Ultrasound Appearance of the Endometrium Post-Radiofrequency Ablation.

OBJECTIVE: To describe the ultrasonographic appearance of the post-ablative endometrium to improve knowledge of its sonographic findings. METHODS: This was an Institutional Review Board approved prospective study of patients who underwent second-generation endometrial ablation from 2016 to 2019 at a single health system. Patients had postoperative transvaginal ultrasounds at 2, 6, and 12 months. Ultrasound reports were analyzed for endometrial thickness, description of the endometrium and myometrium, presence of uterine fibroids, and uterine size. Statistical tests for repeated measures were utilized. RESULTS: There were 68 patients with the average age of 42 (SD 6) years and a BMI of 33 (SD 8). Preoperatively the average endometrial thickness was 10 mm, uterine length was 9.7 cm, and 38.2% had leiomyoma. The average endometrial thickness decreased at each ultrasound: 8.4 mm (SD 3.4), 7.2 mm (SD 3.0), and 5.8 mm (SD 2.5) at 2, 6, and 12 months, respectively. When comparing endometrial thickness postoperatively there was a significant difference at 2 and 12 months (P = .041), and 6 and 12 months (P = .031). There was no change during the postoperative period in the presence of leiomyoma, hyperechoic endometrium, hypoechoic endometrium, heterogeneous endometrium, and cystic endometrium on the ultrasounds. CONCLUSION: After ablation with a second-generation device, the endometrial thickness on ultrasound decreases with time following surgery. Additional studies correlating these findings to clinical outcomes would be useful.

The Impact of Heroin Self-Administration and Environmental Enrichment on Ventral Tegmental CRF1 Receptor Expression.

BACKGROUND: There is a strong link between chronic stress and vulnerability to drug abuse and addiction. Corticotropin releasing factor (CRF) is central to the stress response that contributes to continuation and relapse to heroin abuse. Chronic heroin exposure can exacerbate CRF production, leading to dysregulation of the midbrain CRF-dopamine-glutamate interaction. METHODS: Here we investigated the role of midbrain CRF1 receptors in heroin self-administration and assessed neuroplasticity in CRF1 receptor expression in key opioid addiction brain regions. RESULTS: Infusions of antalarmin (a CRF1 receptor antagonist) into the ventral tegmental area (VTA) dose dependently reduced heroin self-administration in rats but had no impact on food reinforcement or locomotor activity in rats. Using RNAscope in situ hybridization, we found that heroin, but not saline, self-administration upregulated CRF1 receptor mRNA in the VTA, particularly on dopamine neurons. AMPA GluR1 and dopamine reuptake transporter mRNA in VTA neurons were not affected by heroin. The western-blot assay showed that CRF1 receptors were upregulated in the VTA and nucleus accumbens. No significant changes in CRF1 protein expression were detected in the prefrontal cortex, insula, dorsal hippocampus, and substantia nigra. In addition, we found that 15 days of environmental enrichment implemented after heroin self-administration does not reverse upregulation of VTA CRF1 receptor mRNA but it downregulates dopamine transporter mRNA. CONCLUSIONS: Overall, these data suggest that heroin self-administration requires stimulation of VTA CRF1 receptors and upregulates their expression in brain regions involved in reinforcement. Such long-lasting neuroadaptations may contribute to continuation of drug use and relapse due to stress exposure and are not easily reversed by EE exposure.

Milnacipran Ameliorates Executive Function Impairments following Frontal Lobe Traumatic Brain Injury in Male Rats: A Multimodal Behavioral Assessment.

