Autologous Breast Reconstruction is Associated with Lower 90-day Readmission Rates.

BACKGROUND: Breast reconstruction is associated with improved quality of life after mastectomy. Options for breast reconstruction include autologous and implant-based methods. Although autologous reconstruction is more technically challenging and requires longer operative time, it is thought of as the gold standard. Our study examined differences in 90-day readmission rates between implant-based and autologous breast reconstruction using discharge data from the National Readmission Database, Healthcare Cost and Utilization Project, and Agency for Healthcare Research and Quality. METHODS: The National Readmission Database was used to identify patients undergoing postmastectomy breast reconstruction. Patients were selected using ICD-10 PCS codes linked to autologous and implant-based reconstruction. Ninety-day readmission rates were determined. After matching the two groups on a 1:1 basis for baseline comorbidities and demographics, a multivariable logistic regression analysis was performed to variables associated with higher readmission rates. RESULTS: The leading diagnoses associated with readmissions were infectious and pulmonary. After one to one matching, autologous breast reconstruction, private insurance versus Medicaid, and income quartile 4 versus 1 were all less likely to be readmitted within 90 days of discharge. Patients with a high Charlson index and those with a longer length of initial hospital stay are significantly more likely to be readmitted within 90 days. CONCLUSIONS: Patients undergoing autologous breast reconstruction were 23% less likely to be readmitted within 90 days from discharge. Fewer comorbidities, shorter length of hospital stay, and higher socioeconomic status are also associated with lower readmission rates following breast reconstruction.

Spitz Nevus: Review and Update.

The Spitz nevus is an uncommon melanocytic nevus. These lesions classically appear in childhood as a red, dome-shaped papule. They appear rarely in adults and may be pigmented. The Spitz nevus can develop suddenly and grow rapidly, reaching a 1-cm diameter in 6 months or less. There are 3 classes of spitzoid neoplasms: typical Spitz nevus, atypical Spitz nevus, and spitzoid melanoma. The diagnosis should be cautiously differentiated, especially in children. Immunohistochemistry and molecular studies have been helpful in differentiating difficult cases; however, no set of criteria has been accepted to predict biological behavior of atypical Spitz nevi.

Life Expectancy and Rate of Decline After Lung Volume Reduction Surgery.

Lung volume reduction surgery (LVRS) patient selection guidelines are based on the National Emphysema Treatment Trial. Because of increased mortality and poor improvement in functional outcomes, patients with non-upper lobe emphysema and low baseline exercise capacity are determined as poor candidates for LVRS. In well-selected patients with heterogeneous emphysema, LVRS has a durable long-term outcome at up to 5-years of follow-up. Five-year survival rates in patients range between 63% and 78%. LVRS seems a durable alternative for end-stage heterogeneous emphysema in patients not eligible for lung transplantation. Future studies will help identify eligible patients with homogeneous emphysema for LVRS.

Migraine Treatment.

Migraine headaches affect more than 35 million Americans and are ranked the third-highest cause of disability worldwide, resulting in decreased quality of life and serious economic consequences. There are 4 types of migraine headaches: frontal, temporal, occipital, and rhinogenic. Each type has a well-described trigger site. Migraines headaches often are refractory to medical therapy and may respond well to botulinum toxin type A. Migraine surgery is another option to release trigger sites. A systematic review of the migraine surgery literature found an average success rate of 90%, with elimination or greater than 50% improvement of migraine headaches after migraine surgery.

Free tibia and fibula-fillet-of-leg flap for pelvic ring reconstruction: A case report.

Pelvic sarcoma resections present large and complex defects, which are a challenge to reconstruct. At times, these cancers are treated with external hemipelvectomy, and both the soft tissue and bony framework of the pelvic ring must be addressed. The purpose of this case report is to describe the use of a free tibia and fibula-fillet-of-leg flap for pelvic ring reconstruction, performed to enhance the quality of life of a patient following hemipelvectomy. A 50-year-old female with advanced stage undifferentiated pleomorphic sarcoma of the left thigh and pelvis underwent free vascularized tibia and fibula-fillet-of-leg flap, including 21 cm of bone length and 21 cm long and full circumferential soft tissues of the leg, accompanying the bone, for the reconstruction of the bony pelvis and soft tissue. Postoperatively, the patient had no surgical complications, was followed for 6 months and went on to have bony healing, and was able to sit prior to disease progression and eventual death from metastatic disease. In the reported case, we have shown that composite tibia-fibula free flap with lower leg soft tissues may be a viable option for the reconstruction of massive external hemipelvectomy defects.

