Cost-Effectiveness of Parathyroid Cryopreservation and Autotransplantation.

Importance: Delayed autotransplantation of cryopreserved parathyroid tissue (DACP) is the only surgical treatment for permanent postoperative hypoparathyroidism. Studies suggest that only a small minority of cryopreserved samples are ultimately autotransplanted with highly variable outcomes. For these reasons, many have questioned the economic utility of the process, although, to the authors' knowledge, this has never been formally studied. Objective: To report the clinical outcomes of parathyroid cryopreservation and DACP at a large academic institution and to determine the cost-effectiveness of this treatment. Design, Setting, and Participants: An institutional review board-approved, retrospective review of patients at a single institution who underwent DACP over a 17-year period was conducted with a median follow-up of 48.2 months. A forward-looking cost-utility analysis was then performed to determine the economic utility of cryopreservation/DACP vs usual care (monitoring and supplementation). Patients who had parathyroid tissue in cryopreserved storage between August 2005 to September 2022 at a single-center, academic, quaternary care center were identified. Exposure: Parathyroid cryopreservation and DACP. Main Outcomes and Measures: Graft functionality, clinical outcomes, and cost utility using a willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY). Results: A total of 591 patients underwent cryopreservation. Of these, 10 patients (1.7%; mean [SD] age, 45.6 [17.9] years; 6 male [60%]) underwent DACP. A minority of autografts (2 [20%]) were subsequently fully functional, one-half (5 [50%]) were partially functional, and 3 (30%) were not functional. The cost-utility model estimated that at a large academic center over 10 years, the additional cost of 591 patients undergoing cryopreservation and 10 patients undergoing autotransplantation would be $618 791.64 (2022 dollars) and would add 8.75 QALYs, resulting in a cost per marginal QALY of $70 719.04, which is less than the common willingness-to-pay threshold of $100 000/QALY. Conclusions and Relevance: The reimplantation rate of cryopreserved tissue was low (<2%), but when implanted, autografts were at least partially functional 70% of the time. In the first-ever, to the authors' knowledge, formal cost analysis for this treatment, results of the current model suggest that cryopreservation and autotransplantation were cost-effective compared with the usual care for hypoparathyroidism at a large, academic institution. It is recommended that each surgical center consider whether the economic and logistical commitments necessary for cryopreservation are worthwhile for their individual needs.

Toward a Consensus Aproach for Assessing Capsular Contracture Severity and Progression: A Systematic Review.

BACKGROUND: Breast implants are the most commonly used medical devices in plastic surgery, and capsular contracture (CC) is one of the most common complications. However, our assessment of CC is based largely on Baker grade, which is problematically subjective and affords only four possible values. METHODS: The authors performed a systematic review concluding in September of 2021 in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. It identified 19 articles that propose approaches to measuring CC. RESULTS: In addition to Baker grade, the authors identified several modalities reported to measure CC. These included magnetic resonance imaging, ultrasonography, sonoelastography, mammacompliance measuring devices, applanation tonometry, histologic evaluation, and serology. Capsule thickness and other measures of CC inconsistently correlated with Baker grade, whereas the presence of synovial metaplasia was consistently associated with Baker grade I and II, but not III and IV capsules. CONCLUSIONS: There remains no particular method to reliably and specifically measure the contracture of capsules that form around breast implants. As such, we would recommend that research investigators use more than one modality to measure CC. Other variables that can impact breast implant stiffness and associated discomfort beyond CC need to be considered when evaluating patient outcomes. Given the value placed on CC outcomes in assessing breast implant safety, and the prevalence of breast implants overall, the need for a more reliable approach to measuring this outcome persists.

Investigating Weekend Effect in the Management of Upper and Lower Extremity Degloving Injuries.

