LaMiNa: A Creative Synergistic Approach to Facial Rejuvenation.

Background: Treating facial aging with CO2 lasering or microneedling are cornerstones of facial rejuvenation. Skin rejuvenation utilizing thermal and mechanical treatments have historically been considered too injurious to be combined at a single setting. Autologous nanofat has been shown to deliver wound healing properties. We investigated the safety and efficacy of co-terminus CO2 lasering and microneedling to resolve fine lines and rhytids in facial skin with addition of autologous nanofat to aid in recovery. Objectives: Combination treatments may result in better results with faster recovery. We investigated the safety and efficacy of co-terminus CO2 lasering and microneedling to resolve fine lines and rhytids in facial skin with addition of autologous nanofat to aid in recovery. Methods: Twenty-three patients underwent facial treatment with CO2 lasering followed by microneedling and application of autologous nanofat (LaMiNa). One volunteer patient had tissue biopsies of treatment areas to demonstrate histologic tissue level changes. Results: All patients verbally reported no pain (Numerical Rating System 0-10) following procedure and had rapid recovery within an average of 5 days. Pathology results demonstrated that CO2 and microneedling had persistent epidermal disruption and perineural inflammation at 4 days, while the introduction of autologous nanofat at the time of CO2 and microneedling resulted in full recovery of epidermis and resolution of perineural inflammation. Conclusions: Triple therapy (LaMiNa) with thermal CO2 remodeling and mechanical microneedling penetration have accelerated and pain-free recovery with the addition of autologous nanofat. Histologic analysis reveals that epidermal recovery is accelerated and perineural inflammation is reduced with the addition of autologous nanofat following skin remodeling from combined CO2 and microneedling.

Rapid recovery pathway without epidural catheter analgesia for surgical treatment of adolescent idiopathic scoliosis: a comparative study.

PURPOSE: To assess effectiveness of a rapid recovery pathway (RRP) without epidural catheter analgesia (ECA) or intravenous patient controlled analgesia (PCA) in accelerating recovery and decreasing opioid consumption in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion (PSF). METHODS: A retrospective cohort study included collection of demographics, ECA use, IV PCA, postoperative opioid consumption, postoperative pain scores, and reoperation rate. Opioid consumption was calculated using morphine milligram equivalents (MME). Hospital length of stay (HLOS) and first reported ambulation with physical therapy (PT) were also recorded. RESULTS: 53 patients were included, with 18 in the RRP group. Patient characteristics were comparable between the groups, except in ECA use and BMI. The RRP group consumed less total MME from postoperative day (POD) 0 to 2 (mean difference 61.6 MME; 95% CI 37.1-86.1 MME; p < 0.001). In addition, the RRP group had significantly shorter HLOS (2.5 vs 4.0 days; p < 0.001). There were no differences in VAS scores between the two groups. A subset analysis comparing patients who did and did not receive ECA showed that ECA resulted in overall higher inpatient MME and HLOS. A prediction model was developed using multiple regression based on the different medications used for multimodal analgesia (MMA) in the RRP. CONCLUSIONS: An RRP without the use of ECA or IV PCA can provide adequate analgesia in patients with AIS undergoing PSF while lowering inpatient narcotic consumption and accelerating immediate postoperative recovery.

Chondrotoxicity of Local Anesthetics: Liposomal Bupivacaine Is Less Chondrotoxic than Standard Bupivacaine.

