Autoimmune, Autoinflammatory Disease and Cutaneous Malignancy Associations with Hidradenitis Suppurativa: A Cross-Sectional Study.

BACKGROUND: Hidradenitis suppurativa (HS) is a debilitating cutaneous disease characterized by severe painful inflammatory nodules/abscesses. At present, data regarding the epidemiology and pathophysiology of this disease are limited. OBJECTIVE: To define the prevalence and comorbidity associations of HS. METHODS: This was a cross-sectional study of EPICTM Cosmos© examining over 180 million US patients. Prevalences were calculated by demographic and odds ratios (OR) and identified comorbidity correlations. RESULTS: All examined metabolism-related, psychological, and autoimmune/autoinflammatory (AI) diseases correlated with HS. The strongest associations were with pyoderma gangrenosum [OR 26.56; confidence interval (CI): 24.98-28.23], Down syndrome (OR 11.31; CI 10.93-11.70), and polycystic ovarian syndrome (OR 11.24; CI 11.09-11.38). Novel AI associations were found between HS and lupus (OR 6.60; CI 6.26-6.94) and multiple sclerosis (MS; OR 2.38; CI 2.29-2.48). Cutaneous malignancies were largely not associated in the unsegmented cohort; however, among Black patients, novel associations with melanoma (OR 2.39; CI 1.86-3.08) and basal cell carcinoma (OR 2.69; CI 2.15-3.36) were identified. LIMITATIONS: International Classification of Diseases (ICD)-based disease identification relies on coding fidelity and diagnostic accuracy. CONCLUSION: This is the first study to identify correlations between HS with melanoma and basal cell carcinoma (BCC) among Black patients as well as MS and lupus in all patients with HS.

Safety and utility of panniculectomy in renal transplant candidates and end stage renal disease patients.

BACKGROUND: As the obesity crisis in the United States continues, some renal transplantation centers have liberalized their BMI criteria necessary for transplant eligibility. More individuals with larger body-habitus related comorbidities with End-Stage Renal Disease (ESRD) now qualify for renal transplantation (RT). Surgical modalities from other fields also interact with this patient population. METHODS: In order to assess surgical outcomes of panniculectomy in the context of renal transplantation and ESRD, the authors performed a systematic review following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) 2020 guidelines. Due to a paucity of existing primary studies, we retrospectively collected data on patients with ESRD undergoing panniculectomy from the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) to evaluate outcomes of body contouring in this patient population. RESULTS: From the systematic review, a total of 783 ESRD patients underwent panniculectomy among the studies identified. Of these, 91 patients underwent panniculectomy simultaneously to RT while 692 had their pannus resected prior to kidney transplant. The most common complication was hematoma followed by wound dehiscence. From the NSQIP database, 24 868 patients met the inclusion criteria for analysis. In the setting of renal transplant status, patients with diabetes, hypertension requiring medication, and requiring dialysis were more likely to suffer postoperative complications (OR 1.31, 1.15, and 2.2, respectively). However, upon sub-analysis of specific types of complications, the only retained association was between diabetes and wound complication. CONCLUSION: Preliminary data show that panniculectomy in ESRD patients appears to be safe, though with a nominal increased risk for complications. Pannus resection does not appear to impact post-transplantation outcomes, including long-term allograft survival. Larger, higher powered, randomized studies are needed to confirm the safety, utility, and medical benefit of panniculectomy in the context of renal transplantation.

Combined Face and Whole Eye Transplantation: Cadaveric Rehearsals and Feasibility Assessment.