Traumatic brain injuries (TBIs) affect more than 10 million patients annually worldwide, causing long-term cognitive and psychosocial impairments. Frontal lobe TBIs commonly impair executive function, but laboratory models typically focus primarily on spatial learning and declarative memory. We implemented a multi-modal approach for clinically relevant cognitive-behavioral assessments of frontal lobe function in rats with TBI and assessed treatment benefits of the serotonin-norepinephrine reuptake inhibitor, milnacipran (MLN). Two attentional set-shifting tasks (AST) evaluated cognitive flexibility via the rats' ability to locate food-based rewards by learning, unlearning, and relearning sequential rule sets with shifting salient cues. Adult male rats reached stable pre-injury operant AST (oAST) performance in 3-4 weeks, then were isoflurane-anesthetized, subjected to a unilateral frontal lobe controlled cortical impact (2.4 mm depth, 4 m/sec velocity) or Sham injury, and randomized to treatment conditions. Milnacipran (30 mg/kg/day) or vehicle (VEH; 10% ethanol in saline) was administered intraperitoneally via implanted osmotic minipumps (continuous infusions post-surgery, 60 µL/h). Rats had a 10-day recovery post-TBI/Sham before performing light/location-based oAST for 10 days and, subsequently, odor/media-based digging AST (dAST) on the last test day (26-27 days post-injury) before sacrifice. Both AST tests revealed significant deficits in TBI+VEH rats, seen as elevated total trials and errors (p < 0.05), which generally normalized in MLN-treated rats (p < 0.05). This first simultaneous dual AST assessment demonstrates oAST and dAST are sufficiently sensitive and robust to detect subtle attentional and cognitive flexibility executive impairments after frontal lobe TBI in rats. Chronic MLN administration shows promise for attenuation of post-TBI executive function deficits, thus meriting further investigation.

Comparing the structural dynamics of the human KCNE3 in reconstituted micelle and lipid bilayered vesicle environments.

KCNE3 is a single transmembrane protein of the KCNE family that modulates the function and trafficking of several voltage-gated potassium channels, including KCNQ1. Structural studies of KCNE3 have been previously conducted in a wide range of model membrane mimics. However, it is important to assess the impact of the membrane mimics used on the observed conformation and dynamics. In this study, we have optimized a method for the reconstitution of the KCNE3 into POPC/POPG lipid bilayer vesicles for electron paramagnetic resonance (EPR) spectroscopy. Our CD spectroscopic data suggested that the degree of regular secondary structure for KCNE3 protein reconstituted into lipid bilayered vesicle is significantly higher than in DPC detergent micelles. Electron paramagnetic resonance (EPR) spectroscopy in combination with site-directed spin labeling (SDSL) was used to probe the structural dynamics of S49C, M59C, L67C, V85C, and S101C mutations of KCNE3 in both DPC micelles and in POPC/POPG lipid bilayered vesicles. Our CW-EPR power saturation data suggested that the site S74C is buried inside the lipid bilayered membrane while the site V85C is located outside the membrane, in contrast to DPC micelle results. These results suggest that the KCNE3 micelle structures need to be refined using data obtained in the lipid bilayered vesicles in order to ascertain the native structure of KCNE3. This work will provide guidelines for detailed structural studies of KCNE3 in a more native membrane environment and comparing the lipid bilayer results to the isotropic bicelle structure and to the KCNQ1-bound cryo-EM structure.

Comparison of Contrast-Enhanced Ultrasound Versus Magnetic Resonance Imaging in the Detection and Characterization of Uterine Leiomyomas.

OBJECTIVES: Uterine fibroids are common findings in women with pelvic pain and abnormal uterine bleeding. The reference standard test in the pretreatment evaluation of fibroids is contrast-enhanced magnetic resonance (MR) imaging. This study compared the number, size, location, and enhancement of uterine fibroids identified by contrast-enhanced ultrasound (CEUS) and MR. The aim of this study was to demonstrate that CEUS performs similarly to MR and could be used as an alternative imaging modality. METHODS: In this prospective observational study, 26 women underwent transabdominal CEUS and MR examinations. Blinded to the original clinical MR interpretations, 2 readers reviewed the MR and CEUS studies for each patient. The number, size, location, and enhancement of each fibroid per patient were reported by MR and CEUS. A Pearson correlation coefficient was calculated for the number of fibroids identified by each modality. RESULTS: In total, 126 fibroids were imaged: 115 (91.3%) were observed on both examinations; 9 (7.1%) were observed by MR only; and 2 (1.6%) were observed by CEUS only. A high correlation was found between the modalities for the number of fibroids identified per patient (r = 0.97; P < .001). There was also no significant difference between the modalities for each patient in the fibroid number, size, location, or enhancement. CONCLUSIONS: These findings suggest that transabdominal CEUS may represent an alternative to MR in pretreatment evaluation of uterine fibroids and could serve as a test of choice in patients with a contraindication to MR.

