The Epidemiology of Mandibular Fractures in the United States, Part 1: A Review of 13,142 Cases from the US National Trauma Data Bank.

PURPOSE: To date, no studies have analyzed the national demographics of mandibular fractures in the United States. This report is part 1 of a 2-part series characterizing the modern demographics, epidemiology, and outcomes of mandibular fractures in the United States. The purpose of this study was to characterize mandibular fractures in relation to age, gender, mechanism of injury, and anatomic location of fracture. MATERIAL AND METHODS: A retrospective cohort study was conducted using the National Trauma Data Bank (NTDB). The sample was derived from the population of hospitalized patients enrolled in the NTDB from 2001 to 2005 using mandibular fracture (International Classification of Diseases, Ninth Revision codes 802.21 through 802.39) as an inclusion criterion. Patient- and injury-related variables, including age, gender, anatomic location of fracture, and mechanism of injury, were analyzed by Fisher exact and χ(2) testing. RESULTS: A total of 13,142 patients with mandibular fractures from participating trauma centers were included in the study. Eighty percent of patients were male. Fracture distribution by age was roughly bell-shaped, with fractures occurring most frequently at 18 to 54 years of age. Mechanism of injury differed by gender, with men most often sustaining mandibular fracture from assault (49.1%), followed by motor vehicle accidents (MVAs; 25.4%) and falls (12.8%). Women most commonly sustained mandibular fracture from MVAs (53.7%), followed by assault (14.5%) and falls (23.7%). Falls were a significantly more common mechanism in patients who were at least 65 years old (P < .001). CONCLUSION: This study sought to characterize the largest, modern, population-based sample of mandibular fractures in the United States. Overall, men had a 4-fold higher incidence, but this distribution varied by age. Similarly, mechanism of injury varied across gender and age range. A better understanding of the influence of age and gender on mechanism of injury and anatomic site is of great clinical importance in the assessment, diagnosis, and treatment of traumatic mandibular fractures.

Novel technique for skin grafting parastomal wounds using a negative-pressure dressing.

Grafting parastomal wounds remains a challenging procedure because of frequent contamination, difficulty isolating the grafted area from the stoma, and an unfavorable environment for skin graft take. The use of negative-pressure dressings has been shown to improve skin graft take by removing excess fluid between the graft and the wound bed, thereby accelerating engraftment. The benefits of negative-pressure dressing around a stoma, however, may be hindered by vacuuming stool into the dressed area. This article reviews a novel approach used for the isolation of a stoma from the parastomal wound area to increase skin graft take in an 82-year-old woman.

Risk factors for death in elderly patients with facial fractures secondary to falls.

BACKGROUND: Craniomaxillofacial trauma is associated with severe injuries and disability. There are no recent reports analyzing the demographics of facial trauma in elderly patients. Our objective was to review the demographics, outcomes, and risk factors associated with death in elderly patients with facial fractures in a single-institution level I trauma center. METHODS: We performed a retrospective review of the University of Pittsburgh Medical Center Trauma Registry from January 1999 to December 2008 in an institutional review board-approved protocol. The search query included all types of craniofacial trauma using International Classification of Diseases, Ninth Revision coding. A χ test was used for analyzing categorical data. Continuous data were analyzed using unpaired t-test or analysis of variance. Logistic regressions were done to determine odds ratio (OR) for death. P = 0.05 was deemed significant. RESULTS: A total of 16,528 patients with facial trauma were identified. Of these, 4536 patients had falls. Among the falls, 1020 patients had facial fractures. Finally, 460 patients were younger than 65 years, and 560 were older than 65 years. The variable with the highest odds for mortality in patients with facial fractures was intensive care unit admission (OR, 13.1), followed by acute renal failure (OR, 10.3), medical history of myocardial infarction (OR, 5.1), coagulopathy (OR, 4.78), age older than 65 years (OR, 4.13), acute respiratory failure (OR, 3.55), Abbreviated Injury Scale score greater than 3 at the head (OR, 3.5), congestive heart failure (OR, 2.64), history of cardiac surgery (OR, 2.4), and vault skull fracture (OR, 2.35). CONCLUSIONS: Craniofacial trauma is a serious condition in the elderly. Associated injuries are demonstrated to have a deleterious effect on survival. Recognition of these risk factors is likely to promote the development of preventive measurements to decrease fatal outcomes.

