Nose-Ocomial Pulmonary Edema: A Rare Complication of Oxymetazoline.

A 72-year-old female with epiphora presented for outpatient punctoplasty with probing and lacrimal stent placement. Oxymetazoline was administered intranasally and the case was completed in standard fashion. Postoperatively, the patient desaturated with a workup revealing elevated cardiac enzymes, pulmonary congestion, and sinus bradycardia. However, the final cardiac testing was noncontributory, suggesting flash pulmonary edema secondary to intranasal oxymetazoline. This case highlights a rare presentation of pulmonary compromise secondary to oxymetazoline, emphasizing the importance of intraoperative and postoperative vigilance in simple outpatient procedures.

Transoral Septoplasty before Le Fort I Downfracture: A Novel Functional Rhinoplasty Technique.

Individuals with maxillary dentofacial deformities commonly have preexisting nasal airway obstruction with associated nasal septal deviation. Combination bimaxillary procedures with intraoral septoplasty after maxillary downfracture have been demonstrated to address dentofacial deformities and nasal obstruction simultaneously. Although effective, current transoral septoplasty techniques offer limited visualization of the superior septum and are challenging to perform due to septal mobility after Le Fort I downfracture. Here, we describe a novel approach in which a transoral septoplasty is performed before completion of the Le Fort I maxillary downfracture, improving septal stability during the dissection and affording better visualization of the septal L-strut for precise cartilage resection.

Minimally Invasive Mandibular Microsurgery: A Systematic Review and Meta-analysis.

Microsurgical advances have led to minimally invasive approaches for mandibular reconstruction. Currently, no resource compares all minimally invasive microvascular mandibular reconstruction (MIMMR) treatment options. Methods: All known cases of MIMMR were identified following the Preferred Reporting Items for Systematic Reviews, Meta-Analyses guidelines, and our own surgical experience. Patient demographics, MIMMR type [submandibular (SM), modified facelift/retroauricular (MFL/RA), or intraoral (IO)], methodology, and clinical outcomes were analyzed with the Fisher exact and Kruskal-Wallis tests. Results: Forty-seven patients underwent MIMMR. Ameloblastoma was the most common pathology treated using all approaches, and MFL/RA was the only approach used to treat squamous cell carcinoma (P = 0.0103). Reconstruction was reported for large, bilateral defects only via the SM or IO approach (P = 0.0216). The iliac crest or fibula was used as a donor site. The facial artery was the most common recipient vessel using the IO and SM approaches, whereas the superior thyroid and external carotid vessels were the most common in the MFL/RA approach (P < 0.0001). Virtual planning was used in all cases performed via an IO approach, 80.0% of cases using an SM approach, and no MFL/RA cases (P < 0.0001). Good aesthetic and functional outcomes were reported for every patient, and there was no difference in complication rates (P = 0.2880). Conclusions: Minimally invasive approaches are safe and effective treatment options for patients requiring mandibular microsurgery, usually in the setting of benign pathology. The IO and SM approaches usually rely on the facial vessels, whereas the MFL/RA approach permits access to the superior thyroid and external carotid vessels and cervical lymphadenectomy.

Quantifying Complications: An Analysis of Operative Time and Intraoperative Factors in Microsurgical Breast Reconstruction.

