Novel Osteomyocutaneous Flap Model for Vascularized Composite Allotransplantation.

Background: Vascularized composite allotransplantation (VCA) has become a viable option for restoration of devastating injuries that are not amenable to conventional reconstructive techniques. However, the relative scarcity of procedures performed worldwide, as well as the potential for iatrogenic injury with biopsies, makes studying the immunopathogenesis of acute rejection challenging. Translational VCA research focuses on developing strategies to overcome these barriers with the use of animal models can be technically challenging and difficult to replicate without highly trained microsurgeons. Methods: We describe a modified model of a femur-based composite tissue allograft using an adapted vascular cuff anastomotic technique with a tunneled skin flap in a rodent model. Results: The use of a heterotopic osteomyocutaneous flap with a subcutaneously tunneled-skin paddle to the posterolateral aspect of the recipient rodent allows for ease of flap monitoring and reduces the risk of self-mutilation. A total of six transplantations were conducted with no signs of self-mutilation. Operative time decreased as our surgical technique improved, and long-term graft tolerance was possible under our immunosuppressive regimen. Additionally, we demonstrate cases of successful transplantation in both an allogeneic and syngeneic rodent model. Conclusion: Animal models, although technically challenging, are a reliable and reproducible modality that has been used to investigate various aspects of VCA immunology. We describe the success of an osteomyocutaneous flap with a modified vascular cuff anastomosis that can be used by investigators with less experience in microsurgical techniques to further our understanding of VCA physiology. Furthermore, tunneling of the skin paddle reduces the risk of self-mutilation and other external factors affecting the graft.

Technical Pearls and Pitfalls of Facial Feminization Surgery: A Review of Techniques From a Single Institutional Practice.

BACKGROUND: Facial feminization surgery (FFS) is an emerging practice that falls under the broader umbrella of gender-affirming surgery. Various approaches exist to feminize the face, yet few published articles describe in detail the techniques of each component procedure. Considering the diversity of interventions employed, the objective of this manuscript is to highlight FFS techniques utilized by the senior author and create a corresponding media gallery. METHODS: All patients with the diagnosis of gender dysphoria that were referred to the senior author for FFS consultation between June 2017 and August 2022 were reviewed. Data were retrospectively collected from electronic medical records according to the institutional review board (IRB)-approved study protocol. Data collected and analyzed included demographics, operative documentation, and postoperative follow-up. Multimedia material was collected intraoperatively and postoperatively. RESULTS: A total of 231 patients underwent 262 operations with a total of 1224 FFS procedures. The average follow-up time was 7.7 ± 11 months. Out of the 262 operations, 24 (9.2%) patients experienced minor complications, including 3 (1.1%) with wound dehiscence, 13 (5.0%) with hematomas, and 14 (5.3%) with postoperative infection requiring antibiotics. Of those, 3 (1.1%) required a return to the operating room for washout or removal of malar implants. CONCLUSION: Although there is a consensus on the fundamental surgical principles to achieve adequate feminization of the facial architecture, the specific techniques to do so differ according to individual practices. As techniques diverge, so do their risk profiles and outcomes; techniques must, thus, align with patients' interventional goals. The material presented here is one of many that can support trainees and junior surgeons as they build a gender-affirming practice.

Risk Factors for Acute-Level Hospital Course in Pediatric Craniofacial Fractures.

PURPOSE: The pediatric craniofacial trauma literature is limited to single institutions or short study periods. Herein, this study analyzes a national database over 10 years to delineate the epidemiology of pediatric craniofacial fractures and to identify risk factors for acute-level hospital course in the largest series to date. METHODS: Utilizing the National Trauma Data Bank, pediatric craniofacial fractures admitted between 2010 and 2019 were identified. Descriptive analyses and multivariable regression were performed to identify risk factors for acute-level hospital course. RESULTS: A total of 155,136 pediatric craniofacial fracture cases were reviewed, including cranial vault (49.0%), nasal (22.4%), midface (21.0%), mandibular (20.2%), and orbital floor fractures (13.7%). Midface and orbital floor fractures occurred commonly as multicraniofacial fractures. Cranial vault fractures were the most common among all age groups, but frequency declined with age. In contrast, facial fractures increased with age. Despite the inherent complexity of multicraniofacial trauma, isolated fractures remained a concern for acute-level hospital course.Cranial vault and midface fractures had an increased risk of intracranial injury and intensive care unit admission (P<0.001). Mandibular and midface fractures had an increased risk for cervical spine fracture and tracheostomy (P<0.001). Patient and injury-specific risk factors among the fractures with the strongest association for each outcome-cranial vault and mandible-were identified. CONCLUSIONS: The inherent limitations of prior studies-geographical biases, small cohorts, and short-term study periods-were addressed. Describing the independent contribution of each craniofacial fracture to the risk of acute-level hospital course outcomes can be employed to better optimize risk stratification, counseling, and management.

