Differential Pulley Release in Trigger Finger: A Prospective, Randomized Clinical Trial.

BACKGROUND: The palmar aponeurosis or "A0 pulley" may play a role in trigger finger pathology. This study assesses the involvement of the A0 pulley in patients receiving trigger finger release. METHODS: This single-surgeon, prospective, randomized clinical trial was conducted among consenting patients with symptomatic trigger finger. Intraoperative coin toss was used to randomize initial release of either the A0 or A1 pulley. Following release, active flexion and extension of the affected digit were examined. The remaining pulley was then released in sequence, and clinical trigger status was recorded. RESULTS: Thirty fingers from 24 patients were released; 17 fingers received A0 release first, and 13 received A1 release. Following initial A0 release, 8 fingers (47%) demonstrated complete resolution of symptoms, 4 (24%) demonstrated improvement but incomplete resolution of triggering, and 5 (29.4%) demonstrated no improvement. Following initial A1 release, 6 fingers (46%) demonstrated complete resolution, 3 (23%) demonstrated improvement but incomplete resolution of triggering, and 4 (31%) demonstrated no improvement. All patients demonstrated complete resolution after surgical release of both sites. Neither initial A1 release nor initial A0 release was statistically associated with complete, incomplete, or failed symptom resolution. CONCLUSIONS: These data implicate the A0 pulley as the primary cause of 31% to 47% of trigger fingers in our study. Although larger trials are needed to validate these results, our study suggests that release of both A0 and A1 pulleys may offer greater symptom resolution than release of the A1 pulley alone.

Patient-Reported Outcomes of Breast Reconstruction: Does the Quality of Decisions Matter?

BACKGROUND: Little is known about how the quality of decisions influences patient-reported outcomes (PROs). We hypothesized that higher decision quality for breast reconstruction would be independently associated with better PROs. METHODS: We conducted a prospective cohort study of patients undergoing mastectomy with or without reconstruction. Patients were enrolled before surgery and followed for 18 months. We used BREAST-Q scales to measure PROs and linear regression models to explore the relationship between decision quality (based on knowledge and preference concordance) and PROs. Final models were adjusted for baseline BREAST-Q score, radiation, chemotherapy, and major complications. RESULTS: The cohort included 101 patients who completed baseline and 18-month surveys. Breast reconstruction was independently associated with higher satisfaction with breasts (ß = 20.2, p = 0.0002), psychosocial well-being (ß = 14.4, p = 0.006), and sexual well-being (ß = 15.7, p = 0.007), but not physical well-being. Patients who made a high-quality decision had similar PROs as patients who did not. Among patients undergoing mastectomy with reconstruction, higher decision quality was associated with lower psychosocial well-being (ß = -14.2, p = 0.01). CONCLUSIONS: Breast reconstruction was associated with better PROs in some but not all domains. Overall, making a high-quality decision was not associated with better PROs. However, patients who did not have reconstruction had a trend toward better well-being after making a high-quality decision, whereas patients who did have reconstruction had poorer well-being after making a high-quality decision. Additional research on the relationship between decision quality and PROs is needed.

Accuracy of Predictions of Patients With Breast Cancer of Future Well-being After Immediate Breast Reconstruction.

Importance: Making a good decision about breast reconstruction requires predicting how one would feel after the procedure, but people tend to overestimate the impact of events on future well-being. Objective: To assess how well patients predict future well-being after mastectomy, with or without immediate reconstruction, with the following a priori hypotheses: Patients will overestimate the negative impact of mastectomy and positive impact of reconstruction, and prediction accuracy will be associated with decision satisfaction and decision regret. Design, Setting, and Participants: This prospective cohort survey study was conducted at a single, multidisciplinary academic oncology clinic from July 2012 to February 2014. Adult women undergoing mastectomy for stage 1, 2, or 3 invasive ductal or lobular breast cancer, ductal carcinoma in situ, or prophylaxis were invited to participate. Data analysis was conducted from September 2015 to October 2017. Exposures: Mastectomy only or mastectomy with immediate reconstruction. Main Outcomes and Measures: Preoperative measures predicted were 12-month happiness (Cantril Ladder) and quality of life, predicted satisfaction with breasts, sexual attractiveness, breast numbness, and pain (measured with BreastQ single items). Measures at 12 months postoperative added the Decision Regret Scale and Satisfaction With Decisions Scale. Results: Of 214 eligible patients, 182 consecutive patients were approached, and 145 enrolled (80%). Of these 145 patients, 131 returned surveys (72%) and 111 of these remained at 12 months (88%). Fifteen who had delayed reconstruction were excluded from analysis, leaving a final cohort of 96 women; 54 had not had reconstruction and 42 had had reconstruction. The mean (SD) age of the cohort was 53.9 (12.1) years; 73 (76%) were white; 50 (52%) were college graduates; 54 (56%) were privately insured; 69 (72%) had disease at stages 0, 1, or 2; and 31 (32%) received adjuvant radiation. Patients having mastectomy without reconstruction underestimated future well-being in all domains. Differences were significant for quality of life scores (mean predicted, 68 vs mean actual, 74; t50, -2.47; P = .02) and satisfaction with breasts-clothed (mean predicted, 2.4 vs mean actual, 2.8; t49, -2.11; P = .04). Patients undergoing mastectomy with reconstruction overestimated future well-being in all but 1 domain. Differences were significant for satisfaction with breasts-unclothed (mean predicted, 3.1 vs mean actual, 2.6; t41, 2.70; P = .01); sexual attractiveness-clothed (mean predicted, 3.7 vs mean actual, 3.3; t39, 2.29; P = .03); sexual attractiveness-unclothed (mean predicted, 3.3 vs mean actual, 2.3; t40, 5.57; P < .001). Both groups experienced more numbness than predicted (mean predicted, 2.79 and 2.72 for mastectomy only and mastectomy with reconstruction groups, respectively; mean actual, 3.52 and 3.56, respectively; t47, -3.4 and t38, -2.9, respectively; P < .01). Patients who were less happy (ß = 6.3; P = .02) or had greater pain (ß = 8.7; P < .001) than predicted had greater regret. Conclusions and Relevance: Patients underestimated future well-being after mastectomy and overestimated well-being after reconstruction. Misprediction was associated with regret. Decision support for breast reconstruction should address expectations about well-being.

