Clozapine Reduces Recurrent Suicidal and Self-Injurious Behavior in Treatment-Refractory Incarcerated Individuals.

This retrospective review examines clozapine's effects on treatment-refractory incarcerated individuals (N = 23) with recurrent thoughts of self-harm and/or self-injurious behavior. Emergent suicide risk assessments and days on suicide watch were assessed for the 3 months pre- and post-clozapine treatment. Total suicide assessments fell from 73 pre- to 14 post-clozapine, with a median of 2 assessments (interquartile range [IQR]: 1,5) pre-clozapine compared with 0 (IQR: 0,1) post-clozapine (p < 0.0001). Total days on suicide watch decreased from 104 days pre- to 32 post-clozapine, with a median of 3 days (IQR: 0,9) pre-clozapine compared with 0 (IQR: 0,0) post-clozapine (p = 0.0012). Emergency room visits and medical hospitalizations decreased substantially for all months of treatment. Clozapine treatment was associated with marked reductions in self-injurious thoughts and behaviors in high-risk incarcerated individuals.

The Impact of Indocyanine Green Angiography on Fat Necrosis in Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

BACKGROUND: The deep inferior epigastric perforator flap (DIEP) is a widely known reliable option for autologous breast reconstruction. One common complication of DIEP procedures is fat necrosis. Consequences of fat necrosis include wound healing complications, pain, infection, and the psychological distress of possible cancerous recurrence. Clinical judgment alone is an imperfect method to detect at-risk segments of adipose tissue. Objective methods to assess perfusion may improve fat necrosis complication rates, reducing additional surgeries to exclude cancer and improve cosmesis for patients. METHODS: The authors performed a retrospective review of patients who underwent analysis of DIEP flap vascularity with or without intraoperative indocyanine green angiography (ICGA). Flap perfusion was assessed using intravenous ICGA and was quantified with both relative and absolute value units of fluorescence. Tissue with observed values less than 25% to 30% relative value units was resected. Postoperative outcomes and fat necrosis incidence were collected. RESULTS: Three hundred fifty-five DIEP flaps were included in the study, 187 (52.7%) of which were assessed intraoperatively with ICGA. Thirty-nine patients (10.9%) experienced operable fat necrosis. No statistically significant difference in incidence of postoperative fat necrosis was found between the 2 groups (P = 0.732). However, a statistically significant relationship was found between fat necrosis incidence and body mass index as both a continuum (P = 0.001) and when categorized as greater than 35 (P = 0.038). CONCLUSIONS: Although ICGA is useful for a variety of plastic surgery procedures, our retrospective review did not show a reduction in operable fat necrosis when using this technology.

Satisfaction With Expectations-Based Education in Women Undergoing Breast Reconstruction.

Women undergoing breast reconstruction sometimes have unrealistic or unformed expectations regarding the reconstructive process and outcomes. The objectives of this study were to assess preoperative expectations in women undergoing mastectomy and initial breast reconstruction, provide expectations-based education, and evaluate satisfaction with education. Fifty-one women undergoing mastectomy and breast tissue expander placement participated in this study. At a preoperative education appointment, participants completed a questionnaire to determine whether their expectations were realistic, unrealistic, or unformed. A nurse practitioner reviewed the results and provided patient-centered, expectations-based education to modify expectations from unrealistic to realistic or to set expectations from unformed to realistic. Four to 6 weeks after surgery, a second questionnaire was provided to assess perceived satisfaction with education. Unrealistic and unformed expectations were identified related to complications, pain, scarring, sensation, symmetry, and aesthetic results. After receiving patient-centered, expectations-based preoperative education, participants agreed they had received the appropriate amount of information and felt well prepared for their surgery and recovery. Most participants reported they were aware of possible complications, had effective tools to manage their pain, and had received adequate information about scarring and sensation changes. Some participants continued to have unrealistic or unformed expectations related to aesthetic results. Women undergoing breast reconstruction often have unrealistic or unformed expectations before surgery. Identifying these expectations and proving expectations-based education resulted in satisfaction with information provided.

