Immediate DIEP Breast Reconstruction in a Trans Woman with Breast Cancer.

Breast cancer is a leading cause of cancer among cisgender women worldwide, with an incidence that continues to rise. Breast reconstruction is increasingly recognized as an integral part of breast cancer management. In tandem, the population of trans women is also increasing. However, few studies have focused on the management of breast cancer in this population, given that estrogen therapy has the potential to increase the risk of breast cancer. We present the case of a 51-year-old trans woman diagnosed with right breast cancer following a 32-year history of estrogen therapy. She presented to our clinic for consultation and immediate breast reconstruction. She opted for bilateral skin-sparing mastectomies, sentinel lymph node biopsies, and immediate breast reconstruction using deep inferior epigastric perforator free flaps. There were no postoperative flap complications. Final pathology revealed invasive mucinous carcinoma, devoid of lymph node involvement. The patient was satisfied with her reconstruction and is currently planning for nipple reconstruction. To the authors' knowledge, this is the first reported case in the literature of bilateral deep inferior epigastric perforator free flap reconstruction in the trans female population after breast cancer diagnosis. This case underscores the need for a holistic treatment approach and heightened vigilance among trans women on estrogen therapy. It also highlights that breast reconstruction should be considered and offered to this patient population.

Leukocyte Count and Coronary Artery Disease Events in People With Human Immunodeficiency Virus: A Longitudinal Study.

BACKGROUND: People with human immunodeficiency virus (HIV; PWH) have increased cardiovascular risk. Higher leukocyte count has been associated with coronary artery disease (CAD) events in the general population. It is unknown whether the leukocyte-CAD association also applies to PWH. METHODS: In a case-control study nested within the Swiss HIV Cohort Study, we obtained uni- and multivariable odds ratios (OR) for CAD events, based on traditional and HIV-related CAD risk factors, leukocyte count, and confounders previously associated with leukocyte count. RESULTS: We included 536 cases with a first CAD event (2000-2021; median age, 56 years; 87% male; 84% with suppressed HIV RNA) and 1464 event-free controls. Cases had higher latest leukocyte count before CAD event than controls (median [interquartile range], 6495 [5300-7995] vs 5900 [4910-7200]; P < .01), but leukocytosis (>11 000/µL) was uncommon (4.3% vs 2.1%; P = .01). In the highest versus lowest leukocyte quintile at latest time point before CAD event, participants had univariable CAD-OR = 2.27 (95% confidence interval, 1.63-3.15) and multivariable adjusted CAD-OR = 1.59 (1.09-2.30). For comparison, univariable CAD-OR for dyslipidemia, diabetes, and recent abacavir exposure were 1.58 (1.29-1.93), 2.19 (1.59-3.03), and 1.73 (1.37-2.17), respectively. Smoking and, to a lesser degree, alcohol and ethnicity attenuated the leukocyte-CAD association. Leukocytes measured up to 8 years before the event were significantly associated with CAD events. CONCLUSIONS: PWH in Switzerland with higher leukocyte counts have an independently increased risk of CAD events, to a degree similar to traditional and HIV-related risk factors.

A Simple Physical Exam Maneuver to Distinguish Trigger Digit, Dupuytren's Nodule, and Flexor Sheath Ganglion.

Trigger digit, Dupuytren's disease, and ganglion cysts are 3 common disorders treated by hand surgeons. Despite the varying nature of their pathology, these 3 entities can all present as a mass at the flexor crease in the distal palm. The regional similarity of these presentations can make diagnosis more difficult. In this paper, we describe a simple clinical exam method that can assist in distinguishing between trigger digit, Dupuytren's disease, and flexor sheath ganglion cysts.

Extradigital glomus tumour of the thigh causing 8 years of undiagnosed debilitating pain.

A woman in her mid-50s was referred to a plastic surgeon with an 8-year history of undiagnosed, localised severe, reproducible pain of the right thigh. Treatment with oral and topical analgesics, corticosteroids, acupuncture and physiotherapy did not provide symptom relief. She was referred to multiple specialists over the preceding 8 years including chronic pain physicians, physiatry, orthopaedic surgery and plastic surgery. Investigations including sonographic and MRI eventually revealed a non-specific soft tissue abnormality in the area of tenderness, which was excised en bloc. Histopathology revealed an extradigital glomus tumour. The patient's symptoms immediately and permanently resolved postexcision.Physicians seeing patients suffering from undiagnosed focal, reproducible pain should consider extradigital glomus tumours in their differential diagnosis. Workup for extradigital glomus tumour includes focused sonographic or MRI over the area of pain. Additionally, local injection of an anaesthetic agent can be used to assist with diagnosis.

