The Vitamin D Binding Protein Gene Polymorphism Association with Covid-19-Infected Iraqi Patients.

Vitamin D deficiency, in general, is usually correlated with increased risks of chronic pulmonary disease such as COVID-19 infection. However, the mechanisms are still unknown. Herein, this study aimed to investigate the correlation between vitamin D binding protein gene polymorphism and COVID-19-infected Iraqi patients. The study has been conducted on patients with Covid-19 during the period extended from June, 2021 to April, 2022. 300 samples were collected from healthy and infected people. The demographic characteristics of patients (age, gender and residency) are shown non-significant in all. However, the distribution of DBP (rs12785878-T/G) Polymorphism was detected by Allele Specific PCR technique. The association between DBP (rs12785878) gene polymorphism and risk of Covid-19 is also shown, the heterozygous genotype TG was more frequent in the patients' group in comparison with the control group, 66 versus 58, respectively. Therefore, genotype TG was a genetic risk factor for Covid-19 with an odds ratio of 2.4074 (95% confidence interval of 1.2462-4.6505) and an etiologic fraction of 0.2963. In the addition, the homozygous genotype GG was more frequent in the patients' group in comparison with the control group, 65 versus 54, respectively, Therefore, genotype GG was a risk factor for Covid-19 with an odds ratio of 1.0578 (95% confidence interval of 0.6386-1.7522) and an etiologic fraction of 0.0299. thus, it can be seen that Covid-19 disease has a direct effect on the level of vitamin D in patients infected with the virus compared to healthy people.

Factors influencing the choice between laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass.

BACKGROUND: While laparoscopic sleeve gastrectomy (LSG) continues to be the most commonly performed bariatric operation, several variables influence surgeons' practice patterns and patients' decision-making in the type of bariatric procedure to perform. The aim of this study was to evaluate patient factors that influence the decision between laparoscopic Roux-en-Y gastric bypass (LRYGB) versus LSG. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried for patients undergoing LSG and LRYGB between 2015 and 2017. Univariate analysis and multivariate logistic regression were used to evaluate factors associated with performing LRYGB compared to LSG. RESULTS: A total of 252,117 (72.3%) LSG and 96,677 (27.7%) LRYGB cases were identified. Patients undergoing LSG were younger (44.3 ± 12.0 vs 45.2 ± 11.8 years; p < 0.01) and had a lower body mass index (BMI; 45.1 ± 7.8 vs 46.2 ± 8.1 kg/m2; p < 0.01). Most of the patients were females (79.4%), white (73.0%), with an American Society of Anesthesiology (ASA) class ≤ 3 (96.4%). The factors associated with undergoing LRYGB compared to LSG were diabetes mellitus, gastroesophageal reflux disease, BMI ≥ 50 kg/m2, ASA class > 3, obstructive sleep apnea, hypertension, and hyperlipidemia. However, patients with kidney disease, black race, chronic steroid use, age ≥ 60 years, recent smoking history, chronic obstructive pulmonary disease, and coronary artery disease were more likely to undergo LSG. CONCLUSIONS: The decision to perform LRYGB is primarily driven by obesity-associated comorbidities and higher BMI, whereas LSG is more likely to be performed in higher risk patients.

Comparison of early outcomes between Roux-en-Y gastric bypass and sleeve gastrectomy among patients with body mass index ≥ 60 kg/m2.

