Tumour size predicts risk of recurrence in tall cell subtype papillary thyroid carcinoma.

BACKGROUND: The tall cell subtype of papillary thyroid cancer (TCPTC) is the most common aggressive subtype and often treated aggressively. This approach may not be necessary in smaller tumours without adverse histological characteristics. METHODS: 97 patients with TCPTC defined as a height-to-width ratio of ≥3:1 and at least 30% tall cells were compared against 390 classical papillary thyroid carcinoma (CPTC) based on tumour size with recurrence free survival (RFS) as the primary outcome. RESULTS: TCPTC are more likely to present with adverse histological characteristics. In smaller tumours (<2 â€‹cm), only central lymph node metastasis (HR7.16 p â€‹= â€‹0.03) and multifocality (HR10.11 p â€‹= â€‹0.026) increased recurrence risk. In larger tumours, TCPTC histology (HR3.78 p â€‹= â€‹0.002), lymphovascular invasion (HR3.02 p â€‹= â€‹0.014) and central lymph node metastasis (HR3.24 p â€‹< â€‹0.001) significantly increased recurrence risk. CONCLUSION: TCPTC tumours <2 â€‹cm without central lymph node metastasis and multifocality are similar in risk of recurrence to classical PTC and could be managed with lobectomy.

Predictive Efficacy of the Perfusion Index for Hypotension following Spinal Anesthesia in Parturient Undergoing Elective Cesarean Section: A Systematic Review and Meta-Analysis.

This meta-analysis assessed the predictive efficacy of perfusion index for hypotension following spinal anesthesia (SA) in parturients undergoing elective cesarean section (CS). Electronic databases, including Google Scholar, EMBASE, Cochrane Library, and MEDLINE, were searched from inception to June 2023. The primary outcome was the diagnostic accuracy of the perfusion index in predicting the probability of perioperative hypotension following SA. The review included 12 studies involving 2009 patients, published between 2017 and 2023. The pooled sensitivity and specificity were 0.81 (95% confidence interval (CI) = 0.72-0.87) and 0.75 (95% CI = 0.67-0.82), respectively. Additionally, the pooled area under the curve (AUC) was calculated as 0.84 (95% CI = 0.81-0.87), suggesting a moderate to good accuracy of the diagnostic test. Using Fagan's nomogram plot, the positive likelihood ratio (LR) and negative LR were found to be 3 and 0.26, respectively. The results demonstrated that the perfusion index exhibited an acceptable level of accuracy in predicting perioperative hypotension after spinal anesthesia in parturients undergoing elective CS. These findings highlight the potential value of incorporating a perfusion index as a useful tool for clinicians to integrate into routine clinical practice, which necessitates further large-scale studies for verification.

The Impact of Obesity on Mortality and Complications in Posterior Retroperitoneoscopic Adrenalectomy.

Background Obesity is a global epidemic. It influences surgical technique, ergonomics, safety, and outcomes. However, there is a paucity of evidence of obesity-related impact in posterior retroperitoneoscopic adrenalectomy (PRA). This study compared perioperative outcomes of obese and non-obese participants undergoing PRA. Methodology  This is a multi-center retrospective cohort study of elective PRA from March 2014 to December 2022. Patient demographics, surgical techniques, clinicopathological parameters, and outcomes, including overall complication rate, were analyzed using SPSS version 27 (IBM Corp., Armonk, NY, USA). Results Seventy-five patients underwent a PRA, of which 97.3% were completed retroperitoneoscopically. The overall complication rate was (9.3%), and on subgroup analysis, the obese cohort had a lower percentage complication profile at 6.5%. Male participants comprised 52%, with a median age of 55 (IQR=19). The median BMI was 29.0 (IQR=8), of which 41% were obese, and 40% were overweight. Univariate analysis showed that being obese was not significantly associated with a higher complication rate (p=0.471). In addition, there was no significant increase in conversion (p=0.508), bleeding/transfusion (p=0.508), surgical site infection (SSI; p=1.000), incisional hernia (p=1.000), ICU or high dependency unit admission (p=0.292) and any-cause mortality (p=1.000). No sentinel deaths directly related to PRA were recorded. Procedure duration was longer in obese (117 mins) vs. non-obese participants (88.9 mins, p=0.022). However, there was no significant difference in the length-of-hospital stay (p=0.592). The cohort conversion rate was (2.7%), and tumor size was associated with a higher conversion rate (35.4 vs. 62.5mm, p=0.040). Conclusion Posterior retroperitoneoscopic adrenalectomy can be a safe procedure in obese populations, and obesity does not increase perioperative morbidity or mortality.