Pediatric vascularized composite allotransplantation: What is the landscape for obtaining appropriate donors in the United States?

Listing the world's first pediatric bilateral hand transplant patient for a donor posed many challenges including matching the appropriate donor age, bone size, skin tone, and growth potential in an already limited donor population. This study describes the prevalence and distribution of potential pediatric VCA donors in the United States. We assessed the UNOS database from 2008 to 2015 to identify the prevalence of potential pediatric VCA donors. Standard VCA inclusion and exclusion criteria were applied to the dataset for all pediatric solid organ donors. Frequency analyses were performed of characteristics important for VCA matching. The dataset began with 57 300 brain-dead donors and after applying the inclusion and exclusion criteria including age <18, decreased to 4663 (8.1%). The number of pediatric potential VCA donors per UNOS region ranged from 11 to 112/year. The majority of pediatric potential VCA donors were blood type O Whites, with the least common profile being blood type AB of "other" ethnicity. The present study confirmed that pediatric VCA donors are rare and may require longer travel times for procurement and listing at multiple centers in order to find a suitable donor. This will be a limiting factor for the expansion of pediatric VCA.

Clinical and Quality of Life Outcomes After Lung Volume Reduction Surgery.

BACKGROUND: Lung volume reduction surgery (LVRS) is the definitive treatment for patients with severe emphysema. There is still a need for long-term data concerning the outcomes of this procedure. This study presents long-term longitudinal data on LVRS including correlation of quality of life (QOL) with pulmonary function testing metrics and includes additional analysis of patients with heterogeneous and homogeneous emphysema. METHODS: Retrospective analysis of data collected from patients undergoing LVRS over a 9-year period at a single center was performed (N = 93). Pulmonary function and 6-minute walk tests as well as QOL questionnaires were administered before and 1 year after surgery. Descriptive statistics were reported for clinical outcomes and QOL indices. Wilcoxon signed-rank tests were used to examine changes from baseline to end of 1-year follow-up. Spearman correlation coefficients were used to evaluate relationships between clinical and QOL outcomes. RESULTS: At 1-year post surgery, mean forced vital capacity (46%, P ≤ .0001), forced expiratory volume (43%, P ≤ .0001), diffusing capacity of the lungs for carbon monoxide (16%, P ≤ .0001), and 6-minute walk distance (20%, P ≤ .0001) were increased from baseline, while residual volume decreased (23%, P ≤ .0001). There was a positive correlation between changes in QOL and forced expiratory volume, forced vital capacity, and, 6-minute walk distance. Patients having heterogeneous disease had greater improvements in forced expiratory volume, forced vital capacity, residual volume, and diffusing capacity of the lungs for carbon monoxide, and greater QOL compared with patients with homogeneous disease. CONCLUSIONS: LVRS continues to be a valuable treatment option for patients with advanced emphysema with reproducible improvements in clinical and QOL metrics. Careful patient selection and optimization prior to surgery are crucial to successful outcomes.

Prevalence and Distribution of Potential Vascularized Composite Allotransplant Donors, Implications for Optimizing the Donor-recipient Match.

BACKGROUND: Vascularized composite allotransplantation (VCA) is an emerging and growing field. Little is known about the prevalence and distribution of the adult potential donor population in the United States now that it falls under the oversight of the United Network for Organ Sharing (UNOS). METHODS: We assessed the UNOS database from 2008 to 2015 to estimate the prevalence and distribution of adult potential vascularized composite allograft donors. Donor inclusion and exclusion criteria were developed in a way to minimize risk to recipients and were applied to the dataset. Donors were categorized by factors that influence vascularized composite allograft matching including ABO blood type, cytomegalovirus status, and ethnicity (correlate for skin color) and sorted by UNOS region. RESULTS: Just under half of all brain dead donors met the inclusion/exclusion criteria. Blood type O, cytomegalovirus+, White donors represented the most frequent donor profile while blood type AB, cytomegalovirus-, Asian donors were the least common. UNOS region 3 had the most and region 1 had the least potential VCA donors per year. Nearly all potential VCA donors were solid organ donors with the liver being the most commonly donated solid organ in this population. CONCLUSIONS: A large portion of the solid organ donor pool would qualify as adult vascularized composite allograft donors in the current UNOS system. These data will assist transplant teams in determining the prevalence and distribution of vascularized composite allograft donors for their individual patients awaiting composite allografts based on relevant matching characteristics in addition to standard transplant criteria.