OBJECTIVE: The purpose of this study is to determine whether (1) liposomal bupivacaine is chondrotoxic; (2) the chondrotoxicity of liposomal bupivacaine differs from standard bupivacaine; and (3) chondrotoxic effects are time dependent. MATERIALS AND METHODS: We obtained 72 10 mm articular cartilage plugs from 12 fresh bovine distal femoral knee joints and exposed them to either saline, 0.5% bupivacaine, or liposomal bupivacaine for either 30 or 90 minutes. Twenty-four hours after treatment, chondrocyte viability was measured with the use of a fluorescent live/dead assay. An ANOVA test of variance was performed followed by a Holm-Sidak test to make pairwise comparisons across conditions. Student's t-test was used to compare means. RESULTS: Percent viability of cells exposed to liposomal bupivacaine for 30 minutes was less versus saline control (53.9% ± 21.5% vs. 73.7 ± 18.4%, p=0.035), and this remained significant at 90 minutes (49.1% ± 20.3% vs. 67.2% ± 25.6%, p < 0.001). Liposomal bupivacaine had less chondrotoxic effects when compared with bupivacaine after 90 minutes, with greater viability (49.1% ± 20.3% vs. 21.4% ± 14.0%, p=0.003). Chondrotoxicity was found to be time dependent within the bupivacaine group (percent viability at 30 min: 45.5 ± 18.2%, 90 min: 21.4 ± 14.0%, p=0.001); however, liposomal bupivacaine did not demonstrate a significant time-dependent chondrotoxic relationship (p=0.583). CONCLUSIONS: Bupivacaine and liposomal bupivacaine are both toxic to chondrocytes. Liposomal bupivacaine is less chondrotoxic than standard bupivacaine and does not demonstrate a time-dependent toxicity.

Chiari-related scoliosis: a single-center experience with long-term radiographic follow-up and relationship to deformity correction.

OBJECTIVE Previous reports have addressed the short-term response of patients with Chiari-related scoliosis (CRS) to suboccipital decompression and duraplasty (SODD); however, the long-term behavior of the curve has not been well defined. The authors undertook a longitudinal study of a cohort of patients who underwent SODD for CRS to determine whether there are factors related to Chiari malformation (CM) that predict long-term scoliotic curve behavior and need for deformity correction. METHODS The authors retrospectively reviewed cases in which patients underwent SODD for CRS during a 14-year period at a single center. Clinical (age, sex, and associated disorders/syndromes) and radiographic (CM type, tonsillar descent, pBC2 line, clival-axial angle [CXA], syrinx length and level, and initial Cobb angle) information was evaluated to identify associations with the primary outcome: delayed thoracolumbar fusion for progressive scoliosis. RESULTS Twenty-eight patients were identified, but 4 were lost to follow-up and 1 underwent fusion within a year. Among the remaining 23 patients, 11 required fusion surgery at an average of 88.3 ± 15.4 months after SODD, including 7 (30%) who needed fusion more than 5 years after SODD. On univariate analysis, a lower CXA (131.5° ± 4.8° vs 146.5° ± 4.6°, p = 0.034), pBC2 > 9 mm (64% vs 25%, p = 0.06), and higher initial Cobb angle (35.1° ± 3.6° vs 22.8° ± 4.0°, p = 0.035) were associated with the need for thoracolumbar fusion. Multivariable modeling revealed that lower CXA was independently associated with a need for delayed thoracolumbar fusion (OR 1.12, p = 0.0128). CONCLUSIONS This investigation demonstrates the long-term outcome and natural history of CRS after SODD. The durability of the effect of SODD on CRS and curve behavior is poor, with late curve progression occurring in 30% of patients. Factors associated with CRS progression include an initial pBC2 > 9 mm, lower CXA, and higher Cobb angle. Lower CXA was an independent predictor of delayed thoracolumbar fusion. Further study is necessary on a larger cohort of patients to fully elucidate this relationship.

