New Kid on the Block: A Systematic Review of the Quadratus Lumborum Block in Plastic and Reconstructive Surgery.

Background: Although the transversus abdominal plane (TAP) block is commonly used in abdominal surgery as part of enhanced recovery after surgery pathways, the quadratus lumborum (QL) block has been hypothesized as an effective alternative to the TAP block in some areas. This review evaluates the current literature, as it relates to the QL block in plastic and reconstructive surgery. Methods: A systematic review using PubMed searched for all original, peer-reviewed articles, including the term "quadratus lumborum block." In total, 509 articles were identified for review by two independent reviewers. Original articles evaluating the use of a QL block in any plastic surgery operation were included. Articles evaluating pediatric patients, animal trials, and the use of a QL block in any nonplastic surgery operation were excluded. Results: Three articles met inclusion criteria. One trial demonstrated decreased subjective pain scores and total opioid use, whereas the second found no statistically significant difference. A case study described the use of a QL block for unilateral breast reconstruction with minimal opiate use and reduced pain scores postoperatively. Limitations include the limited number of studies and the heterogeneity in study type and design, making analysis difficult. Conclusions: Despite its demonstrated efficacy in other surgical subspecialties, there are limited data evaluating the use of the QL block in plastic and reconstructive surgery. Additional research is needed to evaluate the role of the QL block in plastic surgery and how it compares to the more widely utilized TAP block.

Fingertip ischemia following intralesional injection of Candida albicans antigen for treatment of a subungual wart.

Subungual or periungual cutaneous warts are caused by the human papillomavirus (HPV). These lesions can be refractory to destructive therapy, necessitating the use of intralesional immunotherapies such as Candida albicans antigen. In this case report, we present a 23-year-old female who sustained distal fingertip soft tissue necrosis following intralesional injection of Candida albicans antigen for the treatment of a refractory subungual wart. While this patient recovered appropriately with conservative bedside debridement and local wound care, intralesional injections to the digit, or hand are not without sequela. It's important to inject intradermally while avoiding the digital vasculature underneath. In this case, the radial digital vessels were traumatized upon injection, leading to digital ischemia and soft tissue necrosis. While isolated soft tissue ischemia without compromised perfusion can be treated conservatively, these injuries should be evaluated by a hand surgeon to determine the need for emergent revascularization, or future soft tissue reconstruction.

Single Stitch Vicryl Mesh Wrap for Prepectoral Implant Breast Reconstruction.

Acellular dermal matrices are commonly used in prepectoral breast reconstruction for implant coverage and support, but they are associated with significant costs. The authors describe a technique for prepectoral breast reconstruction in which the implant is completely wrapped in a knitted Vicryl mesh and then positioned on the chest, without the need for any tacking sutures. A retrospective review was performed on all consecutive prepectoral breast reconstructions, using this technique at a single institution. A separate cohort undergoing prepectoral reconstruction with a conventional acellular dermal matrix technique was also reviewed for comparison. Patient demographics, oncologic and reconstruction characteristics, outcomes, complications, and materials cost were analyzed. Twelve patients (23 breasts) underwent prepectoral reconstruction with Vicryl mesh, and 34 patients (55 breasts) underwent prepectoral reconstruction with acellular dermal matrices. Overall complication rates in the Vicryl group were low (two infections, one case of skin necrosis, one hematoma) and did not differ statistically from the acellular dermal matrix group. Operative time per breast was nearly twice as fast (35.7 versus 68.0 min, P < 0.01). Calculated materials cost savings was $8273 per breast. Prepectoral breast reconstruction with Vicryl mesh only is a safe technique that is much faster and significantly cheaper compared with conventional reconstructive techniques utilizing acellular dermal matrices.

Period-Prevalence and Risk Factors for Delirium in a Tertiary Referral ICU: A prospective cohort study.

