Patient Characteristics Associated with Free Nipple Graft Reduction Mammoplasty.

PURPOSE: Surgical approaches for reduction mammoplasty most commonly incorporate a parenchymal vascular pedicle. For patients with larger breasts where pedicle viability may be compromised due to excessive length, the free nipple graft (FNG) technique provides a safe alternative. Criteria for whether a patient should undergo a FNG remains controversial due to variable reports in the literature with small sample sizes and inherent surgeon-dependent bias. To address this, we sought to investigate perioperative factors associated with performing FNGs at our institution in order to better elucidate specific indications for this surgery. METHODS: A retrospective chart review was performed for 323 patients who underwent a reduction mammoplasty from August 2009 to July 2019 at Keck Hospital and LAC+USC Medical Center. Data regarding patient demographics, comorbidities, pre-operative breast characteristics, and post-operative complications were extracted. Student's t-test, Fisher's exact test, and logistic regression were performed in R. RESULTS: Of 323 patients, 15 received an FNG. Independent variables analyzed included: age, body mass index (BMI), obesity, smoking, diabetes, hypertension, surgical indication, sternal notch-to-nipple length, nipple-to-inframammary fold length, and weight of breast specimens removed. BMI, obesity, gigantomastia, and weight of specimen resected were significantly associated with use of the FNG (p < 0.001, p < 0.05, p < 0.0001, p < 0.0001, respectively). Regression analysis revealed that patients who had an average of more than 1500 g of tissue removed from each breast were 1.41 (95% CI: 1.17-1.71, p<0.001) times more likely to undergo an FNG procedure than those who had less than 1500 g of tissue removed. Demographic data and breast characteristics, such as notch-to-nipple length and nipple-to-inframammary fold length, were not significantly associated. CONCLUSION: Total weight of the breast specimens removed and BMI were significantly associated with the FNG technique. Removing more than 1500 g gof total breast tissue was also significantly correlated. These findings may guide surgeons during the decision-making process of when to use an FNG.

Peritoneal Dialysis Patient Outcomes under the Medicare Expanded Dialysis Prospective Payment System.

BACKGROUND AND OBJECTIVES: Peritoneal dialysis (PD) use increased in the United States with the introduction of a new Medicare prospective payment system in January 2011 that likely reduced financial disincentives for facility use of this home therapy. The expansion of PD to a broader population and facilities having less PD experience may have implications for patient outcomes. We assessed the impact of PD expansion on PD discontinuation and patient mortality. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A prospective cohort study was conducted of patients treated with PD at 90 days of ESKD. Patients were grouped by study start date relative to the Medicare payment reform: prereform (July 1, 2008 to December 31, 2009; n=10,585), interim (January 1, 2010 to December 31, 2010; n=7832), and reform period (January 1, 2011 to December 31, 2012; n=18,742). Patient characteristics and facility PD experience were compared at baseline (day 91 of ESKD). Patients were followed for 3 years for the major outcomes of PD discontinuation and mortality using Cox proportional hazards models. RESULTS: Patient characteristics, including age, sex, race, ethnicity, rurality, cause of ESKD, and comorbidity, were similar or showed small changes across the three study periods. There was an increasing tendency for patients on PD to be treated in facilities with less PD experience (from 34% during the prereform period being treated in facilities averaging <14 patients on PD per year to 44% in the reform period). Patients treated in facilities with less PD experience had a higher rate of PD discontinuation than patients treated in facilities with the most experience (hazard ratio [HR], 1.16; 95% confidence interval [95% CI], 1.10 to 1.23 for the first versus fifth quintile of PD experience). Nevertheless, the risk of PD discontinuation fell during the late interim period (HR, 0.88; 95% CI, 0.82 to 0.95) and most of the reform period (from HR, 0.85; 95% CI, 0.79 to 0.91 to HR, 0.94; 95% CI, 0.87 to 1.01). Mortality risk was stable across the three study periods. CONCLUSIONS: In the context of expanding PD use and declining facility PD experience, the risk of PD discontinuation fell, and there was no adverse effect on mortality. PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_09_12_CJN01610219.mp3.

Mesenchymal Stromal Cells Isolated from Irradiated Human Skin Have Diminished Capacity for Proliferation, Differentiation, Colony Formation, and Paracrine Stimulation.

Ionizing radiation, commonly used in the treatment of solid tumors, has unintended but deleterious effects on overlying skin and is associated with chronic nonhealing wounds. Skin-derived mesenchymal stromal cells (SMSCs) are a pluripotent population of cells that are critically involved in skin homeostasis and wound healing. The aim of this study was to isolate and functionally characterize SMSCs from human skin that was previously irradiated as part of neoadjuvant or adjuvant cancer therapy. To this end, SMSCs were isolated from paired irradiated and nonirradiated human skin samples. Irradiated SMSCs expressed characteristic SMSC markers at lower levels, had disorganized cytoskeletal structure, and had disordered morphology. Functionally, these cells had diminished proliferative capacity and substantial defects in colony-forming capacity and differentiation in vitro. These changes were associated with significant differential expression of genes known to be involved in skin physiology and wound healing. Conditioned media obtained from irradiated SMSCs affected fibroblast but not endothelial cell proliferation and migration. These results suggest that in situ damage to SMSCs during neoadjuvant or adjuvant radiation may play a critical role in the pathogenesis of slow or nonhealing radiation wounds. Stem Cells Translational Medicine 2019;8:925&934.