Effect of Clozapine on Time Assigned to Restrictive Housing in a State Prison Population.

This study examined the effect of clozapine on time assigned to restrictive housing (RH; i.e., solitary confinement), disciplinary infractions, and assaults on custody staff among patients treated within the North Carolina prison system. Records were reviewed for patients initiated on clozapine (n = 84) over a 3.5-year period. Fifty-nine patients completed at least three consecutive months of treatment and were included in data analysis. Assigned RH days and disciplinary infractions were assessed for the periods prior to and after treatment with clozapine. Patients accumulated 13,500 RH days pretreatment and 3,560 days postclozapine initiation. There was a significant reduction in RH days with clozapine treatment (P < .05). Patients with personality disorders (n = 36) had a significant decrease in RH days (P < .05), while those with psychotic disorders (n = 23) showed a decrease with borderline significance (P = .051). There were 253 disciplinary infractions pretreatment, including 27 assaults on custody staff, and 118 infractions posttreatment, including 7 assaults; the decrease in infractions was significant in the first three months of treatment (P < .05). The mean ± SD duration of treatment was 269 ± 102 days. Expanding clozapine use in state prisons should be a high priority, as these data are consistent with reports of clozapine's benefits in community settings.

Satisfaction With Expectations-Based Education in Women Undergoing Breast Reconstruction.

Women undergoing breast reconstruction sometimes have unrealistic or unformed expectations regarding the reconstructive process and outcomes. The objectives of this study were to assess preoperative expectations in women undergoing mastectomy and initial breast reconstruction, provide expectations-based education, and evaluate satisfaction with education. Fifty-one women undergoing mastectomy and breast tissue expander placement participated in this study. At a preoperative education appointment, participants completed a questionnaire to determine whether their expectations were realistic, unrealistic, or unformed. A nurse practitioner reviewed the results and provided patient-centered, expectations-based education to modify expectations from unrealistic to realistic or to set expectations from unformed to realistic. Four to 6 weeks after surgery, a second questionnaire was provided to assess perceived satisfaction with education. Unrealistic and unformed expectations were identified related to complications, pain, scarring, sensation, symmetry, and aesthetic results. After receiving patient-centered, expectations-based preoperative education, participants agreed they had received the appropriate amount of information and felt well prepared for their surgery and recovery. Most participants reported they were aware of possible complications, had effective tools to manage their pain, and had received adequate information about scarring and sensation changes. Some participants continued to have unrealistic or unformed expectations related to aesthetic results. Women undergoing breast reconstruction often have unrealistic or unformed expectations before surgery. Identifying these expectations and proving expectations-based education resulted in satisfaction with information provided.

Decreasing Opioid Prescriptions in Women Undergoing Mastectomy and Breast Reconstruction.

BACKGROUND: Florida enacted legislation limiting opioid prescriptions and affecting the management of acute pain in the postoperative patient. Patients in a reconstructive surgery practice were receiving prescriptions for opioids as their primary method of pain management. Clinic providers identified a need to limit opioid prescriptions. AIM: The aim of this quality improvement initiative was to decrease the number of opioids prescribed while effectively managing pain in women undergoing mastectomy and breast tissue expander placement. DESIGN: This is a quality improvement project. METHODS: The Model for Improvement was used as a framework for this project. An evidence-based pain management plan was developed after a review of the breast reconstruction surgery literature. The plan incorporated preoperative patient and family education and the standard use of preemptive analgesia, intraoperative nerve blocks, and postoperative multimodal analgesia in all patients undergoing mastectomy with breast tissue expander placement. Patient and family education and perioperative pain management were provided to patients, and the number of opioid tablets prescribed was tracked. RESULTS: Between January 2018 and August 2019, the average number of opioid tablets prescribed per patient decreased from 84.7 to 8.4. CONCLUSIONS: Opioid prescriptions can be decreased in women undergoing breast reconstruction with the use of patient education and multimodal analgesia.