Preoperative Gabapentin for Minimally Invasive Hysterectomy: A Randomized Controlled Trial.

STUDY OBJECTIVE: To evaluate whether a single dose of gabapentin given preoperatively reduces narcotic use 24 hours after minimally invasive hysterectomy (MIH). DESIGN: Randomized controlled trial. SETTING: Single academic-affiliated community hospital. PATIENTS: Women undergoing MIH for benign indications between June 2016 and June 2017. INTERVENTIONS: Subjects were randomized to receive a preoperative regimen of acetaminophen, celecoxib, and gabapentin versus acetaminophen and celecoxib alone. MEASUREMENTS AND MAIN RESULTS: The primary outcome assessed was the total amount of narcotics used at 24 hours after surgery. Secondary outcomes included adverse effects from gabapentin use, total narcotics used, and pain scores at 2 weeks after surgery. A total of 129 women were randomized and eligible for analysis in the gabapentin study arm (n = 68) or the control arm (n = 61). Demographic characteristics and surgical details were similar between groups. Narcotics used at 24 hours after surgery totaling 168 versus 161 oral morphine milligram equivalents in the gabapentin and control groups, respectively, did not significantly differ between groups (p = .60). Total narcotics used and pain scores at 2 weeks after surgery and the rates of adverse effects from gabapentin were also similar between study arms. CONCLUSION: Single-dose, preoperative gabapentin for women undergoing benign MIH does not reduce total opioid use 24 hours after surgery.

Utility of anesthetic block for endometrial ablation pain: a randomized controlled trial.

BACKGROUND: Second-generation endometrial ablation has been demonstrated safe for abnormal uterine bleeding treatment, in premenopausal women who have completed childbearing, in short-stay surgical centers and in physicians' offices. However, no standard regarding anesthesia exists, and practice varies depending on physician or patient preference and hospital policy and setting. OBJECTIVE: The aim of this study was to evaluate whether local anesthetic, in combination with general anesthesia, affects postoperative pain and associated narcotic use following endometrial ablation. MATERIALS AND METHODS: This was a single-center single-blind randomized controlled trial conducted in an academic-affiliated community hospital. A total of 84 English-speaking premenopausal women, aged 30 to 55 years, who were undergoing outpatient endometrial ablation for benign disease were randomized to receive standardized paracervical injection of 20 mL 0.25% bupivacaine (treatment group) or 20 mL normal saline solution (control group) upon completion of ablation. The study was designed to test a 40% 1-hour mean visual analog scale (VAS) pain score difference with an average standard deviation of 75% of both groups' mean VAS scores, using a 2-tailed test, a type I error of 5%, and statistical power of 80%. A sample of 36 patients per study group was required. Assuming a 15% attrition rate, the study enrolled 42 patients per study arm randomized in blocks of 2 (84 total). Two-tailed cross-tabulations with Fisher exact significance values where appropriate and Student t tests were used to compare patient characteristics. Backward stepwise regressions were conducted to control for confounding. RESULTS: Between April 2016 and February 2017, a total of 108 women scheduled for endometrial ablation were screened (refusals, n = 21; ineligible, n = 3) to determine whether there were meaningful differences in postoperative VAS pain scores and postoperative narcotic use. Of the 84 randomized women, 2 age-ineligible women were excluded. Intent-to-treat analyses included 1 incorrect randomization (in which the provider consciously decided to provide analgesia regardless of the protocol, after which the provider was excluded from further study participation) and 3 women having no ablation because of operative difficulties. Three were lost to second-day follow-up. Treatment group patients (n = 41) experienced 1.3 points lower 1-hour postoperative VAS pain scores than the control group (n = 41, P = .02). The difference diminished by 4 hours (P = .31) and was negligible by 8 hours (P = .62). Treatment group patients used 3.6 less morphine equivalents of postoperative pain medication (P = .05). Regression analyses controlled for confounding reduced the 1-hour postoperative treatment group pain score difference to 0.8 (confidence interval [CI], -0.6 to 0.1) but slightly increased the average postoperative morphine equivalents to 3.7 (CI, -6.8 to -0.7). CONCLUSION: This randomized controlled trial found that local anesthetic with low risk for complications, used in conjunction with general anesthesia, decreased postoperative pain at 1 hour and significantly reduced postoperative narcotic use following endometrial ablation. Further research is needed to determine whether the study results are generalizable and whether post procedure is the best time to administer the paracervical block to decrease endometrial ablation pain.

