Comparison of N···I and N···O Halogen Bonds in Organoiodine Cocrystals of Heterocyclic Aromatic Diazine Mono-N-oxides.

A series of cocrystals of halogen bond donors 1,4-diiodotetrafluorobenzene (p-F4DIB) and tetraiodoethylene (TIE) with five aromatic heterocyclic diazine mono-N-oxides based on pyrazine, tetramethylpyrazine, quinoxaline, phenazine, and pyrimidine as halogen bonding acceptors were studied. Structural analysis of the mono-N-oxides allows comparison of the competitive occurrence of N···I vs O···I interactions and the relative strength and directionality of these two types of interactions. Of the aromatic heterocyclic diazine mono-N-oxide organoiodine cocrystals examined, six exhibited 1:1 stoichiometry, forming chains that utilized both N···I and O···I interactions. Two cocrystals presented 1:1 stoichiometry with exclusive O···I interactions. Two cocrystals displayed a 2:1 stoichiometry-one characterized solely by O···I interactions and the other solely by N···I interactions. We have also compared these interactions to those present in the corresponding diazines, some of which we report here and some which have been previously reported. In addition, a computational analysis using density functional theory (M062X/def2-SVPD) was performed on these two systems and has been compared to the experimental results. The calculated complex formation energies were, on average, 4.7 kJ/mol lower for the I···O halogen bonding interaction as compared to the corresponding N···I interaction. The average I···O interaction distances were calculated to be 0.15 Å shorter than the corresponding I···N interactions.

Custom 3D-Printed External Cranial Orthotic for Prevention and Treatment of Syndrome of the Trephined.

Syndrome of the Trephined (SoT) is a frequently misunderstood and underdiagnosed outcome of decompressive craniectomy, especially in cases of trauma. The pressure gradient between atmospheric pressure and the sub-atmospheric intracranial pressure results in a sinking of the scalp overlying the craniectomy site. This gradually compresses the underlying brain parenchyma. This parenchymal compression can disrupt normal autoregulation and subsequent metabolism, yielding symptoms ranging from headaches, dizziness, altered behavior to changes in sensation, and difficulty with ambulation, coordination, and activities of daily living. We present a case of SoT treated with a 3D-printed custom polycarbonate external cranial orthotic that allowed us to re-establish this pressure gradient by returning the cranium to a closed system. The patient demonstrated subjective improvement in quality of life and his symptoms. This was consistent with the re-expanded brain parenchyma on CT imaging.

Regenerative Peripheral Nerve Interface Surgery: Anatomic and Technical Guide.

Regenerative peripheral nerve interface (RPNI) surgery has been demonstrated to be an effective tool as an interface for neuroprosthetics. Additionally, it has been shown to be a reproducible and reliable strategy for the active treatment and for prevention of neuromas. The purpose of this article is to provide a comprehensive review of RPNI surgery to demonstrate its simplicity and empower reconstructive surgeons to add this to their armamentarium. This article discusses the basic science of neuroma formation and prevention, as well as the theory of RPNI. An anatomic review and discussion of surgical technique for each level of amputation and considerations for other etiologies of traumatic neuromas are included. Lastly, the authors discuss the future of RPNI surgery and compare this with other active techniques for the treatment of neuromas.

Infiltrating Wound Vacuum-Assisted Closure With Topical Amphotericin for Mucormycosis Infection of the Achilles Tendon.

Background: The rarity and heterogeneity of mucormycosis make treatment variable, and no prospective or randomized clinical trials exist in plastic surgery literature. The use of wound vacuum-assisted closure in combination with the instillation of amphotericin B to treat cutaneous mucormycosis is not well documented. Case Presentation: A 53-year-old man underwent left Achilles tendon reconstruction with allograft after a complete tear during exercise. About 1 week after the operation, he began having incisional breakdown later found to be secondary to mucormycosis infection, prompting presentation to an emergency department. The use of negative pressure wound therapy with wound vacuum-assisted closure and intervals of instilling amphotericin B facilitated infection control in this lower extremity mucormycosis infection. Conclusions: Patients with a localized mucormycosis infection may benefit from treatment with an instillation wound vacuum-assisted closure with topical amphotericin B as presented in this case study.

The Intercostal Artery Perforator Flap: Expanding Breast-Conserving Therapy With a Modified Oncoplastic Approach.