Vertical Profunda Artery Perforator Flap for Plantar Foot Wound Closure: A New Application.

BACKGROUND: Plantar foot reconstruction requires special consideration of both form and function. There are several fasciocutaneous flap options, each with indications and reservations. CASE STUDY: This case presents a new application of the vertical profunda artery perforator flap for definitive closure of a neuropathic foot ulcer in a young woman with spina bifida. The postoperative course was uneventful, and the flap survived completely. The surgical and donor sites were without wound recurrence at 5-month follow-up. DISCUSSION: Understanding the variability of foot flap options is important because of unique cases such as the one presented where the wound was caused by specific and less commonly observed foot anatomy. The specific choice to use the vertical profunda artery perforator flap for this patient and her neuropathic wound type was made based on its excellent flexibility, durability, and donor site appeal. CONCLUSIONS: The vertical profunda artery perforator flap has adequate surface area and bulk and a favorable pedicle length and caliber, can be thinned, and leaves a donor scar in a less conspicuous area than other popular free flaps for lower-extremity reconstruction. For these reasons, it should be considered a first-line therapy for free flap coverage of selected foot wounds.

Avoiding Facial Incisions with Midface Free Tissue Transfer.

BACKGROUND: We have adopted an intraoral microsurgical anastomosis to the facial vessels to eliminate the need for any visible facial incisions. METHODS: Cadaveric dissection was used to demonstrate accessibility of the facial artery and vein through an intraoral approach. Additionally, 5 patients underwent free tissue transfer for reconstruction of major defects of the midface through an intraoral, transmucosal approach, obviating the need for visible skin incisions. RESULTS: The pathology included palatal defects due to mucoepidermoid carcinoma and ischemic necrosis from cocaine abuse, maxillary defects secondary to fibrous dysplasia and avascular necrosis from traumatic blast injury, and a residual posttraumatic bony deformity of the zygoma. Reconstructions were performed with a free ulnar forearm flap, a free vastus lateralis muscle flap, a deep circumflex iliac artery myoosseous flap, a free fibula flap, and a deep circumflex iliac artery osseous flap, respectively. The facial artery and vein were used as recipient vessels for microvascular anastomosis for all cases. Mean follow-up was 12.2 months. All free tissue transfers were successful, and each patient had a satisfactory aesthetic outcome with no associated facial scars. CONCLUSION: This technique can be employed during reconstruction of an array of bony or soft-tissue midface deficits with minimal morbidity. This small series effectively demonstrates the varied pathologies and tissue deficiencies that can be successfully reconstructed with free tissue transfer using an entirely intraoral approach to the recipient facial vessels, resulting in no visible scars on the face and an improvement in the overall aesthetic outcome.

The Profunda Artery Perforator Flap Experience for Breast Reconstruction.

BACKGROUND: The profunda artery perforator flap was first introduced for breast reconstruction in 2010. In this article, the authors analyze the results of all profunda artery perforator flaps performed by their group to date. METHODS: A retrospective review was completed of consecutive profunda artery perforator flaps performed by the senior author (R.J.A.) from 2010 to 2014. Patient demographics, indications, operative techniques, flap specifics, complications, and number of operations were recorded. RESULTS: Ninety-six patients have undergone 164 profunda artery perforator flap operations for breast reconstruction since 2010. Reconstructions were performed following breast cancer management (59.5 percent), following prophylactic mastectomy for cancer risk reduction (35.7 percent), and for congenital breast deformity (4.8 percent). The average age of the patients was 48 years (range, 24 to 64 years) and their average body mass index was 22.5 kg/m. Average flap weight was 367.4 g and average pedicle length was found to be 10.2 cm. The success rate of the profunda artery perforator flap was greater than 99 percent, with a 3 percent take-back rate and only one flap loss recorded. Complications included hematoma (1.9 percent), seroma (6 percent), fat necrosis (7 percent), and donor-site infection (1.9 percent). CONCLUSIONS: The profunda artery perforator flap is an excellent option for breast reconstruction. Advantages include a reliable blood supply, long pedicle, thick donor tissue, and a favorable donor site. Currently, the profunda artery perforator flap is second only to the deep inferior epigastric artery perforator among flaps used by the authors for breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Expanding the Applications of the Profunda Artery Perforator Flap.