Efficacy and safety of gefapixant for chronic cough: a meta-analysis of randomised controlled trials.

BACKGROUND: The efficacy and safety of gefapixant in adults with chronic cough remain unclear. Our objective was to assess the efficacy and safety of gefapixant using updated evidence. METHODS: MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL) and Embase databases were searched from inception through September 2022. Subgroup analysis based on dose of gefapixant (i.e. ≤20, 45-50 and ≥100 mg twice daily for low, moderate and high doses, respectively) was performed to explore a potential dose-dependent effect. RESULTS: Five studies involving seven trials showed the efficacy of moderate- or high-dose gefapixant for reducing objective 24-h cough frequency (estimated relative reduction 30.9% and 58.5%, respectively) (i.e. primary outcome) and awake cough frequency (estimated relative reduction 47.3% and 62.8%, respectively). Night-time cough frequency was only reduced with high-dose gefapixant. Consistently, the use of moderate- or high-dose gefapixant significantly alleviated cough severity and improved cough-related quality of life, but increased the risk of all-cause adverse events (AEs), treatment-related AEs and ageusia/dysgeusia/hypogeusia. Subgroup analysis showed dose dependency in both efficacy and AEs with a cut-off dose being ≥45 mg twice daily. CONCLUSIONS: This meta-analysis revealed dose-dependent efficacy and adverse effects of gefapixant against chronic cough. Further studies are required to investigate the feasibility of moderate-dose (i.e. 45-50 mg twice daily) gefapixant in clinical practice.

Transoral endoscopic thyroidectomy vestibular approach (TOETVA): initial experience in Australia.

BACKGROUND: Thyroidectomy is traditionally an open procedure. The potential for and unpredictability of patients developing an unsightly anterior neck scar has led many investigators to develop various 'scarless' thyroidectomy techniques. Here we report on our initial experience, and to our knowledge, the first and largest series of this technique in Australia and New Zealand. METHODS: Across two centres in Western Australia, three Endocrine surgeons utilized the Transoral Endoscopic Thyroidectomy vestibular approach (TOETVA). Key endpoints such as operating time, blood loss, pain scores, recurrent laryngeal nerve injury and hypoparathyroidism was collected. Data was analysed using R statistical program. RESULTS: One hundred and two TOETVAs were performed between March 2018 and May 2021. There were 66 hemithyroidectomies, 34 total thyroidectomies (four converted to open), and two isthmusectomies. We noted a trend in median operating time decreasing over the study period. There were no cases of permanent recurrent laryngeal nerve palsy, wound infection, seroma or haematoma. We had four instances of open conversion; one temporary RLN palsy, and 12 cases of temporary hypoparathyroidism. CONCLUSION: This is the first series of TOETVA reported in Australia and New Zealand. Our results demonstrate that with appropriate surgeon experience, training, collaboration, and in well selected patients, this is a feasible and safe thyroidectomy technique. We hope that our work will build confidence in Endocrine Surgical units seeking to develop this technique in Australia.

Elevated Surgical Pleth Index at the End of Surgery Is Associated with Postoperative Moderate-to-Severe Pain: A Systematic Review and Meta-Analysis.