BACKGROUND: Analysis of operative flow has been shown to improve efficiency in breast microsurgery. Both complex decision-making skills and technical mastery are required to overcome intraoperative challenges encountered during microsurgical reconstruction. Effects of intraoperative complications on operative time have not yet been reported. METHODS: A retrospective chart review of microsurgical breast reconstructions by three surgeons between 2013-2020 analyzed operative variables and duration. Intraoperative complications were determined from the operative report. Correlations between continuous variables were determined using Spearman correlation coefficients. Nonparametric testing was used when comparing operative duration between groups. RESULTS: Operative duration was analyzed for 547 autologous breast reconstruction cases; 210 reconstructions were unilateral and 337 were bilateral. Average operative duration was 471.2 SD 132.2 minutes overall (360.1 SD 100.5 minutes for unilateral cases and 530.5 SD 110.5 minutes for bilateral cases). Operative duration decreased with surgeon experience (r = -0.17, p< .001).Regarding intraoperative complications, difficult donor dissection was correlated with an average operative duration increase of 91.7 minutes (n = 43, 7.9%, p< .001), pedicle injury with an additional 67.7 minutes (n = 19, 3.5%, p = .02) and difficult recipient vessel dissection with an increase of 63.0 minutes (n = 35, 6.4%, p = .003). Complications with anastomosis also showed a statistically significant increase in operative duration, with arterial complications resulting in an increase of 104.3 minutes (n = 41, 7.5%, p< .001) and venous complications resulting in an increase in 78.8 minutes (n = 32, 5.8%, p< .001). Intraoperative thrombus resulted in an increase of 125.5 minutes (n = 20, 3.7%, p< .001), and requiring alternative venous outflow added an average of 193.7 minutes (n = 8, 1.5%, p< .001). CONCLUSION: Intraoperative complications in autologous breast reconstruction significantly increase operative time. The greatest increase in operative time is seen with intraoperative thrombosis or requiring alternative venous outflow. As these complications are rarely encountered in breast microsurgery, opportunities for simulation and case-based practice exist to improve efficiency.

Spontaneous necrotizing granuloma of the cerebellum: a case report.

BACKGROUND: Intracranial necrotizing granulomatous space-occupying lesions are sparsely reported in literature. Variability in presenting symptomatology and radiographic features makes diagnostic work-up difficult. CASE PRESENTATION: This report presents the case of a 77-year-old female with sinusitis and fatigue who underwent an MRI revealing a posterior fossa lesion compressing the fourth ventricle. Subsequent contrast CT of the chest, abdomen, and pelvis was negative for primary malignancy. Histopathologic examination of the lesion following biopsy showed it to be a necrotizing granuloma in an antineutrophil cytoplasmic antibody (ANCA) negative patient. The most likely diagnosis was determined to be spontaneous necrotizing granuloma, a rare entity with only one previous report noted. CONCLUSIONS: Spontaneous necrotizing granuloma of the CNS is a rare entity that represents an important differential consideration in the work-up of space occupying lesions of the CNS.

The Effect of Divalent Cations on the Thermostability of Type II Polyketide Synthase Acyl Carrier Proteins.

The successful engineering of biosynthetic pathways hinges on understanding the factors that influence acyl carrier protein (ACP) stability and function. The stability and structure of ACPs can be influenced by the presence of divalent cations, but how this relates to primary sequence remains poorly understood. As part of a course-based undergraduate research experience, we investigated the thermostability of type II polyketide synthase (PKS) ACPs. We observed an approximate 40 °C range in the thermostability amongst the 14 ACPs studied, as well as an increase in stability (5 - 26 °C) of the ACPs in the presence of divalent cations. Distribution of charges in the helix II-loop-helix III region was found to impact the enthalpy of denaturation. Taken together, our results reveal clues as to how the sequence of type II PKS ACPs relates to their structural stability, information that can be used to study how ACP sequence relates to function.

Uncovering protein-protein interactions through a team-based undergraduate biochemistry course.

How can we provide fertile ground for students to simultaneously explore a breadth of foundational knowledge, develop cross-disciplinary problem-solving skills, gain resiliency, and learn to work as a member of a team? One way is to integrate original research in the context of an undergraduate biochemistry course. In this Community Page, we discuss the development and execution of an interdisciplinary and cross-departmental undergraduate biochemistry laboratory course. We present a template for how a similar course can be replicated at other institutions and provide pedagogical and research results from a sample module in which we challenged our students to study the binding interface between 2 important biosynthetic proteins. Finally, we address the community and invite others to join us in making a larger impact on undergraduate education and the field of biochemistry by coordinating efforts to integrate research and teaching across campuses.