BACKGROUND: The profunda artery perforator free flap has not gained traction for nonbreast reconstruction, likely because of the presence of a proven workhorse in the anterolateral thigh flap. The authors believe that the profunda artery perforator flap offers similar coverage characteristics with the benefits of a medial donor site, a more consistent anatomy, and relatively easy dissection. The authors review their indications, technique, and outcomes in seven patients requiring eight free flap reconstructions. METHODS: The authors applied the use of the vertically oriented profunda artery perforator flap to both lower extremity and head and neck reconstructions in which an anterolateral thigh flap would normally have been used. Details reviewed include soft-tissue defect, perforator location, flap size, recipient vessel, and complications. RESULTS: Eight soft-tissue defects were covered with a vertically oriented profunda artery perforator flap in seven patients. Six reconstructions were for distal lower extremity and two were for head and neck reconstruction, both trauma and oncologic reconstructions. Flap sizes ranged from 40 to 92 cm. The pedicle length ranged from 7 to 10 cm. There were no partial or complete flap losses. One complication of seroma at the donor site requiring washout and closure was encountered. CONCLUSIONS: The profunda artery perforator flap is a safe and effective option for perforator-based free flap reconstruction with relative ease of harvest and an inconspicuous donor site. This flap offers an excellent alternative to the anterolateral thigh flap. In certain patient demographics, the profunda artery perforator flap should be considered as a primary option. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Four-flap Breast Reconstruction: Bilateral Stacked DIEP and PAP Flaps.

BACKGROUND: In cases of bilateral breast reconstruction when the deep inferior epigastric perforator (DIEP) free flap alone does not provide sufficient volume for body-specific reconstruction, stacking each DIEP flap with a second free flap will deliver added volume and maintain a purely autologous reconstruction. Stacking the profunda artery perforator (PAP) flap with the DIEP flap offers favorable aesthetics and ideal operative efficiency. We present the indications, technique, and outcomes of our experience with 4-flap breast reconstruction using stacked DIEP/PAP flaps. METHODS: The authors performed 4-flap DIEP/PAP breast reconstruction in 20 patients who required bilateral reconstruction without adequate single donor flap volume. The timing of reconstruction, average mastectomy/flap weights, and operative time are reported. Complications reviewed include fat necrosis, dehiscence, hematoma, seroma, mastectomy flap necrosis, and flap loss. RESULTS: Twenty patients underwent 4-flap DIEP/PAP breast reconstruction. Surgical time averaged 7 hours and 20 minutes. The primary recipient vessels were the antegrade and retrograde internal mammary vessels. No flap losses occurred. Complications included 1 hematoma, 1 incidence of arterial and venous thrombosis successfully treated with anastomotic revision, 1 incidence of thigh donor site dehiscence, and 3 episodes of minor mastectomy skin flap necrosis. CONCLUSIONS: Four-flap breast reconstruction is a favorable autologous reconstructive option for patients requiring bilateral reconstruction without adequate single donor flap volume. Stacking DIEP/PAP flaps as described is both safe and efficient. Furthermore, this combination provides superior aesthetics mirroring the natural geometry of the breast. Bilateral stacked DIEP/PAP flaps represent our first choice for breast reconstruction in this patient population.