Despite acceptance of the surgical pleth index (SPI) for monitoring the intraoperative balance between noxious stimulation and anti-nociception under general anesthesia, its efficacy for predicting postoperative moderate-to-severe pain remains unclear. We searched electronic databases (e.g., Google Scholar, MEDLINE, Cochrane Library, and EMBASE) to identify articles focusing on associations of SPI at the end of surgery with immediate moderate-to-severe pain in the postanesthesia care unit from inception to 7 July 2022. A total of six observational studies involving 756 adults published between 2016 and 2020 were eligible for quantitative syntheses. Pooled results revealed higher values of SPI in patients with moderate-to-severe pain than those without (mean difference: 7.82, 95% CI: 3.69 to 11.95, p = 0.002, I2 = 46%). In addition, an elevated SPI at the end of surgery was able to predict moderate-to-severe pain with a sensitivity of 0.71 (95% confidence interval (CI): 0.65-0.77; I2 = 29.01%) and a specificity of 0.58 (95% CI: 0.39-0.74; I2 = 79.31%). The overall accuracy based on the summary receiver operating characteristic (sROC) curve was 0.72. In conclusion, this meta-analysis highlighted the feasibility of the surgical pleth index to predict postoperative moderate-to-severe pain immediately after surgery. Our results from a limited number of studies warrant further investigations for verification.

Prophylactic effect of intravenous lidocaine against cognitive deficit after cardiac surgery: A PRISMA-compliant meta-analysis and trial sequential analysis.

BACKGROUND: This study aimed at providing an updated evidence of the association between intraoperative lidocaine and risk of postcardiac surgery cognitive deficit. METHODS: Randomized clinical trials (RCTs) investigating effects of intravenous lidocaine against cognitive deficit in adults undergoing cardiac surgeries were retrieved from the EMBASE, MEDLINE, Google scholar, and Cochrane controlled trials register databases from inception till May 2021. Risk of cognitive deficit was the primary endpoint, while secondary endpoints were length of stay (LOS) in intensive care unit/hospital. Impact of individual studies and cumulative evidence reliability were evaluated with sensitivity analyses and trial sequential analysis, respectively. RESULTS: Six RCTs involving 963 patients published from 1999 to 2019 were included. In early postoperative period (i.e., 2 weeks), the use of intravenous lidocaine (overall incidence = 14.8%) was associated with a lower risk of cognitive deficit compared to that with placebo (overall incidence = 33.1%) (relative risk = 0.49, 95% confidence interval: 0.32-0.75). However, sensitivity analysis and trial sequential analysis signified insufficient evidence to arrive at a firm conclusion. In the late postoperative period (i.e., 6-10 weeks), perioperative intravenous lidocaine (overall incidence = 37.9%) did not reduce the risk of cognitive deficit (relative risk = 0.99, 95% confidence interval: 0.84) compared to the placebo (overall incidence = 38.6%). Intravenous lidocaine was associated with a shortened LOS in intensive care unit/hospital with weak evidence. CONCLUSION: Our results indicated a prophylactic effect of intravenous lidocaine against cognitive deficit only at the early postoperative period despite insufficient evidence. Further large-scale studies are warranted to assess its use for the prevention of cognitive deficit and enhancement of recovery (e.g., LOS).

Impact of intravenous and topical lidocaine on clinical outcomes in patients receiving propofol for gastrointestinal endoscopic procedures: a meta-analysis of randomised controlled trials.

BACKGROUND: The efficacy of i.v. or topical lidocaine as an anaesthesia adjunct in improving clinical outcomes in patients receiving gastrointestinal endoscopic procedures under propofol sedation remains unclear. METHODS: Electronic databases (MEDLINE, EMBASE, and Cochrane Library) were searched for RCTs comparing the clinical outcomes with or without lidocaine application (i.v. or topical) in patients receiving propofol for gastrointestinal endoscopic procedures from inception to 29 March 2021. The primary outcome was propofol dosage, while secondary outcomes included procedure time, recovery time, adverse events (e.g. oxygen desaturation), post-procedural pain, and levels of endoscopist and patient satisfaction. RESULTS: Twelve trials (1707 patients) published between 2011 and 2020 demonstrated that addition of i.v. (n=7) or topical (n=5) lidocaine to propofol sedation decreased the level of post-procedural pain (standardised mean difference [SMD]=-0.47, 95% confidence interval [CI]: -0.8 to -0.14), risks of gag events (risk ratio [RR]=0.51, 95% CI: 0.35-0.75), and involuntary movement (RR=0.4, 95% CI: 0.16-0.96). Subgroup analysis demonstrated that only i.v. lidocaine reduced propofol dosage required for gastrointestinal endoscopic procedures (SMD=-0.83, 95% CI: -1.19 to -0.47), increased endoscopist satisfaction (SMD=0.75, 95% CI: 0.21-1.29), and shortened the recovery time (SMD=-0.83, 95% CI: -1.45 to -0.21). Intravenous or topical lidocaine did not affect the incidence of oxygen desaturation (RR=0.72, 95% CI: 0.41-1.24) or arterial hypotension (RR=0.6, 95% CI: 0.22-1.65) and procedure time (SMD=0.21, 95% CI: -0.09 to 0.51). CONCLUSION: This meta-analysis demonstrated that i.v. or topical lidocaine appears safe to use and may be of benefit for improving propofol sedation in patients undergoing gastrointestinal endoscopic procedures. Further large-scale trials are warranted to support our findings.