BACKGROUND: There is no consensus on the ideal bariatric operation to choose for patients with extremely high body mass index (BMI). The aim of this study was to compare the perioperative complications, weight loss, and comorbidity remission between laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) among patients with BMI ≥ 60 kg/m2. METHODS: Data from a statewide bariatric surgery registry were used to identify all patients with BMI ≥ 60 kg/m2 undergoing LRYGB or LSG between January 2006 and June 2019. Risk and reliability adjustment were used to compare outcomes between the two groups. RESULTS: A total of 6015 patients were identified and 2505 (41.6%) underwent LRYGB and 3510 (58.4%) underwent LSG. The overall mean age was 43.1 ± 11.2 years with a mean preoperative BMI of 66.7 ± 6.4 kg/m2. Females accounted for 69.3% and the majority were either white (68.5%) or black (21.2%). LRYGB was associated with a higher rate of adjusted 30-day postoperative serious complications (4.0% vs 2.2%; p < 0.01) including anastomotic leak, obstruction, and bleeding. Resource utilization was also higher with LRYGB (23.7% vs 14.8%; p < 0.01) and included more emergency department visits, readmissions, reoperations, and length of stay ≥ 4 days. The overall 1-year follow-up rate was 38.8%. The adjusted percent total weight loss at 1 year was significantly higher following LRYGB compared to LSG (36.6 ± 9.3 vs 31.3 ± 9.3%; p < 0.01). LRYGB was associated with a higher rate of treatment discontinuation for diabetes mellitus, hyperlipidemia, and obstructive sleep apnea. CONCLUSIONS: In patients with BMI ≥ 60 kg/m2, LRYGB was associated with better weight loss and medication discontinuation 1 year following surgery at the expense of an increase in perioperative complications and resource utilization compared to LSG.

A randomized, phase 1, placebo-controlled trial of APG-157 in oral cancer demonstrates systemic absorption and an inhibitory effect on cytokines and tumor-associated microbes.

BACKGROUND: Although curcumin's effect on head and neck cancer has been studied in vitro and in vivo, to the authors' knowledge its efficacy is limited by poor systemic absorption from oral administration. APG-157 is a botanical drug containing multiple polyphenols, including curcumin, developed under the US Food and Drug Administration's Botanical Drug Development, that delivers the active components to oromucosal tissues near the tumor target. METHODS: A double-blind, randomized, placebo-controlled, phase 1 clinical trial was conducted with APG-157 in 13 normal subjects and 12 patients with oral cancer. Two doses, 100 mg or 200 mg, were delivered transorally every hour for 3 hours. Blood and saliva were collected before and 1 hour, 2 hours, 3 hours, and 24 hours after treatment. Electrocardiograms and blood tests did not demonstrate any toxicity. RESULTS: Treatment with APG-157 resulted in circulating concentrations of curcumin and analogs peaking at 3 hours with reduced IL-1ß, IL-6, and IL-8 concentrations in the salivary supernatant fluid of patients with cancer. Salivary microbial flora analysis showed a reduction in Bacteroidetes species in cancer subjects. RNA and immunofluorescence analyses of tumor tissues of a subject demonstrated increased expression of genes associated with differentiation and T-cell recruitment to the tumor microenvironment. CONCLUSIONS: The results of the current study suggested that APG-157 could serve as a therapeutic drug in combination with immunotherapy. LAY SUMMARY: Curcumin has been shown to suppress tumor cells because of its antioxidant and anti-inflammatory properties. However, its effectiveness has been limited by poor absorption when delivered orally. Subjects with oral cancer were given oral APG-157, a botanical drug containing multiple polyphenols, including curcumin. Curcumin was found in the blood and in tumor tissues. Inflammatory markers and Bacteroides species were found to be decreased in the saliva, and immune T cells were increased in the tumor tissue. APG-157 is absorbed well, reduces inflammation, and attracts T cells to the tumor, suggesting its potential use in combination with immunotherapy drugs.

Risk Factors for Surgical Site Infection After Laparoscopic Colectomy: An NSQIP Database Analysis.

