Vaccination impact on impending HIV-COVID-19 dual epidemic with autogenous behavior modification: Hill-type functional response and premeditated optimization technique.

An HIV-COVID-19 co-infection dynamics is modeled mathematically assimilating the vaccination mechanism that incorporates endogenous modification of human practices generated by the COVID-19 prevalence, absorbing the relevance of the treatment mechanism in suppressing the co-infection burden. Envisaging a COVID-19 situation, the HIV-subsystem is analyzed by introducing COVID-19 vaccination for the HIV-infected population as a prevention, and the "vaccination influenced basic reproduction number" of HIV is derived. The mono-infection systems experience forward bifurcation that evidences the persistence of diseases above unit epidemic thresholds. Delicate simulation methodologies are employed to explore the impacts of baseline vaccination, prevalence-dependent spontaneous behavioral change that induces supplementary vaccination, and medication on the dual epidemic. Captivatingly, a paradox is revealed showing that people start to get vaccinated at an additional rate with the increased COVID-19 prevalence, which ultimately diminishes the dual epidemic load. It suggests increasing the baseline vaccination rate and the potency of propagated awareness. Co-infection treatment needs to be emphasized parallelly with single infection medication under dual epidemic situations. Further, an optimization technique is introduced to the co-infection model integrating vaccination and treatment control mechanisms, which approves the strategy combining vaccination with awareness and medication as the ideal one for epidemic and economic gain. Conclusively, it is manifested that waiting frivolously for any anticipated outbreak, depending on autogenous behavior modification generated by the increased COVID-19 prevalence, instead of elevating vaccination campaigns and the efficacy of awareness beforehand, may cause devastation to the population under future co-epidemic conditions.

Bifurcation analysis of autonomous and nonautonomous modified Leslie-Gower models.

In ecological systems, the predator-induced fear dampens the prey's birth rate; yet, it fails to extinguish their population, as they endure and survive even under significant fear-induced costs. In this study, we unveil a modified Leslie-Gower predator-prey model by incorporating the fear of predators, cooperative hunting, and predator-taxis sensitivity. We embark upon an exploration of the positivity and boundedness of solutions, unearthing ecologically viable equilibrium points and their stability conditions governed by the model parameters. Delving deeper, we unravel the scenario of transcritical, saddle-node, Hopf, Bogdanov-Takens, and generalized-Hopf bifurcations within the system's intricate dynamics. Additionally, we observe the bistable nature of the system under some parametric conditions. Further, the nonautonomous extension of our model introduces the intriguing interplay of seasonality in some crucial parameters. We establish a set of sufficient conditions that guarantee the permanence of the seasonally driven system. By conducting a numerical study on the seasonally forced model, we observe a myriad of phenomena manifesting the predator-prey dynamics. Notably, periodic solutions, higher periodic solutions, and bursting patterns emerge, alongside intriguing chaotic dynamics. Specifically, seasonal variations of the predator-taxis sensitivity and hunting cooperation can lead to the extinction of prey species and even the control of chaotic (higher periodic) solutions through the generation of a simple periodic solution. Remarkably, the seasonal forcing has the capacity to govern the chaotic behavior, leading to an exceptionally quasi-periodic arrangement in both prey and predator populations.

Dynamics of a stage-structured predator-prey system with fear-induced group defense in autonomous and nonautonomous settings.

In this investigation, we construct a predator-prey model that distinguishes between immature and mature prey, highlighting group defense strategies within the mature prey. First, we embark on exploring the positivity and boundedness of the solution, unraveling sustainable equilibrium points, and deducing their stability conditions. Upon further investigation, we observe that the system exhibits diverse bifurcations, including Hopf, saddle-node, transcritical, generalized Hopf, cusp, and Bogdanov-Takens bifurcations. The results reveal that heightened fear decreases mature prey density, potentially causing prey extinction beyond a certain threshold. Increased maturation rates lead to the coexistence of immature and mature prey populations and higher predator density. Stronger group defense boosts mature prey density, while weaker defense results in weak persistence. Lower values of the maturation rate of prey and the decline rate of predators sustain only the predator population, reliant on resources other than focal prey. Furthermore, our model demonstrates intriguing and diverse dynamical phenomena, including various forms of bistability across distinct bi-parameter planes. We also explore the dynamics of a related nonautonomous system, where certain parameters are considered to vary with time. In the seasonally forced model, we set out to define criteria regarding the existence and stability of positive periodic solutions. Numerical investigations into the seasonally forced model uncover a spectrum of dynamics, ranging from simple periodic solutions to higher periodicities, bursting patterns, and chaotic behavior.