Incidence and predictors of failed second-generation endometrial ablation.

BACKGROUND: The need for any treatment following an endometrial ablation is frequently cited as "failed therapy," with the two most common secondary interventions being repeat ablation and hysterectomy. Since second-generation devices have become standard of care, no large cohort study has assessed treatment outcomes with regard to only these newer devices. We sought to determine the incidence and predictors of failed second-generation endometrial ablation, defined as the need for surgical re-intervention.We performed a retrospective cohort study at a single academic-affiliated community hospital. Subjects included women undergoing second-generation endometrial ablation for benign indications between October 2003 and March 2016. Second-generation devices utilized during the study period included the radiofrequency ablation device (RFA), hydrothermal ablation device (HTA), and the uterine balloon ablation system (UBA). RESULTS: Five thousand nine hundred thirty-six women underwent endometrial ablation at a single institution (3757 RFA (63.3%), 1848 HTA (31.1%), and 331 UBA (5.6%)). The primary outcome assessed was surgical re-intervention, defined as hysterectomy or repeat endometrial ablation. Of the total 927 (15.6%) women who required re-intervention, 822 (13.9%) underwent hysterectomy and 105 (1.8%) underwent repeat endometrial ablation. Women who underwent re-intervention were younger (41.6 versus 42.9 years, p < .001), were more often African-American (21.8% versus 16.2%, p < .001), and were more likely to have had a primary radiofrequency ablation procedure (hazard ratio 1.37; 95%CI 1.01 to 1.86). Older age was associated with decreased risk for treatment failure with women older than 45 years of age having the lowest risk for failure (p < .001). Age between 35 and 40 years conferred the highest risk of treatment failure (HR 1.59, 95% CI 1.32-1.92). Indications for re-intervention following ablation included menorrhagia (81.8%), abnormal uterine bleeding (27.8%), polyps/fibroids (18.7%), and pain (9.5%). CONCLUSION: Surgical re-intervention was required in 15.6% of women who underwent second-generation endometrial ablation. Age, ethnicity, and radiofrequency ablation were significant risk factors for failed endometrial ablation, and menorrhagia was the leading indication for re-intervention.

The Need for Clinical Hand Education in Emergency Medicine Residency Programs.

BACKGROUND: Complaints related to the hands, wrists, and fingers comprise approximately 3.7 million emergency department visits annually. The complexity of this subject can confound timely diagnosis and treatment, particularly if the treating physician has not received specialized training. We set out to determine whether emergency medicine training in the USA provides adequate preparation for dealing with the identification, management, and treatment of hand, wrist, and finger injuries. METHODS: The curricula for 160 accredited U.S. emergency medicine programs were obtained. Each of these was examined to see whether a clinical "hand" rotation was included as a required module. Clinical hand rotations were then classified by length of rotation, the postgraduate years in which they were offered, and if they were offered as stand-alone modules or combined with other rotations. RESULTS: Of the 160 programs, 21 (13.1%) require a clinical hand rotation. Sixteen offer a dedicated module, and five are part of another rotation. The mean amount of time dedicated to hand education was 3 weeks. The 16 dedicated hand rotations had a mean duration of 2.69 weeks; combined rotations were 4 weeks. Four incorporated hand education in the first postgraduate year (PGY-1), 13 into the second (PGY-2), and 3 into the third (PGY-3). CONCLUSIONS: Despite the preponderance of hand injuries seen by emergency physicians, the clinical and legal pitfalls that accompany these conditions, and the benefits to be gained from specialized training, very few programs emphasize clinical hand training in an equivalent fashion.