Optimizing Efficiency in Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

BACKGROUND: The process of harvesting and performing microsurgical anastomosis in a deep inferior epigastric perforator (DIEP) flap for breast reconstruction can be a lengthy procedure, which could affect outcomes and patient safety. We hypothesize that the implementation of a high volume center, preoperative planning, and the adaptation of key intraoperative components will optimize the efficiency of perforator flap surgery for breast reconstruction. METHODS: A retrospective review of 68 consecutive patients who underwent 104 DIEP flaps for immediate or delayed breast reconstruction was performed. Standardized preoperative planning, including computed tomography/magnetic resonance imaging angiogram, operating room setup, and operative technique, was followed. The times of flap harvest, internal mammary vessel harvest, microsurgical anastomosis, flap inset, wound closure, and total length of procedure were reviewed as well as patient outcomes. RESULTS: The average length of surgery for a unilateral DIEP was 3 hours and 21 minutes and for a bilateral DIEP was 5 hours and 46 minutes. In bilateral DIEP flaps, a significantly longer operative time was noted in immediate (363 ± 14 minutes) compared to delayed (296 ± 17 minutes) (P < 0.05) reconstruction and between procedures performed by 1 surgeon (400 ± 29 minutes) versus 2 surgeons (326 ± 11 minutes) (P < 0.05). Interestingly, no significant difference in operative time was seen in DIEP flaps performed on patients with a body mass index (BMI) less than 30 (193 ± 7.6, 352 ± 17 minutes) versus a BMI greater than 30 (213 ± 11, 333 ± 14 minutes) in both unilateral and bilateral procedures, respectively. CONCLUSIONS: Efficiency is optimized by preoperative planning with computed tomography/magnetic resonance imaging angiogram, a dedicated operating room team, including 2 microsurgeons and a systematic approach for surgery. The BMI may not significantly affect the duration of surgery.

Managing treatment resistant violent adolescents: a step forward by substituting seclusion for mechanical restraint?

Despite a growing consensus that seclusion or restraint should never be used with children or adolescents, there are a few patients who are resistant to treatment, and are persistently violent. The purpose of this study was to measure the efficacy of installing a padded seclusion room to decrease the use of mechanical restraints, a potentially more emotionally traumatic and dangerous intervention than seclusion. After padded room installation, the number of monthly mechanical restraint events per 1000 patient days decreased by 93.7%, from 21.2 to 1.3. A padded seclusion room may offer a safer, albeit a less than desirable alternative to mechanical restraint.

Comparative ecophysiology of the chromosome races in Viola adunca J.E. Smith.

Comparisons of net CO2 assimilation, dark respiration, leaf resistance, and leaf water potential were made between diploid and polyploid races of Viola adunca from the Cypress Hills, Alberta, Canada. The mean maximum net CO2 assimilation rate, at 20 C and 500 µE m-2 s-1 (phAR) was 26 mg CO2 g-1 h-1 (12 mg CO2 dm-2 h-1) for polyploids, and 23 mg CO2 g-1 h-1 (11 mg dm-2 h-1) for diploids. The difference is not statistically significant. Net CO2 assimilation rates at low (0° C) and high (40° C) temperatures were virtually the same for diploids and polyploids. There were no statistically significant differences between the chromosome races in light compensation or light saturation over the 0° to 40° C temperature range studied. Average dark respiration of the polyploid race at 20 C was 2.2 mg CO2 g-1 h-1 (1.0 mg CO2 dm-2 h-1) compared with 2.0 mg CO2 g-1 h-1 (0.95 mg CO2 dm-2 h-1) for the diploid race. The mean maximum leaf water potential of well watered plants was-7.9 bars for both ploidy levels. Minimum leaf resistance was ca. 3.6 s cm-1 for both ploidy levels. Maximum net CO2 assimilation rates in both ploidy levels occurred at-9 bars leaf water potential. Based upon the plant responses studied, there are no differences between chromosome races collected from the same general area, and the polyploids do not respond more favorably to extremes of temperature and water potential. Ploidy per se does not affect the response of Viola adunca to its environment in this particular case.