The Two-Stage Folded Paramedian Forehead Flap Without Cartilage Grafts for Full Thickness Distal Nasal Defects: A Review of 35 Patients.

BACKGROUND: Full thickness defects of the ala, soft triangle, and nasal tip involving the nasal lining have traditionally been repaired with the three-stage folded paramedian forehead flap (FPFF), with a cartilage graft for support. For similar defects, the authors utilize the two-stage FPFF without cartilaginous support which provides reproducible functional and aesthetic results.  Objective: To describe the authors’ experience with the two-stage FPFF, including outcomes, complications, and design modifications to enhance functional and aesthetic success.  Methods: An IRB-approved retrospective database review of FPFF was performed at two sites. Using postoperative photographs, outcomes were assessed by blinded non-investigator dermatologist raters using a modified observer scar assessment scale. RESULTS: Thirty-five patients were reconstructed using the two-stage FPFF without cartilage grafts. Subjective assessment of scar vascularity, pigment, relief, and thickness by 3 independent reviewers yielded an overall cosmesis score of 8.4±1.9 (out of 40). CONCLUSION: The two-stage FPFF without cartilage grafts is a reliable, cosmetically elegant repair that can provide optimal functional and aesthetic results for complex unilateral distal nose defects.J Drugs Dermatol. 2024;23(4): doi:10.36849/JDD.7358.

Validation of the LACE readmission and mortality prediction model in a large surgical cohort: Comparison of performance at preoperative assessment and discharge time points.

STUDY OBJECTIVE: The LACE index (Length of stay, admission Acuity, Charlson comorbidity index, and Emergency department visits within 6 months of current admission) is a practical tool designed to predict the risk of readmission or mortality within 30 days of hospital discharge. We sought to validate and examine its performance in a large surgical population at both the preoperative assessment and discharge time points. DESIGN: Retrospective cohort study. SETTING: We identified all admissions with a surgery or procedure at Vanderbilt University Medical Center (VUMC) between 2010 and 2015. PATIENTS: A total of 192,670 admissions (age ≥ 18) were included in the study. INTERVENTIONS: None. MEASUREMENTS: LACE scores were calculated and analyzed with multivariable logistic regression. Discrimination was assessed with the c-statistic, calibration was assessed with calibration plots, and overall performance evaluated with the Brier score. Four models were created: admissions with any surgery or procedure, surgical admissions using actual length of stay (ALOS), surgical admissions using estimated length of stay (ELOS) and non-surgical procedural admissions. MAIN RESULTS: 192,670 admissions were included. The all admissions model c-statistic was 0.77 with a Brier score of 0.13. Surgical admissions with ALOS and ELOS had a c-statistic of 0.80, 0.82 and a Brier score of 0.10, 0.08 respectively. Non-surgical procedural admissions had a c-statistic of 0.76 and a Brier score of 0.14. Calibration for all models was adequate. CONCLUSIONS: The LACE model for surgical and procedural admissions had good discrimination and adequate calibration. Analysis of the model applied to surgical admissions using ELOS demonstrated slightly better overall performance than ALOS, suggesting that LACE could be utilized for readmission risk stratification at the time of preoperative assessment. Clinical Trial and Registry URL: Not applicable.

Islet Hypersensitivity to Glucose Is Associated With Disrupted Oscillations and Increased Impact of Proinflammatory Cytokines in Islets From Diabetes-Prone Male Mice.

Pulsatile insulin release is the primary means of blood glucose regulation. The loss of pulsatility is thought to be an early marker and possible factor in developing type 2 diabetes. Another early adaptation in islet function to compensate for obesity is increased glucose sensitivity (left shift) associated with increased basal insulin release. We provide evidence that oscillatory disruptions may be linked with overcompensation (glucose hypersensitivity) in islets from diabetes-prone mice. We isolated islets from male 4- to 5-week-old (prediabetic) and 10- to 12-week-old (diabetic) leptin-receptor-deficient (db/db) mice and age-matched heterozygous controls. After an overnight incubation in media with 11 mM glucose, we measured islet intracellular calcium in 5, 8, 11, or 15 mM glucose. Islets from heterozygous 10- to 12-week-old mice were quiescent in 5 mM glucose and displayed oscillations with increasing amplitude and/or duration in 8, 11, and 15 mM glucose, respectively. Islets from diabetic 10- to 12-week-old mice, in contrast, showed robust oscillations in 5 mM glucose that declined with increasing glucose. Similar trends were observed at 4-5-weeks of age. A progressive left shift in maximal insulin release was also observed in islets as db/db mice aged. Reducing glucokinase activity with 1 mM D-mannoheptulose restored oscillations in 11 mM glucose. Finally, overnight low-dose cytokine exposure negatively impacted oscillations preferentially in high glucose in diabetic islets compared with heterozygous controls. Our findings suggest the following: 1) islets from frankly diabetic mice can produce oscillations, 2) elevated sensitivity to glucose prevents diabetic mouse islets from producing oscillations in normal postprandial (11-15 mM glucose) conditions, and 3) hypersensitivity to glucose may magnify stress effects from inflammation or other sources.

Diagnostic and predictive values of thirst, angiotensin II, and vasopressin during trauma resuscitation.

BACKGROUND: Thirst perception involves neurochemical signals attributed to acute elevation of arginine vasopressin (AVP) and angiotensin II (AT2) levels, and may accompany acute hemorrhage. OBJECTIVE: To determine whether thirst or plasma AVP or AT2 levels predict hemorrhagic shock, injury severity, or outcome in trauma patients at initial presentation. METHODS: This was a prospective case series of adult subjects presenting as trauma activations to an urban level I trauma center. Subjects were included if they were alert and nonintoxicated. During resuscitation, subjects were queried for thirst perception using binary and continuous data formats employing a 100-mm nonhatched visual analog scale. Blood for AT2 and AVP assessment was obtained during initial laboratory collection. Other data were abstracted retrospectively from our trauma registry. Crude and stratified analyses (blunt and penetrating trauma) assessed the correlation of thirst, AVP, and AT2 to the initial shock index, base deficit, blood transfusion requirement, admission, and Injury Severity Score (ISS). Our institutional review board (IRB) granted a waiver of informed consent. RESULTS: Of 105 subjects, the average age was 35 years (95% confidence interval [CI] 32 to 38), with 31% penetrating trauma. For AVP, there was no difference in thirst perception between subjects with normal (59 mm, 95% CI 47 to 71) versus elevated (63 mm, 95% CI 56 to 70) plasma levels. For AT2, results were likewise insignificant for normal (63 mm, 95% CI 56 to 70) versus elevated (58 mm, 95% CI 46 to 70) plasma levels. Thirst, AT2 level, and AVP level demonstrated no correlation to shock index, base deficit, transfusion requirement, hospital admission, or ISS. CONCLUSION: The results of this study imply that thirst severity and AVP and AT2 plasma levels are not reliable predictors of impending hemorrhagic shock, injury severity, or outcome. The presence or absence of severe thirst should not be employed as a primary marker for dismissing or suspecting incipient shock.