The impact of post-mastectomy radiation timing on overall outcomes of autologous free-flap breast reconstruction.

BACKGROUND: The optimal timing of post-mastectomy radiation therapy (PMRT) in autologous breast reconstruction is controversial. Our study compares overall reconstructive outcomes in patients who received post-mastectomy radiation therapy either before or after the autologous flap. METHODS: A single-center retrospective review was performed for patients who underwent free flap breast reconstruction and post-mastectomy radiation from January 2004 through January 2021. Demographic, intraoperative, and post-operative variables were recorded. RESULTS: A total of 452 free flaps were identified, and 82 underwent PMRT. 59.8% were radiated with an expander prior to free flap surgery (PreFlap), and 40.2% flaps underwent PMRT (PostFlap). PostFlap patients were significantly younger (43.0 vs. 47.9 years, p = .016). There were no significant differences in free flap outcomes between the two cohorts including thrombosis, venous congestion, flap loss, takebacks, fat necrosis, seroma, or infection. Mastectomy skin flap necrosis was significantly higher in the PostFlap cohort (9.1% vs. 0%, p = .032), but nipple necrosis rates did not differ. There were no significant differences in number or need for revision surgeries, fat necrosis, or fat grafting between groups. However, there were significantly more total reconstructive complications, including infection and wound breakdown, experienced by the PreFlap cohort (46.9% vs. 24.2%, p = .038). CONCLUSIONS: Timing of PMRT did not impact free flap outcomes, but those who had the expander radiated experienced significantly more complications overall. For the 34.7% of patients in the preFlap group who planned for autologous reconstruction form initial consultation, radiation after the flap may have improved their overall outcomes. As added complications cause delays in cancer therapy and final reconstruction, our results suggest that PMRT of the flap when possible may improve the overall experience for breast cancer patients.

Patient Perceptions on Barriers and Facilitators to Accessing Low-acuity Surgery During COVID-19 Pandemic.

BACKGROUND: The onset of the COVID-19 pandemic led to the postponement of low-acuity surgical procedures in an effort to conserve resources and ensure patient safety. This study aimed to characterize patient-reported concerns about undergoing surgical procedures during the pandemic. METHODS: We administered a cross-sectional survey to patients who had their general and plastic surgical procedures postponed at the onset of the pandemic, asking about barriers to accessing surgical care. Questions addressed dependent care, transportation, employment and insurance status, as well as perceptions of and concerns about COVID-19. Mixed methods and inductive thematic analyses were conducted. RESULTS: One hundred thirty-five patients were interviewed. We identified the following patient concerns: contracting COVID-19 in the hospital (46%), being alone during hospitalization (40%), facing financial stressors (29%), organizing transportation (28%), experiencing changes to health insurance coverage (25%), and arranging care for dependents (18%). Nonwhite participants were 5 and 2.5 times more likely to have concerns about childcare and transportation, respectively. Perceptions of decreased hospital safety and the consequences of possible COVID-19 infection led to delay in rescheduling. Education about safety measures and communication about scheduling partially mitigated concerns about COVID-19. However, uncertainty about timeline for rescheduling and resolution of the pandemic contributed to ongoing concerns. CONCLUSIONS: Providing effective surgical care during this unprecedented time requires both awareness of societal shifts impacting surgical patients and system-level change to address new barriers to care. Eliciting patients' perspectives, adapting processes to address potential barriers, and effectively educating patients about institutional measures to minimize in-hospital transmission of COVID-19 should be integrated into surgical care.

Level of UV Exposure, Skin Type, and Age Are More Important than Thiopurine Use for Keratinocyte Carcinoma Development in IBD Patients.

