Association between Usage of Prophylactic AYUSH Medicines and Disease Severity in COVID-19 Patients: A Retrospective Cohort Study.

BACKGROUND: Prior vaccination is often studied for its impact on individuals' post-infection prognosis. Ayurveda, Yoga, Unani, Siddha and Homeopathy (AYUSH) medicines, advised by the Government of India as prophylaxis during the first wave of the coronavirus disease 2019 (COVID-19) pandemic, were consumed by the masses in 2020. A study was therefore undertaken to observe any association between the prior usage of AYUSH prophylactic medicines and post-infection severity as reported by recovered COVID-19 individuals. METHODS: This was a retrospective, multi-centre, cohort study conducted in 21 cities of India from 5th August to 30th November 2020. Data from recovered COVID-19 patients, of either sex or any age, captured information about AYUSH prophylactic medicines intake prior to infection, disease severity, symptomatology, duration of complaints, etc. The study participants were grouped into AYUSH intake and non-intake. Primary composite outcome was the disease clinical course. Secondary clinical outcomes were the rate of and time to clinical recovery. RESULTS: Data of 5,023 persons were analysed. Ayurveda or homeopathic prophylactic medicines were consumed by more than half of the study participants: that is, 56.85% (n = 1,556) and 56.81% (n = 1,555) respectively. The overall adjusted protective effect (PE) of AYUSH prophylactic intake against moderate/severe forms of COVID-19 disease was 56.7% (95% confidence interval [CI], 48.7 to 63.50; p < 0.001). Adjusted PE for homeopathy and Siddha was 52.9% (95% CI, 42.30 to 61.50; p < 0.001) and 59.8% (95% CI, 37.80 to 74.10; p < 0.001), respectively. A statistically significant association was found between AYUSH prophylactic medicine intake and clinical recovery more frequently by the 3rd day of illness (χ2 = 9.01; p = 0.002). Time to resolution of symptoms in the AYUSH intake group was on average 0.3 days earlier than in the non-intake group (p = 0.002). CONCLUSION: AYUSH prophylactics were associated with statistically significant levels of protection against COVID-19 disease severity. Amongst these, previous intake of homeopathy or Siddha medicines was associated with some protection against moderate/severe illness and with a somewhat quicker clinical recovery. Prospective studies with experimental research design are needed to validate the findings of this study. STUDY REGISTRATION: Clinical Trials Registry-India (CTRI/2020/08/027000).

From Tip of Brush to Tip of Knife: The Relationship Between Post-Mastectomy Breast Reconstruction and the Classical Arts.

Breast reconstruction is highly complex, requiring navigation of not only clinical and operative realities, but of patient expectations as well. The authors sought to identify historical art pieces that exhibit breast asymmetries and deformities for comparison with photos of breast reconstruction patients seen at the clinic of the senior author to demonstrate that achievement of perfect breast cosmesis is challenging in both breast reconstruction as well as in the classical arts. Open access libraries and Creative Commons images were reviewed to identify appropriate works of art from various time periods and geographic locations. Following artwork selection, photos of breast reconstruction patients were reviewed and paired with selected artworks exhibiting cosmetically similar breasts. A total of 9 pieces of selected historic art were found to have at least one matching patient photo, with 11 correlative patient photos ultimately chosen. Common breast asymmetries and deformities identified included ptosis, asymmetric chest wall placement, asymmetric nipple placement, and absence of the nipple. This review identified diverse artworks of varying styles spanning vast expanses of both geography and time that exhibit breast deformities and asymmetries commonly encountered in patients seeking revision of breast reconstruction. This underscores that creating the cosmetically ideal breast is difficult both in the operating room and the art studio. Importantly, the authors emphasize that the arts frequently celebrate that which is considered beautiful, though to the trained eye of a plastic surgeon, that which is considered beautiful, is often classified as dysmorphic or asymmetric.

Pediatric Hand Burns Requiring Emergency Care in the United States.

Hand and finger burns represent a relatively common occurrence in children, and serious injuries may require surgical intervention to prevent long-term disability. This study examines the epidemiological characteristics of pediatric patients presenting for emergency care of hand and finger burns within the United States. We report a cross-sectional study of patients reported to the National Electronic Injury Surveillance System from January 1, 2010 to December 31, 2019. Patients were included in our study if they were younger than 18 years old and evaluated for an isolated hand or finger burn. U.S. census data from the same period were used for determining epidemiological estimates of injury incidence. During the 10-year study period, an estimated 300,245 pediatric hand and finger burns were treated in 778,497,380 person-years: an incidence rate of 38.6 burns per 100,000 person-years. Most treated burns occurred in the 1- to 2-year age group (28.3%) with an approximate 50% reduction in incidence for each 1-year age stratum until stabilizing at 6 years. Most burns occurred in white children (58%), but black children had a higher incidence than white children when corrected for the U.S. population (45.15 burns vs 21.45 burns per 100,000 person-years). The most common etiology was a stove or oven (1595/10,420; 15%). Pediatric hand and finger burns occurred most frequently in young children from the oven and/or stove. We urge that parents be assertively counseled about potential burn risks to their young children's hands and fingers, especially once they reach ambulatory age.