Background: In properly selected patients, combined face and whole eye transplantation (FWET) may offer a more optimal aesthetic and potentially functional outcome while avoiding the complications and stigma of enucleation and prosthetics. This study presents the most comprehensive cadaveric assessment for FWET to date, including rehearsal allograft procurement on a brain-dead donor. Methods: Over a 2-year period, 15 rehearsal dissections were performed on 21 cadavers and one brain-dead donor. After identification of a potential recipient, rehearsals assessed clinical feasibility and enabled operative planning, technical practice, refinement of personalized equipment, and improved communication among team members. Operative techniques are described. Results: Facial allograft procurement closely followed previously described face transplant techniques. Ophthalmic to superficial temporal (O-ST) vessel anastomosis for globe survival was assessed. Craniectomy allowed for maximal optic nerve and ophthalmic vessel pedicle length. Appropriate pedicle length and vessel caliber for O-ST anastomosis was seen. Research procurement demonstrated collateral blood flow to the orbit and surrounding structures from the external carotid system as well as confirmed the feasibility of timely O-ST anastomosis. Personalized cutting guides enabled highly accurate bony inset. Conclusions: This study formalizes an approach to FWET, which is feasible for clinical translation in judiciously selected patients. O-ST anastomosis seems to minimize retinal ischemia time and allow perfusion of the combined allograft on a single external carotid pedicle. Although restoration of vision likely remains out of reach, globe survival is possible.

Minimally and Non-invasive Approaches to Rejection Identification in Vascularized Composite Allotransplantation.

OBJECTIVE: Rejection is common and pernicious following Vascularized Composite Allotransplantation (VCA). Current monitoring and diagnostic modalities include the clinical exam which is subjective and biopsy with dermatohistopathologic Banff grading, which is subjective and invasive. We reviewed literature exploring non- and minimally invasive modalities for diagnosing and monitoring rejection (NIMMs) in VCA. METHODS: PubMed, Cochrane, and Embase databases were queried, 3125 unique articles were reviewed, yielding 26 included studies exploring 17 distinct NIMMs. Broadly, NIMMs involved Imaging, Liquid Biomarkers, Epidermal Sampling, Clinical Grading Scales, and Introduction of Additional Donor Tissue. RESULTS: Serum biomarkers including MMP3 and donor-derived microparticles rose with rejection onset. Epidermal sampling non-invasively enabled measurement of cytokine & gene expression profiles implicated in rejection. Both hold promise for monitoring. Clinical grading scales were useful diagnostically as was reflection confocal microscopy. Introducing additional donor tissue showed promise for preemptively identifying rejection but requires additional allograft tissue burden for the recipient. CONCLUSION: NIMMs have the potential to dramatically improve monitoring and diagnosis in VCA. Many modalities show promise however, additional research is needed and a multimodal algorithmic approach should be explored.

Vascularized Composite Allotransplantation of the Hand: A Systematic Review of Eligibility Criteria.

BACKGROUND: Hand transplantation (HT) has emerged as an intervention of last resort for those who endured amputation or irreparable loss of upper extremity function. However, because of the considerable effort required for allograft management and the risks of lifelong immunosuppression, patient eligibility is critical to treatment success. Thus, the objective of this article is to investigate the reported eligibility criteria of HT centers globally. METHODS: A systematic review of the HT literature was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines, using PubMed, Cochrane, Ovid/Medline, and Scopus. Program Web sites and clinicaltrials.gov entries were included where available. RESULTS: A total of 354 articles were reviewed, 101 of which met inclusion criteria. Furthermore, 10 patient-facing Web sites and 11 clinical trials were included. The most reported criteria related to the capacity to manage the allograft posttransplantation, including access to follow-up, insurance coverage, psychological stability, and history of medical compliance. Other factors related to the impact of immunosuppression, such as active pregnancy and patient immune status, were less emphasized. CONCLUSIONS: Because of the novelty of the field, eligibility criteria continue to evolve. While there is consensus on certain eligibility factors, other criteria diverge between programs, and very few factors were considered absolute contraindications. As the popularity of the field continues to grow, we encourage the development of consensus evidence-based eligibility criteria.

The Role of Radiation Therapy in Adult and Pediatric Keloid Management: A National Survey of Radiation Oncologists.