BACKGROUND: Delirium is common in intensive care and leads to increases in morbidity, mortality, Intensive Care Unit (ICU) length of stay, and hospital length of stay. Certain risk factors predict the appearance of delirium. STUDY OBJECTIVES: To determine the rates of delirium, the rate of risk factors, and their relationship to the occurrence of delirium in an adult ICU. METHODS: Single-centre, prospective, observational study. Demographic and treatment data were collected. The Confusion Assessment Method for ICU (CAM-ICU) was performed twice daily to assess for delirium continuously during a 3-week period. Statistical analysis was used to determine the relationship between risk factors and the occurrence of delirium. RESULTS: 86 patients were screened, 44 patients were included, and 260 patient-days were analyzed. The incidence of delirium was 42.9%, the prevalence of delirium in ICU was 50%. Urinary catheters and use of opioids were the most common factors with a positive association for occurrence of delirium. Exposure to daylight and sleeping for more than 4 hours at night were the factors most commonly associated with a lack of delirium. CONCLUSION: The rates of delirium in ICU were high and risk factors occurred frequently. Addressing modifiable risk factors, including the promotion of adequate sleep, could improve outcomes.

How Fat Grafting Works.

Fat grafting has been shown to improve diseased soft issue. Although the mechanism behind fat grafting's regenerative properties is currently debated, published studies agree that there is an associated vasculogenic effect. A systematic literature review was conducted to elucidate the biochemical pathways responsible for establishing neo-vasculature to grafted fat. METHODS: A systematic literature review was conducted by searching PubMed for current basic science and clinical research relating to fat grafting. In total, 144 of 269 (54%) articles met the inclusion criteria for our literature review. These 144 articles were summarized, with 86 of them (60%) used to construct this article at the authors' discretion. RESULTS: Fat grafting-induced neovascularization can be divided into 3 parts. First, tissue trauma induced via fat injection activates a host inflammatory response necessary for cellular recruitment. Recruited cells promote the formation of connective tissue and neo-vasculature at the graft site. Second, cellular elements within the lipoaspirate contribute to neovascularization through a cytokine burst. Third, a synergistic relationship is established between recruited inflammatory cells and the cytokine burst of grafted fat. The end product of these processes is the differentiation of progenitor cells and the creation of neo-vasculature at the graft site. CONCLUSIONS: Establishing neovasculature is paramount for the survival of grafted fat. Fat graft take can be divided into 2 steps: imbibition and neovascularization. We believe this process occurs through 3 distinct concepts: host inflammation via graft injection, hypoxic response of lipoaspirate-derived cellular elements, and a synergistic relationship between host inflammation and grafted fat.

MOC-PSSM CME article: Zygomatic fractures.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the common signs, symptoms, and treatment options for zygomatic fractures. 2. Answer basic questions on therapy for zygomatic fractures. SUMMARY: This maintenance of certification article on zygomatic fractures attempts to review the current approaches to the treatment of these fractures. Although the article does not deal with extended approaches to treatment, it does in a general sense present the preoperative, intraoperative, and postoperative thinking for the plastic surgeon approaching these patients in general practice. A further in-depth review can be obtained through the references at the end of the article.

Do diabetic patients have higher in-hospital complication rates when admitted from the emergency department for possible myocardial ischemia?

OBJECTIVE: To compare in-hospital complication rates for diabetic and nondiabetic patients admitted from the emergency department (ED) for possible myocardial ischemia. METHODS: This was a prospective, observational study of consecutive consenting patients presenting to a suburban university hospital ED during study hours with typical and atypical symptoms consistent with cardiac ischemia. Demographic, historical, and clinical data were recorded by trained research assistants using a standardized, closed-question, data collection instrument. Inpatient records were reviewed by trained data abstractors to ascertain hospital course and occurrence of complications. Final discharge diagnosis of acute myocardial infarction (AMI) was assigned by World Health Organization criteria. Categorical and continuous data were analyzed by chi-square and t-tests, respectively. All tests were two-tailed with alpha set at 0.05. RESULTS: There were 1,543 patients enrolled who did not have complications at initial presentation; 283 were diabetic. The rule-in rate for AMI was 13.8% for nondiabetic patients and 17.7% for diabetic patients (p = 0.09). Times to presentation were similar for nondiabetic vs diabetic patients [248 minutes (95% CI = 231 to 266) vs 235 minutes (95% CI = 202 to 269); p = 0.32]. Nondiabetic patients tended to be younger [56.6 years (95% CI = 55.8 to 57.4) vs 61.6 years (95% CI = 60.2 to 63.1); p = 0.001] and were less likely to be female (34.3% vs 48.1%; p = 0.001). The two groups had similar prevalences for initial electrocardiograms diagnostic for AMI (5.5% vs 7.4%; p = 0.21). There was no significant difference between nondiabetic and diabetic patients for the occurrence of the following complications after admission to the hospital: congestive heart failure (1.3% vs 1.1%, p = 0.77); nonsustained ventricular tachycardia (VT) (1.3% vs 1.2%, p = 0.93); sustained VT (1.2% vs 1.1%, p = 0.85); supraventricular tachycardia (1.7% vs 3.2%, p = 0.12); bradydysrhythmias (1.9% vs 1.1%, p = 0.33); hypotension necessitating the use of pressors (0.9% vs 1.1%, p = 0.76); cardiopulmonary resuscitation (0.2% vs 0.7%, p = 0.10); and death (0.3% vs 0.7%, p = 0.34). One or more complications occurred with similar frequencies for patients in the two groups (6.3% vs 5.7%; p = 0.70). CONCLUSIONS: No statistically significant difference was found in the postadmission complication rates for initially stable diabetic vs nondiabetic patients admitted for possible myocardial ischemia. Based on these results, the presence or absence of diabetes as a comorbid condition does not indicate a need to alter admitting decisions with respect to risk for inpatient complications.