Comorbidities Associated With Increased Likelihood of Postoperative Surgical Site Infection in Patients Treated for Hand or Finger Fracture and/or Dislocations.

BACKGROUND: We aimed to determine the relationship between common preoperative comorbidities and subsequent incidence of postoperative surgical site infections (SSIs) in hand and finger fractures and/or dislocations. METHODS: We queried the American College of Surgeons National Safety and Quality Improvement Program from January 1, 2015 to December 31, 2019. Patients were included in our study if they were treated by open or percutaneous fixation for any hand or finger fracture and/or dislocation. Predictor variables were smoking status, diabetes mellitus status, and obesity (body mass index > 30) status. Primary outcome was incidence of postoperative SSI. RESULTS: There were a total of 9245 patients included in our study, and 148 patients (1.6%) experienced postoperative SSI. Of these, 59 patients (39.9%) were only smokers, 7 patients (4.7%) only had diabetes mellitus, and 55 patients (37.2%) were only obese. Overall, patients experienced greater odds of sustaining a postoperative SSI if they were a smoker or diabetic compared to non-smokers and non-diabetics, respectively. Considering only open fixation modality, patients with comorbidities were not at significantly increased odds of sustaining postoperative SSI. Considering only percutaneous fixation modality, patients experienced significantly greater odds of sustaining postoperative SSI if they were a smoker compared to non-smoker. CONCLUSIONS: Common preoperative comorbidities, including smoking status and diabetes mellitus, increase the likelihood of postoperative complication in patients with hand and finger fractures and/or dislocations undergoing surgical treatment. Further investigation into the different relationship of these comorbidities between open and closed fractures with larger sample sizes will be valuable.

Routine Preoperative Nutritional Optimization Not Required in Patients Undergoing Breast Reconstruction.

Purpose: There are no data describing the need for preoperative nutritional optimization in patients undergoing breast reconstruction surgery. The purpose of this research was to identify if preoperative breast reconstruction patients are grossly nutritionally deficient as defined by preoperative serum albumin and, thus, if routine preoperative nutrition screening and optimization is necessary in this patient population. Methods: Adult patients who underwent breast reconstruction surgery between 2015 and 2019 were identified within the National Safety and Quality Improvement Program database. Variables of interest for this group of patients were collected, and comparisons were made for these variables between three different breast reconstruction modalities (implant-based reconstruction [IBR], expander-based reconstruction [EBR], and free tissue-based reconstruction [FTBR]) with χ2 and ANOVA statistical tests. Results: A total of 14,509 patients were included. There was not a significant difference in preoperative serum albumin measurements between the three reconstruction modalities and mean measurements for the three reconstruction modalities were all within normal limits. Secondarily, when comparing groups, FTBR had higher incidence of superficial surgical site infection (SSI) (4.49% vs. 1.6% vs. 1.56%, respectively; p < 0.00001), deep SSI (1.57% vs. 0.48% vs. 0.94%, respectively; p < 0.00001), and wound disruption (2.16% vs. 0.78% vs. 0.94%, respectively; p < 0.00001) than IBR and EBR. Conclusion: Preoperative nutritional status was found to be grossly appropriate in a large population of breast reconstruction patients. Furthermore, the ordering of routine preoperative serum albumin is unnecessary and represents an extraneous healthcare cost that does not lead to improved outcomes in breast reconstruction. FTBR incurred the greatest risk of surgical complication independent of preoperative nutritional status.

The Contribution of the Lower Third of the Face to Perceived Age: Do Masks Make You Appear Younger?