Background: Weekend presentation has been associated with adverse outcomes in emergent conditions, including stroke, myocardial infarction, and critical limb ischemia. We examine whether a weekend effect exists in the management of and outcomes after extremity degloving injuries. Methods: The cohort included adults presenting with open extremity degloving injuries to a tertiary level one trauma center between June 2018 and May 2022. We collected demographics, comorbidities, injury information, interventions, and complications. Propensity score weighting was used to minimize confounding differences between those presenting on weekends (Sat-Sun) versus weekdays (Mon-Fri). Weighted regressions were used to examine differences in interventions by day of presentation. Multivariable weighted regressions accounting for differences in interventions received were used to examine whether weekend presentation was associated with amputation risk, complications, or functional deficits. Results: Ninety-five patients with 100 open extremity degloving injuries were included. In total, 39% of injuries were weekend-presenting. There was a higher rate of noninsulin-dependent diabetes among patients presenting on weekends (P = 0.03). Weekend-presenting injuries had higher median Injury Severity Scores (P = 0.04). Propensity-weighted regression analysis revealed differences in interventions received on weekends, including lower rates of pedicled and free flaps and bone graft, and increased rates of negative-pressure wound therapy (P ≤ 0.02). Multivariable regression analysis revealed weekend presentation was a significant independent risk factor for amputation of the affected extremity [odds ratio 2.27, 95% CI (1.01-5.33), P = 0.05]. Conclusion: Weekend presentation may impact interventions received and amputation risk in patients presenting with open extremity degloving injuries.

From Augmented to Virtual Reality in Plastic Surgery: Blazing the Trail to a New Frontier.

BACKGROUND: Augmented reality (AR) and virtual reality (VR)-termed mixed reality-have shown promise in the care of operative patients. Currently, AR and VR have well-known applications for craniofacial surgery, specifically in preoperative planning. However, the application of AR/VR technology to other reconstructive challenges has not been widely adopted. Thus, the purpose of this investigation is to outline the current applications of AR and VR in the operative setting. METHODS: The literature pertaining to the use of AR/VR technology in the operative setting was examined. Emphasis was placed on the use of mixed reality technology in surgical subspecialities, including plastic surgery, oral and maxillofacial surgery, colorectal surgery, neurosurgery, otolaryngology, neurosurgery, and orthopaedic surgery. RESULTS: Presently, mixed reality is widely used in the care of patients requiring complex reconstruction of the craniomaxillofacial skeleton for pre- and intraoperative planning. For upper extremity amputees, there is evidence that VR may be efficacious in the treatment of phantom limb pain. Furthermore, VR has untapped potential as a cost-effective tool for microsurgical education and for training residents on techniques in surgical and nonsurgical aesthetic treatment. There is utility for mixed reality in breast reconstruction for preoperative planning, mapping perforators, and decreasing operative time. VR has well- documented applications in the planning of deep inferior epigastric perforator flaps by creating three-dimensional immersive simulations based on a patient's preoperative computed tomography angiogram. CONCLUSION: The benefits of AR and VR are numerous for both patients and surgeons. VR has been shown to increase surgical precision and decrease operative time. Furthermore, it is effective for patient-specific rehearsal which uses the patient's exact anatomical data to rehearse the procedure before performing it on the actual patient. Taken together, AR/VR technology can improve patient outcomes, decrease operative times, and lower the burden of care on both patients and health care institutions.

Magnitude of parathyroid hormone elevation in primary hyperparathyroidism: Does time of day matter?

BACKGROUND: Parathyroid hormone demonstrates a circadian rhythm in nondiseased patients, but it is unclear if this diurnal variation persists in the context of primary hyperparathyroidism. We anecdotally noticed that parathyroid hormone levels drawn early on the morning of parathyroid surgery (preincision parathyroid hormone), were of lower magnitude than values obtained at later times in the day. If present, a time-of-day based variation in parathyroid hormone could have important clinical implications on intraoperative surgical decision making. METHODS: We performed an Institutional Review Board-approved, retrospective chart review of patients undergoing parathyroidectomy for primary hyperparathyroidism between October 2019 and February 2022 at a quaternary care referral center. Demographic, laboratory, imaging, and operative parameters were extracted. Analysis was performed using mixed models for repeated measures with a first order autoregression correlation structure. Parathyroid hormone values were compared before and after hourly intervals between 6:00 A.M. and 12:00 P.M. RESULTS: Of 418 patients, the mean age was 61 years old, 80% of patients were female, and two-thirds had single-gland disease. A total of 933 parathyroid hormone levels were included in the analysis and median parathyroid hormone was 97.3 pg/mL. Parathyroid hormone levels were noted to be significantly lower if they were drawn before 7:00 A.M. This diurnal variation persisted in patients with single-gland and advanced hyperparathyroidism but was abrogated in multi-gland and low-baseline-parathyroid hormone disease. CONCLUSION: In patients with primary hyperparathyroidism, parathyroid hormone levels were significantly lower in the early morning hours, especially in patients with single-gland and high-baseline-parathyroid hormone hyperparathyroidism. This may have implications for intraoperative decision making when utilizing an early morning, preincision parathyroid hormone value.