Quality of Patient Decisions About Breast Reconstruction After Mastectomy.

IMPORTANCE: Breast reconstruction has the potential to improve a person's body image and quality of life but has important risks. Variations in who undergoes breast reconstruction have led to questions about the quality of patient decisions. OBJECTIVE: To assess the quality of patient decisions about breast reconstruction. DESIGN, SETTING, AND PARTICIPANTS: A prospective, cross-sectional survey study was conducted from June 27, 2012, to February 28, 2014, at a single, academic, multidisciplinary oncology clinic among women planning to undergo mastectomy for stage I to III invasive ductal or lobular breast cancer, ductal carcinoma in situ, or prophylaxis. EXPOSURES: Mastectomy only and mastectomy with reconstruction. MAIN OUTCOME AND MEASURES: Knowledge, as ascertained using the Decision Quality Instrument; preference concordance, based on rating and ranking of key attributes; and decision quality, defined as having knowledge of 50% or more and preference concordance. RESULTS: During the 20-month period, 214 patients were eligible, 182 were approached, and 32 missed. We enrolled 145 patients (79.7% enrollment rate), and received surveys from 131 patients (72.0% participation rate). Five participants became ineligible. The final study population was 126 patients. Among the 126 women in the study (mean [SD] age, 53.2 [12.1] years), the mean (SD) knowledge score was 58.5% (16.2%) and did not differ by treatment group (mastectomy only, 55.2% [15.0%]; mastectomy with reconstruction, 60.5% [16.5%]). A total of 82 of 123 participants (66.7%) had a calculated treatment preference of mastectomy only; 39 of these women (47.6%) underwent mastectomy only. A total of 41 participants (32.5%) had a calculated treatment preference of mastectomy with reconstruction; 36 of these women (87.8%) underwent mastectomy with reconstruction. Overall, 52 of 120 participants (43.3%) made a high-quality decision. In multivariable analysis, white race/ethnicity (odds ratio [OR], 2.72; 95% CI, 1.00-7.38; P = .05), having private insurance (OR, 1.61; 95% CI, 1.35-1.93; P < .001), having a high school education or less (vs some college) (OR, 4.84; 95% CI, 1.22-19.21; P = .02), having a college degree (vs some college) (OR, 1.95; 95% CI, 1.53-2.49; P < .001), and not having a malignant neoplasm (eg, BRCA carriers) (OR, 3.13; 95% CI, 1.25-7.85; P = .01) were independently associated with making a high-quality decision. CONCLUSIONS AND RELEVANCE: A minority of patients undergoing mastectomy in a single academic center made a high-quality decision about reconstruction. Shared decision making is needed to support decisions about breast reconstruction.

Response to Video Capture of Plastic Surgery Procedures Using the GoPro HERO 3+: Patient Privacy and Compliance.

Supplemental Digital Content is available in the text.

Aesthetic breast shape preferences among plastic surgeons.