BACKGROUND: Historically, breast-conserving surgery may not be pursued when the oncologic deformity is too significant and/or not tolerant of radiotherapy. Reconstruction using recruitment of upper abdominal wall tissue based on the intercostal artery perforating vessels can expand breast conservation therapy indications for cases that would otherwise require mastectomy. This report aims to describe the expanded use of the intercostal artery perforator (ICAP) as well as detail its ease of adoption. METHODS: All patients who underwent ICAP flaps for reconstruction of partial mastectomy defects at a single institution were included. Demographic data, intraoperative data, and postoperative outcomes were recorded. Intercostal artery perforator flap outcomes are compared with standard alloplastic reconstruction after mastectomy. RESULTS: Twenty-seven patients received ICAP flaps compared with 27 unilateral tissue expanders (TE). Six cases included nipple-areolar reconstruction, and 6 included skin resurfacing. The average defect size was 217.7 (30.3-557.9) cm 3 . Plastic-specific operative time was significantly longer in the ICAP cohort ( P < 0.01) with no difference in total operative time ( P > 0.05). Length of stay was significantly longer, and major postoperative complications were significantly more common in TE patients ( P < 0.01, P > 0.05). Seven TE patients required outpatient opiate refills (26%) versus 1 ICAP patient (4%) ( P = 0.02). One ICAP patient required additional surgery. Patients reported satisfaction with aesthetic outcomes. Average follow-up in the ICAP cohort was 7 months. CONCLUSIONS: Lumpectomy reconstruction using ICAP flaps can effectively expand breast conservation therapy indications in resection of breast skin, nipple-areola, or large volume defects. This technique is adoptable and of limited complexity. Enhancing breast-conserving surgery may improve outcomes compared with mastectomy reconstruction. Intercostal artery perforator patients may require fewer opioids, shorter hospital stays, and lower operative burden.

Rise of Acellular Dermal Matrix: Cost Consciousness, Industry Payment, and Publication Productivity.

BACKGROUND: Despite high cost and lack of FDA approval for breast surgery, acellular dermal matrix (ADM) has become commonplace in reconstructive surgery and has been the focus of more than 500 plastic surgery publications since its wide adoption. We hypothesized that ADM-related academic output would correlate with public interest and industry funding. STUDY DESIGN: All PubMed-indexed studies focusing on ADM in 11 plastic surgery journals were included (n = 535). Data on industry funding to the 17 most productive authors were extracted from the Open Payments Database. Google Trends in "breast surgery cost" and related terms were queried. Relationships among publication quantity, author industry funding, and public interest were analyzed by Pearson's correlation and linear regression. RESULTS: The most published authors produced 8 qualifying publications on average (range 5 to 17), with 80% focused on breast surgery. These individuals grossed a total of $19 million industry dollars overall with $17 million (89%) in nonconsulting compensation from ADM-producing companies (NC-ADM). Individual total compensation and NC-ADM compensation, by quartile, were $194,000/$320,000/$1.25 million and $17,000/$210,000/$1.1 million, respectively. These variables showed strong correlation with individual publication rate with a linear regression coefficient of $110K in NC-ADM per publication (p < 0.01). Authors disclosed funding in a mean ± SD of 65 ± 26% of their work with strong correlation between disclosure and NC-ADM (p < 0.01). Google "breast surgery cost" search volume has grown rapidly in significant correlation with ADM publications (p = 0.02). CONCLUSIONS: This study demonstrates significant correlation between ADM-related publication, industry funding, funding disclosure, and public interest. Education in the potential for such relationships and the importance of objectivity in plastic surgery warrants discussion.

Impact of ACAPS Coordinated Interview Release Policy: Applicant and Program Attitudes, Adherence, and Interview Trends.