A Systematic Review of Surgical Management of Melanoma of the External Ear.

BACKGROUND: Historically, external ear melanomas have been treated aggressively, due to early perceptions suggesting they had poor prognosis and aggressive biological behavior. More recent evidence has not supported these notions. METHODS: We completed a complete review of the literature involving malignant melanoma of the external ear. We then completed a quantitative analysis on seventy-three cases from 8 reports that contained case-level data, assessing factors that influence recurrence, and assessing characteristics of the melanomas based on histological subtype. Baseline and outcomes data for all 20 studies were then compiled but not statistically evaluated. RESULTS: In our subanalysis, patients who had recurrence were significantly more likely to have had wedge resection versus wide-local excision, and those with no recurrence were more likely to have undergone wide local excision. Nodular tumors had significantly greater thickness. Overall, conservative excisions provided excellent outcomes. CONCLUSIONS: Conservative treatment for external ear melanoma produces satisfactory outcomes. There is no evidence to support the use of radical amputation and little evidence to support the removal of cartilage or perichondrium. Sentinel lymph node biopsy is warranted only with positive nodes. There is no role for elective neck dissection. The roles for chemo/radiation therapy are unclear and guidelines for other cutaneous melanomas should be followed.

Artery-Only Ear Replantation in a Child: A Case Report With Daily Photographic Documentation.

Objective: Ear replantation poses a significant technical challenge even for the skilled microsurgeon. Many ear amputations result from avulsion and thus have damaged and often diminutive vessels with a paucity of veins. Artery-only replantation is an option for ear salvage, but little is published on the clinical course and appearance after this procedure. Methods: A subtotal ear replantation was performed on a 10-year-old boy without a venous anastomosis. Leech therapy was used to manage venous congestion postoperatively, and daily photography was performed to document the clinical course. Results: Postoperative venous congestion was successfully managed with leech therapy. Four days after the replantation, arterial thrombosis occurred that required a take back and salvage with an interposition vein graft for arterial repair. Native venous drainage and arterial revascularization from skin edges were evident by postoperative day 12, and leeches were discontinued on day 14. The patient required debridement of the posterior ear and superior helix necrotic skin, with burying of the upper portion of the ear in a superior auricular skin flap. The ear was subsequently released from the head, and the exposed portions were covered successfully with a full-thickness skin graft. Conclusions: While arterial and venous anastomoses should always be attempted, arterial-only ear replantation can provide excellent results when venous congestion is properly managed. Daily photography can be a useful tool to monitor subtle skin color changes that may indicate native venous drainage and arterial revascularization.

Improving the gas barrier property of clay-polymer multilayer thin films using shorter deposition times.

Relatively fast exposure times (5 s) to aqueous solutions were found to improve the gas barrier of clay-polymer thin films prepared using layer-by-layer (LbL) assembly. Contrary to the common belief about deposition time (i.e., the longer the better), oxygen transmission rates (OTRs) of these nano-brick-wall assemblies are improved by reducing exposure time (from 1 min to 5 s). Regardless of composition, LbL films fabricated using shorter deposition time are always thicker in the first few layers, which correspond to greater clay spacing and lower OTR. A quadlayer (QL) assembly consisting of three repeat units of branched polyethylenimine (PEI), poly(acrylic acid) (PAA), PEI and montmorillonite (MMT) clay is only 24 nm thick when deposited with 1 min exposure to each ingredient. Reducing the exposure time of polyelectrolytes to 5 s not only increases this film thickness to 55 nm but also reduces the oxygen transmission rate (OTR) to 0.05 cm3/(m2 day atm), which is 2 orders of magnitude lower than the same film made using 1 min exposures. A conceptual model is proposed to explain the differences in growth and barrier, which are linked to polyelectrolyte relaxation, desorption, and interdiffusion. The universality of these findings is further exemplified by depositing clays with varying aspect ratios. This ability to quickly deposit high-barrier nanocomposite thin films opens up a tremendous opportunity in terms of commercial-scale processing of LbL assemblies.