BACKGROUND: There is evidence that changes to the midface and lower third of the face in isolation contribute significantly to one's perception of the overall facial age. Since the spread of the coronavirus disease 2019 (COVID-19), mask wearing has become commonplace. To date, there have been no studies that explore how covering the lower third of the face impacts the perception of age. OBJECTIVES: The authors hypothesized that covering the lower third of the face with a mask will make a person appear younger. METHODS: One hundred consecutive plastic surgery patients were photographed in a standardized fashion, both masked and unmasked. A questionnaire for factors known to contribute to facial aging was administered. These photographs were randomized to 6 judges who estimated the patients' age and also quantified facial rhytids with the validated Lemperle wrinkle assessment score of 6. Data were analyzed using PROC MIXED analysis. RESULTS: Masked patients on average appeared 6.17% younger (mean difference = 3.16 years, P < 0.0001). Wrinkle assessment scores were 9.81% lower in the masked group (mean difference = 0.21, P = 0.0003). All subgroups appeared younger in a mask except for patients aged 18 to 40 years chronological age (P = 0.0617) and patients BMI > 35 (P = 0.5084). CONCLUSIONS: The mask group appeared younger and had lower overall and visible wrinkle assessment scores when compared with the unmasked group. This has implications for our understanding of the contributions of the lower third of the face to overall perceived facial age.

Multispecialty Microsurgical Course Utilizing the Blue-Blood Chicken Thigh Model Significantly Improves Resident Comfort, Confidence, and Attitudes in Multiple Domains.

BACKGROUND: The high level of technical skill required by microsurgical procedures has prompted the development of in vitro educational models. Current models are cost-ineffective, unrealistic, or carry ethical implications and are utilized as isolated experiences within single surgical specialties. The purpose of this study was to assess the educational and interprofessional effect of a microsurgical training course utilizing the nonliving "Blue-Blood" chicken thigh model (BBCTM) in a multidisciplinary environment. METHODS: A 10-hour course was developed integrating didactic lectures, case presentations, and one-on-one practical sessions utilizing hydrogel microvessels and the BBCTM. Pre- and postcourse surveys were administered assessing participants' self-reported comfort and confidence within fundamental microsurgical domains, assessments of the models utilized, and the effects of a multidisciplinary environment on the experience. RESULTS: A total of 19 residents attended the course on two separate occasions (n = 10 and n = 9, respectively). Respondents varied from postgraduate year-2 (PGY-2) to PGY-6+ and represented plastic and reconstructive surgery (n = 10), urology (n = 6), and otolaryngology (n = 3). On average, each participant performed 4.3 end-to-end, 1.3 end-to-side, and 0.4 coupler-assisted anastomoses. Following the course, participants felt significantly more comfortable operating a microscope and handling microsurgical instruments. They felt significantly more confident handling tissues, manipulating needles, microdissecting, performing end-to-end anastomoses, performing end-to-side anastomoses, using an anastomotic coupler, and declaring anastomoses suitable (all p < 0.05). The majority of participants believed that the use of live animals in the course would have minimally improved their learning. All but two respondents believed the course improved their awareness of the value of microsurgery in other specialties "very much" or "incredibly." CONCLUSION: A microsurgical training course utilizing nonliving models such as the "BBCTM significantly improves resident comfort and confidence in core operative domains and offers an in vivo experience without the use of live animals. Multispecialty training experiences in microsurgery are beneficial, desired, and likely underutilized.

Elastic Recoil after Balloon Angioplasty in Hemodialysis Accesses: Does It Actually Occur and Is It Clinically Relevant?

Purpose To qualify and quantify elastic recoil and determine its effect on access patency. Materials and Methods Research ethics board approval was obtained and all patients signed an informed consent form. This was a prospective, nonrandomized study of mature accesses that underwent balloon percutaneous transluminal angioplasty (PTA) between January 2009 and December 2012. After PTA, completion fistulography was performed at 0-, 5-, 10-, and 15-minute intervals. From Digital Imaging and Communications in Medicine images, percentage of lesion stenosis before and after PTA was measured at each time point. A total of 76 patients (44 men, 32 women; mean age, 59.6 years) were enrolled and underwent 154 PTAs in 56 grafts and 98 fistulas. Venous elastic recoil was defined as recurrent luminal narrowing greater than 50% within 15 minutes after full effacement of the stenosis by the angioplasty balloon. Data collected included sex, age, access type and location, lesion location, length, and time to next intervention. Access patency was estimated by using Kaplan-Meier survival method, association of variables with the risk of loss of patency was assessed by using a Cox proportional hazards model, and a multiple variable model was examined by considering all variables. Results Technical success of PTA with less than 30% residual stenosis was 78%. By 15 minutes, 15.6% (24 of 154) of treated lesions recurrently narrowed by more than 50%, with a majority observed at 5 minutes (15 of 24). Technical failure of PTA was predictive of elastic recoil (P < .001), as was cephalic arch stenosis in fistulas (P = .047) and autogenous fistulas (P = .04). Elastic recoil, when it did occur, did not influence patency. Six-month primary patency was 34.8% in grafts and 47.1% in fistulas. Conclusion Venous elastic recoil after PTA of stenoses in hemodialysis access circuits is common, but its occurrence does not influence access primary patency after PTA. (©) RSNA, 2015.