Approach to venous thromboembolism prophylaxis: are we evolving fast enough in plastic surgery?

Venous thromboembolism has become a target for research by the American Society of Plastic Surgery. The current article reviews the steps that plastic surgeons and the American Society of Plastic Surgery have taken for creating guidelines in our field. We summarized the current reported incidences of venous thromboembolism in various plastic surgical procedures, and reviewed the current efforts that the society is taking to address the burden of this deadly preventable disease.

Prevention of venous thromboembolism in body contouring surgery: a national survey of 596 ASPS surgeons.

INTRODUCTION: Venous thromboembolism (VTE) has been identified as a major public health issue. Postbariatric body contouring surgery represents a major challenge for VTE prophylaxis due to the presence of multiple risk factors and broad areas of dissection that potentially increase the risk of postoperative bleeding. AIM: To define current VTE prophylaxis practices among surgeons of the American Society of Plastic Surgeons, performing postbariatric body contouring surgery in the United States. MATERIAL AND METHODS: A total of 4081 surveys were sent to registered members of the American Society of Plastic Surgeons by e-mail. We received 596 (14.6%) responses. RESULTS: A total of 596 surgeons returned completed surveys, with 83% of respondents in private practice and 17% in academic practice. Deep venous thrombosis (DVT) was reported by 40% surgeons, pulmonary embolism (PE) by 34%, and 7% had at least 1 patient having died of a postoperative PE. About 39% to 48% participant surgeons reported providing no chemoprophylaxis to their postbariatric body contouring patients. The most common reason for not using routine prophylaxis was the concern for bleeding (84%), followed by lack of evidence specific to plastic surgery practice (50%). Academic surgeons were more likely to provide chemoprophylaxis when compared with those in nonacademic practice (P < 0.05). CONCLUSION: For postbariatric body contouring surgery, DVT has occurred in over one-third of plastic surgeons' practices with 7% of surgeons reporting a patient death from PE. A substantial proportion of surgeons performing postbariatric body contouring are not using chemoprophylaxis due to bleeding risk and perceived lack of evidence. VTE prophylaxis in postbariatric body contouring remains a topic that deserves further study.

Autologous bone grafting with adjunctive use of acellular dermal matrix for alveolar cleft defects: early outcomes.

BACKGROUND AND PURPOSE: Alveolar bone grafting remains the standard for alveolar cleft repair. Compromised oral and/or nasal closure may impede healing and result in graft failure or persistent fistulae. Incorporating acellular dermal matrix into these repairs may protect the bone graft during mucosal healing by providing an additional layer of soft tissue coverage. METHODS: A retrospective review of alveolar bone grafts undertaken at our cleft-craniofacial center from 2005 to 2007 was performed. The use of acellular dermal matrix for nasal and/or oral lining augmentation was determined. A minimum 3 months' follow-up was required for inclusion. Outcomes included (1) mucosal disruption, (2) time to complete mucosal healing, (3) bone graft exposure, (4) postoperative bone graft incorporation using the Chelsea scale, and (5) canine eruption through the graft site. RESULTS: In total, 35 patients were included. Of those, 15 patients (four girls, 11 boys; seven Veau III, eight Veau IV) received acellular dermal matrix for mucosal augmentation (five nasal, one oral, nine nasal and oral lining). Average age at surgery was 10 years (range, 9 to 16 years). Average follow-up was 23 months (range, 3 to 35 months). Mucosal disruption occurred in 20% of the acellular group and in 30% of the control group (p=nonsignificant). Complete mucosal healing was achieved at an average of 4 weeks (range, 1 to 14 weeks) in the acellular dermal matrix group versus 4 weeks (range, 2 to 11 weeks) in the control group (p=nonsignificant). Exposure of bone graft occurred in 0% of the acellular dermal matrix group and in 30% of the control group (p=.016). The Chelsea scale demonstrated no significant radiographic difference in postoperative bone graft incorporation between the acellular dermal matrix and control groups. Canine eruption through the graft site was similar for both groups. CONCLUSIONS: These data support the conclusions that using acellular dermal matrix to augment nasal/oral mucosal lining in alveolar bone grafts (1) does not increase mucosal disruption or time to complete healing, (2) prevents postoperative bone graft exposure, and (3) appears to have no negative effect on postoperative bone graft incorporation or canine eruption through the graft site.