BACKGROUND: Surgical site infection (SSI) is a common complication after colon surgery. This study aimed to evaluate risk factors for SSI and its types in laparoscopic colectomy patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. MATERIALS AND METHODS: The NSQIP database was queried for patients undergoing laparoscopic colectomy from 2011 through 2017. Univariate analysis and multivariable logistic regression were used to evaluate risk factors associated with any SSI, superficial SSI, deep-incisional SSI, and organ-space SSI. RESULTS: Of 72,519 patients, 4906 cases of SSI were identified: 2276 superficial SSI, 357 deep-incisional SSI, and 2483 organ-space SSI. Risk factors associated with superficial SSI were admission before procedure (adjusted odds ratio [AOR] = 1.31; 95% confidence interval [CI] 1.17-1.47; P < 0.01), smoking (AOR = 1.29; 95% CI 1.16-1.44; P < 0.01), and higher body mass index (AOR = 1.24 for every 5 kg/m2 increase; 95% CI 1.20-1.27; P < 0.01). Deep-incisional SSI was associated with steroid use (AOR = 1.81; 95% CI 1.31-2.49; P < 0.01), admission before procedure (AOR = 1.66; 95% CI 1.30-2.13; P < 0.01), and smoking (AOR = 1.50; 95% CI 1.17-1.94; P < 0.01). Risk factors associated with organ-space SSI were wound class (AOR = 2.45 for class 4 versus ≤ 2; 95% CI 2.16-2.78; P < 0.01), chemotherapy within 90 d (AOR = 1.57; 95% CI 1.33-1.84; P < 0.01), and steroid use (AOR = 1.46; 95% CI 1.29-1.65; P < 0.01). Receipt of an oral antibiotic prep preoperatively was the strongest factor associated with SSI. CONCLUSIONS: SSI types in patients undergoing laparoscopic colectomy have different risk factors. Modifiable risk factors may provide an opportunity to reduce SSI risk and its associated morbidity.

Perioperative Outcomes of Robotic Versus Laparoscopic Sleeve Gastrectomy in the Super-obese.

BACKGROUND: The robotic platform is often used for bariatric surgery in superobese patients (body mass index ≥ 50 kg/m2) with the assumption that it offers a technical advantage. This study aimed to compare perioperative outcomes of robotic-assisted sleeve gastrectomy (RSG) and laparoscopic sleeve gastrectomy (LSG) in superobese patients. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was queried for superobese patients undergoing nonrevisional RSG and LSG from 2015 through 2017. Univariate analysis and multivariable logistic regression were used to compare outcomes in RSG and LSG. RESULTS: A total of 61,493 patients (4685 RSG and 56,808 LSG) were identified. Patients were similar in terms of age (RSG 42.3 ± 11.8 versus LSG 42.4 ± 11.7 y; P = 0.60) and body mass index (RSG 56.8 ± 6.9 versus LSG 56.9 ± 7.1 kg/m2; P = 0.17). The RSG group had a longer operative time (102.4 ± 46.0 versus 74.7 ± 37.5 min; P < 0.01) and length of stay (1.79 ± 1.78 versus 1.66 ± 1.51 d; P < 0.01). Overall morbidity (RSG 3.5% versus LSG 3.7%; P = 0.54) and mortality (RSG 0.1% versus LSG 0.1%; P = 0.73) were similar between the two groups. After adjustment, RSG represented an independent risk factor for organ-space surgical site infection (adjusted odds ratio 2.70; 95% confidence interval 1.54-4.73; P < 0.01). CONCLUSIONS: Use of RSG in superobese patients infers higher risk for organ-space surgical site infection and is associated with prolonged operative time and length of stay. This questions the role of robotics in superobese patients undergoing sleeve gastrectomy.

Salvage Options for Fundoplication Failure.

PURPOSE OF REVIEW: Gastroesophageal reflux disease (GERD) affects millions of people worldwide. Many patients with medically refractory symptoms ultimately undergo antireflux surgery, most often with a laparoscopic fundoplication. Symptoms related to GERD may persist or recur. Revisional surgery is necessary in some patients. RECENT FINDINGS: A reoperative fundoplication is the most commonly performed salvage procedure for failed fundoplication. Although redo fundoplication has been reported to have increased risk of morbidity compared with primary cases, increasing experience with the minimally invasive approach to reoperative surgery has significantly improved patient outcome with acceptable resolution of reflux symptoms in the majority of patients. Recurrence of reflux symptoms after an initial fundoplication requires a thorough work-up and a thoughtful approach. While reoperative fundoplication is the most common procedure performed, there are other options and the treatment should be tailored to the patient, their history, and the mechanism of fundoplication failure.