Advanced testicular cancer presenting with phlegmasia cerulea dolens.

A case of fulminating deep venous thrombosis secondary to invasion of the inferior vena cava is described in a 45 year old man presenting with a germ cell tumour. Despite aggressive supportive care and emergency chemotherapy his late presentation caused his death. The case highlights the necessity for increased public education of the attendant risks in delayed presentation with a testicular lump.

Clinical characteristics of diabetic vs nondiabetic patients who "rule-in" for acute myocardial infarction.

OBJECTIVE: To compare the clinical characteristics of diabetic vs nondiabetic patients who present to the ED with acute myocardial infarction (AMI). METHODS: This was a prospective, observational study at a suburban, university hospital ED of patients presenting to the ED during study hours between December 1993 and October 1996 with typical and atypical symptoms consistent with cardiac ischemia. Diabetic and nondiabetic patients with AMI were compared. Demographic, historical, and clinical data were recorded by trained research assistants using a standardized, closed-question, data collection instrument. Final discharge diagnosis of AMI was assigned by WHO criteria. Continuous variables were analyzed by t-tests. Clinical variables were analyzed by chi-square tests. All tests were two-tailed with alpha preset at 0.05. RESULTS: There were 216 patients with AMI during the study period; 51 of these patients (24%) were diabetic. For diabetic vs nondiabetic patients with AMI, there was no significant difference in age (64.0 +/- 13 vs 60.0 +/- 14 years, p = 0.13), female gender (37% vs 26%, p = 0.13), and time to presentation from symptom onset (192 +/- 238 vs 251 +/- 456 minutes, p = 0.41). Hypertension was the only cardiac risk factor significantly more prevalent in diabetic vs nondiabetic patients with AMI (77% vs 50%, OR = 1.54, 95% CI = 1.24 to 1.91, p = 0.001), though elevated cholesterol (48% vs 33%, OR = 1.47, 95% CI = 1.02 to 2.12, p = 0.06) tended to be more prevalent in the diabetic group. There was no statistically significant difference between the two groups in terms of the frequency of chest pain (OR = 1.04, 95% CI = 0.95 to 1.14, p = 0.30), associated symptoms, and diagnostic ECGs (OR = 1.16, 95% CI = 0.76 to 1.79, p = 0.53). CONCLUSION: Diabetic patients with AMI may have similar symptoms upon presentation as do nondiabetic patients with AMI. Of the cardiac risk factors, hypertension is more prevalent in diabetic vs nondiabetic patients with AMI.

Evaluation of CK-MB isoform analysis for early diagnosis of myocardial infarction.