Efficacy of greater occipital nerve block for pain relief in patients with postdural puncture headache: A meta-analysis.

BACKGROUND: This study aimed at assessing the therapeutic effectiveness of greater occipital nerve block (GONB) against postdural puncture headache (PDPH). METHODS: Studies investigating analgesic effects of GONB against PDPH in adults were retrieved from the MEDLINE, EMBASE, Google scholar, and Cochrane central databases from their inception dates to May, 2021. Pain score at postprocedural 24 hours was the primary endpoint, while secondary endpoints were pain score at postprocedural 1 hour and 12 hours as well as the risk of intervention failure. RESULTS: Of the 7 studies (randomized controlled trials [RCTs], n = 4; non-RCTs, n = 3) that recruited 275 patients, 2 investigated female patients undergoing cesarean section and the other 5 were conducted in both obstetric and nonobstetric settings. Pooled results showed a lower mean pain score at 24 hours (i.e., primary outcome) (mean difference [MD] = -2.66, 95%: CI: -3.98 to -1.33, P < .001; I2 = 97%, 6 studies), 1 hour (MD = -4.23, 95% confidence interval [CI]: -5.08 to -3.37, P < .00001; I2 = 86%, 5 studies), and 6 hours (MD = -2.78, 95% CI: -4.99 to -0.57, P = .01; I2 = 98%, 4 studies) in patients with GONB compared to those without. Trial sequential analysis supported the robustness of evidence at postprocedural 24 hours. The use of GONB also decreased the risk of intervention failure (relative ratio [RR] = 0.4, 95% CI: 0.19 to 0.82, P = .01; I2 = 96%, 6 studies, 277 patients). CONCLUSION: Our results suggested a therapeutic effect of greater occipital nerve block against postdural puncture headache up to postprocedural 24 hours. Further large-scale studies are warranted to evaluate its therapeutic benefit beyond the acute stage.

A Study of the Strength Performance of Peat Soil: A Modified Cement-Based Stabilization Agent Using Fly Ash and Polypropylene Fiber.

The use of cement as a soil stabilization agent is one of the common solutions to enhancing the engineering properties of soil. However, the impact and cost of using cement have raised environmental concerns, generating much interest in the search for alternative materials to reduce the use of cement as a stabilizing agent in soil treatment. This study looked into limiting cement content in peat soil stabilization by using fly ash waste and polypropylene fiber (PPF). It focused on soil mechanical mediation for stabilization of peat with fly ash cement and PPF cement by comparing the mechanical properties, using unconfined compressive strength (UCS) and California bearing ratio (CBR) tests. The control (untreated) peat specimen and specimens with either fly ash (10%, 20% and 30%) and PPF (0.1%, 0.15% and 0.2%) were studied. Test results showed that 30% of fly ash and cement content displays the highest UCS and CBR values and gives the most reliable compressibility properties. On the other hand, UCS and CBR test results indicate optimum values of PPF-cement stabilizing agent content in the specimen of 0.15% PPF and 30% cement. Selected specimens were analyzed using scanning electron microscopy (SEM), and PPF threads were found to be well surrounded by cement-stabilized peat matrices. It was also observed that the specimen with 30% fly ash generated more hydration products when compared to the specimen with 100% cement content. It is concluded that the use of fly ash cement and PPF cement as stabilizing agents to limit the cement usage in peat soil treatment is potentially viable.