Hemorrhagic giant adrenal myelolipoma discovered incidentally: a case report.

Adrenal myelolipomas are rare, benign, nonfunctional tumors composed of mature adipose tissue and hematopoietic elements. Hemorrhage within an adrenal myelolipoma is an uncommon occurrence, and when it happens, it can present with various clinical manifestations. Here, we report a case of a hemorrhagic giant adrenal myelolipoma in a 45-year-old female that was discovered incidentally. We discuss the clinical presentation, radiological findings, surgical intervention, and postoperative outcomes in this case report.

Growing cocoa in semi-arid climate and the rhythmicity of stem growth and leaf flushing determined by dendrometers.

This study investigated the performance of cocoa trees within an irrigated cocoa plantation situated in the semi-arid region of Bahia, Brazil. Two treatments were compared: "full sun," where cocoa trees were not shaded, and "shade," where trees were covered with a shading net absorbing 30 % of the radiation. The number of leaves and the leaf area index (LAI) were assessed using destructive method on 8 trees. In addition, new flushing of leaves, categorized into four flushing stages, were assessed visually on a weekly basis during two years. The variation of the stem diameter was measured using dendrometer sensors (n = 12 trees). Yield parameters like dry bean yield and number of fruits (healthy and aborted) were assessed on 40 trees per treatment. Both treatments, performed well in the semi-arid region. Generative parameters, such as dry bean yield (±2,000 kg/ha), fruit healthy and abortion rate per plot, were unaffected by full sun and shade treatments. The treatments showed high fruit abortion rates of (±60 %), showing that there's still much room for yield optimization. Additionally, stem diameter of the trees showed a significant reduction of the stem growth (daily increase of stem diameter) and maximum daily shrinkage (daily variation of stem diameter) during the flushing of new leaves. This implies that the emergence of new leaves significantly influences stem growth, consequently affecting the fruits which are growing on the stem. This assumption was corroborated by the significantly increased fruit abortion rate during the flushing of new leaves (stages 1 & 2). These findings highlight the potential of dendrometers to quantify this effect what can be used in future to optimize management practices. By doing so, more effective strategies can be developed to enhance cocoa yield and overall productivity in semi-arid regions.

Numerical solution of some types of fractional optimal control problems.

We present two different approaches for the numerical solution of fractional optimal control problems (FOCPs) based on a spectral method using Chebyshev polynomials. The fractional derivative is described in the Caputo sense. The first approach follows the paradigm "optimize first, then discretize" and relies on the approximation of the necessary optimality conditions in terms of the associated Hamiltonian. In the second approach, the state equation is discretized first using the Clenshaw and Curtis scheme for the numerical integration of nonsingular functions followed by the Rayleigh-Ritz method to evaluate both the state and control variables. Two illustrative examples are included to demonstrate the validity and applicability of the suggested approaches.

Esophagectomies for Malignancy Among General and Thoracic Surgeons: A Propensity Score Matched National Surgical Quality Improvement Program Analysis Stratified by Surgical Approach.

Previous studies of esophagectomy outcomes by surgical specialty do not address malignancy or surgical approach. We sought to evaluate these cases using a national database. The National Surgical Quality Improvement Program (NSQIP)-targeted esophagectomy data set was queried for esophagectomies for malignancy and grouped by surgeon specialty: thoracic surgery (TS) or general surgery (GS). 1:1 propensity score matching was performed. Associations of surgical specialty with outcomes of interest (30-day mortality, anastomotic leak, Clavien-Dindo grade ≥ 3, and positive margin rate) were assessed overall and in surgical approach subsets. 1463 patients met inclusion criteria (512 GS and 951 TS). Propensity score matching yielded matched groups of 512, with similar demographics, preoperative stage, and neoadjuvant therapy rates. All outcomes of interest were similar between TS and GS groups, both overall and when stratified by surgical approach. Esophagectomy for malignancy has a similar perioperative safety profile and positive margin rate among general and thoracic surgeons, regardless of surgical approach.