Does Time Affect Patient Satisfaction and Health-Related Quality of Life After Reduction Mammoplasty?

OBJECTIVE: A total of 62,611 patients with breast hypertrophy underwent breast reduction surgery in 2013 in the United States to improve their symptoms and health-related quality of life. While multiple studies utilizing various outcome instruments demonstrate the efficacy of reductive surgery, it is presently unknown how the postoperative course affects patient satisfaction and health-related quality of life as measured by the BREAST-Q. Our objective was to determine the temporal relationship of patient satisfaction and health-related quality of life after reduction mammoplasty. METHODS: Patients prospectively completed the BREAST-Q reduction mammoplasty module at 3 time points during their treatment: preoperatively, at less than 3 months postoperatively, and at more than 3 months (<12 months) postoperatively. A single surgeon (N.P.P.) performed all of the breast reduction procedures. RESULTS: Each time point contained 20 questionnaires. Mean preoperative BREAST-Q scores were significantly lower than scores at the less than 3-month postoperative time point for the scales Satisfaction With Breasts, Psychosocial Well-being, Sexual Well-being, and Physical Well-being (P < .001). There was no significant difference in BREAST-Q scores between the postoperative time points in these measures. CONCLUSION: Breast reduction surgery offers a vast improvement in patients' satisfaction and health-related quality of life that is maintained throughout the postoperative period. These findings can assist surgeons in managing patient expectations after reduction mammoplasty and help improve the probability of obtaining prior authorization for insurance coverage.

An Algorithm for Building an Electronic Database.

OBJECTIVE: We propose an algorithm on how to create a prospectively maintained database, which can then be used to analyze prospective data in a retrospective fashion. Our algorithm provides future researchers a road map on how to set up, maintain, and use an electronic database to improve evidence-based care and future clinical outcomes. METHODS: The database was created using Microsoft Access and included demographic information, socioeconomic information, and intraoperative and postoperative details via standardized drop-down menus. A printed out form from the Microsoft Access template was given to each surgeon to be completed after each case and a member of the health care team then entered the case information into the database. RESULTS: By utilizing straightforward, HIPAA-compliant data input fields, we permitted data collection and transcription to be easy and efficient. Collecting a wide variety of data allowed us the freedom to evolve our clinical interests, while the platform also permitted new categories to be added at will. CONCLUSION: We have proposed a reproducible method for institutions to create a database, which will then allow senior and junior surgeons to analyze their outcomes and compare them with others in an effort to improve patient care and outcomes. This is a cost-efficient way to create and maintain a database without additional software.

Traditional Versus Simulation Resident Surgical Laparoscopic Salpingectomy Training: A Randomized Controlled Trial.