A low serum iron level is a potential predictor of poor renal function in patients following laparoscopic sleeve gastrectomy: a retrospective study.

This study aimed to assess the association of serum iron level (Iron) with the estimated glomerular filtration rate (eGFR) after bariatric surgery (BS). We reviewed 210 patients with mean age of 39.1 ± 10.6 years (body mass index, 41.4 ± 5.5 kg/m2) undergoing BS. The primary outcome was the relationship between Iron and eGFR at 12-month after surgery. Multiple linear regression analyses were performed using postoperative eGFR as dependent variables and using Iron and other variables (i.e., age) as independent variables. At 12-month follow-up, 94 patients were analyzed. BMI significantly decreased, whereas serum iron level significantly increased. Although the percentage of patients with eGFR of < 90 mL/min/1.73 m2 increased during the study period, no significant difference was found in postoperative 12-month eGFR. No correlations were noted between Iron and eGFR at baseline and postoperative 1 and 6 months, whereas a significant relationship was observed between Iron and postoperative 12-month eGFR. Multiple linear regression analyses revealed that Iron and presence of diabetes were the independent predictors of postoperative 12-month eGFR. This pilot study showed a positive association of postoperative serum iron level with renal function in this patient population. Further large-scale trials are needed to confirm the findings.

Comparison of video-stylet and video-laryngoscope for endotracheal intubation in adults with cervical neck immobilisation: A meta-analysis of randomised controlled trials.

BACKGROUND: The efficacy of video-stylet versus video-laryngoscope for tracheal intubation in patients with cervical spine immobilisation, which is known to impede the intubation process, remains unclear. METHODS: We searched electronic databases including EMBASE, MEDLINE, Google Scholar, and Cochrane Library for randomised controlled trials comparing video-stylets with video-laryngoscopes in human subjects with cervical spine immobilisation from inception to the 25th of January 2021. The primary outcome was the rate of successful first-attempt intubation, while secondary outcomes included overall intubation success rate, time for successful intubation, and risk of tissue damage. RESULTS: Five trials (709 patients) published between 2009 and 2020 met the inclusion criteria. There were four types of video-stylets and three types of video-laryngoscopes examined. Hard cervical collar was applied in four studies, while manual inline stabilisation was used in one study for cervical immobilisation. There was no difference in successful first-attempt intubation rate between the video-stylet and the video-laryngoscope groups [risk ratio (RR) = 0.96, 95% CI: 0.90-1.03, p = 0.3; I2 = 47%] (5 trials, 709 patients). The overall success rate (RR = 0.98, 95% CI: 0.96-1.0, p = 0.05; I2 = 0%), intubation time [mean difference (MD) = 5.24, 95% CI: -8.95 to 19.43, p = 0.47; I2 = 92%], and risk of tissue damage (RR = 0.87, 95% CI: 0.26-2.85, p = 0.81; I2 = 39%) were also comparable between the two groups. CONCLUSIONS: This study validates the efficacy of both video-stylets and video-laryngoscopes for tracheal intubation in the situation of cervical spine immobilisation. Further large-scale trials are warranted to support our findings in this clinical setting.

Mechanical and Thermal Properties of Synthetic Polypropylene Fiber-Reinforced Renewable Oil Palm Shell Lightweight Concrete.

Oil palm shell (OPS) is an agricultural solid waste from the extraction process of palm oil. All these wastes from industry pose serious disposal issues for the environment. This research aims to promote the replacement of conventional coarse aggregates with eco-friendly OPS aggregate which offers several advantages, such as being lightweight, renewable, and domestically available. This paper evaluates the mechanical and thermal performances of renewable OPS lightweight concrete (LWC) reinforced with various type of synthetic polypropylene (SPP) fibers. Monofilament polypropylene (MPS) and barchip polypropylene straight (BPS) were added to concrete at different volume fractions (singly and hybrid) of 0%, 0.1%, 0.3% and 0.4%. All specimens were mixed by using a new mixing method with a time saving of up to 14.3% compared to conventional mixing methods. The effects of SPP fibers on the mechanical properties were investigated by compressive strength, splitting tensile strength and residual strength. The strength of the oil palm shell lightweight concrete hybrid 0.4% (OPSLWC-HYB-0.4%) mixture achieved the highest compressive strength of 29 MPa at 28 days. The inclusion of 0.3% of BPS showed a positive outcome with the lowest thermal conductivity value at 0.55 W/m °C. Therefore, the results revealed that incorporation of BPS fiber enhanced the performance of thermal conductivity tests as compared to inclusion of MPS fiber. Hence, renewable OPS LWC was proven to be a highly recommended environmentally friendly aggregate as an alternative solution to replace natural aggregates used in the concrete industry.