Chaos and extinction risks of sexually reproductive generalist top predator in a seasonally forced food chain system with Allee effect.

This paper investigates the dynamics of a tritrophic food chain model incorporating an Allee effect, sexually reproductive generalist top predators, and Holling type IV and Beddington-DeAngelis functional responses for interactions across different trophic levels. Analytically, we explore the feasible equilibria, their local stability, and various bifurcations, including Hopf, saddle-node, transcritical, and Bogdanov-Takens bifurcations. Numerical findings suggest that higher Allee intensity in prey growth leads to the inability of species coexistence, resulting in a decline in species density. Likewise, a lower reproduction rate and a higher strength of intraspecific competition among top predators also prevent the coexistence of species. Conversely, a rapid increase in the reproduction rate and a decrease in the strength of intraspecific competition among top predators enhance the densities of prey and top predators while decreasing intermediate predator density. We also reveal the presence of bistability and tristability phenomena within the system. Furthermore, we extend our autonomous model to its nonautonomous counterpart by introducing seasonally perturbed parameters. Numerical analysis of the nonautonomous model reveals that higher seasonal strength in the reproduction rate and intraspecific competition of top predators induce chaotic behavior, which is also confirmed by the maximum Lyapunov exponent. Additionally, we observe that seasonality may lead to the extinction of species from the ecosystem. Factors such as the Allee effect and growth rate of prey can cause periodicity in population densities. Understanding these trends is critical for controlling changes in population density within the ecosystem. Ecologists, environmentalists, and policymakers stand to benefit significantly from the invaluable insights garnered from this study. Specifically, our findings offer pivotal guidance for shaping future strategies aimed at safeguarding biodiversity and maintaining ecological stability amidst changing environmental conditions. By contributing to the existing body of knowledge, our study advances the field of ecological science, enhancing the comprehension of predator-prey dynamics across diverse ecological conditions.

Engineering a Hyperstable Yersinia pestis Outer Membrane Protein Ail Using Thermodynamic Design.

Development of viable therapeutics to effectively combat tier I pneumopathogens such as Yersinia pestis requires a thorough understanding of proteins vital for pathogenicity. The host invasion protein Ail, although indispensable for Yersinia pathogenesis, has evaded detailed characterization, as it is an outer membrane protein with intrinsically low stability and high aggregation propensity. Here, we identify molecular elements of the metastable Ail structure that considerably alter protein-lipid and intraprotein thermodynamics. In addition, we find that four residues Q50, L88, L92, and A94 contribute additively to the lowered stability of Ail, and their conserved substitution is sufficient to re-engineer Ail to Out14, a thermodynamically hyperstable low-aggregation variant with a functional scaffold. Interestingly, Ail also shows two (parallel) folding pathways, which has not yet been reported for ß-barrel membrane proteins. Additionally, we identify the molecular mechanism of enhanced thermodynamic stability of Out14. We show that this enhanced stability of Out14 is due to a favorable change in the nonpolar accessible surface, and the accumulation of a kinetically accelerated off-pathway folding intermediate, which is absent in wild-type Ail. Such engineered hyperstable Ail ß-barrels can be harnessed for targeted drug screening and developing medical countermeasures against Yersiniae. Application of similar strategies will help design effective translational therapeutics to combat biopathogens.

Insight into the High Proton Conductivity of One-/Two-Dimensional Cadmium Phosphites.