STUDY OBJECTIVES: To evaluate the effectiveness of the porcine training model for obstetrics-gynecology (OB/GYN) residents in laparoscopic salpingectomy. DESIGN: Randomized, controlled single-blinded trial. CLASSIFICATION: Canadian Task Force Classification I. SETTING: A large community-based teaching hospital. PARTICIPANTS: All postgraduate year 1 through year 4 OB/GYN residents were enrolled (n = 22). INTERVENTION: All participants underwent a preintervention objective skills assessment test (OSAT), in which the participant performed live human laparoscopic salpingectomy. Residents were randomly assigned (using a computer-generated randomization table, in blocks of 2, stratified by ranked baseline OSAT scores) to the intervention or control group. The intervention group consisted of 1 educational session with presession assigned reading, a 40-min didactic lecture, viewing of a procedural video, and simulation and practice of laparoscopic salpingectomy on a porcine cadaver. The control group received traditional training per routine residency rotations. MEASUREMENTS AND MAIN RESULTS: Laparoscopic salpingectomy was performed on live patients by study participants pre- and postintervention. These procedures were video recorded, and then scored by a single blinded evaluator of the OSATs. Nine pre- and postintervention OSAT indicators, reflecting provider knowledge and skill, were the primary outcome measures. Secondary outcomes were the changes in 10 subjective measures of comfort, assessed by a pre- and postintervention survey. The outcomes were assessed using 5-point Likert scales (for OSATs 1 = lowest score; for the subjective survey 1 = highest score). The control group OSAT scores did not change (pre: 26.6 ± 10.8, post: 26.2 ± 10.1; p = .65). There were significant improvements in 2-handed surgery (pre: 2.8 ± 1.6, post: 3.5 ± 1.3; p = .004) and use of energy (pre: 2.9 ± 1.3, post: 3.6 ± 1.0; p = .01) in the intervention group, contributing to an overall score change (pre: 26.7 ± 10.6, post: 29.9 ± 9.8; p ≤ .001). The control group had no change in comfort levels. The intervention group experienced both increases (anatomy, steps of surgery, 2-handed surgery, and use of energy) and decreases (reading and learning in operating room) in reported comfort levels. CONCLUSION: This study demonstrates that simulation can improve surgical technique OSATs. However, of 45 possible points, both groups' average scores were <70% of the optimum. Thus, the improvement, although statistically significant, was relatively small and indicates that further supplementation in training is needed to substantially increase the residents' surgical skills.

A novel three serum phospholipid panel differentiates normal individuals from those with prostate cancer.

BACKGROUND: The results of prostate specific antigen (PSA) and digital rectal examination (DRE) screenings lead to both under and over treatment of prostate cancer (PCa). As such, there is an urgent need for the identification and evaluation of new markers for early diagnosis and disease prognosis. Studies have shown a link between PCa, lipids and lipid metabolism. Therefore, the aim of this study was to examine the concentrations and distribution of serum lipids in patients with PCa as compared with serum from controls. METHOD: Using Electrospray ionization mass spectrometry (ESI-MS/MS) lipid profiling, we analyzed serum phospholipids from age-matched subjects who were either newly diagnosed with PCa or healthy (normal). RESULTS: We found that cholester (CE), dihydrosphingomyelin (DSM), phosphatidylcholine (PC), egg phosphatidylcholine (ePC) and egg phosphatidylethanolamine (ePE) are the 5 major lipid groups that varied between normal and cancer serums. ePC 38:5, PC 40:3, and PC 42:4 represent the lipids species most prevalent in PCa as compared with normal serum. Further analysis revealed that serum ePC 38:5 ≥0.015 nmoles, PC 40.3 ≤0.001 nmoles and PC 42:4 ≤0.0001 nmoles correlated with the absence of PCa at 94% prediction. Conversely, serum ePC 38:5 ≤0.015 nmoles, PC 40:3 ≥0.001 nmoles, and PC 42:4 ≥0.0001 nmoles correlated with the presence of PCa. CONCLUSION: In summary, we have demonstrated that ePC 38:5, PC 40:3, and PC 42:4 may serve as early predictive serum markers for the presence of PCa.

Outcomes of delayed abdominal-based autologous reconstruction versus latissimus dorsi flap plus implant reconstruction in previously irradiated patients.