Reason for Lawsuit in Spinal Cord Injury Affects Final Outcome.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To review past cases and analyze them to determine whether reason for lawsuit led to a defense versus plaintiff verdict when patients sustain spinal cord injury. Secondary objectives included analyzing demographic factors and monetary awards for plaintiff verdicts and settlements. SUMMARY OF BACKGROUND DATA: Evaluating malpractice cases could provide valuable information for the physician who has been sued by a patient. Previous studies about litigation and spine have been focused on medical tort reform and not on the reasons for litigation and lawsuit outcome. METHODS: A large national medicolegal research service for civil and criminal court called "VerdictSearch" was queried for "spinal cord injury" between the years 2000 and 2010. Reason for lawsuit separated into 2 groups, error in diagnosis (n = 48), and error in treatment (n = 25). The anatomical region, outcome, cost, and job for sued health care workers recorded for each lawsuit. RESULTS: Compared with physicians who were sued for errors in diagnosis, those sued for an error of treatment had a relative risk of 2.69 (95% confidence interval, 1.40-5.16) to receive a defense verdict (P = 0.003). There were no significant differences in demographic information, including age, sex, occupation type, and level of injury. Among specialties, surgeons had the highest number of suits. The median value for each anatomic area was highest in thoracic spine ($1.90 million), followed by cervical spine ($1.80 million) and lumbar spine ($0.750 million), although there were no statistical differences between the 3 areas (P = 0.301). The median monetary award for a plaintiff verdict was higher than that for a settlement ($2.90 million, interquartile range: 1.50-12.5 million vs. $1.45 million, interquartile range: 1.00-2.90 million, P = 0.008). CONCLUSION: Physicians are more likely to successfully defend a lawsuit for an error in treatment than for an error in diagnosis. The key to increase the success of defending a lawsuit in regard to spinal cord injury is to avoid delayed and incorrect diagnosis. LEVEL OF EVIDENCE: N/A.

Assessing the risk of work-related international travel.

OBJECTIVE: To identify factors affecting the likelihood of requiring medical services during international business trips. METHODS: Data from more than 800,000 international trips and medical assistance cases provided to 48 multinational corporations in 2009. Travel destination countries were grouped into four a priori risk-related categories. RESULTS: Travel to "low" medical risk countries in aggregate accounted for more hospitalizations and medical evacuations than travel to "high" medical risk countries. Nevertheless, the risk per trip was much higher for travel to higher medical risk countries. CONCLUSIONS: Corporations with employees on international travel should allocate sufficient resources to manage and ideally prevent medical issues during business travel. Travel medicine must focus on more than infectious diseases, and programs are necessary for both high- and low-risk regions. Improved understanding of travel-related needs determines resource allocation and risk mitigation efforts.

On-site implantation of a ventricular assist device to facilitate aeromedical transport.

BACKGROUND: Experiencing an acute coronary event in a remote or community hospital can be fatal, particularly if the event is complicated by cardiogenic shock. Many remote and community hospitals do not have adequate resources to support such a compromised patient. Extrapolating from the domestic hub-and-spoke model, presently used between academic tertiary care facilities and community hospitals, we outline the implementation of such an ad hoc arrangement between Panama (spoke) and South Florida (hub). CASE REPORT: We transported a team of cardiovascular experts from Florida to Panama, in tandem air ambulances (to limit mandatory crew rest time), to implant a left ventricular assist device (LVAD) in a patient in cardiogenic shock refractory to mechanical/pharmacological support. The low profile LVAD inserted percutaneously by the American team stabilized the patient (a U.S. citizen on assignment in Panama), enabling his air ambulance transport back to South Florida. DISCUSSION: In this first-of-a-kind report, we outline the challenges and logistics involved in the planning, resuscitation, and aeromedical transport of a patient who was discharged from the hub hospital in Florida after just 30 d.

Country factors associated with the risk of hospitalization and aeromedical evacuation among expatriate workers.

OBJECTIVE: To assess country factors associated with the risk of requiring aeromedical evacuation and hospitalization among expatriate workers and their dependents. METHODS: The 2009-2010 data including 5725 aeromedical evacuations and 17,828 hospitalizations, and 2009 data of hospitalizations and aeromedical evacuations among 94,651 at-risk expatriates, were analyzed to assess 2 country risk rating tools. Each tool utilized four risk categories and reflected level of development and medical capabilities. RESULTS: Country risk category was strongly associated with risk of evacuation and/or hospitalization for each risk rating tool (eg, 46-fold increase from lowest to highest country risk category). CONCLUSION: Country risk tools strongly associate hospitalization and aeromedical evacuation with country risk category, and thus can be important indicators of relative medical risk. Employers may use these results to implement targeted prevention programs to support expatriate workers and their families.

Successful trans-Atlantic air ambulance transfer of a patient supported by a bi-ventricular assist device.