Resident Physicians' Knowledge and Preparedness Regarding Human Monkeypox: A Cross-Sectional Study from Saudi Arabia.

This study aimed to evaluate knowledge about monkeypox and confidence in dealing with monkeypox diagnosis and management among resident physicians in the Asir region of Saudi Arabia. The data of this cross-sectional study were collected online through a structured questionnaire (N = 315). Knowledge about monkeypox was assessed by 24 questions and a three-item scale assessed confidence in managing monkeypox cases. Multiple logistic regression analysis was performed to assess the associations. Overall, two-thirds of the respondents (67.3%) showed good knowledge about monkeypox and the rest of them (32.7%) had poor knowledge. Respondents who received a copy of the Saudi MOH protocol for monkeypox and attended any conference or lecture about monkeypox were more likely to have good knowledge about monkeypox. Moreover, almost two-thirds of the participants were not confident that they could diagnose or manage the monkeypox. Respondents who received information about monkeypox during residency or medical school had higher confidence in managing monkeypox cases. It can be concluded that the Saudi healthcare system has scope to take necessary steps to contain the monkeypox endemic. The Saudi MOH should arrange conferences and educational programs on monkeypox so that healthcare professionals can improve their knowledge and be confident in the management and diagnosis of monkeypox cases.

Intraoperative Nerve Monitoring in Thyroidectomies for Malignancy: Does It Matter?

BACKGROUND: Recurrent laryngeal nerve (RLN) injury and postoperative hypocalcemia are potential complications of thyroidectomy, particularly in malignancy. Intraoperative nerve monitoring (IONM) remains controversial. We sought to evaluate the impact of IONM on these complications using a national data set. METHODS: The American College of Surgeons National Surgical Quality Improvement Program thyroidectomy-targeted data set was queried for patients who underwent thyroidectomies from 2016 to 2017. Patients were grouped according to IONM use. Logistic regression models were constructed to evaluate associations of variables with 30-day hypocalcemic events (HCEs) and RLN injury. Associations were expressed as odds ratios (ORs) with 95% confidence intervals (95% CIs). A subgroup analysis was performed of patients with malignancy. RESULTS: A total of 9527 patients were identified; 5969 (62.7%) underwent thyroidectomy with IONM and 3558 (37.3%) without. By multivariable analysis, IONM had protective associations with HCE (OR = .81, 95% CI = .68-.96; P = .013) and RLN injury (OR = .83, 95% CI = .69-.98; P = .033). Malignancy increased risk of HCE (OR = 1.21, 95% CI=1.01-1.45; P = .038) and RLN injury (OR = 1.22, 95% CI = 1.02-1.46; P = .034). A large proportion (5943/9527, 62.4%) of patients had malignancy; 3646 (61.3%) underwent thyroidectomy with IONM and 2297 (38.7%) without. In the subgroup analysis, IONM had stronger protective associations with HCE (OR = .73, 95% CI = .60-.90; P = .003) and RLN injury (OR = .76, 95% CI = .62-.94; P = .012). DISCUSSION: Malignancy was associated with increased risk of HCE and RLN injury. Intraoperative nerve monitoring had a protective association with HCE and RLN injury, both overall, and in the malignant subgroup. Intraoperative nerve monitoring was correlated with improved thyroidectomy outcomes, especially if the indication was malignancy. This warrants further study to clarify cause and effect.

Clear cell sarcoma of the kidney with inferior vena cava thrombus: a case report.