Myocardial perfusion imaging determination using an appropriate use smartphone application.

BACKGROUND: Inappropriate cardiac imaging has been a significant cost concern and cause of radiation burden to patients. OBJECTIVE: To assess if a smartphone application (app) based on 2009 Appropriate Use Criteria (AUC) for Cardiac Radionuclide Imaging published by American College of Cardiology would be feasible at the point of order. METHODS: We evaluated stress myocardial perfusion imaging (MPI) (N = 403) (mean age = 62.23 years; 47.89% males) over a 4 month period using a smartphone app to determine whether the study ordered was Appropriate, Inappropriate, or Uncertain per 2009 AUC. We also monitored the time needed to use the app to determine the level of appropriateness of each stress MPI. The results of the stress MPI were noted. RESULTS: Of the 403 stress MPIs evaluated, 267 (66.25%) were noted to be Appropriate, 118 (29.28%) were Inappropriate, and 13 (3.23%) were Uncertain, per AUC; 5 (1.25%) remained unclassified. Average time needed to use the app to assess each stress MPI for appropriateness was noted to be 44 (±9) seconds. Non-teaching physicians ordered 70 (38.89%) inappropriate stress MPIs as compared to 20 (23.53%) ordered by physicians on resident teaching service, and 28 (23.33%) by cardiologists (P = .0045). Among inappropriately ordered stress MPIs, 87 (42.65%) were ordered in females as compared to 31 (17.13%) in males (P < .0001). 70 (26.22%) stress MPIs among appropriately ordered were abnormal (reversible ischemia or fixed perfusion defect) as compared to 15 (12.17%) among inappropriately ordered stress MPIs (P = .0032). CONCLUSION: A free and convenient smartphone app provides an easy-to-use tool to assist physicians in determining the level of appropriateness of stress MPI in a time- and cost-effective manner at the point of order. The smartphone app may have potential to promote the usage of the AUC and possibly aid reduction of healthcare cost and ionizing radiation burden.

Patient safety in the operating room: I. Preoperative.

BACKGROUND: Beyond the controlled trauma of surgery, the operating room can be a hazardous place for patients and health care workers alike. Modern plastic surgery requires a thorough knowledge of various perioperative risks and methods to minimize these risks. As the importance of teamwork becomes more evident, clear communication skills preoperatively, intraoperatively, and postoperatively become equally critical. To facilitate an improvement in perioperative patient safety, this article will review aspects of communication, including crew resource management, root cause analysis, and surgical-site verification. In addition, the authors will discuss patient positioning, antiseptic hand and patient preparations, and barriers, such as surgical scrubs, gowns, gloves, and drapes. METHODS: The authors reviewed the literature regarding operating room safety, both primary research and secondary reviews, via multiple PubMed queries and literature searches. Topics most relevant to inpatient plastic surgery were included in the final analysis and summarized, as a full review of each topic is beyond the scope of this article. RESULTS: Many possible interventions were identified, with the goal of reducing perioperative complications, such as wrong site surgery, neuropathies, myopathies, compartment syndromes, pressure ulcers, surgical-site infections, and blood-borne disease transmissions among plastic surgeons and their patients. CONCLUSIONS: There are ample opportunities for the reduction of preventable adverse events in plastic surgery. This article aims to provide its reader with the tools to research adverse events and a basic education in avoiding specific preoperative events. A second article addressing intraoperative and postoperative patient safety follows.

Patient safety in the operating room: II. Intraoperative and postoperative.

BACKGROUND: The perioperative environment can be hazardous to patients and providers alike. Although many risks are best addressed preoperatively, some hazards require constant attention by the surgeon, anesthesiologist, and staff in the operating room. In a previous article, the authors discussed preoperative aspects of patient safety. In this article, the authors review intraoperative and postoperative risks and techniques to decrease these risks. METHODS: The authors reviewed the literature regarding operating room safety, both primary research and secondary reviews, via multiple PubMed queries and literature searches. Topics most relevant to inpatient plastic surgery were included in the final analysis and summarized, as a full review of each topic is beyond the scope of this article. RESULTS: Several intraoperative and postoperative risks were identified, in addition to methods designed to decrease the incidence of those risks, complications, and other adverse events among plastic surgeons and their patients. CONCLUSIONS: In this article covering intraoperative and postoperative hazards, the authors build upon a previous article addressing preoperative risks to patients during inpatient plastic surgery. Although neither article covers an exhaustive list of potential risks, the goal is to provide the modern plastic surgeon with the means to prevent common adverse events, as well as the tools to research new hazards.