Joint practice guidelines for radionuclide lymphoscintigraphy for sentinel node localization in oral/oropharyngeal squamous cell carcinoma.

Involvement of the cervical lymph nodes is the most important prognostic factor for patients with oral/oropharyngeal squamous cell carcinoma (OSCC), and the decision whether to electively treat patients with clinically negative necks remains a controversial topic. Sentinel node biopsy (SNB) provides a minimally invasive method of determining the disease status of the cervical node basin, without the need for a formal neck dissection. This technique potentially improves the accuracy of histological nodal staging and avoids over-treating three-quarters of this patient population, minimizing associated morbidity. The technique has been validated for patients with OSCC, and larger-scale studies are in progress to determine its exact role in the management of this patient population. This article was designed to outline the current best practice guidelines for the provision of SNB in patients with early-stage OSCC, and to provide a framework for the currently evolving recommendations for its use. These guidelines were prepared by a multidisciplinary surgical/nuclear medicine/pathology expert panel under the joint auspices of the European Association of Nuclear Medicine (EANM) Oncology Committee and the Sentinel European Node Trial Committee.

Targeted AKT Inhibition in Prostate Cancer Cells and Spheroids Reduces Aerobic Glycolysis and Generation of Hyperpolarized [1-13C] Lactate.

The PI3K/AKT/mTOR (PAM) signaling pathway is frequently mutated in prostate cancer. Specific AKT inhibitors are now in advanced clinical trials, and this study investigates the effect of MK2206, a non-ATP-competitive inhibitor, on the cellular metabolism of prostate cancer cells. We observed a reduction in cell motility and aerobic glycolysis in prostate cancer cells with treatment. These changes were not accompanied by a reduction in the ratio of high-energy phosphates or a change in total protein levels of enzymes and transporters involved in glycolysis. However, a decreased ratio of NAD+/NADH was observed, motivating the use of hyperpolarized magnetic resonance spectroscopy (HP-MRS) to detect treatment response. Spectroscopic experiments were performed on tumor spheroids, 3D structures that self-organize in the presence of an extracellular matrix. Treated spheroids showed decreased lactate production with on-target inhibition confirmed using IHC, demonstrating that HP-MRS can be used to probe treatment response in prostate cancer spheroids and can provide a biomarker for treatment response. Mol Cancer Res; 16(3); 453-60. ©2018 AACR.

Sampling Hyperpolarized Molecules Utilizing a 1 Tesla Permanent Magnetic Field.

Hyperpolarized magnetic resonance spectroscopy (HP MRS) using dynamic nuclear polarization (DNP) is a technique that has greatly enhanced the sensitivity of detecting (13)C nuclei. However, the HP MRS polarization decays in the liquid state according to the spin-lattice relaxation time (T1) of the nucleus. Sampling of the signal also destroys polarization, resulting in a limited temporal ability to observe biologically interesting reactions. In this study, we demonstrate that sampling hyperpolarized signals using a permanent magnet at 1 Tesla (1T) is a simple and cost-effective method to increase T1s without sacrificing signal-to-noise. Biologically-relevant information may be obtained with a permanent magnet using enzyme solutions and in whole cells. Of significance, our findings indicate that changes in pyruvate metabolism can also be quantified in a xenograft model at this field strength.