Comparison of the Effects of Postoperative Arm Restraints and Mittens on Cleft Lip Scar Quality after Primary Repair.

Introduction: Postoperative management following primary cleft lip repair varies across institutions, cleft care teams, and individual surgeons. Postoperative precautions employed after cleft lip repair include dietary restrictions, pacifier limitations, and immobilization, with arm restraints long being used. Yet, restraint distress has led to the exploration of other forms of immobilization. Thus, this study aims to assess cleft lip scar quality and complication rates after postoperative immobilization with arm restraints versus hand mittens. Methods: A retrospective review of patients with unilateral cleft who underwent primary repair with the senior surgeon was done. Data on demographics, surgical characteristics, and immobilization utilized were gathered. A survey with pictures of postoperative scars were sent to laypeople who assessed scar quality with Modified Scar-Rating Scale scores for surface appearance, height, and color of the scar tissue. Statistical analysis was carried out for significance. Results: Twenty-eight patients with a unilateral cleft underwent arm restraints after primary lip repair, and twenty-seven utilized mittens. In total, 42 medical students completed the scar assessment. Photographs were taken an average of 23.9 (±5.8) and 28.2 (±11.9) months postoperatively in the restraint and mitten groups, respectively (p = 0.239). There were no statistically significant differences in scores between scar surface, height, color, or overall scar appearance. Complication rates were also similar between groups. Conclusions: Arm restraints appear to have no additional benefit relative to scar quality, as compared to mittens. Considering the arm restraints' burden of care, mittens should be considered as a measure to protect the lip after primary repair.

MethParquet: an R package for rapid and efficient DNA methylation association analysis adopting Apache Parquet.

SUMMARY: Genome-wide DNA methylation (DNAm) profiling is indispensable for unveiling how DNAm regulates biological pathways and individual phenotypes. However, managing and analyzing extensive DNAm data generated from large cohort studies present computational obstacles. Apache Parquet is a data file format that allows for efficient data storage, retrieval, and manipulation, alleviating computational hurdles associated with conventional row-based formats. We here introduce MethParquet, the first R package leveraging the columnar Parquet format for efficient DNAm data analysis. It can be used for data extraction, methylation risk score calculation, epigenome-wide association analyses, and other standard post-quality control tasks. The package flexibly implements diverse regression models. Via a public methylation dataset, we show the efficiency of this package in reducing running time and RAM usage in large-scale EWAS. AVAILABILITY AND IMPLEMENTATION: The MethParquet R package is publicly available on the GitHub repository https://github.com/ZWangTen/MethParquet. It includes a vignette and a toy dataset derived from a public resource.

Sustained success of a Caprini postoperative venous thromboembolism prevention protocol over one decade.

BACKGROUND: The objective of this study was to review the long-term efficacy of a post-operative venous thromboembolism (VTE) prevention program at our institution. METHODS: We performed a review of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data at our hospital from January 2008-December 2022. The primary outcome was risk-adjusted VTE events. RESULTS: In 2009, a postoperative general surgery patient was three times more likely to have a postoperative VTE event than predicted (O/E ratio 3.02, 95% CI 1.99-4.40). After implementing a mandatory VTE risk assessment model and a risk-commensurate prophylaxis protocol in the electronic medical record in 2011, the odds ratio of a patient developing a postoperative VTE declined to 0.70 by 2014 (95% CI 0.40-1.23). This success persisted through 2022. CONCLUSIONS: Since the implementation of a standardized postoperative VTE prevention program in 2011, our institution has sustained a desirably low likelihood of VTE events in general surgery patients.

Assessing breast cancer-related lymphedema screening and treatment gaps in a safety-net hospital.

