Robotic Repair: An Alternative Technique for Rectus Diastasis and Abdominal Bulge Following DIEP Flap Breast Reconstruction.

BACKGROUND: The Deep Inferior Epigastric Artery Perforator (DIEP) flap is the gold standard in autologous breast reconstruction. Despite advances in perforator dissection, abdominal morbidity still occurs. Traditional rectus diastasis (RD), abdominal bulge, and hernia repair with open techniques are associated with higher complication rates and recurrence. OBJECTIVES: We present a novel case series of robotic repair of symptomatic RD and/or abdominal bulge with concurrent hernia following DIEP flap surgery. METHODS: A single-center, retrospective review was conducted on 10 patients who underwent bilateral DIEP flap breast reconstruction and subsequent robotic repair of RD and/or abdominal bulge and hernia. Pre-operative demographics and post-operative clinical outcomes were reviewed. RD up to 5 cm, abdominal bulge, and any concurrent ventral/umbilical hernias were repaired robotically via retrorectus plication and macroporus mesh reinforcement. RESULTS: The average age and BMI were 49 years (range 41-63) and 31 kg/m2 (range 26-44), respectively. The average number of perforators harvested per flap was 2.5 (range 1-4). Average RD and hernia size were 3.95 cm (range 2-5) and 5.8 cm2 (1-15), respectively. Eight patients stayed one night in the hospital, two went home the same day as the robotic repair. No patients converted to open technique and none experienced complications within 30 days. CONCLUSIONS: For the patients who experience donor site morbidity following DIEP flap breast reconstruction, minimally invasive robotic repair of RD and/or abdominal bulge with hernia can be performed with mesh reinforcement. This technique is effective with low complication rates and should be considered over open repair.

Detection of Microbiota in Post Radiation Sinusitis.

OBJECTIVES: A shift in the microbiota of chronic rhinosinusitis has been described after radiotherapy to the sinonasal cavity and skull base. There is a paucity of literature characterizing the bacteriology of post radiation sinusitis using next-generation gene sequencing techniques. This study aims to describe and compare the microbial flora of rhinosinusitis after radiotherapy using both culture and molecular techniques for microbial DNA detection. METHODS: The medical records of patients treated with external beam radiation for sinonasal, nasopharyngeal, or skull base malignancy were reviewed at a tertiary care facility. Patients' sinonasal cavities were swabbed for routine culture or brushed for molecular gene sequencing. Swab specimens were processed for standard microbial culture, and brush specimens were sent for gene sequencing at Micro GenX Laboratory (Lubbock, Texas, USA). RESULTS: Twenty-two patients were diagnosed with chronic sinusitis after undergoing radiotherapy. Staphylococcus aureus was the most common organism identified by both culture and gene sequencing, followed by Pseudomonas aeruginosa. Several additional organisms were detected by gene sequencing that were not isolated by routine culture techniques. Gene sequencing identified pathogens differing from culture results in 50% of patients examined. CONCLUSION: The bacteriology of post radiation sinusitis appears to resemble the microorganisms responsible for chronic sinusitis in healthy adults. Next generation gene sequencing techniques may reveal additional organisms responsible for sinusitis and provide complementary results that may impact the medical treatment of post radiation sinusitis.

Temporal and spectral contributions to musical instrument identification and discrimination among cochlear implant users.

OBJECTIVE: To investigate the contributions of envelope and fine-structure to the perception of timbre by cochlear implant (CI) users as compared to normal hearing (NH) listeners. METHODS: This was a prospective cohort comparison study. Normal hearing and cochlear implant patients were tested. Three experiments were performed in sound field using musical notes altered to affect the characteristic pitch of an instrument and the acoustic envelope. Experiment 1 assessed the ability to identify the instrument playing each note, while experiments 2 and 3 assessed the ability to discriminate the different stimuli. RESULTS: Normal hearing subjects performed better than CI subjects in all instrument identification tasks, reaching statistical significance for 4 of 5 stimulus conditions. Within the CI population, acoustic envelope modifications did not significantly affect instrument identification or discrimination. With envelope and pitch cues removed, fine structure discrimination performance was similar between normal hearing and CI users for the majority of conditions, but some specific instrument comparisons were significantly more challenging for CI users. CONCLUSIONS: Cochlear implant users perform significantly worse than normal hearing listeners on tasks of instrument identification. However, cochlear implant listeners can discriminate differences in envelope and some fine structure components of musical instrument sounds as well as normal hearing listeners. The results indicated that certain fine structure cues are important for cochlear implant users to make discrimination judgments, and therefore may affect interpretation toward associating with a specific instrument for identification.