Biomedical device innovation methodology: applications in biophotonics.

The process of medical device innovation involves an iterative method that focuses on designing innovative, device-oriented solutions that address unmet clinical needs. This process has been applied to the field of biophotonics with many notable successes. Device innovation begins with identifying an unmet clinical need and evaluating this need through a variety of lenses, including currently existing solutions for the need, stakeholders who are interested in the need, and the market that will support an innovative solution. Only once the clinical need is understood in detail can the invention process begin. The ideation phase often involves multiple levels of brainstorming and prototyping with the aim of addressing technical and clinical questions early and in a cost-efficient manner. Once potential solutions are found, they are tested against a number of known translational factors, including intellectual property, regulatory, and reimbursement landscapes. Only when the solution matches the clinical need, the next phase of building a "to market" strategy should begin. Most aspects of the innovation process can be conducted relatively quickly and without significant capital expense. This white paper focuses on key points of the medical device innovation method and how the field of biophotonics has been applied within this framework to generate clinical and commercial success.

Ovatodiolide suppresses colon tumorigenesis and prevents polarization of M2 tumor-associated macrophages through YAP oncogenic pathways.

BACKGROUND: An increased expression of Yes-associated protein (YAP1) has been shown to promote tumorigenesis in many cancer types including colon. However, the role of YAP1 in promoting colon tumorigenesis remains unclear. Here, we demonstrate that YAP1 expression is associated with M2 tumor-associated macrophage polarization and the generation of colon cancer stem-like cells. YAP1 downregulation by gene silencing or a phytochemical, ovatodiolide, not only suppresses colon cancer tumorigenesis but also prevents M2 TAM polarization. METHODS: Human monocytic cells, THP-1, and colon cancer cell lines, HCT116 and DLD-1, were co-cultured to mimic the interactions between tumor and its microenvironment. M2 polarization of the THP-1 cells were examined using both flow cytometry and q-PCR technique. The inhibition of YAP1 signaling was achieved by gene-silencing technique or ovatodiolide. The molecular consequences of YAP1 inhibition was demonstrated via colony formation, migration, and colon-sphere formation assays. 5-FU and ovatodiolide were used in drug combination studies. Xenograft and syngeneic mouse models were used to investigate the role of YAP1 in colon tumorigenesis and TAM generation. RESULTS: An increased YAP1 expression was found to be associated with a poor prognosis in patients with colon cancer using bioinformatics approach. We showed an increased YAP1 expression in the colon spheres, and colon cancer cells co-cultured with M2 TAMs. YAP1-silencing led to the concomitant decreased expression of major oncogenic pathways including Kras, mTOR, ß-catenin, and M2-promoting IL-4 and tumor-promoting IL-6 cytokines. TAM co-cultured colon spheres showed a significantly higher tumor-initiating ability in vivo. Ovatodiolide treatment alone and in combination with 5-FU significantly suppressed in vivo tumorigenesis and less TAM infiltration in CT26 syngeneic mouse model. CONCLUSIONS: We have identified the dual function of YAP1 where its suppression not only inhibited tumorigenesis but also prevented the generation of cancer stem-like cells and M2 TAM polarization. Ovatodiolide treatment suppressed YAP1 oncogenic pathways to inhibit colon tumorigenesis and M2 TAM generation both in vitro and in vivo. Ovatodiolide should be considered for its potential for adjuvant therapeutic development.