BACKGROUND: The authors studied the impact of a new, coordinated interview release date for integrated plastic surgery residencies. METHODS: A cross-sectional study of all 2020 integrated plastic surgery residencies and applicants was performed. Voluntary, anonymous surveys were administered following implementation of the interview policy. RESULTS: Program response rates were 55.6% for the initial survey and 57.1% for the follow-up survey. Programs released an average of 2.1 (95% CI, 1.8 to 2.4) rounds of interview invitations and invited 39.0 (95% CI, 35.3 to 42.6) applicants to interview. Policy adherence was high (91.1%). Most programs believed the interview policy was an improvement for applicants (46.5% yes; 9.1% no) and programs (41.9% yes; 27.0% no). Median rank of matched candidates was 13, and 55.1% of programs matched candidates within the top quartile of their rank list. The average candidate applied to 72 programs, attended 11 interviews, and ranked 12 programs. Interview distribution was bimodal, with peaks at six and 15 total interview invitations. Applicants within the top fifth, tenth, and fifteenth percentile for total interview invites disproportionately accounted for 15.3%, 26.6%, and 36.5%, respectively, of all invitations received. Survey data suggested applicant satisfaction with travel planning, improved scheduling, and cost savings following implementation of the interview policy. Applicants were somewhat dissatisfied with interview distribution. CONCLUSIONS: A coordinated interview release date is facile to adopt and does not adversely impact program interview trends or match rates. Applicants benefit from improved scheduling, travel planning, and cost savings; however, interview distribution continues to favor top-tier candidates.

Virtual Surgical Subinternships: Course Objectives and a Proposed Curriculum.

BACKGROUND: Due to the recent COVID-19 pandemic, patient care and medical education have faced many significant changes. The Association of American Medical Colleges and the American Council of Academic Plastic Surgery officially recommended halting all student rotations and interviews for the year. This change has unfortunately fallen squarely at the onset of a vital season for education and recruitment of plastic surgery subinterns. This article presents a curriculum for a single institution's virtual surgical subinternship to help inspire ideas and inspiration for programs developing their own virtual subinternships. METHODS: The goals for the virtual surgical subinternship are focused on student preparation for residency and remain similar to those outlined by the core competencies for in-person rotations. The first virtual subinternship in plastic surgery modeled after the curriculum presented was offered as a 2-week course starting May of 2020. RESULTS: The components of the curriculum include a self-study syllabus, virtual case reviews, virtual suture laboratory, educational teleconferences, participation in research, and mentorship meetings. The 2-week course has approximately 25 hours of conferences and teaching, involving direct interaction with residents and faculty, and approximately 15 hours of self-directed learning. CONCLUSIONS: To the authors' knowledge, this was the first virtual subinternship offered for rising fourth-year medical students. They strongly encourage other residency training programs to offer similar virtual learning opportunities for medical students, particularly for those without access to a home plastic surgery training program. The curriculum presented in this article is simply to provide ideas, inspiration, and a potential framework for programs wishing to create similar virtual learning opportunities.

Long-Term Treatment Outcomes of Primary Alveolar Bone Grafts for Alveolar Clefts: A Qualitative Systematic Review.

BACKGROUND: Alveolar bone grafting is utilized to manage alveolar clefts in patients with cleft lip and palate. However, the timing of bone grafting is variable with conflicting evidence supporting the use of primary alveolar bone grafting (PABG) in clinical practice. PRIMARY AIM: To provide a qualitative systematic review analysis of long-term outcomes after PABG. MATERIALS AND METHODS: A qualitative systematic review was performed following the Cochrane Handbook and reported using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Summative findings were evaluated using Confidence in the Evidence from Reviews of Qualitative research to assess the quality of evidence supporting the findings. RESULTS: After removing duplication, 2182 publications were identified, and 2131 were excluded after screening through titles and abstracts. Inclusion criteria for this study included patients who underwent PABG at 24 months of age or younger and a minimum of 5 year follow-up. Thirty-two publications met the inclusion criteria and were included for qualitative analysis. Primary outcome measures included cephalometric analysis, bone graft survival, occlusal analysis, hypomineralization, tooth eruption, radiograph analysis, and arch relationships. Four assessment themes were characterized from the systematic review: (1) bone graft survival, (2) craniofacial skeletal relationships, (3) occlusion and arch forms, and (4) recommendations for utilizing PABG in practice. CONCLUSION: The reported systematic review provides evidence that performing PABG leads to poor long-term outcomes related to bone graft survival and maxillary growth restriction despite some reported positive outcomes.

Reduction of Work-Related Musculoskeletal Disorders in Plastic Surgeons by Introduction of a Posture Training Device.