Analysis of Preoperative Predictors of Single and Multigland Primary Hyperparathyroidism.

INTRODUCTION: Preoperative differentiation of single-gland (SG) versus multigland (MG) primary hyperparathyroidism (PHPT) can assist with surgical planning, treatment prognostication, and patient counseling. The aim of this study was to identify preoperative predictors of SG-PHPT. METHODS: Retrospective analysis of 408 patients with PHPT who underwent parathyroidectomy at a tertiary referral center. Comprehensive preoperative parameters, including demographic, laboratory, clinical, and imaging results were analyzed. Univariate analysis and binary logistic regression identified preoperative predictors of SG-PHPT. Receiver operator curves were used to analyze the predictive values of existing and novel preoperative predictive models. RESULTS: Elevated parathyroid hormone (PTH) (99.1 pg/mL in SG versus 93.0 pg/mL in MG), elevated calcium (10.8 mg/dL in SG versus 10.6 mg/dL in MG), lower phosphate levels (2.80 mg/dL in SG versus 2.95 mg/dL in MG), and positive imaging (ultrasound 75.6% in SG versus 56.5% in MG; sestamibi 70.8% in SG versus 45.5% in MG) were significantly associated with SG-PHPT. The Washington University Score (a predictive scoring system made from calcium, PTH, phosphate, ultrasound, and sestamibi) and the Washington University Index ([calcium × PTH]/phosphate) were comparable to previous scoring systems used to predict SG versus MG-PHPT. CONCLUSIONS: The association of lower phosphate with SG-PHPT is a novel finding. Previously identified predictors of SG-PHPT, including elevated PTH and positive imaging were confirmed. The Washington University Score and Index are comparable to previously described models and can be used to help surgeons predict if a patient may have SG versus MG-PHPT.

Integrating a Patient Decision Aid into the Electronic Health Record: A Case Report on the Implementation of BREASTChoice at 2 Sites.

Patient decision aids can support shared decision making and improve decision quality. However, decision aids are not widely used in clinical practice due to multiple barriers. Integrating patient decision aids into the electronic health record (EHR) can increase their use by making them more clinically relevant, personalized, and actionable. In this article, we describe the procedures and considerations for integrating a patient decision aid into the EHR, based on the example of BREASTChoice, a decision aid for breast reconstruction after mastectomy. BREASTChoice's unique features include 1) personalized risk prediction using clinical data from the EHR, 2) clinician- and patient-facing components, and 3) an interactive format. Integrating a decision aid with patient- and clinician-facing components plus interactive sections presents unique deployment issues. Based on this experience, we outline 5 key implementation recommendations: 1) engage all relevant stakeholders, including patients, clinicians, and informatics experts; 2) explicitly and continually map all persons and processes; 3) actively seek out pertinent institutional policies and procedures; 4) plan for integration to take longer than development of a stand-alone decision aid or one with static components; and 5) transfer knowledge about the software programming from one institution to another but expect local and context-specific changes. Integration of patient decision aids into the EHR is feasible and scalable but requires preparation for specific challenges and a flexible mindset focused on implementation. Highlights: Integrating an interactive decision aid with patient- and clinician-facing components into the electronic health record could advance shared decision making but presents unique implementation challenges.We successfully integrated a decision aid for breast reconstruction after mastectomy called BREASTChoice into the electronic health record.Based on this experience, we offer these implementation recommendations: 1) engage relevant stakeholders, 2) explicitly and continually map persons and processes, 3) seek out institutional policies and procedures, 4) plan for it to take longer than for a stand-alone decision aid, and 5) transfer software programming from one site to another but expect local changes.

Behavioral Differences between Male and Hermaphrodite C. elegans.

C. elegans are microscopic nematodes used extensively as a model organism due to their simplicity, allowing researchers to study basic molecular processes in biology. Most C. elegans are hermaphrodites, possessing two X chromosomes and the ability to reproduce asexually, but approximately 0.1% are males, arising due to a spontaneous loss of an X chromosome. In order to evaluate the behavioral sex differences in C. elegans, we expanded upon existing literature and compared spontaneous movement, sensitivity to mechanosensation, and sensitivity to chemosensation between males and hermaphrodites. In our paradigms, we found that males and hermaphrodites exhibit similar spontaneous movement as well as similar slow and sustained behaviors such as chemotaxis, but differ in quick-response to mechanical and chemosensory stimuli.