The study describes the synthesis and structural attributes of two new cadmium phosphites, [Cd{OP(O)(OH)H}2(4,4'-bipy)] (1) and [H2pip][Cd(HPO3)2(H2O)]·H2O (2). The structure of 1 adopts a two-dimensional motif featuring alternate [Cd-µ2-O]2 and [Cd-O-P-O]2-cyclic rings, while the inorganic chains are held together by 4,4'-bipyridine. The presence of strong hydrogen bonding interactions between the appended H2PO3 groups (O---O = 2.55 Å) provides a facile proton conduction pathway and results in a proton conductivity of 3.2 × 10-3 S cm-1 at 75 °C under 77% relative humidity (RH). Compound 2 comprises an anionic framework formed by vertex-shared [Cd-O-P-O]2-cyclic rings, while the [H2pip] cations between the adjacent chains assist a well-directed O-H---O hydrogen-bonded network between coordinated water, lattice water, and phospite groups. The bulk proton conductivity value under conditions as in 1 reaches 4.3 × 10-1 S cm-1. For both 1 and 2, the proton conductivity remains practically unchanged under ambient temperatures (25-35 °C), suggesting their potential in low-temperature fuel cells.

Shifts in Bacterial Community Composition and Functional Traits at Different Time Periods Post-deglaciation of Gangotri Glacier, Himalaya.

Climate change causes an unprecedented increase in glacial retreats. The melting ice exposes land for colonization and diversification of bacterial communities leading to soil development, changes in plant community composition, and ecosystem functioning. Although a few studies have focused on macro-level deglaciation impacts, little is known about such effects on the bacterial community succession. Here, we provide meta-barcoding-based insight into the ecological attributes of bacterial community across different retreating periods of the Gangotri glacier, western Himalaya. We selected three sites along a terminal moraine representing recent (~ 20 yrs), intermediate (~ 100 yrs), and late (~ 300 yrs) deglaciation periods. Results showed that the genus Mycobacterium belonging to phylum Actinobacteria dominated recently deglaciated land. Relative abundance of these pioneer bacterial taxa decreased by 20-50% in the later stages with the emergence of new and rising of the less abundant members of the phyla Proteobacteria, Firmicutes, Planctomycetes, Acidobacteria, Verrucomicrobia, Candidatus TM6, and Chloroflexi. The community in the recent stage was less rich and harbored competitive interactions, while the later stages experienced a surge in bacterial diversity with cooperative interactions. The shift in α-diversity and composition was strongly influenced by soil organic carbon, carbon to nitrogen ratio, and soil moisture content. The functional analyses revealed a progression from a metabolism focused to a functionally progressive community required for bacterial co-existence and succession in plant communities. Overall, the findings indicate that the bacterial communities inhabit, diversify, and develop specialized functions post-deglaciation leading to nutrient inputs to soil and vegetation development, which may provide feedback to climate change.

Impact of saturated treatments on HIV-TB dual epidemic as a consequence of COVID-19: optimal control with awareness and treatment.

In this study, we propose an HIV-TB co-infection model by considering the treatment provision limitation induced by recent COVID-19 pandemic that impacts this dual epidemic immensely, assimilating the significance of educational attempts. We analyze the model and its submodels with single infections individually. We obtain the awareness-induced basic reproduction numbers and discuss the global stability of disease-free equilibrium when provision limitation is zero. We observe that the submodels exhibit forward as well as backward bifurcations under provision restriction. Further, we derive thresholds for resource limitations regulating the dynamical behavior of the systems while analyzing the stability of endemic equilibrium of the models with single infections. Sophisticated simulation approaches are implemented to discover the influences of provision-restricted medication and awareness on dual epidemic. Our findings convey the persistence of co-infection though the basic reproduction number is below unity, if the provision restriction remains uncurbed. An observable insight is that, in spite of having epidemic threshold less than unity and no limitation in TB treatment, co-infection relapses and persists in the population, when there is no awareness attempt. Numerical findings emphasize the urgent need of increased treatment accessibility and importance of awareness in the current situation. Moreover, an optimization problem incorporating treatment and awareness controls is formulated and solved to find the ideal strategy to manage HIV-TB co-epidemic that recommends to diminish the medical resource limitation to get the enormous impact in dominating the adversity caused by COVID-19.

Impact of social media advertisements on the transmission dynamics of COVID-19 pandemic in India.

