Primary Cleft Lip and Palate Repair in Assam, India: Does Preoperative Anthropometric Analysis Help Identify Patients With Increased Surgical Risk in a Clinically Prescreened Population?

OBJECTIVE: To compare anthropometric z-scores with incidence of post-operative complications for patients undergoing primary cleft lip or palate repair. DESIGN: This was a retrospective observational analysis of patients from a surgical center in Assam, India, and includes a cohort from a single surgical mission completed before the opening of the center. SETTING: Patients included in the study underwent surgery during an Operation Smile mission before the opening of Operation Smile's Guwahati Comprehensive Cleft Care Center in Guwahati, India. The remaining cohort received treatment at the center. All patients received preoperative assessment and screening; surgery; and postoperative care, education, and follow-up. PATIENTS, PARTICIPANTS: Our sample size included 1941 patients and consisted of all patients with complete information in the database who returned for follow-up after receiving primary cleft lip repair or primary cleft palate repair between January 2011 and April 2013. INTERVENTIONS: Preoperative anthropometric measurements. MAIN OUTCOME MEASURE(S): Postoperative complications. RESULTS: Anthropometric z-scores were not a significant predictor of adverse surgical outcomes in the group analyzed. Palate surgery had increased risk of complication versus lip repair, with an overall odds ratio of 5.66 (P < .001) for all patients aged 3 to 228 months. CONCLUSIONS: Anthropometric z-scores were not correlated with increased risk of surgical complications, possibly because patients were well screened for malnutrition before surgery at this center. Primary palate repair is associated with an approximate fivefold increased risk of developing postoperative complication(s) compared with primary lip repair.

Erratum: Scar Revision Surgery: The Patient's Perspective.

[This corrects the article on p. 729 in vol. 42, PMID: 26618120.].

Scar Revision Surgery: The Patient's Perspective.

BACKGROUND: Insufficient satisfaction outcome literature exists to assist consultations for scar revision surgery; such outcomes should reflect the patient's perspective. The aim of this study was to prospectively investigate scar revision patient satisfaction outcomes, according to specified patient-selection criteria. METHODS: Patients (250) were randomly selected for telephone contacting regarding scar revisions undertaken between 2007-2011. Visual analogue scores were obtained for scars pre- and post-revision surgery. Surgery selection criteria were; 'presence' of sufficient time for scar maturation prior to revision, technical issues during or wound complications from the initial procedure that contributed to poor scarring, and 'absence' of site-specific or patient factors that negatively influence outcomes. Patient demographics, scar pathogenesis (elective vs. trauma), underlying issue (functional/symptomatic vs. cosmetic) and revision surgery details were also collected with the added use of a real-time, hospital database. RESULTS: Telephone contacting was achieved for 211 patients (214 scar revisions). Satisfaction outcomes were '2% worse, 16% no change, and 82% better'; a distribution maintained between body sites and despite whether surgery was functional/symptomatic vs. cosmetic. Better outcomes were reported by patients who sustained traumatic scars vs. those who sustained scars by elective procedures (91.80% vs. 77.78%, P=0.016) and by females vs. males (85.52% vs. 75.36%, P<0.05), particularly in the elective group where males (36.17%) were more likely to report no change or worse outcomes versus females (16.04%) (P<0.01). CONCLUSIONS: Successful scar revision outcomes may be achieved using careful patient selection. This study provides useful information for referring general practitioners, and patient-surgeon consultations, when planning scar revision.

Best BETs from the Manchester Royal Infirmary. BET 1: intranasal lorazepam is an acceptable alternative to intravenous lorazepam in the control of acute seizures in children.

A short-cut review was carried out to determine whether intranasal lorazepam was as effective as intravenous lorazepam in the control of seizures in children. Eighteen papers were found using the reported search, of which one was directly relevant and another compared intranasal lorazepam with intramuscular paraldehyde. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses are shown in table 1. It is concluded that intranasal lorazepam appears to be a safe and effective treatment for this condition.

Estrogen alters the splicing of type 1 corticotropin-releasing hormone receptor in breast cancer cells.