BACKGROUND: Retrospective studies observe an increased risk of keratinocyte carcinomas (KCs) in patients with inflammatory bowel disease (IBD) on thiopurine (TP) medication. The role of traditional risk factors such as skin type and sun protection behavior has not been studied in this population. This study aimed to examine traditional KC risk factors and thiopurine use on skin cancer development in an IBD cohort. METHODS: Consecutive IBD patients were recruited from four specialist centers in Australia and New Zealand, each with varying UV exposure indices. Data pertaining to race, skin color, freckling and sun protection behavior, dose of TP therapy, and skin cancer development were elicited through a self-reported questionnaire. RESULTS: A total of 691 IBD patients were included with 62 reporting KC development. Thiopurine usage was similar among patients who developed skin cancer compared with those who did not (92% vs. 89%, p = 0.3). There was no statistically significant association between KC development and TP dose or 6-thioguanine nucleotide levels. In multivariate modeling, four factors were independently and significantly associated with KC: age over 61 years old versus less than 30 years old (OR 6.76; 95% CI 2.38-19.18), residing in Brisbane versus Christchurch (OR 3.3; 95% CI 1.6-6.8), never staying in the shade versus staying in the shade ≥ 50% of the time (OR 3.8; 95% CI 1.4-10.5), and having a skin type that never tanned versus other skin types (OR 6.9; 95% CI 2.9-16.0). CONCLUSION: Skin type, age, and sun protection behavior are more important risk factors for KC development than thiopurine medication use in this IBD population.

Occurrence of parasitism promoted by Myzobdella lugubris Leidy, 1851 (Annelida: Piscicolidae) in Callinectes bocourti (Crustacea: Portunidae): A report of invasive leech in Brazilian Amazon province.

This study reports the presence of high parasitic load by Myzobdella lugubris Leidy, 1851 in the swimming crab Callinectes bocourti A. Milne-Edwards, 1879 from Amazon mangrove. We sampled the swimming crabs using a baited trap, between January and June 2023, in Santa Maria River, located in the municipality of Curuçá, state of Pará, Brazil (geographical coordinates 0°40'3.705"S, 047°54'43.405"W). After sampling, each swimming crab was individually placed in plastic containers for the count of leeches per individual. In the laboratory, the specimens were sexed, measured (parasite and host) and fixed in 70% alcohol. For the leech species identification, macroscopic techniques were combined with light microscopy (LM) and scanning electron microscopy (SEM). We examined 86 specimens of C. bocourti (75 males and 11 females) in a ratio of 1 M:0.14 F, all infested with leeches. In total, 186 leech specimens were collected, ranging from 1 to 21 leeches per host. Leeches oviposited the cocoons in greater quantities in ventral area of swimming crab carapace (32%), followed by dorsal area of carapace (29.09%), chelipeds (24.34%) and ambulatory legs (14.57%). The presence of M. lugubris is a risk to the health of the host, once it may transmit a range of diseases to aquatic organisms, and subsequently risk to human health.

Barriers to Performing Soft Tissue Reconstruction Procedures among Orthopedic Surgeons in Low- and Middle-income Countries: Results of a Surgical Skills Training Course.

BACKGROUND: Appropriate management of soft tissue injury associated with orthopedic trauma is challenging in low- and middle-income countries (LMICs) due to the lack of available reconstructive surgeons. The Surgical Management and Reconstructive Training (SMART) course teaches orthopedic surgeons reconstructive techniques aimed at improving soft tissue management. This study aims to identify additional barriers to implementing these techniques for surgeons in LMICs who have attended SMART courses. METHODS: This is a mixed-methods study including a Likert-scale-based survey administered to 150 surgeons from LMICs attending the 2018 SMART courses in Tanzania and San Francisco and key informant interviews with 20 surgeons who perform soft tissue coverage procedures. RESULTS: In surveys, respondents reported inadequate local plastic surgeon availability for lower extremity fracture requiring muscle flaps (88%). Surgeons agreed that flap surgeries are important for patients with significant soft tissue injury following open fractures (97%). They reported inadequate access to instruments, such as dermatomes (59%) and Humby knives (32%), and senior-level support (31%). Fewer than half of surgeons with flap experience (n = 85) felt confident in training peers (45%). In interviews, delays in returning patients to operating rooms were frequently cited as a barrier (90%). CONCLUSIONS: Our study demonstrates that soft tissue procedures are perceived as a high priority among orthopedic surgeons, but there are multiple barriers, including a lack of plastic surgeons, and many modifiable barriers including a lack of surgical equipment, peer training, and senior colleague support.