INTRODUCTION: Radiation therapy is a promising modality for treating keloids after surgical excision. However, it is currently not standard practice among physicians because of concern surrounding the risk of radiation-induced secondary cancers, especially among pediatric patients. There is minimal research assessing the complications for radiation therapy in keloid management. AIM: The goal of this study was to determine radiation oncologists' perspectives about the utility and appropriateness of radiation therapy for keloid management in both adult and pediatric patients. This study also aimed to characterize radiation modality, dose, fractionation, and secondary complications observed by providers. METHODS: An electronic survey was delivered to 3102 members of the American Society for Radiation Oncology. The survey subjects were radiation oncologists who are currently practicing in the United States. Rates of responses were analyzed. RESULTS: A total of 114 responses from practicing radiation oncologists were received. Of these, 113 providers (99.1%) supported radiation therapy for keloid management in adults, whereas only 54.9% supported radiation therapy for pediatric patients. Of 101 providers that treated adults in the past year, the majority used external beam: electrons (84.2%), applied 3 fraction regimens (54.4%), and delivered radiation within 24 hours postexcision (45.5%). In pediatric patients, only 42 providers reported treating at least 1 patient. The majority used electron beam radiation (76.2%), applied 3 faction regimens (65%), and delivered radiation on the same day of keloid excision (50.0%) The main concern when treating pediatric patients were risk of secondary malignancy (92.1%). CONCLUSION: Although radiation therapy appears to be a widely accepted adjuvant treatment option for adults with keloids, the use of radiation therapy for pediatric patients is less widely accepted because of concerns regarding secondary malignancy. The findings suggest additional studies need to be carried out to assess the risk of those complications.

Comparative Outcomes of Malar Implants Versus Fat Transfer to Cheeks Among Transfeminine Individuals Undergoing Malar Augmentation.

BACKGROUND: Malar augmentation is a key procedure sought out by transfeminine individuals seeking to feminize their facial appearance. Different surgical techniques have been described in the literature including fat transfer to the cheeks and malar implant placement. Because of the paucity of information in the literature, there is no consensus on best practices for this procedure. The objective of our study is to determine the effectiveness and safety of malar implants as compared with fat transfer to the cheeks in transfeminine individuals. METHODS: We examined all patients with the diagnosis of gender dysphoria that were referred to the senior author seeking consultation for feminizing facial procedures between June 2017 and August 2022. Patients who underwent fat transfer to the cheeks or malar implant placement were included in our study. We reviewed the electronic medical record of each patient, and we retrieved and analyzed data regarding demographics, medical and surgical history, operative dictations, clinic notes, and postoperative follow-up. Univariate analysis was used to assess for differences in postoperative complications between these 2 groups. RESULTS: We identified 231 patients underwent feminizing facial gender affirming surgery, with 152 patients receiving malar augmentation through malar implants or fat grafting. One hundred twenty-nine patients (84.9%) underwent malar implant placement and 23 (15.1%) underwent fat grafting to the cheeks. The mean follow-up time was 3.6 ± 2.7 months. Patient satisfaction was greater in the malar implant group (126/129, 97.7%) compared with the fat transfer group (20/23, 87%, P < 0.045). Two patients who received implants (1.8%) experienced postoperative complications. No patient undergoing fat transfer experiences similar adverse outcomes. Nevertheless, the difference was not statistically significant (P = 1.00). CONCLUSIONS: Our findings support the contention that malar implants are a safe alternative for malar augmentation among transfeminine individuals. While autologous fat transfer to the cheek is an indispensable option in patients requiring minor malar enhancement, malar implants offer a more permanent option with a better aesthetic outcome in patients requiring major malar enhancement. To minimize postoperative complications, surgeons should emphasize patient compliance with postoperative directions.

Technical Feasibility of Whole-eye Vascular Composite Allotransplantation: A Systematic Review.