Improving Equity, Diversity, and Inclusion in Plastic, Reconstructive, and Aesthetic Surgery in Canada: A Call to Action.

The global COVID-19 pandemic has brought to light the significant inequities in the delivery of healthcare, vaccine inequity, and differential access to life-saving treatments, which have disproportionately impacted marginalized and racialized populations. In this article, we acknowledge and recognize the centuries-old legacies perpetuating inequity, injustice, and oppression, we discuss the principles of Equity, Diversity, and Inclusion (EDI) and we call our Canadian plastic surgery colleagues and trainees to action. We propose a plan for (1) Education, (2) Mitigating Disparities in the Clinical Setting, and (3) Policy, Societies, and Leadership Education.

La pandémie mondiale de COVID-19 a mis en lumière des iniquités importantes dans la prestation des soins, l'iniquité vaccinale et l'accès différentiel à des traitements salvateurs, qui ont touché démesurément les populations marginalisées et racisées. Dans le présent article, les auteurs reconnaissent les héritages séculaires qui perpétuent l'iniquité, l'injustice et l'oppression, ils abordent les principes d'équité, de diversité et d'inclusion et ils appellent à l'action leurs collègues et leurs stagiaires canadiens en chirurgie plastique. Ils proposent un plan en matière (1) d'éducation, (2) d'atténuation des disparités en milieu clinique et (3) de politique, de société et d'éducation au leadership.

Accelerometry as an objective measure of upper-extremity activity.

Most studies evaluating the effectiveness of treatments targeting shoulder pathologies use subjective outcome measures such as self-administered questionnaires. To date, there are no validated tools that objectively measure shoulder-specific functional activity. The purpose of this study was to validate wearable accelerometers as an objective proxy for shoulder activity. Ten healthy volunteers wore accelerometers placed at both wrists, the dominant upper arm and the chest while performing standardised shoulder and non-shoulder activities. Recorded tridimensional acceleration was computed into activity counts for epochs of 10 s. Receiver operating characteristics (ROC) curves were built to determine the optimal configuration to classify shoulder-type activities. For single accelerometer placement, the area under the ROC curve (AUC) was optimal for the 10-s epoch (AUC = 0.779) using the wrist placement, with a sensitivity of 94.1% and specificity of 67.5%. The combined upper arm and chest placement had an AUC of 0.985 (94.8% sensitivity, 94.8% specificity). Dual-accelerometer placement (upper arm and chest) is the optimal configuration to classify shoulder activity. However, a sole wrist-based accelerometer can be used as an objective proxy for shoulder activity in long-term unsupervised monitoring with excellent sensitivity and acceptable specificity.

Survey of epilepsy and seizure awareness in Manitoba: An evaluation.

BACKGROUND: Epilepsy and seizure awareness is gradually improving across Canada. With the strategic proposal for a Comprehensive Epilepsy Program in Manitoba (including formation of a new Pediatric Epilepsy Monitoring Unit (EMU)), a provincial strategy has been recommended outlining a path towards improved access to epilepsy care. We sought to qualify the current state of clinician knowledge and comfort towards diagnosis and management of this condition. METHODS: A qualitative online survey (Survey of Epilepsy and Seizure Awareness in Manitoba: An Evaluation (SESAME)), comprised of 36 short-answer questions, was delivered to primary care and specialist physicians in Manitoba. RESULTS: One hundred and eight subjects responded across varying medical disciplines. One hundred and one (93.5%) had previously managed patients with epilepsy, and 87 (80.6%) had previously ordered an electroencephalogram (EEG). A total of 63 (59.4%) had referred to a neurologist, with a lower proportion (30, 28.3%) referring specifically to an epileptologist. Only 36 respondents (33.3%) had heard of the International League Against Epilepsy (ILAE) guidelines. A total of 61 (56.5%) were unaware of invasive EEG techniques. Most (85, 78.7%) understood a role for surgery in treating epilepsy, with 12 (11.1%) unaware of surgical therapies beyond vagal nerve stimulation (VNS). Finally, less than half (44.2%) had heard about the Comprehensive Epilepsy Program in Manitoba, with nearly two-thirds (62.8%) indicating that they would like to have more information on epilepsy management. CONCLUSIONS: The SESAME successfully identified strong awareness towards epilepsy, with identifiable lapses in knowledge that will benefit from a formal provincial-wide educational curriculum.