BACKGROUND: Local recurrence after breast conservation therapy is usually managed with salvage mastectomy. Multiple methods of reconstruction are possible, although delayed autologous reconstruction provides the most reliable results. METHODS: We compared complications in delayed abdominal-based [transverse rectus abdominis muscle (TRAM)/deep inferior epigastric perforator (DIEP)] reconstruction with delayed latissimus dorsi plus implant-based reconstruction in previously irradiated breasts. The authors reviewed 133 consecutive cases of delayed breast reconstructions performed in patients who had postmastectomy radiation therapy and reconstruction with abdominal-based methods (single-pedicle TRAM, supercharged pedicle TRAM, muscle-sparing TRAM free flap, DIEP flap, and superficial inferior epigastric artery flap) or a pedicled latissimus dorsi flap plus implant. Complications for donor and recipient sites were recorded including infection, seroma, hematoma, and partial flap loss. RESULTS: Seventy-five patients were reconstructed with abdominal-based flaps (37 muscle-sparing TRAMs, 19 pedicled TRAMs, 12 DIEPs, 6 supercharged pedicled TRAMs, and 1 superficial inferior epigastric artery). Their median age was 50 years and mean follow-up was 22.7 months. Three (4.0%) patients required reoperation during the same hospital visit for vascular compromise that resulted in 2 (2.7%) flap failures. Three (4.0%) patients had partial flap loss that ultimately required debridement and primary closure. Seventeen (22.7%) patients had minor complications including seroma, small hematoma, cellulitis, and abdominal bulge. Fifty-six patients were reconstructed with latissimus dorsi flaps plus implants. Their median age was 47 years and mean follow-up was 32 months. Three (5.4%) patients developed infections resulting in implant loss. Four (7.1%) patients had partial flap loss that required debridement and primary closure. Thirteen (23.2%) patients had minor complications including seroma (12 patients) and hematoma (1 patient) that required drainage. Fisher exact test was used to determine statistical significance of complication and failure rates between the 2 types of reconstruction. In patients who had postmastectomy radiation therapy, those with abdominal-based reconstructions had fewer complications compared with latissimus dorsi flap plus implant reconstructions (28.0% vs 30.4%, P=0.846). Also, fewer reconstructions failed in patients with abdominal-based reconstruction (2.7% vs 5.4%, P=0.650). CONCLUSIONS: Abdominal-based autologous reconstruction had fewer complications and fewer reconstruction failures than latissimus dorsi flap plus implant reconstructions in patients with postmastectomy radiation therapy in our series; however, these rates were not statistically significant.

The use of the multi-island vertical rectus abdominis myocutaneous flap in head and neck reconstruction.

BACKGROUND: Head and neck cancer extirpation frequently creates complex 3-dimensional defects involving both intraoral and external tissues. Reconstruction can be accomplished either with 2 free flaps, a simultaneous free and pedicle flap, or a single double-island folded free flap. Herein, the outcomes and rationale for reconstruction of multilaminar head and neck defects using the multi-island vertical rectus abdominis myocutaneous (MI-VRAM) flap are reported. METHODS: A retrospective review was performed of a prospectively collected database of all head and neck reconstructions completed by a single surgeon between 1992 and 2011. Forty-six patients were identified who underwent reconstruction of composite defects using MI-VRAM flaps. Oncologic defects were classified into 3 categories based on anatomic location, namely, the midface, lower face, and neck. Indications and outcomes were reviewed. RESULTS: Patients' ages ranged from 7 to 84 years with two thirds being male; 45% received preoperative radiation. Average MI-VRAM skin paddle size was 9×25.5 cm. Of the 46 reconstructions, 27 (59%) were performed in the midface, 14 (30%) in the lower face, and 5 (11%) in the neck region. There were no complete flap loses; however, 1 patient lost the external skin island, requiring pectoralis flap coverage. Of these cases, 15% had surgically related complications. Ten patients required secondary contouring procedures to revise bulky flaps. CONCLUSIONS: The MI-VRAM flap is a safe and reliable technique for reconstruction of complex defects throughout the head and neck region. Compared to 2 simultaneous free flaps or a free flap combined with a regional flap, it saves time and eliminates a second donor site. LEVEL OF EVIDENCE: Level IV. Clinical question addressed in this paper is whether a multi-island VRAM flap is a safe technique in head and neck reconstruction.

A new dimension: robotic reconstruction in plastic surgery.

BACKGROUND: Robot-assisted surgery was first approved by the Federal Drug Administration in 1994. The robotic system has the advantages of three-dimensional visualization of the operating field, 7° range of motion, tremor elimination, 360°of freedom at 10-mm distance, and a comfortable, seated operating posture. The purpose of this paper is to present a new surgical tool, the robot, for use in reconstructive surgery. METHODS: A case is presented in which the robotic system was used to elevate a pedicled, myocutaneous latissimus dorsi flap for shoulder reconstruction. RESULTS: The robot was used successfully to harvest a pedicled latissimus dorsi flap. Since this case, we have used the robotic system to harvest one other pedicled latissimus flap for breast reconstruction as well as to perform the microvascular anastomoses in a radial forearm and rectus abdominus free flaps to the lower extremity. CONCLUSION: There is great potential for the use of robot as a surgical tool in the field of plastic surgery. The advantages are numerous, including superior visibility, greater range of motion as a more comfortable position for the operating surgeon. The limitations include the learning curve and the lack of biofeedback.