In this paper, we propose a mathematical model to assess the impact of social media advertisements in combating the coronavirus pandemic in India. We assume that dissemination of awareness among susceptible individuals modifies public attitudes and behaviours towards this contagious disease which results in reducing the chance of contact with the coronavirus and hence decreasing the disease transmission. Moreover, the individual's behavioral response in the presence of global information campaigns accelerate the rate of hospitalization of symptomatic individuals and also encourage the asymptomatic individuals for conducting health protocols, such as self-isolation, social distancing, etc. We calibrate the proposed model with the cumulative confirmed COVID-19 cases for the Republic of India. We estimate eight epidemiologically important parameters, and also the size of basic reproduction number for India. We find that the basic reproduction number for India is greater than unity, which represents the substantial outbreak of COVID-19 in the country. Sophisticated techniques of sensitivity analysis are employed to determine the impacts of model parameters on basic reproduction number and symptomatic infected population. Our results reveal that to reduce disease burden in India, non-pharmaceutical interventions strategies should be implemented effectively to decrease basic reproduction number below unity. Continuous propagation of awareness through the internet and social media platforms should be regularly circulated by the health authorities/government officials for hospitalization of symptomatic individuals and quarantine of asymptomatic individuals to control the prevalence of disease in India.

Studies on the Genesis and Proton Conductivity of Imidazole-Based Linear and Open-Framework Zinc Phosphites.

Three new zinc phosphites, [HIm]2[Zn3(HPO3)4] (1), [Zn2(HPO3)2Im2] (2), and [Zn(HPO3)Im] (3) (Im = imidazole), have been synthesized from the hydro/solvothermal reaction of zinc acetate, dimethyl phosphite, and imidazole by varying the temperature and solvent of the reaction medium. The structure of 1 is built from vertex-sharing of four HPO3-capped Zn3P3 units and adopts an open framework with 12-ring channels stabilized by HIm cations via N-H···O hydrogen bonds. For 2, the inorganic skeleton is comprised of alternating ZnO4 and HPO3 tetrahedra, while the coordinatively associated ZnN2O2 fragments occupy the 12-ring hexagonal channels. Compound 3 adopts a ladder-type one-dimensional structure and exhibits N-H···O hydrogen-bonding interactions to afford a supramolecular assembly. A plausible rationale on the genesis of 1-3 has been put forth by reacting the preformed inorganic zinc phosphites Zn{OP(O)(OMe)H}2 or [Zn2(HPO3)2(H2O)4]·H2O with imidazole as the structure-directing ligand. Alternating-current impedance measurements reveal that 1 and 3 exhibit proton conductivities on the order of 10-3-10-4 S cm-1 between 25 and 100 °C under 35 and 77% relative humidity in repeated impedance cycles (Ea = 0.22-0.35 eV). On the contrary, the conduction property is completely impaired in 2 under similar conditions.

Bifurcations, chaos, and multistability in a nonautonomous predator-prey model with fear.

Classical predator-prey models usually emphasize direct predation as the primary means of interaction between predators and prey. However, several field studies and experiments suggest that the mere presence of predators nearby can reduce prey density by forcing them to adopt costly defensive strategies. Adoption of such kind would cause a substantial change in prey demography. The present paper investigates a predator-prey model in which the predator's consumption rate (described by a functional response) is affected by both prey and predator densities. Perceived fear of predators leads to a drop in prey's birth rate. We also consider both constant and time-varying (seasonal) forms of prey's birth rate and investigate the model system's respective autonomous and nonautonomous implementations. Our analytical studies include finding conditions for the local stability of equilibrium points, the existence, direction of Hopf bifurcation, etc. Numerical illustrations include bifurcation diagrams assisted by phase portraits, construction of isospike and Lyapunov exponent diagrams in bi-parametric space that reveal the rich and complex dynamics embedded in the system. We observe different organized periodic structures within the chaotic regime, multistability between multiple pairs of coexisting attractors with intriguing basins of attractions. Our results show that even relatively slight changes in system parameters, perturbations, or environmental fluctuations may have drastic consequences on population oscillations. Our observations indicate that the fear effect alters the system dynamics significantly and drives an otherwise irregular system toward regularity.