The ventricular assist device (VAD) is a hemodynamic support device that augments cardiac output for patients with severe ventricular dysfunction. With improved reliability and technological advances, the use of VADs to support patients is increasing. Many VAD-dependent patients ultimately require heart transplants that are only available in specialized centers, necessitating an interhospital transfer. To date there are few reports of long-distance fixed wing aeromedical transport of patients dependent on a VAD. Here we describe the successful transfer of a patient supported by a biventricular assist device (BiVAD) from Cambridge, UK, to Durham, NC, via fixed-wing jet aircraft. During this transfer, we observed hemodynamic alterations secondary to gravitational forces, which should be anticipated and may be mitigated with simple maneuvers. With high-level logistical planning and appropriate medical oversight, patients dependant on BiVADs can be safely transported by fixed wing aircraft over long distances.

A hybrid approach to cardiac resynchronization therapy.

BACKGROUND: CRT (atrial-synchronized bi-ventricular pacing) has been shown to significantly improve the quality of life and exercise tolerance in patients with moderate-severe heart failure and an interventricular conduction delay (>120 msec) when compared to controls. Traditionally it has been performed by cardiologists in electrophysiology laboratories. In the event that the left ventricular lead cannot be positioned percutaneously the procedure is aborted and the cardiac surgeon consulted. The subsequent intervention by the surgeon, typically on another day, requires reexploration of the pocket, a thoracotomy, which results in an increase in length of stay (LOS), and an increase in infection risk. The objective of this study was to demonstrate that CRT could routinely be performed in a surgical operating room (OR) as a single rather than a staged procedure. METHODS: Between 1/1/06 and 7/1/06 18 patients (17 male and 1 female) with an average age of 56 years (range 36-79) underwent CRT. Transthoracic echo (TTE) revealed that all had left ventricular ejection fractions (LVEF) <30% (range 8%-28%). Five of the 18 had moderate-severe mitral regurgitation (MR). The etiology of the cardiomyopathies was ischemia in 4 and non-ischemia in 14. All had QRS intervals >120 msec (range 120-200 msec) and all were maintained preoperatively on their conventional therapy for heart failure (B-blockers, ± diuretic, ± ACE-I or ARB) and all were either New York Heart Association (NYHA) functional class III or IV. Every case was performed under general anesthesia with an arterial line and Foley catheter in the semi right lateral decubitous position. Nine of the 18 patients underwent a left anterolateral mini-thoracotomy for epicardial left ventricular (LV) lead placement. All hardware included defibrillation technology (ICD). RESULTS: All 18 patients left the OR with successful bi-ventricular pacing in an average time of 170 minutes (range 140-200 min). The average epicardial lead pacing threshold was 0.9v (range 0.4-1.5v) while the average endocardial (transvenous) threshold was 0.4v (range 0.2-0.7v) at a pulse width of 0.5 msec. TTE at 1 month demonstrated an improvement in LVEF in 14/18 patients with an average increase of 5% (range 2%-9%). Four of the 5 patients with moderate-severe MR were reduced to mild. The average length of stay (LOS) following the procedure, in those patients who did not undergo a thoracotomy, was 4 days (range 3-6 days) while it was 7 days (range 6-10 days) in those who underwent a thoracotomy. CONCLUSION: These data clearly indicate that CRT can be successfully performed as a single-staged procedure in a cardiac OR. Although transvenous LV lead placement avoids a thoracotomy, the epicardial LV lead thresholds, in this series, are competitive with the transvenous results. We propose that in the spirit of cost containment, fee bundling, decreasing reimbursement, pay-for-performance, and infection control, these complex interventions should be performed in multipurpose interdisciplinary hybrid cardiac OR's, now available in most major medical centers, with designated time limitations and role assignments.

Sequential bypass on the beating heart can be achieved without compromising patient safety or regional myocardial blood flow.