Monitoring skeletal muscle and subcutaneous tissue acid-base status and oxygenation during hemorrhagic shock and resuscitation.

Gastric tonometry correlates with the severity of blood loss during shock. However, tonometry is cumbersome, has a slow response time, and is not practical to apply in the acute resuscitation setting. We hypothesized that subcutaneous tissue (SC) and skeletal muscle (SM) pH, pCO2, and pO2 changes are comparable with changes seen in bowel tonometry during shock and resuscitation. Thirteen male mini-swine (25-35 kg; n = 4 control, n = 9 shock) underwent laparotomy and jejunal tonometry. A multisensor probe (Diametrics Medical, Roseville, MN) was placed in the carotid artery, the chest SC, and the adductor muscle of the leg (SM). PaCO2 was maintained between 40 and 45 mmHg. Shocked animals were hemorrhaged and kept at mean arterial pressure of 40 mmHg. Animals were bled until a reinfusion of >10% of the total shed blood was needed to maintain the mean arterial pressure at 40 mmHg. Animals were resuscitated with shed blood plus 2x shed volume in lactated Ringer's solution (20 min) and were observed for 3 h. The average blood loss was 47.2% +/- 8.7% of calculated blood volume. During the hemorrhagic phase, SM and SC displayed tissue acidosis (r2 = 0.951), tissue hypercapnea (r2 = 0.931), and tissue hypoxia (r2 = 0.748). Overall, pH displayed the best correlation between SM and SC during shock and resuscitation. PCO2 in the jejunum (tonometry), SM, and SC increased during decompensation. However, during resuscitation as tonometric pCO2 normalized, only SC pCO2 decreased to its baseline value, whereas the SM pCO2 decrease tended to lag behind. Bland-Altman analyses demonstrated that the variability of the tissue pH changes in SM and SC are predictable according to the phases of hemorrhage and resuscitation. Changes in tissue pH correlated during bleeding and during resuscitation among SC and SM, and these changes followed the trends in gut tonometry as well. Continuous pCO2 and pO2 monitoring in the SM and SC tissues had significant correlations during the induction of shock only. SM and SC continuous pH and pCO2 monitoring reflect bowel pCO2 values during hemorrhagic shock. The response of these indicators as potential surrogates of impaired tissue metabolism varies among tissues and according to the phases of hemorrhage or resuscitation.

Necesidades de aprendizaje en la atención a urgencias en Estomatología / Learning needs for emergency care in Odontology

Fundamento: la determinación de las necesidades de aprendizaje que afectan la competencia y el desempeño en la atención a las urgencias estomatológicas, garantiza que se pueda planificar con más calidad y pertinencia social la superación profesional de posgrado. Objetivo: identificar las necesidades de aprendizaje que presentan los estomatólogos en relación con la atención al paciente portador de una urgencia estomatológica en el área de salud del municipio de Cruces, Cienfuegos. Métodos: se realizó una investigación exploratoria, analítica y transversal entre septiembre de 2015 y marzo de 2016, para identificar necesidades de aprendizaje en 18 estomatólogos de Cruces. Para ello se emplearon métodos teóricos: análisis-síntesis e inducción-deducción; empíricos: encuesta en forma de cuestionario, observación directa y un examen escrito tipo test objetivo; y matemáticos para los valores absolutos y relativos. Resultados: se detectaron omisiones no esenciales y esenciales que no causan iatrogenias, relacionadas con la comunicación y la interrelación personal, el consentimiento informado, la no entrega de indicación de medicamentos por un método escrito y otras, es decir: insuficiencias en conocimientos y habilidades básicas acerca de la atención al paciente portador de urgencias estomatológicas. Conclusiones: las dificultades encontradas en las competencias en lo referente a la aplicación de conocimientos y habilidades, así como en el desempeño al enfrentar y solucionar el problema de un portador de una urgencia en Estomatología, permitieron conocer las necesidades de superación profesional de posgrado(AU)

Development of consensus guidelines for venous thromboembolism prophylaxis in patients undergoing microvascular reconstruction of the mandible.