Measurement of CK-MB and its isoforms by high-voltage electrophoresis has been proposed as a sensitive test for early detection of myocardial infarction (MI). We performed a prospective study of this test in 231 patients presenting to the Emergency Department with symptoms consistent with ischemic chest pain. Blood specimens were obtained at 0, 1, and 3 h following presentation, and plasma was immediately frozen and analyzed within 1 week by high-voltage electrophoresis for total CK-MB and isoforms. The test was considered positive whenever total CK-MB was elevated (>6 U/L) or the cardiac isoform MB2 was relatively increased (MB2 > 2 U/L and MB2/MB1 > 1.7). This test had a sensitivity of 68% overall and 55% for specimens collected within 3 h of symptom onset. It was positive within 3 h of presentation in 36/39 (92%) of patients with confirmed MI. Specificity was 92% overall and did not vary with time after symptoms. The CK-MB alone, at the cutoff of 6 U/L, had lower sensitivity overall (56%; p = 0.01) and within 3 h of onset (39%; p = 0.03), and higher specificity overall (98%; p < 0.001). Lowering the cutoff for CK-MB alone to match the sensitivity of the isoform test caused a greater loss of specificity. It is concluded that analysis of CK-MB by high-voltage electrophoresis is an effective method for rapid diagnosis of MI, with the isoform analysis enhancing early sensitivity.

Cardiac marker point-of-care testing in the Emergency Department and Cardiac Care Unit.

There has been much interest in improving the accuracy and speed with which chest pain patients presenting to the emergency department are diagnosed and treated. Recently, attention has been directed toward alternative site or point-of-care testing for biochemical markers of myocardial cell necrosis in addition to traditional diagnostic methodologies. The various point-of-care cardiac marker devices available and their potential applications are discussed. Regulatory and quality management issues related of point-of-care testing are reviewed.

Effect of duration from symptom onset on the negative predictive value of a normal ECG for exclusion of acute myocardial infarction.

STUDY OBJECTIVE: We hypothesized that the negative predictive value of the ECG would improve with time and assessed the effect of time elapsed from symptom onset to ED presentation on the negative predictive value, sensitivity, specificity, and positive predictive value of the initial ECG in patients presenting with symptoms suggestive of acute myocardial infarction (AMI). METHODS: We conducted a cross-sectional study in a university teaching hospital. Our structured data instrument, completed at the time of presentation included demographics, time of onset of symptoms, history, laboratory, and ECG findings. AMI was diagnosed with the use of international diagnostic criteria. Patients were stratified according to duration of time from symptom onset at 3-hour intervals. RESULTS: We enrolled 526 patients in the study group. The mean age was 59 years; 40% were female. The mean time elapsed from symptom onset to presentation was 185 minutes. A diagnosis of AMI was made in 104 patients (20%). The negative predictive values of a normal ECG for exclusion of AMI, stratified by duration of time from symptom onset, were: 0 to 3 hours, 93.2% (95% confidence interval [CI], 87.4% to 96.1%); 3 to 6 hours, 93.0% (95% CI, 83.0% to 98.1%); 6 to 9 hours, 92.6% (95% CI, 75.8% to 99.1%); and 9 to 12 hours, 94.1% (95% CI, 71.3% to 99.9%) (P = 1.0). The sensitivity, specificity, and positive predictive value of the ECG were similar in all groups. CONCLUSION: The negative predictive value of a normal ECG for exclusion of AMI does not improve as the duration of time from symptom onset to presentation increases. Normal ECG findings cannot be used to rule out an AMI, even those obtained up to 12 hours after symptom onset.

Are monitored telemetry beds necessary for patients with nontraumatic chest pain and normal or nonspecific electrocardiograms?

We evaluated the frequency of cardiovascular complications in chest pain patients with normal or non-specific electrocardiograms admitted to noncardiac care unit monitored beds and found that none of 261 patients had life-threatening dysrrhythmias requiring treatment.

Academic associate program: integrating clinical emergency medicine research with undergraduate education.

An educational program that teaches undergraduate students about clinical research related to emergency medicine is described. The students work as research assistants within the ED, thus providing a departmental framework for the enrollment of patients in clinical studies. Volunteers interested in the program undergo a physical examination, vaccination history, and standard serologic testing, and sit through a formal blood and body fluid exposure course offered by the university prior to their clinical research participation. A didactic curriculum on clinical research concepts and course examinations is provided. Over the 4 years since the department established its departmental research goals and this educational program, the departmental publication rate has increased from 2 to 20 manuscripts. While there was only 1 faculty member with a research publication in 1992, there were 9 faculty with manuscripts accepted for publication in the first 6 months of 1996. Similarly, more nurses and ancillary staff have become involved in prospective clinical research. Much of this success is attributed to the novel use of resources through the academic associate program.