Modeling the avoidance behavior of zooplankton on phytoplankton infected by free viruses.

In any ecosystem, chaotic situations may arise from equilibrium state for different reasons. To overcome these chaotic situations, sometimes the system itself exhibits some mechanisms of self-adaptability. In this paper, we explore an eco-epidemiological model consisting of three aquatic groups: phytoplankton, zooplankton, and marine free viruses. We assume that the phytoplankton population is infected by external free viruses and zooplankton get affected on consumption of infected phytoplankton; also, the infected phytoplankton do not compete for resources with the susceptible one. In addition, we model a mechanism by which zooplankton recognize and avoid infected phytoplankton, at least when susceptible phytoplankton are present. The zooplankton extinction chance increases on increasing the force of infection or decreasing the intensity of avoidance. Further, when the viral infection triggers chaotic dynamics, high zooplankton avoidance intensity can stabilize again the system. Interestingly, for high avoidance intensity, nutrient enrichment has a destabilizing effect on the system dynamics, which is in line with the paradox of enrichment. Global sensitivity analysis helps to identify the most significant parameters that reduce the infected phytoplankton in the system. Finally, we compare the dynamics of the system by allowing the infected phytoplankton also to share resources with the susceptible phytoplankton. A gradual increase of the virus replication factor turns the system dynamics from chaos to doubling state to limit cycle to stable state and the system finally settles down to the zooplankton-free equilibrium point. Moreover, on increasing the intensity of avoidance, the system shows a transcritical bifurcation from the zooplankton-free equilibrium to the coexistence steady state and remains stable thereafter.

Chaos in a nonautonomous eco-epidemiological model with delay.

In this paper, we propose and analyze a nonautonomous predator-prey model with disease in prey, and a discrete time delay for the incubation period in disease transmission. Employing the theory of differential inequalities, we find sufficient conditions for the permanence of the system. Further, we use Lyapunov's functional method to obtain sufficient conditions for global asymptotic stability of the system. We observe that the permanence of the system is unaffected due to presence of incubation delay. However, incubation delay affects the global stability of the positive periodic solution of the system. To reinforce the analytical results and to get more insight into the system's behavior, we perform some numerical simulations of the autonomous and nonautonomous systems with and without time delay. We observe that for the gradual increase in the magnitude of incubation delay, the autonomous system develops limit cycle oscillation through a Hopf-bifurcation while the corresponding nonautonomous system shows chaotic dynamics through quasi-periodic oscillations. We apply basic tools of non-linear dynamics such as Poincaré section and maximum Lyapunov exponent to confirm the chaotic behavior of the system.

Effect of active case finding on dengue control: Implications from a mathematical model.

Dengue control in India is a challenging task due to complex healthcare settings. In yesteryears, an amplification of dengue infections in India posed the need for introspection of existing dengue control policies. Prior understanding of the impacts of control interventions is necessary for their future implementation. In this paper, we propose and analyze a compartmental model of dengue to assess the impact of active case finding (ACF) on dengue disease transmission. Currently, primary prevention of dengue is possible only with vector control and personal protection from the bites of infected mosquitoes. Although a few experimental studies are performed to assess ACF in dengue disease, but this is the first attempt to represent and study the dynamics of disease using ACF as a control strategy. Local and global dynamics of the system are studied. We use sensitivity analysis to see the effects of controllable parameters of the model on the basic reproduction number and total number of infective population. We find that decrease in the biting rate of mosquitoes, and increase in the rate of hospitalization and/or notification, death rate of mosquitoes and ACF for asymptomatic and symptomatic individuals play crucial role for the reduction of disease prevalence. We calibrate our model to the yearly dengue cases in eight dengue endemic states of India. The results of our study show that ACF of symptomatic individuals will have significant effect on dengue case reduction but ACF of asymptomatic individuals cannot be ignored. Our findings indicate that the healthcare organizations must focus on ACF of symptomatic as well as asymptomatic individuals along with personal protection and mosquitoes control to achieve rapid reduction of dengue cases in India.

Production of novel rhamnolipids via biodegradation of waste cooking oil using Pseudomonas aeruginosa MTCC7815.