BACKGROUND: Plastic surgeons have an increased risk for the development of musculoskeletal disorders because of frequent poor ergonomics of the operating room. This study characterizes selected plastic surgery procedures, with an attempt to identify high-risk procedures and procedural components as well as the impact of biofeedback on surgical ergonomics. METHODS: A commercially available posture training device was used to initially record neck and spine positioning and later to send biofeedback to prompt surgeons to correct posture. Device data were correlated with in-person observations to characterize factors associated with more time spent in the slouched/nonneutral cervical and thoracic spine posture. RESULTS: The proportion of time spent in the upright position during surgery was significantly different among male and female participants, level of training, participant height, in the sitting versus nonsitting positioning (P < 0.001), with loupes use, and if there was more than an 8-inch height difference between 2 participants (mean, 0.70 ± 0.285). Using the device intervention, all participants spent a larger proportion of operating time upright. Half of these improvements in posture were statistically significant. While in feedback mode, participants experienced shorter and more frequent periods of slouching/nonneutral posture. When comparing the same participant performing the same procedure with and without device biofeedback, 72.2% of participants spent more time in the upright/neutral posture during the surgery when the device was sending feedback. CONCLUSIONS: Biofeedback devices used in the operating room can lead to improved surgical posture, which may translate to reduction of workplace injuries, and overall physician health. This study found that a commercially available posture training device and sitting stools in the operating room could significantly improve physician cervical and thoracic spine posture.

Disparity in Opportunities: Is It Harder to Match Into Plastic Surgery Residency Without a Home Plastic Surgery Division?

ABSTRACT: Medical students pursuing plastic surgery training must overcome multiple challenges to successfully match in such a highly coveted subspecialty. This adversity is amplified in applicants from medical schools without a home plastic surgery residency program and academic division. There is a paucity of data on the advantage of medical students applying from an institution with a home residency program. Applicant data from the past 5 years were accessed from the Association of American Medical Colleges Electronic Residency Application Services statistics form. Individual home programs of successfully matched applicants were collected from plastic surgery residency websites. A survey was distributed to 32 students pursuing specialty residencies from home medical schools without a plastic surgery residency. Evaluation of a subset of incoming plastic surgery interns revealed that 72% of matched applicants attended home medical institutions with plastic surgery residency programs. Seventy-seven percent of survey respondents felt strongly that students at institutions with home residency programs had a significant advantage. The current COVID pandemic is changing the landscape of subinternships and bringing to light the disadvantage students face without home residency programs. The development of virtual subinternships, online mentorship, and selection of students for subinternships from geographic areas without home programs may help address some disparities in educational opportunities. Continuing these virtual programs and offering preferential help to disadvantaged medical students permanently is an avenue for the field of plastic surgery to be a leader in diversity and inclusion.

The Influence of Academic Pedigree on Integrated Plastic Surgery Resident Training Location.

INTRODUCTION: Plastic surgery residencies are among the most competitive programs for graduate medical education. While board scores and research output are well-studied indicators of match success, no studies describe the association between an applicant's medical school ranking and subsequent residency ranking. METHODS: A cross-sectional study of integrated plastic surgery residents for the 2019 to 2020 academic year was performed. Integrated plastic surgery residency programs were ranked according to 2020 Doximity Residency Navigator. AAMC-affiliated allopathic medical schools were ranked according to US News & World Report 2020 Best Medical Schools. Multiple regression analysis was used to determine if academic pedigree predicted placement at highly competitive plastic surgery residency programs. RESULTS: A total of 914 residents across 69 integrated plastic surgery residency programs were included. Ten medical schools accounted for 169 (18.4%) of all trainees. 159 (16.5%) matched at their home program for residency. Medical school ranking and medical school-affiliated integrated plastic surgery program ranking were significant predictors of match success and future residency competitiveness. The presence of an affiliated plastic surgery residency program predicted total number of medical school graduates who matriculated into plastic surgery residency (p < 0.0005). Graduates of top-ranked schools represented a disproportionate number of current plastic surgery residents (Top 10 program: 12.5%, Top 20: 24.1%, Top 40: 40.9%, Top 50: 49.1%). CONCLUSIONS: Both medical school ranking and home plastic surgery program ranking appeared to influence match success and future residency training program competitiveness. This is the first study to demonstrate these associations.

Infection and mortality of healthcare workers worldwide from COVID-19: a systematic review.