Current Challenges of Plastic Surgical Care in Sub-Saharan Africa (Maputo, Mozambique).

BACKGROUND: Limited data exist on plastic surgery practices in Sub-Saharan Africa. The aim of this study was to characterize the spectrum of disease and operative procedures at a teaching hospital in Maputo, Mozambique to help understand the challenges of providing care for the local providers and to provide contextual relevance for training through partnerships. METHODS: A mixed-methods approach was utilized to perform an ongoing needs assessment. A retrospective review was performed of plastic surgery operative records, ward admissions records, and death records in a tertiary-care hospital in Maputo, Mozambique for the period January 2015 to December 2015. RESULTS: Limited resources (equipment, block-time, personnel, and perioperative services) were observed. The most common diagnoses for the 455 patients evaluated were burns (44%) and neoplasms (17%). Congenital abnormalities accounted for only 1% of the patient diagnoses. Of the 408 procedures performed, the majority were skin grafts (43%) and skin excisions (31%). Sepsis from burns accounted for 70% of documented deaths (14/20). The mean number of days to skin grafting for inpatients was 53 days. CONCLUSION: We observed a large burden of burns and skin graft procedures at a public referral teaching hospital in Mozambique. Our findings provide contextual relevance to help focus public health efforts and improve plastic surgery training and practices.

Evaluation of 4 Outcomes Measures in Microtia Treatment: Exposures, Infections, Aesthetics, and Psychosocial Ramifications.

BACKGROUND: In craniofacial microsomia, microtia and canal atresia pose formidable reconstructive challenges. We review our institutional experience in treating microtia and atresia to identify variables associated with 4 outcomes measures: complications, surgical revisions, aesthetic outcomes, and psychosocial function. METHODS: Craniofacial microsomia patients treated at the University of California Los Angeles Craniofacial Clinic between 2008 and 2014 greater than 13 years of age (n = 68) were reviewed for microtia and atresia treatment and outcomes. RESULTS: In total, 91.2% of patients diagnosed with craniofacial microsomia presented with microtia, affecting 75 ears. Both a male and right-sided predominance were observed. Fifty-six patients (90.3%) underwent autologous external ear reconstruction at an average age of 8.5 years. Age, type of incision, and size of cartilage framework did not predict total number of surgeries or complications. Severity of ear anomalies correlated with increased number of surgeries (P < 0.001) and decreased aesthetic outcomes (P < 0.001) but not complications. In total, 87.1% of patients with microtia had documented hearing loss, of which the majority were conductive and 18.5% were mixed sensorineural and conductive. Hearing deficits were addressed in 70.4% of patients with external hearing aids, bone anchored hearing aids, or canaloplasty. Of all variables, improvement of psychosocial function was correlated only to hearing loss treatment of any type (P = 0.01). CONCLUSIONS: On evaluation of surgical and patient characteristics, severity of microtia predicted the total number of surgical revisions performed and aesthetic ratings. In addition, we found that the only factor that correlated with improved patient and parent-reported psychosocial outcomes was treatment of hearing loss.

Global general pediatric surgery partnership: The UCLA-Mozambique experience.