BACKGROUND: Clear cell sarcoma of the kidney is an uncommon pediatric renal malignant neoplasm that is typically characterized in 2-3-year-olds by aggressive behavior and late relapses. Our literature review revealed fewer than ten previously reported cases of CCSK with inferior vena cava thrombus, with only five in the pediatric age group. CASE PRESENTATION: We report the case of a 14-year-old Syrian girl who complained of mild pain in the left lumbar region pain with hematuria. On physical examination, a mass was palpated in the left flank. Abdominal ultrasonography revealed a left renal mass (7 × 5 × 2 cm3), associated with dilatation of the left renal vein. Contrast abdominal computed tomography showed a mass measuring 7 × 5 × 3 cm3 with the presence of thrombus extending into the inferior cavity down to the right atrium that was initially diagnosed as Wilms' tumor. Radical right nephrectomy with excision of the thrombus was undertaken. Histological immunostaining revealed a diagnosis of the tumor as clear cell sarcoma with vascular tumor thrombus extending to the inferior vena cava. CONCLUSION: Clear cell sarcoma and Wilms' tumor are similar in terms of typical age of appearance, clinical features, and histopathology, but with different methods of treatment and prognosis. The differential diagnosis of such masses is thus very important. We present the case of a patient with clear cell sarcoma with unusual age, with complete removal of the thromboses in the inferior vena cava and the right atrium.

Lateral border and scapular tip free flaps: Old school versus new school.

Free tissue transfer from the subscapular system provides a wide array of options for both soft tissue and bony reconstruction. When bone stock is required for head and neck reconstruction, both the lateral scapular border free flap (LSBFF), supplied by the circumflex scapular artery, and the scapular tip free flap (STFF), supplied by the angular artery, are excellent options. Issues with positioning had previously prevented the widespread use of these bony subscapular system flaps. However, through the use of a Spider Limb Positioner, current clinical practice patterns allow for two team approaches in both of these free flaps. The following pictorial essay compares and contrasts the specific positioning and harvesting technique used for both the LSBFF and STFF, while discussing the clinical advantages and drawbacks of each. Both the lateral border scapula and scapular tip free flaps provide excellent bone stock for head and neck reconstruction. By positioning with currently available technology, both of these free flaps can be harvested through a two team approach.

Contemporary management of chronic indwelling inferior vena cava filters.

OBJECTIVE: Despite increasing retrieval rates of the inferior vena cava (IVC) filter, less than one-third are removed within the recommended timeline. Prolonged filter dwell times may increase the technical difficulty of retrieval and filter-related complications. We sought to evaluate the contemporary outcomes of patients with chronic indwelling IVC filters at a tertiary care center. METHODS: A retrospective analysis was performed from August 2015 through August 2019 of all patients who were referred for removal of a prolonged IVC filter with a dwell time >1 year. Descriptive analysis was used to evaluate patients' characteristics and procedural outcomes, which were reviewed through electronic medical records. Data were expressed as median with interquartile range (IQR) or number and percentage, as appropriate. RESULTS: A total of 47 patients were identified with a median filter dwell time of 10.0 years (IQR, 6-13 years); 34 patients underwent IVC filter removal, and 13 patients refused retrieval. The median age of patients was 54.9 years (IQR, 42.5-64.0 years); the majority were female (57%) and white (53%). The most common indication for filter placement was high risk despite anticoagulation (49%), followed by venous thromboembolism prophylaxis (21%). The majority of patients were symptomatic (72%). If symptomatic, the most common reason for retrieval was IVC penetration (94%), and the chief complaint was pain (56%). Retrieval success was 97%, with a median length of stay of 0 days. The majority of retrievals were performed through an endovascular approach (97%). There was one postprocedural complication (3%). CONCLUSIONS: Despite prolonged dwell times, IVC filter retrieval can be performed safely and effectively in carefully selected patients at a tertiary referral center.

Prescribing Habits of Providers and Risk Factors for Nonadherence to Opioid Prescribing Guidelines.