BACKGROUND: The purpose of this study was to determine how guidelines for venous thromboembolism prophylaxis can be applied to patients undergoing microsurgical reconstruction of the mandible. METHODS: Retrospective review of our institutional use of thromboprophylaxis and the associated outcomes in 114 patients (58 free fibular flaps and 56 osteocutaneous radial forearm flaps). RESULTS: Twenty-two patients (19.3%) received only intermittent pneumatic compression. Overall, 80.7% received postoperative chemoprophylaxis. Sixty-four percent initiated chemoprophylaxis within 24 hours after surgery. Only 13.2% received the recommended frequency of chemoprophylaxis. One patient had development of a pulmonary embolism. Four patients undergoing chemoprophylaxis had development of neck hematomas; in each case the cause of bleeding could be attributed to a cause distinct from chemoprophylaxis. CONCLUSIONS: No consistent chemoprophylaxis protocol was followed. Chemoprophylaxis was not associated with an increased risk of bleeding. Physician education is the next step in decreasing variations in chemoprophylaxis and adopting guidelines similar to The American College of Chest Physicians.

FGF-2 enhances vascularization for adipose tissue engineering.

BACKGROUND: Current therapies for soft-tissue reconstruction include autologous tissue flaps and alloplastic implants. Although autologous fat transplantation using a minimally invasive cannula harvest has less donor-site morbidity than tissue flaps, there is a variable degree of fat resorption over time. Preadipocytes isolated from harvested fat are better able to withstand the mechanical trauma from the suction cannula and subsequently may result in improved cell survival and generation of new fat tissue after transfer to another anatomic site. The authors hypothesized that particulate small intestinal submucosa could be useful as injectable cell delivery vehicles for preadipocytes, and that the release of fibroblast growth factor (FGF)-2 would enhance vascularization. METHODS: Preadipocytes were isolated from discarded human adipose tissue and cultured on small intestinal submucosa particles in a stirred bioreactor (spinner flask). Preadipocytes attached and proliferated on small intestinal submucosa microparticles and maintained high viability over several weeks of culture. FGF-2 was encapsulated in poly(lactic-co-glycolic acid) microspheres and injected in conjunction with the preadipocyte/small intestinal submucosa particles into a mouse subcutaneous model. RESULTS: Preadipocytes attached and proliferated on small intestinal submucosa particles in vitro. In vivo, vascularization was significantly enhanced with the incorporation of FGF-2-loaded poly(lactic-co-glycolic acid) microspheres. In addition, cell survival during the 14-day in vivo observation period was confirmed by fluorescent dye labeling. CONCLUSIONS: Small intestinal submucosa particles are a favorable scaffold for preadipocytes, allowing ex vivo proliferation on particles small enough to be injected. Delivery of FGF-2 from poly(lactic-co-glycolic acid) microspheres resulted in cell survival and enhanced vascularization.

Postoperative video debriefing reduces technical errors in laparoscopic surgery.

BACKGROUND: Because of the learning curve required to master laparoscopic procedures, there is a growing concern that patient safety may be compromised due to technical errors by a novice surgeon. We evaluated the effect of videotape debriefing on the performance of a complex laparoscopic procedure. METHODS: Twenty-four surgical residents performed a laparoscopic jejunojejunal anastomosis under the supervision of a single laparoscopic surgeon. All procedures were videotaped. Half of the residents underwent video debriefing. Videotapes were analyzed for knot-tying time, anastomotic time, and frequency of minor technical errors and adverse events. The performance of the debriefed group was compared with a non-debriefed group. RESULTS: Knot-tying time, minor errors, and anastomotic time were similar between the debriefed and non-debriefed groups. However, adverse events from technical errors were more frequent in the non-debriefed group (chi2 = 7.647, P = .006). CONCLUSIONS: Postoperative video debriefing is an effective educational tool for reducing adverse events during a complex laparoscopic procedure.

Immunologic approaches to composite tissue allograft.

