Outcomes of the Keystone Island Perforator Flap: A Systematic Review.

BACKGROUND: The Keystone Design Perforator Island Flap (KDPIF), first described by Behan in 2003, has been demonstrated as a versatile, safe, and straightforward reconstructive option for various soft tissue defects. The purpose of this systematic review is to evaluate the indications, variations, and overall complication profile of the keystone flap in reconstructive surgery. METHODS: A literature review was conducted in accordance with PRISMA guidelines using MeSH term "surgical flaps" with the keyword "keystone flap." Empirical studies with at least 15 patients who underwent keystone flap reconstruction were assessed for quantitative analysis. Outcomes of interest included patient demographics, indications, anatomic location, flap design, and complications. RESULTS: Database search produced 135 articles, of which 25 were selected for full-text review. Out of 23 studies selected qualitative analysis and 22 met criteria for quantitative analysis. Overall success rate of this flap was 98%. Wound complications were highest in extremity flaps. Several modifications of this flap were described. CONCLUSION: Keystone reconstruction demonstrates excellent success rates and versatility. However, further studies with more standard reporting are needed to determine guidelines for patient specific surgical planning.

Resident experiences with virtual education during the COVID-19 crisis.

BACKGROUND: Residency education has adapted to current social distancing recommendations by relying heavily on videoconferences. There is concern however, that this new paradigm may lead to over-saturation or burnout. METHODS: A 12-question survey investigating resident experiences with educational videoconferences was distributed to University of Washington plastic surgery residents. A modified Maslach Burnout Inventory was used to assess resident burnout from virtual conferences. Conference attendance and reasons for missing conferences were compared using paired two-tailed t-tests. RESULTS: A total of 24 residents were given the survey with 100% response rate. There was a significant decrease in the total number of weekly attended videoconferences (p<0.01) and in the number of attended educational videoconferences (p<0.01) over time. Reasons for absences included clinical duties (92% of respondents) followed by symptoms of burnout, including forgetfulness (67%) and feeling fatigued by videoconferencing lectures (54%), and to a lesser extent the belief that the lecture was not educational (25%). 79% of residents reported at least occasionally feeling emotionally drained from videoconferencing and 88% reported at least occasionally feeling burned out due to the number of videoconferencing activities. Despite declining attendance and burnout, 96% believe that videoconferences should continue after the end of quarantine but in a limited quantity. CONCLUSION: Videoconferences have become a valued means of resident education. The data suggests however that attendance has waned, largely due to what can be perceived as burnout. Residents remain interested in continuing educational videoconferences, although prioritizing quality over quantity will remain essential to prevent emotional fatigue and burnout.

Treatment With a Ghrelin Agonist in Outpatient Women With Anorexia Nervosa: A Randomized Clinical Trial.

OBJECTIVE: To assess the effects of relamorelin-an agonist of the appetite-stimulating hormone ghrelin, which has effects on gastric emptying-on (1) weight gain and (2) gastric emptying in women with anorexia nervosa. METHODS: In a randomized, double-blind, placebo-controlled design, the effects of the ghrelin agonist relamorelin were studied in 22 outpatient women with anorexia nervosa, diagnosed using DSM-5 criteria. The study was conducted at the Massachusetts General Hospital Clinical Research Center between March 11, 2013, and February 26, 2015. Ten participants were randomly assigned to relamorelin 100 µg subcutaneously daily (mean ± SEM age: 28.9 ± 2.4 y), and 12 were randomly assigned to placebo (28.9 ± 1.9 y). We measured changes in weight and gastric emptying time using a gastric emptying breath test (GEBT) for relamorelin versus placebo after 4 weeks of treatment. RESULTS: At baseline, subjects did not differ in weight, plasma ghrelin levels, or gastric emptying time. Three subjects randomized to relamorelin stopped use of the study medication due to reported feelings of increased hunger. After 4 weeks, there was a trend toward an increase in weight in participants randomized to relamorelin (mean ± SEM change: 0.86 ± 0.40 kg) compared to placebo (0.04 ± 0.28 kg; P = .07), and gastric emptying time was significantly shorter in patients taking relamorelin (median [interquartile range]: 58.0 [51.0, 78.0] minutes) compared to placebo (85.0 [75.8,100.5] minutes; P = .03). CONCLUSIONS: Treatment with a ghrelin agonist in women with anorexia nervosa significantly decreases gastric emptying time, leads to a trend in weight gain after only 4 weeks, and is well-tolerated. Further study is necessary to determine the long-term safety and efficacy of a ghrelin agonist in the treatment of anorexia nervosa. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01642550.

Oxytocin reduces caloric intake in men.