Prescription medication borrowing among adult patients at an urban medical center.

Prescription medication borrowing can result in adverse health outcomes. We aimed to study the patterns of borrowing prescription medications in an adult urban population seeking healthcare in the outpatient, emergency, and inpatient units of an urban medical center. Participants indicated whether they (1) had a primary care doctor, medical insurance, a prior history of substance abuse, psychiatric disorders, or chronic pain; and (2) had borrowed a prescription medication. If so, they noted the medication obtained, source, frequency of use, and reasons why they had not obtained a prescription from a licensed medical provider. Of the 641 participants, most were African American (75%), urban residents (75%), high school educated or less (71%), and lacked full-time employment (68%). Many had health insurance (90%) and had recently seen their primary medical provider (75%). Eighteen percent reported ever borrowing a prescription medication. On multivariate analysis, history of chronic pain was marginally associated with increased medication borrowing (odds ratio [OR] = 1.58) while having Medicare insurance (OR = 0.436) or a primary care medical provider routinely ask about medication usage (OR = 0.589) were significantly associated with decreased medication borrowing. The most commonly obtained medications were for pain (74%), usually in the form of opioids, and were obtained from a family member (49%) or friend (38%). Thirty-five percent of those who borrowed medications did so more than once a year, with lack of convenient access to medical care the most frequently cited reason for use (67%). Only a third of those who borrowed medications had informed their primary medical providers of the behavior. In conclusion, borrowing prescription medications is a common behavior in the population studied. Further research is warranted into interventions to reduce such use, especially the impact of methods to improve the convenience of contacting licensed medical providers.

Treatment of keratoacanthoma: Is intralesional methotrexate an option?

BACKGROUND: Keratoacanthomas (KAs) are a variant of squamous cell carcinomas. Some KAs have shown aggressive behaviour, leading to metastasis and death. Surgical excision is the treatment of choice for most KA patients. Intralesional methotrexate (MTX) may also be a potential treatment option for KAs. OBJECTIVE: To evaluate intralesional MTX as a treatment modality for KA. METHODS: A retrospective chart review of nine patients with KAs treated with intralesional MTX was performed. Each patient had biopsy-proven KA. The lesion was initially debulked, and MTX was injected at the base. Patients were seen weekly in the office, and reinjected with intralesional MTX depending on the response of the lesion. Each patient was evaluated for their response to the intralesional MTX injections, the number of injections required and complications. RESULTS: Patients required approximately two to four intralesional injections (12.5 mg to 25 mg per injection) before KA resolution. Eight of nine (88.9%) patients experienced complete resolution of their tumours. One patient experienced treatment failure, and underwent surgical excision of the KA. The average follow-up period was 2.8 years, and there were no recurrences. CONCLUSION: The results from the present retrospective study show that intralesional MTX injection is an effective treatment option for KAs. The authors propose that intralesional MTX injection with initial debulking of the KA should be used as a first line of treatment when KAs present on the extremities, in cosmetically sensitive areas and in elderly patients with multiple comorbities.

Median cleft of the upper lip: a rare case.

Median cleft lip is a midline vertical cleft through the upper lip. This is a rare anomaly with very few cases described in the literature. Median cleft lip has been thought to be associated with hypertelorism or hypotelorism. It is caused by the failure of fusion of the medial nasal prominences. In this case report, a 4½-year-old girl with a median cleft is presented. The patient has no other anomalies of the nose or alveolus. The patient has normotelorism. A shortened bifid frenulum of the upper lip is present. A technique using an elliptical excision of the cleft with muscle approximation is described.