Payment Reform and Health Disparities: Changes in Dialysis Modality under the New Medicare Dialysis Payment System.

OBJECTIVE: To evaluate the effect of the Medicare dialysis payment reform on potential disparities in the selection of peritoneal dialysis (PD) for the treatment of end-stage renal disease (ESRD). DATA SOURCES: Centers for Medicare & Medicaid Services (CMS) ESRD Medical Evidence Form, Medicare claims, and other CMS data for 2008-2013. STUDY DESIGN: We examined the association of patient age, race/ethnicity, urban/rural location, pre-ESRD care, comorbidities, insurance, and other factors with the selection of PD as initial dialysis modality across prereform (2008-2009), interim (2010), and postreform (2011-2013) time periods. PRINCIPAL FINDINGS: Selection of PD increased among diverse patient subgroups following the payment reform. However, the lower PD selection observed with older age, black race, Hispanic ethnicity, less pre-ESRD care, and Medicaid insurance before the reform largely remained in the initial postreform years. CONCLUSIONS: Despite recent growth in PD, there may be ongoing disparities in access to PD that have largely not been mitigated by the payment reform. There is potential for modifying provider financial incentives to achieve policy goals related to cost and quality of care. However, even with a substantial shift in financial incentives, separate initiatives to reduce existing disparities in care may be needed.

Topical Fibronectin Improves Wound Healing of Irradiated Skin.

Wound healing is significantly delayed in irradiated skin. To better understand global changes in protein expression after radiation, we utilized a reverse phase protein array (RPPA) to identify significant changes in paired samples of normal and irradiated human skin. Of the 210 proteins studied, fibronectin was the most significantly and consistently downregulated in radiation-damaged skin. Using a murine model, we confirmed that radiation leads to decreased fibronectin expression in the skin as well as delayed wound healing. Topically applied fibronectin was found to significantly improve wound healing in irradiated skin and was associated with decreased inflammatory infiltrate and increased angiogenesis. Fibronectin treatment may be a useful adjunctive modality in the treatment of non-healing radiation wounds.

Laser applications in surgery.

In modern medicine, lasers are increasingly utilized for treatment of a variety of pathologies as interest in less invasive treatment modalities intensifies. The physics behind lasers allows the same basic principles to be applied to a multitude of tissue types using slight modifications of the system. Multiple laser systems have been studied within each field of medicine. The term "laser" was combined with "surgery," "ablation," "lithotripsy," "cancer treatment," "tumor ablation," "dermatology," "skin rejuvenation," "lipolysis," "cardiology," "atrial fibrillation (AF)," and "epilepsy" during separate searches in the PubMed database. Original articles that studied the application of laser energy for these conditions were reviewed and included. A review of laser therapy is presented. Laser energy can be safely and effectively used for lithotripsy, for the treatment of various types of cancer, for a multitude of cosmetic and reconstructive procedures, and for the ablation of abnormal conductive pathways. For each of these conditions, management with lasers is comparable to, and potentially superior to, management with more traditional methods.

Breast implants and minimally invasive cardiac surgery: a case series.

INTRODUCTION: The number of women affected by valvular heart disease and the number of women with breast implants are both on the rise. Minimally invasive heart surgery using a limited thoracotomy offers many potential benefits including reduction in blood loss, shorter hospital stay, faster recovery time, decreased pain, and improved cosmesis. Minimally invasive heart surgery often requires access to the second, third, or fourth intercostal space of the anterior chest wall. The presence of a breast implant may interfere with the surgeon's ability to gain adequate exposure for entry to the appropriate intercostal space. We present a case series of 5 women with breast implants who successfully underwent minimally invasive cardiac valve surgery. METHODS: A retrospective review was conducted of all patients with breast implants who underwent minimally invasive cardiac valve surgery at the University of Southern California University Hospital. In each patient, an inframammary incision was performed, facilitating removal of the implant, performance of the cardiac operation, and reimplantation of the implant. RESULTS: Five women with breast implants who underwent minimally invasive cardiac valve surgery were identified; of these, 4 (80%) patients underwent repair of the mitral valve for mitral regurgitation, whereas 1 (20%) underwent an aortic valve replacement for aortic stenosis. Two patients underwent a concomitant maze procedure for atrial fibrillation during the same operation. The median follow-up time was 7.4 months, and the follow-up period ranged from 2 to 12 months. There were no significant postoperative complications such as infection, hematoma, or need for reoperation. CONCLUSIONS: Our series of 5 patients demonstrates that minimally invasive heart surgery performed through an inframammary incision can be safely performed in those with breast implants.