In this paper, Pseudomonas aeruginosa MTCC7815, a biosurfactant producing strain was studied for its ability to utilize waste cooking oil (WCO) as a sole carbon source for the production of biosurfactant. Culture conditions were optimized based on surface tension reduction and biomass concentration. The obtained biosurfactant was characterized using 1H NMR, FTIR, LC-MS, and MALDI-TOF techniques. The chemical properties of the produced biosurfactant were estimated by assessing the critical micelle concentration (CMC), emulsification index (E24) and oil displacement test. The optimal culture conditions were found to be similar to the natural domestic sewage such as basic pH value of 10, temperature of 25 °C and a very high WCO concentration of 40 gL-1 (C/N ratio of 40/1). The biosurfactant yield was found to be significant as 11 ± 0.2 gL-1 upon utilizing about 90% of WCO within 5 days of incubation. The biosurfactant produced was found to be a mixture of mono- and di-rhamnolipid in nature and comprised excellent surface active properties i.e. an extremely low CMC of 8.8 ± 0.3 mgL-1, E24 of 62.5 ± 0.3% and surface tension reduction up to 26.2 ± 0.5 mNm-1. These results suggest the suitability of Pseudomonas aeruginosa for the biosurfactant production at commercial scale along with waste remediation in an economic way.

Inpatient Flap Monitoring after Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction: How Long Is Long Enough?

BACKGROUND: There is a growing trend across health care to perform increasingly complex procedures in less acute settings. This shift has been fueled, in part, by enhanced recovery protocols, which have shortened hospital stays after major surgeries. We set out to determine the timing of microvascular complications after deep inferior epigastric artery perforator (DIEP) free flap breast reconstruction in a high-volume practice using continuous flap monitoring technologies. METHODS: The medical charts of all patients who underwent breast reconstruction with DIEP flaps over 24 consecutive months were reviewed. Postoperatively, all flaps were monitored according to a protocol that included continuous tissue oximetry with near-infrared spectroscopy. The primary end points evaluated included any unplanned return to the operating room, time to takeback, and flap loss rate. RESULTS: A total of 196 patients underwent breast reconstruction with a total of 301 DIEP flaps. Five of the flaps (1.7%) were taken back to the operating room for microvascular issues, and nine (3.0%) were taken back for nonvascular issues. Of patients who were brought back for microvascular issues, all five (100.0%) were initially identified by continuous noninvasive monitoring and taken back to the operating room within the first 14 hours (range: 1.2-13.6 hours). In the series, the flap failure rate was 0.66% (n = 2). CONCLUSION: All of the microvascular issues were detected in the initial 23 hours after surgery, leading to prompt flap salvage. The results of this study bring into question the need for lengthy flap monitoring protocols and suggest that shorter inpatient, or even observation admissions, may be reasonable, particularly when flap monitoring protocols incorporating continuous noninvasive flap monitoring are used.

Reconstruction of a large external hemipelvectomy defect after chordoma resection using a 5-component chimeric rotational flap.

Management of complex lumbosacral neoplastic disease presents unique challenges and requires a multidisciplinary approach. Large pelvic tumors may require external hemipelvectomy where an entire lower extremity including the hemipelvis is removed with disarticulation of the sacroiliac joint and symphysis pubis. When external hemipelvectomy is performed, the reconstructive surgeon must consider osseous reconstruction for structural pelvic support, the elimination of dead space, protection of implanted hardware, intra-abdominal support, and skin coverage. Reconstruction must minimize wound healing morbidity, operative time and the number of operative sites, and maximize the potential for rehabilitation. We present a case demonstrating use of a rotational chimeric flap for the reconstruction of an external hemipelvectomy defect.

Analysis of factors contributing to severity of breast cancer-related lymphedema.