There are over 43 million individuals in the world who are blind. As retinal ganglion cells are incapable of regeneration, treatment modalities for this condition are limited. Since first incepted in 1885, whole-eye transplantation (WET) has been proposed as the ultimate cure for blindness. As the field evolves, different aspects of the surgery have been individually explored, including allograft viability, retinal survival, and optic nerve regeneration. Due to the paucity in the WET literature, we aimed to systematically review proposed WET surgical techniques to assess surgical feasibility. Additionally, we hope to identify barriers to future clinical application and potential ethical concerns that could be raised with surgery. Methods: We conducted a systematic review of PubMed, Embase, Cochrane Library, and Scopus from inception to June 10, 2022, to identify articles pertaining to WET. Data collection included model organisms studied, surgical techniques utilized, and postoperative functional outcomes. Results: Our results yielded 33 articles, including 14 mammalian and 19 cold-blooded models. In studies performing microvascular anastomosis in mammals, 96% of allografts survived after surgery. With nervous coaptation, 82.9% of retinas had positive electroretinogram signals after surgery, indicating functional retinal cells after transplantation. Results on optic nerve function were inconclusive. Ocular-motor functionality was rarely addressed. Conclusions: Regarding allograft survival, WET appears feasible with no complications to the recipient recorded in previous literature. Functional restoration is potentially achievable with a demonstrated positive retinal survival in live models. Nevertheless, the potential of optic nerve regeneration remains undetermined.

The impact of youth-onset type 2 diabetes on postoperative wound healing complications.

Youth-onset type 2 diabetes mellitus is associated with a more rapid decline in ß cells, and earlier onset of medical complications compared to adult-onset diabetes. However, its impact on surgical wounds remains less clear. Therefore, this study aimed to determine whether youth-onset diabetes is a risk factor for wound healing complications in the 30-day postoperative period. To do so, the National Surgical Quality Improvement Program Database years 2012-2019 was analysed. Patients aged 18-24 with non-insulin-dependent diabetes were included. Outcomes assessed included wound infections, wound dehiscence, readmissions, and reoperation. Univariate analysis identified differences between the diabetic and non-diabetic cohorts after which, multivariate logistic regression was employed to control for potential confounding. Analysis included 1589 diabetic and 196,902 non-diabetic patients ages 18-24. The diabetic cohort exhibited a higher proportion of female (83.8% vs. 55.2%, p < 0.001), non-white (22.7% vs. 19.5%, p = 0.001), and Hispanic patients (16.2% vs. 13.6%, p = 0.002). Diabetic patients were less likely to have dirty or contaminated wounds (16.2% vs. 25.2%, p < 0.001); however had increased rates of superficial surgical site infections (SSSIs; 2.0% vs. 0.8%, p < 0.001) and readmission (4.0% vs. 3.0%, p = 0.026). After regression, diabetes remained a significant positive predictor of SSSI (odds ratio: 1.546, p = 0.022); however, it no longer significantly predicted 30-day readmission. Overall, this analysis of a large multicentre surgical outcomes database found that when compared to non-diabetics, youth-onset diabetic patients exhibited a higher proportion of SSSIs in the 30-day postoperative period. These infections were found, despite the diabetic cohort exhibiting lower rates of wound contamination. After controlling for confounding variables, youth-onset diabetes remained a significant predictor of SSSI. Clinically, prevention and treatment of diabetes along with judicious wound care is recommended.

Social support criteria in vascularized composite allotransplantation versus solid organ transplantation: Should the same ethical considerations apply?

The field of vascularized composite allotransplantation (VCA) is evolving, with some procedures poised to transition from highly experimental research toward standard of care. At present, the use of social support as an eligibility criterion for VCA candidacy is at the discretion of individual VCA programs, allowing VCA teams to consider the unique needs of each potential candidate. Yet this flexibility also creates potential for bias during the evaluation process which may disproportionately impact members of certain communities where social configurations may not resemble the model considered "optimal." We examine the extent to which ethical considerations for social support in solid organ transplantation (SOT) may be applied to or adapted for VCA, and the ethically meaningful ways in which VCA procedures differ from SOT. We conclude that VCA programs must retain some flexibility in determining criteria for candidacy at present; however, considerations of equity will become more pressing as VCA procedures evolve toward standard of care, and further empirical evidence will be needed to demonstrate the association between social support and post-operative success. The field of VCA has an opportunity to proactively address considerations of equity and justice and incorporate fair, inclusive practices into this innovative area of transplantation.

Secondary Surgery in Facial Feminization: Reasons and Recommendations.