Orbital Adherence Syndrome following the Use of Titanium Precontoured Orbital Mesh for the Reconstruction of Posttraumatic Orbital Floor Defects.

Orbital blowout fractures are a common occurrence following orbital trauma. Depending on the size of the defect and the contents that have herniated or incarcerated, possible sequelae include enophthalmos, diplopia, dystopia, and entrapment. Surgical intervention aims to prevent or alleviate this through the use of a bone graft or an alloplastic implant to reconstitute the continuity of the orbit. However, in doing so, the implant itself may result in the unexpected adherence of the periorbita, resulting in orbital adherence syndrome. We present two cases of orbital adherence syndrome following the use of titanium mesh for orbital floor reconstruction. In both cases, we also delineate the management of this syndrome. Our first patient reported good recovery after surgical intervention to relieve the tethering to the titanium mesh and subsequent placement of a smooth interface implant. The other patient was managed nonsurgically with resolution of symptoms. We highlight possible signs that might suggest the need for early surgical intervention. Orbital adherence syndrome is a poorly described and understood phenomenon and appears to occur after the use of large-pored titanium mesh for orbital reconstruction. Prevention is possible through careful patient selection and the placement of a smooth interface medium in the initial surgery.

Surgical predictors of acute postoperative pain after hip arthroscopy.

BACKGROUND: Pain following hip arthroscopy is highly variable and can be severe. Little published data exists demonstrating reliable predictors of significant pain after hip arthroscopy. The aim of this study was to identify influence of intraoperative factors (arthroscopic fluid infusion pressure, operative type) on the severity of postoperative pain. METHODS: A retrospective review of 131 patients who had received a variety of arthroscopic hip interventions was performed. A standardized anaesthetic technique was used on all patients and postoperative pain was analysed using recovery pain severity outcomes and analgesic use. A multivariate logistic regression analysis was performed on intraoperative factors including patient age, sex and BMI, arthroscopic infusion pressures (40 vs 80 mm Hg), amount of fluid used, length of surgery and types of arthroscopic interventions performed. Thirty six patients were also prospectively examined to determine arthroscopic fluid infusion rates for 40 and 80 mm Hg infusion pressures. RESULTS: Use of a higher infusion pressure of 80 mm Hg was strongly associated with all pain severity endpoints (OR 2.8 - 8.2). Other significant factors included hip arthroscopy that involved femoral chondro-ostectomy (OR 5.8) and labral repair (OR 7.5). Length of surgery and total amount of infusion fluid used were not associated with increased pain. CONCLUSIONS: 80 mm Hg arthroscopic infusion pressures, femoral chondro-osteoectomy and labral repair are strongly associated with significant postoperative pain, whereas intraoperative infusion volumes or surgical duration are not. Identification of these predictors in individual patients may guide clinical practice regarding the choice of more invasive regional analgesia options. The use of 40 mm Hg arthroscopic infusion pressures will assist in reducing postoperative pain.

An improved perforator-based island flap: the heart balloon flap.

BACKGROUND: Reconstructive surgery has entered a "perforator flap era" with more surgeons performing successful perforator flap procedures. The perforator-based island flap is an extension of this perforator concept and one of the most successful. In perforator-rich or -reliable areas, this allows for primary closure of the donor site and the construction of highly customized flaps with little tissue waste. METHODS: The authors present a design modification of the perforator-based island flap used in 73 patients who underwent heart balloon perforator-based island flap reconstruction between 2008 and 2012. RESULTS: There were no reported cases of total flap necrosis. Marginal necrosis of the flap was noted in three cases, which resolved with simple dressings. The donor sites were closed primarily in all cases. CONCLUSIONS: The heart balloon perforator-based island flap enables tension-free closure of the donor site, reduces donor-site complications, and minimizes tissue waste. The resulting shape resembles a heart and gives rise to the flap's name. Key principles for success are perforators close to the defect, a flap axis that allows for primary donor-site closure, flap border adjacent to the defect that is smaller than the postresection defect, flap harvest until an adequate arc of rotation is obtained, primary closure of the donor site before flap inset, and preservation of a triangular area between the proximal apex of the flap and the defect. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.