BACKGROUND AND OBJECTIVES: We evaluated the unmet breast cancer-related lymphedema (BCRL) treatment and education needs at New England's largest safety-net hospital serving a diverse population by assessing prevalence, risk factors, and treatment. METHODS: This was a retrospective cohort study examining breast cancer surgery patients from September 2016 to September 2021. The primary outcome was BCRL diagnosis. Secondary outcomes included BCRL risk factors, and physical and occupational therapy (PT/OT) referral frequency and completion. RESULTS: Of 639 patients, 17% of patients had documented BCRL, which was significantly associated with axillary lymph node dissection (ALND). There were no racial, insurance, breast radiation, or BMI category differences between patients with and without a BCRL diagnosis. Of those with BCRL, 58% received a PT/OT referral, and 56% completed their referral. There were no racial, insurance, or BMI category differences between those who received a PT/OT referral and those who did not. CONCLUSION: In our high-risk population, rates of documented BCRL were higher than expected, approaching rates of ALND, despite the majority undergoing sentinel lymph node biopsy (SLNB). PT/OT referral and completion rates were low, concerning for an unmet BCRL treatment and education need. No disparities in care delivery were seen, but a program that addresses treatment gaps and ensures accessible and patient-centered BCRL care is urgently needed.

Contemporary Prevalence of Oral Clefts in the US: Geographic and Socioeconomic Considerations.

Background: Socio-economic status, living environments, and race have been implicated in the development of different congenital abnormalities. As orofacial clefting is the most common anomaly affecting the face, an understanding of its prevalence in the United States and its relationship with different determinants of health is paramount. Therefore, the purpose of this study is to determine the modern prevalence of oral-facial clefting in the United States and its association with different social determinants of health. Methods: Utilizing Epic Cosmos, data from approximately 180 US institutions were queried. Patients born between November 2012 and November 2022 were included. Eight orofacial clefting (OC) cohorts were identified. The Social Vulnerability Index (SVI) was used to assess social determinants of health. Results: Of the 15,697,366 patients identified, 31,216 were diagnosed with OC, resulting in a prevalence of 19.9 (95% CI: 19.7-20.1) per 10,000 live births. OC prevalence was highest among Asian (27.5 CI: 26.2-28.8) and Native American (32.8 CI: 30.4-35.2) patients and lowest among Black patients (12.96 CI: 12.5-13.4). Male and Hispanic patients exhibited higher OC prevalence than female and non-Hispanic patients. No significant differences were found among metropolitan (20.23/10,000), micropolitan (20.18/10,000), and rural populations (20.02/10,000). SVI data demonstrated that OC prevalence was positively associated with the percentage of the population below the poverty line and negatively associated with the proportion of minority language speakers. Conclusions: This study examined the largest US cohort of OC patients to date to define contemporary US prevalence, reporting a marginally higher rate than previous estimates. Multiple social determinants of health were found to be associated with OC prevalence, underscoring the importance of holistic prenatal care. These data may inform clinicians about screening and counseling of expectant families based on socio-economic factors and direct future research as it identifies potential risk factors and provides prevalence data, both of which are useful in addressing common questions related to screening and counseling.

Breast Cancer Screening and BI-RADS Scoring Trends Before and During the COVID-19 Pandemic in an Academic Safety-Net Hospital.

BACKGROUND: Little is known about how the COVID-19 pandemic affected screening mammography rates and Breast Imaging Reporting and Data Systems (BI-RADS) categorizations within populations facing social and economic inequities. Our study seeks to compare trends in breast cancer screening and BI-RADS assessments in an academic safety-net patient population before and during the COVID-19 pandemic. PATIENTS AND METHODS: Our single-center retrospective study evaluated women ≥ 18 years old with no known breast cancer diagnosis who received breast cancer screening from March 2019-September 2020. The screening BI-RADS score, completion of recommended diagnostic imaging, and diagnostic BI-RADS scores were compared between the pre-COVID-19 era (from 1 March 2019 to 19 March 2020) and COVID-19 era (from 20 March 2020 to 30 September 2020). RESULTS: Among the 11,798 patients identified, screened patients were younger (median age 57 versus 59 years, p < 0.001) and more likely covered by private insurance (35.9% versus 32.3%, p < 0.001) during the COVID-19 era compared with the pre-COVID-19 era. During the pandemic, there was an increase in screening mammograms categorized as BI-RADS 0 compared with the pre-COVID-19 era (20% versus 14.5%, p < 0.0001). There was no statistically significant difference in rates of completion of diagnostic imaging (81.6% versus 85.4%, p = 0.764) or assignment of suspicious BI-RADS scores (BI-RADS 4-5; 79.9% versus 80.8%, p = 0.762) between the two eras. CONCLUSIONS: Although more patients were recommended to undergo diagnostic imaging during the pandemic, there were no significant differences in race, completion of diagnostic imaging, or proportions of mammograms categorized as suspicious between the two time periods. These findings likely reflect efforts to maintain equitable care among diverse racial groups served by our safety-net hospital.