For some cardiac surgeons, operating on the beating heart is the preferred method of coronary revascularization. In an effort to minimize manipulation of the aorta, we have used, in addition to an internal mammary artery (IMA) graft to the left anterior descending (LAD) coronary artery, a sequential reversed saphenous vein graft (rSVG) to revascularize the lateral, inferior, and posterior myocardium with a single proximal aortic anastomosis. In this report, we retrospectively summarize a recent series of off-pump coronary bypass grafting (OPCABG) cases, including the evaluation of distal conduit blood flow. Between January 1, 2005, and January 1, 2007, a consecutive series of 175 patients underwent OPCABG with 1 IMA graft and 1 sequential rSVG performed by a single surgeon (RLQ). The average number of grafts/patient was 3.4 (range, 3-5). Flow rates were measured in each segment of the sequential graft using a Transonic Flowmeter (HT314, Transonic Systems Inc, Ithaca, NY). All patients were given PO clopidogrel (75 mg/d) for 6 weeks beginning on postoperative day #1. Mean flow through the distal segment of the sequential venous bypass was 36 ml/min, which was not significantly influenced by the number of proximal coronary anastomoses nor by the size of the proximal coronary bed. The 30-day mortality and stroke rate was 0% (0/175). The incidence of postoperative atrial fibrillation in those patients with normal baseline sinus rhythm was 29% (49/169). No postoperative myocardial infarctions [enzyme/electrocardiographic (ECG) criteria] nor renal failure requiring dialysis occurred. As the complexity of the surgical candidate continues to increase, less invasive approaches to coronary revascularization will prevail. The results of this retrospective study indicate that this technique is safe, and that regional coronary blood flow is not compromised by the creation of sequential anastomoses.

Left atrial myxoma and mitral valve endocarditis--a cause and effect: a case report.

We report the case of a 55-year-old man who presented with an infected left atrial myxoma that seeded a normal native mitral valve. Despite the absence of mitral regurgitation or heart failure, prior to the patient completing a course of IV antibiotic therapy we removed the tumor, replaced the mitral valve, and added 3 coronary artery bypass grafts, following a single embolic event. Although a completed course of antibiotic therapy may have allowed preservation of the native mitral valve, we believed that the risk of recurrent embolization from either the mass or the mitral valve vegetations was greater that the long-term risks of valve replacement.

Prevention of systolic anterior motion after repair of the severely myxomatous mitral valve with an anterior leaflet valvuloplasty.

BACKGROUND: Systolic anterior motion after mitral valve repair of severely myxomatous valves is due to excess tissue or anterior displacement, or both, of the leaflet coaptation point. Our series of anterior leaflet valvuloplasty, an alternative to the sliding leaflet technique to prevent systolic anterior motion, is presented. METHODS: Between January 1, 1996 and January 6, 2003, we performed elliptical excisions of the base of the anterior leaflet in 47 patients with a mean age of 66 years (range, 29 to 86). All patients had an anterior leaflet height of 3.0 cm or more and an annular diameter of 4.0 cm or more. Repairs included posterior leaflet (37; 80%), and anterior leaflet (28; 61%) resections, with occasional transposition flaps (9; 19%). All 47 (100%) had an annuloplasty ring (9, Physio; 37, Seguin). Four (8%) included tricuspid repair, 6 (13%) aortic valve replacement, and 9 (19%) coronary artery bypass. Follow-up was between 2 months and 8 years. RESULTS: There was no systolic anterior motion or in-hospital (30-day) mortality. Postoperative echocardiography revealed an average anterior leaflet height of 2.2 +/- 0.3 cm, with an annular diameter of 3 +/- 0.2 cm. The anterior/posterior leaflet ratio decreased from 1.6 +/- 0.2 to 1.4 +/- 0.1 cm while the coaptation point-annular plane distance decreased from 1.2 +/- 0.2 to 0.9 +/- 0.1 cm. There were 4 late noncardiac deaths. Two patients have required mitral valve replacement owing to progressive disease and 6 patients were lost to follow-up. The 35 patients remaining have trace-mild mitral regurgitation. CONCLUSIONS: Our anterior mitral valve leaflet valvuloplasty, regardless of the ring, results in a decrease in surface area and excursion of the anterior leaflet without systolic anterior motion.