BACKGROUND: Upper extremity lymphedema is a well-described complication of breast cancer treatment. Risk factors for lymphedema development include axillary lymph node dissection (ALND), obesity, increasing age, radiation, and postoperative complications. In this study, we seek to evaluate a cohort of patients who have either self-referred or been referred to the Department of Physical Therapy for lymphedema treatment. Our goal is to evaluate specific risk factors associated with the severity of lymphedema in this patient population. METHODS: All patients who presented to the Wexner Medical Center at the Ohio State University between January 1, 2009, and December 31, 2010, with a chief complaint of upper extremity lymphedema after breast cancer treatment were reviewed retrospectively. Upper extremity lymphedema index (UELI) was used as a severity indicator and patient factors including demographics and breast cancer treatments were evaluated. Univariate and multivariate statistical analyses were performed. RESULTS: Fifty (4.5%) patients presented for upper extremity lymphedema treatment after breast cancer treatment (total of 1106 patients treated surgically for breast cancer). Greater UELIs were found in patients 50 years and older, those with ALND, radiation, chemotherapy, pathologic stage greater than 3, and an International Society of Lymphology lymphedema stage II (P < 0.05). The multivariate model showed age older than 50 years and pathologic stage greater than 3 were significant predictors of higher UELI (P < 0.05). CONCLUSIONS: In this study, we report that in patients who present for lymphedema treatment, increased UELI is significantly related to ALND, radiation therapy, chemotherapy, age, and pathologic stage. An improved understanding of the patient population referred for lymphedema treatment will allow for the identification of patients who may be candidates for therapeutic intervention.

The impending shortage and cost of training the future plastic surgical workforce.

An expanding US population with increasing demand for aesthetic surgery, growing competition from other specialties, a constant rate of retiring plastic surgeons, and a static number of residents places increasing demands on the plastic surgical workforce in the coming years. Without certain changes, the plastic surgical workforce will be unable to meet their demand, and other specialties will increasingly encroach on aesthetic and reconstructive procedures. Given Census Bureau predictions for the US population, the numbers of residents allotted by the Balanced Budget Act of 1997, The American Board of Plastic Surgery data on the current plastic surgical workforce, and using a population-based analysis to predict future shortages in plastic surgery residents, the workforce shortage can be estimated as 800 residents in 2020 and up to 3223 residents in 2050. Based on previously reported figures, the additional cost in training these residents by 2050 is more than $1.5 billion.

Timing of prophylactic hysterectomy-oophorectomy, mastectomy, and microsurgical breast reconstruction in BRCA1 and BRCA2 carriers.

BACKGROUND: BRCA (breast cancer susceptibility gene) carriers are at high risk for breast and ovarian malignancies, and often undergo prophylactic total abdominal hysterectomy-bilateral salpingo-oophorectomy (TAH-BSO), bilateral mastectomy, and microsurgical breast reconstruction. Our goal was to determine whether abdominal wall complications and flap choice are affected by the order of those procedures. METHODS: All BRCA carriers who underwent microsurgical breast reconstruction between 2007 and 2012 were studied. Abdominal wall complications and changes in the reconstructive plan were analyzed depending on the order of breast reconstruction and TAH-BSO. RESULTS: 442 patients underwent 612 microsurgical breast reconstructions, 47 of whom were BRCA carriers. TAH-BSO was not a predictor of requiring mesh for fascial closure (OR 1.1, P = 0.8), or of hernia/bulge (OR = 1.6, P = 0.65). In five patients, a DIEP flap was altered to another flap as a direct result of prior TAH-BSO. Robotic TAH-BSO after breast reconstruction took longer to perform than before breast reconstruction (4.48 ± 1.00 hours vs. 3.23 ± 0.70 hours, respectively, P = 0.023), due to abdominal wall tightness. However, none were converted to open. Full-muscle free TRAM flaps (compared to other flaps) and bilateral reconstructions (compared to unilateral) were the only predictors of mesh (OR = 9.85, P < 0.001 and 4.01, P < 0.001), and hernia/bulge (OR = 6.18, P < 0.001 and 2.13, P = 0.07). The order of TAH-BSO and breast reconstruction did not affect complications. CONCLUSIONS: In BRCA carriers, the order of TAH-BSO and microsurgical breast reconstruction does not affect complication rates. However, prior TAH-BSO may make DIEP flaps unfeasible, and robotic TAH-BSO after breast reconstruction takes longer, but can still be performed safely.