BACKGROUND/PURPOSE: There has been increasing recognition of the disparities in surgical care throughout the world. Increasingly, efforts are being made to improve local infrastructure and training of surgeons in low-income settings. The purpose of this study was to review the first 5-years of a global academic pediatric general surgery partnership between UCLA and the Eduardo Mondlane University in Maputo, Mozambique. METHODS: A mixed-methods approach was utilized to perform an ongoing needs assessment. A retrospective review of admission and operative logbooks was performed. Partnership activities were summarized. RESULTS: The needs assessment identified several challenges including limited operative time, personnel, equipment, and resources. Review of logbooks identified a high frequency of burn admissions and colorectal procedures. Partnership activities focused on providing educational resources, on-site proctoring, training opportunities, and research collaboration. CONCLUSION: This study highlights the spectrum of disease and operative case volume of a referral center for general pediatric surgery in sub-Saharan Africa, and it provides a context for academic partnership activities to facilitate training and improve the quality of pediatric general surgical care in limited-resource settings. LEVEL OF EVIDENCE: Level IV.

Intraoperative Indocyanine Green Laser Angiography in Pediatric Autologous Ear Reconstruction.

Skin flap vascularity is a critical determinant of aesthetic results in autologous ear reconstruction. In this study, we investigate the use of intraoperative laser-assisted indocyanine green angiography (ICGA) as an adjunctive measure of skin flap vascularity in pediatric autologous ear reconstruction. Twenty-one consecutive pediatric patients undergoing first-stage autologous total ear reconstruction were retrospectively evaluated. The first 10 patients were treated traditionally (non-ICGA), and the latter 11 patients were evaluated with ICGA intraoperatively after implantation of the cartilage construct and administration of suction. Relative and absolute perfusion units in the form of contour maps were generated. Statistical analyses were performed using independent sample Student t test. Statistically significant differences in exposure and infection were not found between the 2 groups. However, decreased numbers of surgical revisions were required in cases with ICGA versus without ICGA (P = 0.03), suggesting that greater certainty in skin flap perfusion correlated with a reduction in revision surgeries. In cases of exposure, we found an average lowest absolute perfusion unit of 14.3, whereas cases without exposure had an average of 26.1 (P = 0.02), thereby defining objective parameters for utilizing ICGA data in tailoring surgical decision making for this special population of patients. Defined quantitative parameters for utilizing ICGA in evaluating skin flap vascularity may be a useful adjunctive technique in pediatric autologous ear reconstruction.

Orthognathic Consequences of Sphincter Pharyngoplasty in Cleft Patients: A 2-Institutional Study.

BACKGROUND: Understanding long-term sequelae of cleft treatment is paramount in the refinement of treatment algorithms to accomplish optimized immediate and long-term outcomes. In this study, we reviewed sphincter pharyngoplasties as a method of velopharyngeal insufficiency (VPI) treatment in relationship to orthognathic surgery. METHODS: Cleft lip/palate and cleft palate patients, 15 years of age and older, were reviewed for demographics, VPI surgery, revisions, and subsequent orthognathic surgery at 2 institutions. Chi-square test, Student's t test, and logistic regression analyses were performed. RESULTS: In 214 patients reviewed (mean age, 19.5 years), 61.7% were male, 18.2% had isolated cleft palate, 61.2% had unilateral cleft lip and palate, and 20.6% had bilateral cleft lip and palate. A total of 33.6% were diagnosed with VPI and received a sphincter pharyngoplasty (mean age, 11.9 years). When subsequent orthognathic surgery was examined, sphincter pharyngoplasty was not associated with maxillary advancement (P = 0.59) but did correlate with an increase in mandibular surgery from 2.8% to 11.1% (P = 0.02). The indications for mandibular surgery in the pharyngoplasty population were related to congenital micrognathia. When cephalometric analyses were evaluated, sphincter pharyngoplasty resulted in a decreased sella-to-nasion-to-B point angle (mean, 79.0-76.3 degrees, P = 0.02) and a higher incidence of normal to class II maxillomandibular relationships as defined by A point-to-nasion-to-B point angles >0.5 (P = 0.02). CONCLUSIONS: Sphincter pharyngoplasty decreases anterior mandibular growth and the discrepancy between maxillomandibular skeletal relationships because of the frequent predisposition of cleft patients to maxillary hypoplasia. In patients with congenital mandibular micrognathia, a small increase in mandibular surgeries may occur.