Steroids Limit Myocardial Edema During Ex Vivo Perfusion of Hearts Donated After Circulatory Death.

BACKGROUND: Normothermic ex vivo heart perfusion (EVHP) has been shown to improve the preservation of hearts donated after circulatory arrest and to facilitate clinical successful transplantation. Steroids are added to the perfusate solution in current clinical EVHP protocols; however, the impact of this approach on donor heart preservation has not been previously investigated. We sought to determine the impact of steroids on the inflammatory response and development of myocardial edema during EVHP. METHODS: Thirteen pigs were anesthetized, mechanical ventilation was discontinued, and a hypoxemic cardiac arrest ensued. A 15-minute warm-ischemic standoff period was observed, and then hearts were resuscitated with a cardioplegic solution. Donor hearts were then perfused ex vivo in a normothermic beating state for 6 hours with 500 mg of methylprednisolone (steroid: n = 5) or without (control: n = 8). RESULTS: The addition of steroids to the perfusate solution reduced the generation of proinflammatory cytokines (interleukin-6, -8, -1ß, and tumor necrosis factor-α) and the development of myocardial edema during EVHP (percentage of weight gain: control = 26% ± 7% versus steroid = 16% ± 10%, p = 0.049). Electron microscopy suggested less endothelial cell edema in the steroid group (injury score: control = 1.8 ± 0.2 versus steroid = 1.2 ± 0.2, p = 0.06), whereas perfusate troponin-I (control = 11.9 ± 1.9 ng/mL versus steroid = 9.5 ± 2.4 ng/mL, p = 0.448) and myocardial function were comparable between the groups. CONCLUSIONS: The addition of methylprednisolone to the perfusion solution minimizes the generation of proinflammatory cytokines and development of myocardial edema during normothermic ex vivo perfusion of hearts donated after circulatory arrest.

Impact of Reperfusion Calcium and pH on the Resuscitation of Hearts Donated After Circulatory Death.

BACKGROUND: Hearts donated after circulatory death may represent an additional donor source. The influx of sodium and calcium ions across the sarcolemma play a central role in the pathogenesis of ischemia-reperfusion injury; however, this process may be inhibited if the initial reperfusion solution is rendered hypocalcemic and acidic. We sought to determine the calcium concentration and pH of the initial reperfusion solution that yielded optimal functional recovery of hearts donated after circulatory death during ex vivo heart perfusion. METHODS: Pigs were anesthetized, mechanical ventilation was discontinued, and a 15-minute standoff period was observed after circulatory arrest. Hearts were reperfused with a normothermic cardioplegia of varying calcium concentrations (part 1 [50 µmol/L, n = 4; 220 µmol/L, n = 9; 500 µmol/L, n = 4; and 1,250 µmol/L, n = 5]) and pH (part 2 [7.9, n = 5; 7.4, n = 9; 6.9, n = 8; and 6.4, n = 6]). Myocardial function was then assessed in a physiologic working model 1 hour after initiation of normothermic ex vivo heart perfusion. RESULTS: The calcium concentration and pH of the cardioplegic solution affected the development of myocardial edema (part 1: 50 µmol/L = 5.8% ± 0.9%; 220 µmol/L = 4.3% ± 0.4%; 500 µmol/L = 7.0% ± 0.6%; and 1,250 µmol/L = 6.6% ± 0.8% weight gain, p = 0.015; part 2: 7.9 = 3.6% ± 0.4%, 7.4 = 4.3% ± 0.4%, 6.9 = 3.7% ± 0.6%, and 6.4 = 6.4% ± 1.3% weight gain, p = 0.056) and the recovery of myocardial function (cardiac index part 1: 50 µmol/L = 2.6 ± 0.6; 220 µmol/L = 6.0 ± 0.8; 500 µmol/L = 2.3 ± 0.5; and 1,250 µmol/L = 1.9 ± 0.6 mL · m-1 · g-1, p < 0.001; part 2: 7.9 = 1.5 ± 0.7; 7.4 = 6.0 ± 0.8; 6.9 = 8.4 ± 1.8; and 6.4 = 3.1 ± 0.8 mL · m-1 · g-1, p = 0.003) during ex vivo heart perfusion. CONCLUSIONS: Initial reperfusion of hearts donated after circulatory death with a hypocalcemic and moderately acidic cardioplegia minimizes edema and optimizes functional recovery during subsequent ex vivo heart perfusion.