BACKGROUND: As facial feminization surgery (FFS) continues to grow in access and popularity, the need for secondary FFS can be expected to increase. The purpose of this study was to identify reasons for FFS reoperation and offer recommendations to minimize secondary surgery. METHODS: A retrospective cohort study of patients who underwent FFS from October 2017 to 2021 was performed. Patients who underwent nonstaged secondary surgery were identified and sorted in 2 non-mutually exclusive surgical cohorts: additional surgery, defined as unplanned additional feminization surgery on previously unoperated facial units, and revision surgery, defined as redo surgery on previously operated facial units. Reasons for secondary surgery were examined in the context of the senior author's experience. RESULTS: Of 161 patients who underwent FFS, 41 (25.5%) underwent secondary surgery consisting of additional surgery (n = 32) and/or revision surgery (n = 30). There were no significant differences in clinical or demographic data between the secondary surgery and total FFS cohorts. Among additional surgery patients, facial units that had been previously operated on were as follows: nose (46.3%), trachea (31.7%), forehead/brow (22.0%), chin (12.2%), lips (9.8%), and cheeks (7.3%). Among revision patients, facial units revised were as follows: nose (36.6%), forehead/brow (26.8%), cheeks (17.1%), chin (17.1%), lips (12.5%), and trachea (2.4%). The main indication for revision for all facial units was undercorrection to feminine ideals. CONCLUSIONS: One-quarter of patients who underwent FFS had prior FFS and/or sought revision. Keeping in mind that the dominant indication for revision was undercorrection, FFS surgeons can minimize the need for secondary surgery in the future.

Quantification of Facial Allograft Edema During Acute Rejection: A Software-Based 3-Dimensional Analysis.

BACKGROUND: Acute rejection (AR) is a common complication in facial transplant (FT) patients associated with allograft edema and erythema. Our study aims to demonstrate the feasibility of using software-based 3-dimensional (3D) facial analysis to quantify edema as it resolves during/after AR treatment in an FT patient. METHODS: Our patient is a 23-year-old man who underwent a face and bilateral hand allotransplant in August 2020. The Vectra H1 (Canfield, Fairfield, NJ) portable scanner was used to capture 3D facial images at 8 time points between postoperative day (POD) 392 and 539. The images were analyzed with the Vectra Software using a rejection-free image (POD 539) as a control. RESULTS: Edema increased in the periorbital, lower third, and submandibular regions before AR treatment (POD 392-415). At POD 448, total facial edema was reduced to near baseline values in response to plasmapheresis and thymoglobulin (+156.94 to +28.2 mL). The fastest and most notable response to treatment was seen in the periorbital region, while some edema remained in the submandibular (+19.79 mL) and right lower third (+8.65 mL) regions. On POD 465, after the initial improvement, the edema increased but was resolved with steroid use. Facial edema did not correlate with the histopathological evaluation in our patient. CONCLUSIONS: We demonstrated the feasibility of analyzing 3D facial images to quantify edema during/after AR treatment in an FT patient. Our analysis detected edema changes consistent with AR followed by an improvement after treatment. This technology shows promise for noninvasive monitoring of FT patients.

Capturing Essentials in Wound Photography Past, Present, and Future: A Proposed Algorithm for Standardization.

GENERAL PURPOSE: To discuss a standardized methodology for wound photography with a focus on aiding clinicians in capturing high-fidelity images. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will be able to:1. Discriminate the components of high-quality wound photography.2. Identify the technological innovations that can augment clinical decision-making capacity.3. Choose strategies that can help clinicians avoid adverse medicolegal outcomes.