Chemical composition of different muscle zones in pirarucu (Arapaima gigas)

Abstract Identifying potential patterns in pirarucu (Arapaima gigas) composition, as a function of the different fish muscle zones (dorse, venter, ventrecha and tail), was the main objective of this research. For such, the different pirarucu muscle zones were evaluated, in order to obtain proximate composition and minerals content. It was also determined amino acids and fatty acids contents in fish muscle. The dorsal, ventral and tail muscle zones presented similar moisture (76.5-78.2%), protein (17.8-18.9%), total lipids (1.0-1.5%) and ash (0.9-1.2%) contents. On the other hand, the ventrecha zone presented 25.8% of protein and the major total lipids content (17.1%). The main minerals found in fish muscle were K (183.5-288.6 mg/100 g muscle) and Na (65.1-175.5 mg/100 g). Glutamic acid (3027.6 mg/100 g muscle) was the main amino acid found in fish muscle, which presented 48% of essential amino acids in the protein fraction. Lipids content showed 57.3% of unsaturated fatty acids and 42.7% of saturated fatty acids.

Characterization of estrogen receptor betab in sea bream (Sparus auratus): phylogeny, ligand-binding, and comparative analysis of expression.

Estrogens control many physiological processes in both female and male vertebrates, mostly mediated by specific nuclear estrogen receptors (ER). Two ER subtypes (ERalpha and ERbeta) are present in most vertebrates, including the sea bream (Sparus auratus) a hermaphrodite teleost fish. In the present study several variant cDNAs encoding a second sea bream ERbeta (sbERbetab) is reported. Phylogenetic and Southern blot analysis indicate that sbERbetab and the previously cloned sbERbetaa (formerly sbERbeta) are encoded by different genes, which may have arisen by duplication of an ancestral ERbeta gene. Competitive binding assays show that sbERbetab has high affinity for 17beta-estradiol (K(d) = 1 nM) and specifically binds estrogen agonists (diethylstilbestrol and ethynylestradiol) and antagonists (ICI 182,780). In Northern blot sbERalpha, sbERbetaa, sbERbetab produce several different transcripts in a variety of tissues. RT-PCR showed a partially overlapping but differential tissue distribution in both male and female sea bream.

Avaliação clinica do controle químico de placa supragengival em pacientes internados em unidade de terapia intensiva / Clinicai evaluation of chemical supragingival plaque control in intensive care patients

O presente estudo teve como intuito analisar a efetividade de um protocolo de higiene oral utilizado em pacientes internados em unidades de terapia intensiva. A amostra foi constituída de 30 pacientes politraumatizados, portadores de ventilação mecânica, internados por um período entre 5 e 15 dias na Unidade de Terapia Intensiva no Instituto Dr. José Frota na cidade de Fortaleza/CE. Foram realizadas medidas do índice de Placa Visível (IPV), índice de Sangramento Gengival (ISG) e índice Gengival (IG) nas faces vestibulares dos seis dentes anteriores inferiores e os valores médios inicial e final foram comparados entre si. Utilizando-se o programa Bioestat 2.0, os dados foram tabulados e analisados estatisticamente pelo teste não-paramétrico de Wilcoxon. Os resultados demonstraram que o protocolo utilizando-se aplicação tópica de cloreto de cetilpiridínio, diluído em soro fisiológico em partes iguais, 3 vezes/dia, foi suficiente para inibira formação de placa bacteriana (p<0.0l). Entretanto, não foi capaz de reduzir significativa-mente o IG e ISG (p > 0.01). O protocolo utilizado foi efetivo na redução da placa bacteriana e não exerceu efeito sobre a inflamação gengival, apesar desta ter se mantido em níveis compatíveis com saúde periodontal.