BACKGROUND: There has been little discussion in the plastic surgery literature regarding breast shape preferences among plastic surgeons, despite strong evidence that such aesthetic preferences are influenced by multiple factors. Much effort has been focused on delineating the objective criteria by which an "attractive" breast might be defined. This study aimed at providing a better understanding of the presence and significance of differences in personal aesthetic perception, and how these relate to a plastic surgeon's demographic, ethnic, and cultural background, as well as practice type (academic vs private). METHODS: An interactive online survey was designed. Modifiable ranges of upper pole fullness and areola size were achieved via digital alteration, enabling participants to interactively change the shape of a model's breasts. The questionnaire was translated into multiple languages and sent to plastic surgeons worldwide. Demographic data were also collected. Analysis of variance was used to elucidate plastic surgeon's breast shape preferences in respect to sex and age, geographic and ethnic background, as well as practice type. RESULTS: The authors gathered 614 responses from 29 different countries. Significant differences regarding preferences for upper pole fullness, areola size in the natural breast, and areola size in the augmented breast were identified across surgeons from the different countries. Further, significant relationships regarding breast shape preferences were distilled between the age and sex of the surgeon, as well as the practice type. No differences were found in respect to the surgeons' self-reported ethnic background. CONCLUSIONS: Country of residence, age, and practice type significantly impact breast shape preferences of plastic surgeons. These findings have implications for both patients seeking and surgeons performing cosmetic and reconstructive breast surgery. In an increasingly global environment, cultural differences and international variability must be considered when defining and publishing new techniques and aesthetic outcomes. When both the plastic surgeon and the patient are able to adequately and effectively communicate their preferences regarding the shape and relations of the breast, they will be more successful at achieving satisfying results.

The impact of geographic, ethnic, and demographic dynamics on the perception of beauty.

BACKGROUND: Beauty lies in the eyes of the beholder, but influenced by the individual's geographic, ethnic, and demographic background and characteristics. In plastic surgery, objective measurements are used as a foundation for aesthetic evaluations. This study assumes interdependence between variables such as country of residence, sex, age, occupation, and aesthetic perception. METHODS: Computerized images of a model's face were generated with the ability to alter nasal characteristics and the projection of the lips and chin. A survey containing these modifiable images was sent to more than 13,000 plastic surgeons and laypeople in 50 different countries, who were able to virtually create a face that they felt to be the aesthetically "ideal" and most pleasing. Demographic information about the interviewees was obtained. RESULTS: Values of various aesthetic parameters of the nose were described along with their relationship to geography, demography, and occupation of the respondents. Interregional and ethnic comparison revealed that variables of country of residence, ethnicity, occupation (general public vs surgeon), and sex correlate along a 3-way dimension with the ideal projection of the lips and the chin. Significant interaction effects were found between variables of country of residence or ethnicity with occupation and sex of the respondents. CONCLUSIONS: What are considered the "ideal" aesthetics of the face are highly dependent on the individual's cultural and ethnic background and cannot simply and solely be defined by numeric values and divine proportions. As confirmed with this study, ethnic, demographic, and occupational factors impact peoples' perception of beauty significantly.

Phlegmonous gastritis presenting as portal venous pneumatosis.

BACKGROUND: Phlegmonous gastritis is a rare and highly lethal primary bacterial infection of the stomach. The pathogenesis of this disease is understood poorly and no detailed description of its associated findings on computed tomography has been reported. METHODS: Case report and literature review. CASE REPORT: The authors describe an 84-year-old male with phlegmonous gastritis presenting as an abdominal catastrophe with portal venous pneumatosis observed on computed tomography. CONCLUSION: The association of portal venous air and related computed tomographic findings suggesting compromise of the gastric wall should be regarded with suspicion, and the possibility of phlegmonous gastritis should be entertained. Broad-spectrum antibiotic coverage should be instituted. Gram stain of the tissues of the stomach wall may help direct antibiotic therapy toward streptococcal infections as opposed to polymicrobial processes.

Optimal placement of a brachioplasty scar: a survey evaluation.