Hormonal stress response is associated with the pathogenesis of disease, including cancer. The role of the stress hormone CRH (corticotropin-releasing hormone) in breast cancer is complex, and its abundance and biological activity may be modulated by estrogen. In the estrogen receptor-positive (ER+) malignant mammary epithelial cell line MCF7, CRH activated numerous kinases and downstream effectors, at least some of which were mediated by the CRH receptor type 1 (CRH-R1). CRH also increased the transcription of many genes that encode effectors, transcriptional targets, or regulators associated with estrogen signaling. Estrogen increased the abundance of the mRNA encoding CRH-R2 and an alternative splice variant encoding CRH-R1 in which exon 12 was deleted [CRH-R1(Δ12)]. Estrogen inhibited the expression SRSF6, which encodes serine/arginine-rich splicing factor 55 (SRp55). An increase in CRH-R1(Δ12), in response to either estrogen or SRp55 knockdown, dampened the cellular response to CRH and prevented its inhibitory effects on cell invasion. SRp55 knockdown also induced additional splicing events within exons 9 to 12 of CRH-R1, whereas overexpression of SRp55 prevented estrogen-induced generation of CRH-R1(Δ12). ER+ breast tumors had increased CRH-R2 and CRH-R1(Δ12) mRNA abundance, which was associated with decreased abundance of the mRNA encoding SRp55, compared with the amounts in ER- tumors, suggesting that estrogen contributes to the pathophysiology of ER+ breast cancer by altering CRH receptor diversity and disrupting CRH-mediated signaling.

The role of autologous fat grafting in secondary microsurgical breast reconstruction.

BACKGROUND: Autologous breast reconstruction offers higher rates of patient satisfaction, but not all patients are ideal candidates, often due to inadequate volume of donor sites. Although autologous fat grafting is frequently used to augment volume and contour abnormalities in implant-based breast reconstruction, its clear utility in microsurgical breast reconstruction has yet to be defined. Here, we examined patients undergoing autologous microsurgical breast reconstruction with and without the adjunct of autologous fat grafting to clearly define utility and indications for use. METHODS: A retrospective review of all patients undergoing autologous breast reconstruction with microvascular free flaps at a single institution between November 2007 and October 2011 was conducted. Patients were divided into 2 groups as follows: those requiring postoperative fat grafting and those not requiring fat grafting. Patient demographics, indications for surgery, history of radiation therapy, patient body mass index, mastectomy specimen weight, need for rib resection, flap weight, and complications were analyzed in comparison. RESULTS: Two hundred twenty-eight patients underwent 374 microvascular free flaps for breast reconstruction. One hundred (26.7%) reconstructed breasts underwent postoperative fat grafting, with an average of 1.12 operative sessions. Fat was most commonly injected in the medial and superior medial poles of the breast and the average volume injected was 147.8 mL per breast (22-564 mL). The average ratio of fat injected to initial flap weight was 0.59 (0.07-1.39). Patients undergoing fat grafting were more likely to have had deep inferior epigastric perforator and profunda artery perforator flaps as compared to muscle-sparing transverse rectus abdominis myocutaneous. Patients additionally were more likely to have a prophylactic indication 58% (n = 58) versus 42% (n = 117) (P = 0.0087), rib resection 68% (n = 68) versus 54% (n = 148) (P < 0.0153), and acute postoperative complications requiring operative intervention 7% (n = 7) versus 2.1% (n = 8) (P < 0.0480). Additionally, patients undergoing autologous fat grafting had smaller body mass index, mastectomy weight, and flap weight. CONCLUSIONS: Fat grafting is most commonly used in those breasts with rib harvest, deep inferior epigastric perforator flap reconstructions, and those with acute postoperative complications. It should be considered a powerful adjunct to improve aesthetic outcomes in volume-deficient autologous breast reconstructions and additionally optimize contour in volume-adequate breast reconstructions.

Lentiviral vectors express chondroitinase ABC in cortical projections and promote sprouting of injured corticospinal axons.

Several diseases and injuries of the central nervous system could potentially be treated by delivery of an enzyme, which might most effectively be achieved by gene therapy. In particular, the bacterial enzyme chondroitinase ABC is beneficial in animal models of spinal cord injury. We have adapted the chondroitinase gene so that it can direct secretion of active chondroitinase from mammalian cells, and inserted it into lentiviral vectors. When injected into adult rat brain, these vectors lead to extensive secretion of chondroitinase, both locally and from long-distance axon projections, with activity persisting for more than 4 weeks. In animals which received a simultaneous lesion of the corticospinal tract, the vector reduced axonal die-back and promoted sprouting and short-range regeneration of corticospinal axons. The same beneficial effects on damaged corticospinal axons were observed in animals which received the chondroitinase lentiviral vector directly into the vicinity of a spinal cord lesion.