This article discusses the immunologic principles and the most promising immunologic approaches for composite tissue allograft tolerance. We have previously reviewed some of the pharmacologic approaches for composite tissue allo-transplantation. In this review, we will summarize the range of options that may address the challenge of transplantation in reconstructive surgery.

Pharmacologic approaches to composite tissue allograft.

This article discusses the pharmacologic approaches and the most promising new compounds for composite tissue allograft tolerance. Although some approaches rely on a combination of immunosuppressive agents that act synergistically against rejection, other strategies use immunologic manipulation, including major histocompatibility complex matching, induction of chimerism, and use of monoclonal antibodies to abrogate the immune response. There is still a need, however, to reproduce these findings in species phylogenetically closer to humans. This may be the target of future research efforts, which may overcome the challenge of limb and face transplant rejection.

Comparison of biodegradable conduits within aged rat sciatic nerve defects.

BACKGROUND: Considering that little is known about the peripheral nerve regenerative capacity of elderly patients, the authors studied nerve regenerative capacity in aged rats and compared the effect of three synthetic nerve guides with different material characteristics and porosity. The authors hypothesized that the use of a biodegradable composite nerve guide (CultiGuides) would promote nerve regeneration and functional recovery in a manner similar to treatment with autografts or U.S. Food and Drug Administration-approved polyglycolic acid Neurotubes in an aged rat sciatic nerve defect model. METHODS: Aged Sprague-Dawley rats (11 months old) underwent a 1-cm sciatic nerve resection in the right leg [group 1, control (contralateral leg samples), n = 10; group 2, negative (nerve gap defect), n = 6; group 3, autograft, n = 10; group 4, polycaprolactone, n = 10; group 5, CultiGuides, n = 10; and group 6, Neurotube, n = 10]. RESULTS: After 12 weeks, the negative group did not demonstrate any nerve regeneration. In the regenerated and distal nerve, all treated groups had increased myelinated areas compared with the negative control. In the regenerated nerve, there was a significant increase in myelination in the Neurotube group compared with the polycaprolactone group (p < 0.001). However, in the distal nerve, there were no differences among the treatment groups. Walking track analyses and gastrocnemius muscle weight ratios were not different among treatment groups 3 through 6. CONCLUSIONS: The results showed differences in myelination; Neurotubes promoted the highest degree of myelination (p < 0.001) as compared with all groups. The authors found no improvement in function of the repaired nerve as measured by percentage of autotomy, the sciatic function index, and gastrocnemius muscle weight. No group was able to recover function in this aged model.

A novel perfluoroelastomer seeded with adipose-derived stem cells for soft-tissue repair.

BACKGROUND: There is a need for engineered soft tissue in reconstructive surgery, particularly after tumor removal. An ideal implant that will provide structural support and a favorable environment for growing cells is a key element in the process of tissue engineering. Nonbiodegradable materials that become well incorporated within the new tissue are a good solution, but many such materials do not have a surface favorable for cell adherence and proliferation. The authors hypothesized that the modification of the pore size in a novel fluoropolymer would improve the adherence and enhance the proliferation of adipose-derived stem cells. METHODS: Fluoropolymers with two varying pore size ranges were examined. Fluoropolymer compound U48 (pore size, 100 to 180 microm) and fluoropolymer compound P54 (pore size, 10 to 55 microm) were seeded with human adipose-derived stem cells, and cell adherence to the material was measured after 4 hours and cell proliferation was measured after 72 hours. Cell-seeded constructs were implanted subcutaneously in a nude mouse model for 30 days. RESULTS: Fluoropolymer surface treatment with fibronectin improved the attachment of adipose-derived stem cells to the well plates but did not improve attachment to the fluoropolymer, regardless of pore size. Fluoropolymer U48 increases the adherence and provides a favorable surface for proliferation of adipose-derived stem cells. CONCLUSIONS: After subcutaneous implantation into nude mice, tissue growth was observed in the fluoropolymer samples with the larger pore size. The characteristics of this new material will allow for future clinical applications in plastic and reconstructive surgery.