Snails from heavy-metal polluted environments have reduced sensitivity to carbon dioxide-induced acidity.

Anthropogenic atmospheric CO2 reacts with water to form carbonic acid (H2CO3) which increases water acidity. While marine acidification has received recent consideration, less attention has been paid to the effects of atmospheric carbon dioxide on freshwater systems-systems that often have low buffering potential. Since many aquatic systems are already impacted by pollutants such as heavy metals, we wondered about the added effect of rising atmospheric CO2 on freshwater organisms. We studied aquatic pulmonate snails (Physella columbiana) from both a heavy-metal polluted watershed and snails from a reference watershed that has not experienced mining pollution. We used gaseous CO2 to increase water acidity and we then measured changes in antipredatory behavior and also survival. We predicted a simple negative additive effect of low pH. We hypothesized that snails from metal-polluted environments would be physiologically stressed and impaired due to defense responses against heavy metals. Instead, snails from populations that acclimated or evolved in the presence of heavy metal mining pollution were more robust to acidic conditions than were snails from reference habitats. Snails from mining polluted sites seemed to be preadapted to a low pH environment. Their short-term survival in acidic conditions was better than snails from reference sites that lacked metal pollution. In fact, the 48 h survival of snails from polluted sites was so high that it did not significantly differ from the 24 h survival of snails from control sites. This suggests that the response of organisms to a world with rising anthropogenic carbon dioxide levels may be complex and difficult to predict. Snails had a weaker behavioral response to stressful stimuli if kept for 1 month at a pH that differed from their lake of origin. We found that snails raised at a pH of 5.5 had a weaker response (less of a decrease in activity) to concentrated heavy metals than did snails raised at their natal pH of 6.5. Furthermore, snails raised a pH of 5.5, 6.0, and 7.0 all had a weaker antipredatory response to an extract of crushed snail cells than did the pH 6.5 treatment snails.

Intractable epistaxis due to isolated primary telangiectasias.

IMPORTANCE: Epistaxis is the most common otolaryngologic emergency in the United States. Most cases are controlled with first-line measures, but intractable epistaxis can be a challenging clinical problem requiring posterior nasal packing and surgical or endovascular intervention. Bleeding from nasal telangiectasias is well known in hereditary hemorrhagic telangiectasia, but there are no reports in the literature of recurrent epistaxis due to isolated telangiectasias not associated with systemic disease. This report describes a series of cases in which intractable epistaxis due to isolated primary telangiectasias was effectively controlled with bipolar electrosurgery. OBSERVATIONS: We describe a patient with intractable epistaxis that had failed management with posterior packing and embolization. We also report a series of 16 cases of epistaxis, 6 of which were intractable, in adults without hereditary hemorrhagic telangiectasia who received treatment between 2009 and 2012. These cases reveal a common pattern of bleeding from telangiectasias on the anterior septum (8 cases [42%]), nasal sidewall (3 [16%]), inferior meatus (2 [10%]), posterior septum (2 [10%]), nasal floor (2 [10%]), middle turbinate (1 [5%]), and inferior turbinate (1 [5%]). CONCLUSIONS AND RELEVANCE: Telangiectasias not associated with systemic disease are a previously unreported source of significant nasal bleeding that, when identified endoscopically, can be treated successfully with bipolar electrosurgery rather than with more invasive and costly surgical and endovascular measures.

Histologic analysis of pediatric tonsil and adenoid specimens: is it really necessary?

OBJECTIVE: To evaluate the incidence of unexpected histologic findings in routine tonsillectomy and adenoidectomy specimens. METHODS: A retrospective medical record review was performed at a tertiary care children's hospital. The pathology records of 2062 children who underwent tonsil or adenoid surgery were analyzed and the final histologic diagnosis was recorded. RESULTS: Four unexpected histologic findings were found on routine tonsil and adenoid specimens. None were clinically significant. A review of the literature shows a very low rate (0.015%) of unexpected clinically significant diagnoses in pediatric adenotonsillectomy specimens. CONCLUSIONS: Given rarity of unexpected clinically significant diagnoses in pediatric adenotonsillectomy specimens, the cost and effort of analyzing each specimen histologically is difficult to justify.