According to a 2018 study, chronic wounds affect more than 8 million Americans and impose a substantial economic burden, with costs of care reaching upward of US $30 billion. As demographics in the US shift toward an aging population, these numbers are likely to progressively increase annually. Care of these patients relies heavily on photographic documentation, which catalogs disease progression and informs management decisions. This article elaborates a standardized methodology for wound photography and aims to aid clinicians in capturing high-fidelity images. Technological advancements, notably digital cameras and smart phones, have exponentially improved both the rate and quality of wound photography, but their potential has yet to be fully realized. Despite the indispensable nature of wound photography, literature detailing the photography process remains sparse. The absence of a standardized methodology for wound photography leads to subpar documentation, which ultimately hinders patient care. Further, information regarding medicolegal implications of wound photography remains fragmented and opaque to many clinicians. The authors provide a comprehensive overview of best practices in wound photography, medicolegal considerations, and an overview of emerging technologies. Photographic documentation is indispensable in the management of chronic wounds. Capturing consistent, high-fidelity images requires the adoption of standardized protocols. Emerging technologies, such as three-dimensional imagery, biosensors, and artificial intelligence, are poised to profoundly alter wound photography in the future. However, standardized protocols informed by sound clinical judgment will remain of paramount importance.

The Successful Implementation of a Laparoscopic Simulation Training Program in the Dominican Republic.

INTRODUCTION: Mount Sinai Hospital in New York introduced a laparoscopic surgery simulation center to a public hospital in Santiago, Dominican Republic to determine the feasibility of training programs in low-and-middle income countries (LMICs). METHODS: In August 2018, recruitment and preliminary data were collected at the Hospital Jose Maria Cabral y Báez in Santiago, Dominican Republic. The simulation room consists of three simulation stations. Residents were required to practice 1 h/wk guided by a general surgery postgraduate year 3 (PGY3) Mount Sinai resident. Number of hours practiced was self-reported and follow-up data was collected in June 2019. The study endpoints include times on three simulated laparoscopic tasks including peg-transfer, precision cutting, and intracorporeal knot tying. Wilcoxon-signed rank tests were used for statistical analysis. RESULTS: The partnership between hospitals allowed for successful integration into the Dominican general surgery training. Over 10 mo, residents averaged 25 h of practice (range: 8-35 h; SD 9.95 h). In total, 85% of the residents participated in the study (5 postgraduate year 1 [PGY1], 2 postgraduate year 2 [PGY2], and 4 postgraduate year 3 [PGY3]). Resident median simulation times significantly improved for precision cutting (3:49 min versus 2:09 min, P = 0.002) and intracorporeal knot tying (5:20 min versus 2:47 min, P = 0.037). There was neither significant difference in peg-transfer times nor performance between resident years (P = 0.12). CONCLUSIONS: This study demonstrates the successful integration of a laparoscopic simulation program into an LMIC surgical resident training program. With commitment from local institutions and external resources, establishing laparoscopic simulation centers are feasible and expandable, thereby allowing general surgery residents in other LMICs, the opportunity to improve their laparoscopic skills.

Comparative structural and functional analysis of the larval and adult dorsal vessel and its role in hemolymph circulation in the mosquito Anopheles gambiae.

Hemolymph circulation in insects is driven primarily by the contractile action of a dorsal vessel, which is divided into an abdominal heart and a thoracic aorta. As holometabolous insects, mosquitoes undergo striking morphological and physiological changes during metamorphosis. This study presents a comprehensive structural and functional analysis of the larval and adult dorsal vessel in the malaria mosquito Anopheles gambiae. Using intravital video imaging we show that, unlike the adult heart, the larval heart contracts exclusively in the anterograde direction and does not undergo heartbeat directional reversals. The larval heart contracts 24% slower than the adult heart, and hemolymph travels across the larval dorsal vessel at a velocity that is 68% slower than what is seen in adults. By fluorescently labeling muscle tissue we show that although the general structure of the heart and its ostia are similar across life stages, the heart-associated alary muscles are significantly less robust in larvae. Furthermore, unlike the adult ostia, which are the entry points for hemolymph into the heart, the larval ostia are almost entirely lacking in incurrent function. Instead, hemolymph enters the larval heart through incurrent openings located at the posterior terminus of the heart. These posterior openings are structurally similar across life stages, but in adults have an opposite, excurrent function. Finally, the larval aorta and heart differ significantly in the arrangement of their cardiomyocytes. In summary, this study provides an in-depth developmental comparison of the circulatory system of larval and adult mosquitoes.