External carotid compression: a novel technique to improve cerebral perfusion during selective antegrade cerebral perfusion for aortic arch surgery.

PURPOSE: Selective antegrade cerebral perfusion (SACP) involving cannulation of either the axillary or innominate artery is a commonly used technique for maintaining cerebral blood flow (CBF) during the use of hypothermic cardiac arrest (HCA) for operations on the aortic arch. Nevertheless, asymmetrical CBF with hypoperfusion of the left cerebral hemisphere is a common occurrence during SACP. The purpose of this report is to describe an adjunctive maneuver to improve left hemispheric CBF during SACP by applying extrinsic compression to the left carotid artery. CLINICAL FEATURES: A 77-yr-old male patient with a history of aortic valve replacement presented for emergent surgical repair of an acute type A aortic dissection of a previously known ascending aortic aneurysm. His intraoperative course included cannulation of the right axillary artery, which was used as the aortic inflow during cardiopulmonary bypass and also allowed for subsequent SACP during HCA. After the onset of HCA, the innominate artery was clamped at its origin to allow for SACP. Shortly thereafter, however, the left-sided cerebral oxygen saturation (SrO2) began to decrease. Augmenting the PaO2, PaCO2 and both SACP pressure and flow failed to increase left hemispheric SrO2. Following the use of ultrasound guidance to confirm the absence of atherosclerotic disease in the carotid artery, external pressure was applied partially compressing the artery. With the carotid compression, the left cerebral saturation abruptly increased, suggesting pressurization of the left cerebral hemispheric circulation and augmentation of CBF. CONCLUSIONS: Direct ultrasound visualization and cautious partial compression of the left carotid artery may address asymmetrical CBF that occurs with SACP during HCA for aortic arch surgery. This strategy may lead to improved symmetry of CBF and corresponding cerebral oximetry measurements during aortic arch surgery.

RéSUMé: OBJECTIF: La perfusion cérébrale antérograde sélective réalisée via la canulation de l'artère axillaire ou du tronc artériel brachiocéphalique est une technique répandue pour maintenir la circulation sanguine cérébrale pendant un arrêt circulatoire hypothermique pour les opérations de la crosse aortique. Toutefois, on observe fréquemment une circulation sanguine cérébrale asymétrique accompagnée d'une hypoperfusion de l'hémisphère cérébrale gauche pendant la perfusion cérébrale antérograde sélective. L'objectif de ce compte rendu est de décrire une manœuvre d'appoint destinée à améliorer la circulation sanguine cérébrale pendant la perfusion cérébrale antérograde sélective en appliquant une compression extrinsèque à l'artère carotide gauche. ÉLéMENTS CLINIQUES: Un homme de 77 ans avec des antécédents de remplacement valvulaire aortique s'est présenté pour une réparation chirurgicale urgente d'une dissection aortique aiguë de type A d'un anévrisme de l'aorte ascendante connu. Son parcours peropératoire a inclus la canulation de l'artère axillaire droite, qui a été utilisée comme canule artérielle pendant la circulation extracorporelle et a également permis la perfusion cérébrale antérograde sélective subséquente pendant l'arrêt circulatoire hypothermique. Après l'amorce de l'arrêt circulatoire hypothermique, le tronc artériel brachiocéphalique a été clampé à sa base afin de permettre la perfusion cérébrale antérograde sélective. Peu après toutefois, la saturation en oxygène cérébral (SrO2) gauche a commencé à baisser. L'augmentation de la PaO2, de la PaCO2 et de la pression et du débit de perfusion cérébrale antérograde sélective n'a pas réussi à augmenter la SrO2 dans l'hémisphère gauche. Après avoir utilisé l'échographie pour confirmer l'absence d'athérosclérose dans l'artère carotide, une pression externe a été appliquée en comprimant partiellement l'artère. En comprimant la carotide, la saturation cérébrale gauche a subitement augmenté, suggérant une pressurisation de la circulation hémisphérique cérébrale gauche et une augmentation de la circulation sanguine cérébrale. CONCLUSION: Une visualisation directe par échographie et une compression partielle prudente de l'artère carotide gauche pourraient régler le problème de circulation sanguine cérébrale asymétrique qui survient en cas de perfusion cérébrale antérograde sélective pendant l'arrêt circulatoire hypothermique pour la chirurgie de la crosse aortique. Cette stratégie pourrait améliorer la symétrie de la circulation sanguine cérébrale et les mesures de l'oxymétrie cérébrale correspondantes pendant les chirurgies de la crosse aortique.