OBJECTIVES: To estimate COVID-19 infections and deaths in healthcare workers (HCWs) from a global perspective during the early phases of the pandemic. DESIGN: Systematic review. METHODS: Two parallel searches of academic bibliographic databases and grey literature were undertaken until 8 May 2020. Governments were also contacted for further information where possible. There were no restrictions on language, information sources used, publication status and types of sources of evidence. The AACODS checklist or the National Institutes of Health study quality assessment tools were used to appraise each source of evidence. OUTCOME MEASURES: Publication characteristics, country-specific data points, COVID-19-specific data, demographics of affected HCWs and public health measures employed. RESULTS: A total of 152 888 infections and 1413 deaths were reported. Infections were mainly in women (71.6%, n=14 058) and nurses (38.6%, n=10 706), but deaths were mainly in men (70.8%, n=550) and doctors (51.4%, n=525). Limited data suggested that general practitioners and mental health nurses were the highest risk specialities for deaths. There were 37.2 deaths reported per 100 infections for HCWs aged over 70 years. Europe had the highest absolute numbers of reported infections (119 628) and deaths (712), but the Eastern Mediterranean region had the highest number of reported deaths per 100 infections (5.7). CONCLUSIONS: COVID-19 infections and deaths among HCWs follow that of the general population around the world. The reasons for gender and specialty differences require further exploration, as do the low rates reported in Africa and India. Although physicians working in certain specialities may be considered high risk due to exposure to oronasal secretions, the risk to other specialities must not be underestimated. Elderly HCWs may require assigning to less risky settings such as telemedicine or administrative positions. Our pragmatic approach provides general trends, and highlights the need for universal guidelines for testing and reporting of infections in HCWs.

Secondary Abdominoplasty: Management of the Umbilicus after Prior Stalk Transection.

Patients with prior umbilical stalk detachment, secondary to limited abdominoplasty or prior umbilical hernia repair, may in the future be candidates for full abdominoplasty. In these patients, a circumferential incision around the umbilicus detaches the remaining cutaneous blood supply, prompting concern for umbilical viability. Minimal literature exists to guide clinical decision-making for these patients. Inquiries were made to Louisiana Society of Plastic Surgery members and the Plastic Surgery Education Network online forum of the American Society of Plastic Surgeons. Metrics obtained included patient age, sex, nature of primary surgery, time between umbilical stalk detachment and secondary full abdominoplasty, complications, and whether rectus plication was performed at the time of secondary surgery. Eleven physicians provided complete documentation for 18 cases. All patients healed without evidence of umbilical ischemia or necrosis. Average patient age was 40.6 years. Average interval between procedures was 3.6 years. Sixty-seven percent of patients had the umbilicus delayed before the secondary procedure, with the median delay time being 18 days. Rectus fascia was plicated during secondary surgery in 72 percent of patients. This is the first reported series of patients undergoing full abdominoplasty after prior umbilical stalk detachment. It is also the first time the Plastic Surgery Education Network online forum has been used to collect research data, highlighting its potential as a valuable research tool. The data set was obtained from a wide range of practices, which allows for consideration of various technical solutions when this or other diverse clinical scenarios are encountered. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

Assessing Burden of Care in the Patient With Cleft Lip and Palate: Factors Influencing Completion and Noncompletion of Nasoalveolar Molding.

OBJECTIVE: Evaluate the factors that influence caregiver-reported completion of nasoalveolar molding (NAM) therapy for patients with cleft lip and palate. DESIGN: An IRB-approved 30-question survey. SETTING: Outpatient clinic for patients with cleft lip. PATIENTS: Patients with unilateral or bilateral cleft lip treated with NAM therapy. INTERVENTIONS: Survey of previous experiences. MAIN OUTCOME MEASURE(S): Rate of noncompletion for patients initiating NAM therapy and identifiable causes. RESULTS: Of 94 patients who underwent NAM, 13 (13.8%) failed to complete NAM therapy. Reasons for incomplete treatment included: obstructive sleep apnea, device intolerance, tape issues, and lack of support. Patients who did not complete NAM therapy were less likely to have primary caregivers >30-year old (P = .045) and more likely to be the first child for the family (P = .021) and have a bilateral cleft (P = .03). Caregivers of NAM patients were less satisfied with the outcome (P < .001) when they did not complete therapy. CONCLUSION: This study shows that a high number of parents fail to complete this therapy for many reasons, personal and medical. More data are needed to elucidate true prevalence of NAM noncompletion and to establish evidence-based guidelines to reduce barriers to care for completing NAM treatment.