostosis patients (10.2 ± 0.9 mm). All patients tolerated surgery well, and there were no occurrences of sagittal sinus, transverse sinus, or torcular injury. CONCLUSIONS: The use of CAD/CAM technology allows for accurate intraoperative dural venous sinus localization during reconstructive surgery for craniosynostosis and enhances operative efficiency and surgeon confidence while minimizing the risk of patient morbidity.

Trends, Frequency, and Nature of Surgeon-Reported Conflicts of Interest in Plastic Surgery.

BACKGROUND: The purpose of this study was to identify types and trends in industry sponsorship of plastic surgery research since the establishment of conflict-of-interest reporting policies in plastic surgery. METHODS: The authors analyzed the frequency and types of self-reported conflicts of interest in the plastic surgery literature since the adoption of reporting policies in 2007. All original articles that met the authors' inclusion criteria and were published in the following three journals from 2008 to 2013 were included: Annals of Plastic Surgery, Plastic and Reconstructive Surgery, and Journal of Plastic, Reconstructive & Aesthetic Surgery. A multivariate regression analysis was performed to determine what study-specific variables were associated with conflict-of-interest disclosures. RESULTS: A total of 3722 articles were analyzed. The incidence of conflicts of interest increased from 14 percent in 2008 to 24 percent in 2009. However, thereafter, the incidence of conflicts of interest decreased steadily from 21 percent in 2010 to 9 percent in 2013. Furthermore, the authors' analysis revealed that from 2008 to 2013, industry decreased direct research support but steadily increased the rate of consultantships (p < 0.001). A multivariate regression analysis revealed that, after adjusting for potential confounders, self-reported conflicts of interest have decreased since 2008 (p = 0.03) and the prevalence of conflicts of interest differs by plastic surgery subspecialty (p < 0.0001), country of origin (p < 0.0001), and journal of publication (p = 0.05). CONCLUSIONS: If self-reporting of conflicts of interest is assumed to be accurate, the number of surgeon-reported conflicts of interest in plastic surgery declined overall. Although the absolute number of consultantships did not change, the rate of consultantships rather than direct research support increased over this period.

Human Haploid Cell Genetics Reveals Roles for Lipid Metabolism Genes in Nonapoptotic Cell Death.

Little is known about the regulation of nonapoptotic cell death. Using massive insertional mutagenesis of haploid KBM7 cells we identified nine genes involved in small-molecule-induced nonapoptotic cell death, including mediators of fatty acid metabolism (ACSL4) and lipid remodeling (LPCAT3) in ferroptosis. One novel compound, CIL56, triggered cell death dependent upon the rate-limiting de novo lipid synthetic enzyme ACC1. These results provide insight into the genetic regulation of cell death and highlight the central role of lipid metabolism in nonapoptotic cell death.