Prevention of systolic anterior motion after mitral valve repair with an anterior leaflet valvuloplasty.

BACKGROUND AND AIM OF THE STUDY: Mitral valve repair (MVR) is the preferred method of treatment of the complex floppy mitral valve. Immediate repair failure, due to systolic anterior motion (SAM), is related to excessive anterior mitral valve leaflet (AMVL) tissue and/or anterior displacement of the leaflet coaptation point by the posterior mitral valve leaflet (PMVL) with resultant left ventricular outflow tract (LVOT) obstruction. Herein are reported the authors' experience of the AMVL valvuloplasty, a simple alternative to the sliding technique, to prevent post-MVR SAM. METHODS: Between January 1996 and June 2003, elliptical excisions of the base of the AMVL and annuloplasty rings (nine Physio, 38 Seguin) were performed in 47 patients (mean age 66 years; range: 29-86 years). The surgical procedure included posterior mitral valve leaflet (PMVL) resection in 37 patients (80%), AMVL resection in 28 (61%), and transposition flaps in nine (19%). Four patients (8%) had a tricuspid valve repair, six (13%) had an aortic valve replacement, and nine (19%) had coronary bypass grafting. Intraoperative transesophageal echocardiography before and after MVR was performed to assess mitral valve anatomy, the presence and severity of mitral regurgitation (MR), and SAM. RESULTS: There was no postoperative SAM. The severity of MR was reduced to trace or mild in all 47 patients. The mean AMVL length was 3.0 cm before and 2.2 cm after MVR, a tissue reduction of 27%. In those patients with a PMVL resection, the mean length was decreased from 1.95 cm to 1.5 cm, a tissue reduction of 23%. The mean annulus diameter decreased from 3.9 cm to 3.0 cm. The mean AMVL:PMVL ratio decreased from 1.6 to 1.4. The proportional size reduction of the AMVL compared to the PMVL was 17%. The mean coaptation point to annulus distance (CPAD) decreased from 1.1 cm to 0.9 cm. There was no 30-day in-hospital mortality. CONCLUSION: The AMVL valvuloplasty eliminated postoperative SAM. There was both reduction of the AMVL surface area, limiting the excursion of the AMVL into the LVOT, and reduction of CPAD. This technique does not compromise the geometry of the mitral valve apparatus.

Synergy of old and new technology results in successful revascularization of the anterior myocardium with relief of angina in the absence of suitable targets.

BACKGROUND: Diffuse and distal left anterior descending (LAD) coronary disease that is refractory to conventional surgical and/or percutaneous revascularization represents a clinical and economic dilemma. Transmyocardial laser revascularization (TMLR) has improved angina without clear measurable improvement of myocardial perfusion. This study was undertaken to determine if combining a Vineberg implant with TMLR of the LAD distribution enhances myocardial perfusion and relieves symptoms. METHODS: Twenty-one patients with an obliterated LAD and a viable anterior wall underwent off-pump coronary artery bypass grafting (OPCAB) (2.6 grafts/patient). Eight were studied with preoperative, postoperative-early (4-9 days), and postoperative-late (3-5 months) stress and rest nuclear imaging. In all but 3 cases, the Vineberg implant was modified such that the distal end of the conduit, as it emerged from the muscular tunnel, was anastomosed to any patent LAD segment. The anterior wall, to the left of the LAD, was also instrumented with a Holmium yttriumaluminum- garnet laser (8-16 sites). RESULTS: There has been 100% follow-up with durations ranging from 6 to 36 months. There were no deaths. All patients had complete relief of their angina. Serial perfusion scans demonstrated a 2-phase improvement in perfusion. Three of the patients underwent angiography of the implant at 6 to 9 months; angiography in each case demonstrated a patent robust conduit. The 1 patient studied at 24 months demonstrated several sites of a myocardial "blush" consistent with neovascularization. CONCLUSIONS: Although some of the benefits of TMLR/Vineberg may be a consequence of collateral blood flow from other revascularized regions, we believe there to be a synergistic effect on perfusion and angina relief by these combined procedures which may be related to angiogenesis.