The National Practitioner Data Bank: issues in plastic surgery.

BACKGROUND: The purpose of this article is to increase awareness among plastic surgeons of the applications and implications of the National Practitioner Data Bank. METHODS: A literature review using PubMed and Google was conducted regarding the history, function, and outcomes of the National Practitioner Data Bank, a federally maintained database of malpractice payments and disciplinary actions involving licensed healthcare providers. Particular attention was paid to institutional reporting requirements, the process of querying the data bank, and controversies regarding the effectiveness of the data bank as they apply to physicians. RESULTS: Many physicians in practice and training remain unaware of the requirements of the data bank. Specifically, situations in which an institution must report to the National Practitioner Data Bank on a physician's behalf can be surprising, such as payment to a patient in settlement of written claim without the suggestion of malpractice, denial of additional credentialing, and suspension of privileges for greater than 30 days. Mandatory and voluntary querying of the National Practitioner Data Bank also varies among entities. A listing with the National Practitioner Data Bank can have consequences for licensure and credentialing throughout a physician's career, and reporting requirements begin as an intern. Lastly, it is not clear that the existence of the National Practitioner Data Bank has improved the quality of health care in the United States. CONCLUSION: Knowledge of the requirements and limitations of the National Practitioner Data Bank is useful for plastic surgeons because of the diverse implications of its contents for their current and future practices.

Analysis of patient-determined preoperative computer imaging.

OBJECTIVE: To compare patients' goals in aesthetic rhinoplasty with aesthetic ideals by analyzing changes requested through computer imaging during the initial consultation. METHODS: The frontal and lateral views of 20 consecutive female rhinoplasty patients were analyzed retrospectively before and after using image manipulation software. Indexes from the frontal view included the ratio of alar base width to dorsal length and the ratio of alar base width to interpupillary distance. On the lateral view, parameters included the nasolabial angle, nasofacial angle, and tip projection (Goode ratio). Ideal parameters were based on descriptions by Powell and Humphreys. RESULTS: The ideal and patient-determined proportions were compared using a paired 2-tailed t test. The mean nasolabial angle falls within the ideal range before and after image manipulation. However, the Goode ratio and the ratio of alar base width to interpupillary distance were statistically similar to ideal values only after image manipulation. The nasofacial angle and the ratio of alar base width to dorsal length showed a trend toward the ideal ratio. CONCLUSIONS: Patients' preferences were similar to the ideal in 3 of 5 parameters, and the remaining parameters approached the ideal. These parameters are useful in creating satisfying proportions in aesthetic rhinoplasty and reconstructive surgery within our population. Rather than population-based normative data or ideals based on fashion models or Greek statuary, these are proportions requested by patients. Computer imaging software, used by a growing number of aesthetic surgeons, holds a wealth of data regarding common patient preferences.

Prevalence of ICD-9-CM codes for chronic kidney disease in individuals with cardiovascular disease risk factors.

BACKGROUND: Chronic kidney disease (CKD) is a risk factor for cardiovascular disease (CVD). METHODS: We determined the prevalence of diagnosed CKD in 87,128 members older than 40 years of age without CVD who were enrolled in a regional medical care plan with at least 1 claim for medical care. RESULTS: The prevalence of diagnosed CKD was 4%, and 8%, 6%, 5% and 10% in patients with diabetes, hypertension, hyperlipidemia and all 3 risk factors, respectively. In multivariate analysis, the odd ratios for CKD were 1.8 (95% confidence interval [95% CI], 1.7-2.0) for older age, 2.5 (95% CI, 2.3-2.8) for diabetes, 2.2 (95% CI, 2.2-2.4) for hypertension, 1.5 (95% CI, 1.4-1.7) for hyperlipidemia and 4.4 (95% CI, 2.8, 5.1) for all 3 risk factors. CONCLUSION: Prevalence of diagnosed CKD among patients with CVD risk factors is low but increases with age and number of risk factors, suggesting inadequate awareness of CKD. This may have implications for control of CVD risk factors in patients with CKD.

A case of successful ablation of a gastrophrenic fistula with n-Butyl-2-Cyanocrylate.

A 79-year-old woman with a fistula between a subphrenic abscess and the fundus of the stomach was successfully treated with n-Butyl-2-Cyanoacrylate. Conservative management had failed. Clinical presentation, treatment progress and imaging findings by computed tomography scan, ultrasound, gastroscopy and fluoroscopy are presented, along with a brief review of the relevant literature.