OBJECTIVE: Preclinical studies indicate that oxytocin is anorexigenic and has beneficial metabolic effects. Oxytocin effects on nutrition and metabolism in humans are not well defined. It was hypothesized that oxytocin would reduce caloric intake and appetite and alter levels of appetite-regulating hormones. Metabolic effects of oxytocin were also explored. METHODS: A randomized, placebo-controlled crossover study of single-dose intranasal oxytocin (24 IU) in 25 fasting healthy men was performed. After oxytocin/placebo, subjects selected breakfast from a menu and were given double portions. Caloric content of food consumed was measured. Visual analog scales were used to assess appetite, and blood was drawn for appetite-regulating hormones, insulin, and glucose before and after oxytocin/placebo. Indirect calorimetry assessed resting energy expenditure (REE) and substrate utilization. RESULTS: Oxytocin reduced caloric intake with a preferential effect on fat intake and increased levels of the anorexigenic hormone cholecystokinin without affecting appetite or other appetite-regulating hormones. There was no effect of oxytocin on REE. Oxytocin resulted in a shift from carbohydrate to fat utilization and improved insulin sensitivity. CONCLUSIONS: Intranasal oxytocin reduces caloric intake and has beneficial metabolic effects in men without concerning side effects. The efficacy and safety of sustained oxytocin administration in the treatment of obesity warrants investigation.

Increased hypothalamic-pituitary-adrenal drive is associated with decreased appetite and hypoactivation of food-motivation neurocircuitry in anorexia nervosa.

OBJECTIVE: Corticotrophin-releasing hormone (CRH)-mediated hypercortisolemia has been demonstrated in anorexia nervosa (AN), a psychiatric disorder characterized by food restriction despite low body weight. While CRH is anorexigenic, downstream cortisol stimulates hunger. Using a food-related functional magnetic resonance imaging (fMRI) paradigm, we have demonstrated hypoactivation of brain regions involved in food motivation in women with AN, even after weight recovery. The relationship between hypothalamic-pituitary-adrenal (HPA) axis dysregulation and appetite and the association with food-motivation neurocircuitry hypoactivation are unknown in AN. We investigated the relationship between HPA activity, appetite, and food-motivation neurocircuitry hypoactivation in AN. DESIGN: Cross-sectional study of 36 women (13 AN, ten weight-recovered AN (ANWR), and 13 healthy controls (HC)). METHODS: Peripheral cortisol and ACTH levels were measured in a fasting state and 30, 60, and 120 min after a standardized mixed meal. The visual analog scale was used to assess homeostatic and hedonic appetite. fMRI was performed during visual processing of food and non-food stimuli to measure the brain activation pre- and post-meal. RESULTS: In each group, serum cortisol levels decreased following the meal. Mean fasting, 120 min post-meal, and nadir cortisol levels were high in AN vs HC. Mean postprandial ACTH levels were high in ANWR compared with HC and AN subjects. Cortisol levels were associated with lower fasting homeostatic and hedonic appetite, independent of BMI and depressive symptoms. Cortisol levels were also associated with between-group variance in activation in the food-motivation brain regions (e.g. hypothalamus, amygdala, hippocampus, orbitofrontal cortex, and insula). CONCLUSIONS: HPA activation may contribute to the maintenance of AN by the suppression of appetitive drive.

Postprandial oxytocin secretion is associated with severity of anxiety and depressive symptoms in anorexia nervosa.

OBJECTIVE: Anorexia nervosa, a psychiatric disorder characterized by self-induced starvation, is associated with endocrine dysfunction and comorbid anxiety and depression. Animal data suggest that oxytocin may have anxiolytic and antidepressant effects. We have reported increased postprandial oxytocin levels in women with active anorexia nervosa and decreased levels in weight-recovered women with anorexia nervosa compared to healthy controls. A meal may represent a significant source of stress in patients with disordered eating. We therefore investigated the association between postprandial oxytocin secretion and symptoms of anxiety and depression in anorexia nervosa. METHOD: We performed a cross-sectional study of 35 women (13 women with active anorexia nervosa, 9 with weight-recovered anorexia nervosa, and 13 healthy controls). Anorexia nervosa was diagnosed according to DSM-IV-TR criteria. Serum oxytocin and cortisol and plasma leptin levels were measured fasting and 30, 60, and 120 minutes after a standardized mixed meal. The area under the curve (AUC) and, for oxytocin, postprandial nadir and peak levels were determined. Anxiety and depressive symptoms were assessed using the Spielberger State-Trait Anxiety Inventory (STAI) and Beck Depression Inventory II (BDI-II). The study was conducted from January 2009 to March 2011. RESULTS: In women with anorexia nervosa, oxytocin AUC and postprandial nadir and peak levels were positively associated with STAI trait and STAI premeal and postmeal state scores. Oxytocin AUC and nadir levels were positively associated with BDI-II scores. After controlling for cortisol AUC, all of the relationships remained significant. After controlling for leptin AUC, most of the relationships remained significant. Oxytocin secretion explained up to 51% of the variance in STAI trait and 24% of the variance in BDI-II scores. CONCLUSIONS: Abnormal postprandial oxytocin secretion in women with anorexia nervosa is associated with increased symptoms of anxiety and depression. This link may represent an adaptive response of oxytocin secretion to food-related symptoms of anxiety and depression.