BACKGROUND: The Michigan Opioid Prescribing Engagement Network introduced guidelines in October 2017 to combat opioid overprescription following various surgical procedures. We sought to evaluate changes in opioid prescribing at our academic center and identify factors associated with nonadherence to recently implemented opioid prescribing guidelines. METHODS: This retrospective review analyzed opioid prescribing data for appendectomy, cholecystectomy, and hernia repair from January 2015 through September 2017 (pre-guidelines group) and November 2017 through December 2018 (post-guidelines group). October 2017 data were excluded to allow for guideline implementation. Opioid prescribing data were recorded as total morphine equivalents (TMEs). RESULTS: Of 1493 cases (903 pre-vs. 590 post-guidelines), the mean TME prescribed significantly decreased post-guidelines (231.9 ± 108.6 vs. 112.7 ± 73.9 mg; P < .01). More providers prescribed within recommended limits post-guidelines (2.8% vs. 44.8%; P < .01). On multivariable analysis, independent risk factors for guideline nonadherence were the American Society of Anesthesiologists class > 2 (adjusted odds ratio [AOR]:1.65, 95% confidence interval[CI] 1.09-2.49; P = .02), general surgery vs. acute care surgery service (AOR 1.89, 95% CI 1.15-3.10; P = .01), oxycodone vs. hydrocodone (AOR:1.90, 95% CI:1.06-3.41; P = .03), and nonphysician provider vs. resident prescriber (AOR:2.10, 95% CI:1.14-3.11; P < .01). CONCLUSIONS: Opioid prescribing significantly reduced after the adoption of opioid prescribing guidelines at our institution. Numerous factors associated with provider guideline nonadherence may identify actionable targets to minimize opioid overprescribing further.

Revisiting pedicled latissimus dorsi flaps in head and neck reconstruction: contrasting shoulder morbidities across mysofascial flaps.

Free tissue transfer has become the gold standard for reconstruction within the head and neck. However, there are still many instances where pedicled locoregional flaps are the optimal reconstructive option. When myofascial tissue is needed, several options have been described throughout the literature. Various trapezius flaps have been used, although these have variable vascular anatomy and significant donor site morbidity. The pectoralis major myofascial flap has become a mainstay in head and neck reconstruction for its ease of harvest and reliability but suffers from similar issues with donor site morbidity. The pedicled latissimus dorsi flap (PLDF) is another reliable option that has been used for multiple different ablative sites within the head and neck. The thin, pliable structure of the latissimus dorsi makes it a viable option for many defects, and recent reports also support its feasibility for use in an interdisciplinary two-team approach. Furthermore, the donor site morbidity of the PLDF is minimal compared to other similar myofascial options. In this article, we describe the surgical considerations and operative techniques for PLDF transfer along with a review of its associated donor site morbidity.

A Global Survey of COVID-19 Vaccine Acceptance Among Healthcare Workers.

Objectives: Even though several effective vaccines are available to combat the COVID-19 pandemic, wide disparities in vaccine distribution, and vaccine acceptance rates between high- and low-income countries appear to be major threats toward achieving population immunity. Our global descriptive study aims to inform policymakers on factors affecting COVID-19 vaccine acceptance among healthcare workers (HCWs) in 12 countries, based on income index. We also looked for possible predictors of vaccine acceptance among the study sample. Methods: A structured questionnaire prepared after consultation with experts in the field and guided by the "Report of the SAGE working group on vaccine hesitancy" was administered among 2,953 HCWs. Upon obtaining informed consent, apart from demographic information, we collected information on trust in vaccines and health authorities, and agreement to accept a COVID-19 vaccine. Results: Although 69% of the participants agreed to accept a vaccine, there was high heterogeneity in agreement between HCWs in low and lower-middle income countries (L-LMICs) and upper-middle- and high-income countries (UM-HICs), with acceptance rates of 62 and 75%, respectively. Potential predictors of vaccine acceptance included being male, 50 years of age or older, resident of an UM-HIC, updating self about COVID-19 vaccines, greater disease severity perception, greater anxiety of contracting COVID-19 and concern about side effects of vaccines. Conclusions: COVID-19 vaccine acceptance among HCWs in L-LMICs was considerably low as compared to those from UM-HICs. The lowest vaccine acceptance rates were among HCWs from the African continent. This underlines the need for the implementation of country-specific vaccine promotion strategies, with special focus on increasing vaccine supply in L-LMICs.