BACKGROUND: Brachioplasty has become a popular procedure to rejuvenate the upper arm, with its frequency increasing proportionately to the popularity of surgical weight loss procedures. The major complication of the procedure is undesirable, visible scarring. An ongoing, unresolved debate in the brachioplasty literature is the optimal placement of the brachioplasty scar. Some authors advocate a medially based incision along the bicipital groove, whereas others prefer to leave the scar posteriorly in the brachial sulcus. In addition, some advocate a sinusoidal scar over a straight-line closure. This study attempts to resolve the question of where and how to place the scar based on population surveys. METHODS: Photographs were taken of a model with her arm progressively abducted at the shoulder to a level of 90 degrees, with the elbow progressively flexed to 90 degrees and the arm externally rotated. Anterior and posterior views were included. Using Photoshop, a brachioplasty scar was digitally created and placed on the arm first medially in the bicipital groove, then posteriorly in the brachial sulcus. Straight-line scars and sinusoidal scars were also compared in each position. Before creating a computer-generated image of the scars, the scar lines were marked with a marking pen to ensure they could be followed with movement of the model's arm. An online survey was then created and distributed and included multiple variables: position of the scar, length of scar vs residual deformity, and acceptability based on phase of scar in time (early vs late result). The scale was numerical from 1 to 5, with 1 being a very objectionable scar and 5 being a very acceptable scar. The survey was disseminated among the general public, plastic surgeons, and patients in the Yale Cosmetic Surgery Resident Clinic who were either seen in consultation for brachioplasty or who underwent the procedure. RESULTS: Electronic surveys were distributed to and completed by the general public (n = 117), local plastic surgery residents and attendings (n = 10), and patients who had undergone or were seen in consultation for brachioplasty (n = 9). Among all participants, in the chronic phase, a medial straight scar received an average rating of 4.00, a posterior straight scar received an average rating of 3.14, a posterior sinusoidal scar received an average rating of 2.61, and a medial sinusoidal scar received an average rating of 2.03. Across age groups, gender, plastic surgeons, and patients, the medially based straight brachioplasty scar is more acceptable than the posteriorly based straight scar (4.00 vs 3.14, P < 0.001). If the scar shape is made sinusoidal, a posteriorly based scar is favored over a medial one (2.61 vs 2.03, P < 0.001), yet this is still not as aesthetically pleasing as a medial straight scar (4.00 vs 2.61, P < 0.001). Furthermore, survey participants accepted a longer scar over a residual deformity (58.8% vs 41.2%). CONCLUSIONS: Based on the preferences of the populations surveyed, we conclude that the medially based straight scar is the most aesthetically acceptable option when performing a brachioplasty.

Ideal anthropomorphic values of the female breast: correlation of pluralistic aesthetic evaluations with objective measurements.

BACKGROUND: In determining ideal anthropomorphic values of the female breast, previous studies relied on the aesthetic judgments of 1 plastic surgeon alone or conveyed no aesthetic judgment. METHODS: Anthropomorphic measurements were recorded from the breasts of 109 female volunteers. Images of their breasts were arranged into a computerized survey, and plastic surgeons, cosmetic breast surgery patients, and reconstructive breast surgery patients were interviewed for aesthetic feedback. RESULTS: In all, 252 plastic surgeons, 15 cosmetic patients, and 25 reconstructive patients submitted 4446 evaluations. The ideal sternal notch to nipple distance was 21 to 21.5 cm, the ideal nipple to base distance was 6 cm, and the ideal base to inframammary fold distance was 2 cm. These and other ideal anthropomorphic measurements were calculated and compared with previously published values. Among cosmetic patients, insufficient cleavage had the most negative effect on aesthetic value, and among reconstructive patients, severe asymmetry had the most negative effect. CONCLUSIONS: Ideal anthropomorphic values were similar among plastic surgeons and patients, and these values will be useful in achieving quantitative breast surgery. In cosmetic patients, operative planning should focus more on superomedial fullness of the breast to create cleavage, and in reconstructive patients, postoperative asymmetry should be minimized.

Mild intraoperative hypothermia reduces free tissue transfer thrombosis.

Patients undergoing free tissue transfer are particularly susceptible to hypothermia. The goal was to investigate the impact of intraoperative core body temperature on free flap thrombosis. Two hundred twelve cases of free flap reconstruction at Yale-New Haven Hospital between 1992 and 2008 were reviewed. Free flap thrombosis was defined by complete flap necrosis or direct visualization of arterial or venous thrombosis. Temperature measurements were calibrated to bladder temperatures as measured by Foley catheter sensor. Through logistic regression analysis, maximum and minimum intraoperative temperatures were determined to be statistically significant predictors of free flap thrombosis. The optimal temperature was calculated to be 36.2 °C, and maximum intraoperative temperatures between 36.0 °C and 36.4 °C showed lower thrombosis rates than super-warmed patients ( P < 0.03). Therefore, free flap patients should be mildly hypothermic at 36.0 °C to 36.4 °C, compared with normothermia at 37.5 °C, as measured in the bladder. A prospective randomized trial investigating thrombosis rates and intraoperative temperature should be undertaken.

Comprehensive analysis of the pseudogenes of glycolytic enzymes in vertebrates: the anomalously high number of GAPDH pseudogenes highlights a recent burst of retrotrans-positional activity.

BACKGROUND: Pseudogenes provide a record of the molecular evolution of genes. As glycolysis is such a highly conserved and fundamental metabolic pathway, the pseudogenes of glycolytic enzymes comprise a standardized genomic measuring stick and an ideal platform for studying molecular evolution. One of the glycolytic enzymes, glyceraldehyde-3-phosphate dehydrogenase (GAPDH), has already been noted to have one of the largest numbers of associated pseudogenes, among all proteins. RESULTS: We assembled the first comprehensive catalog of the processed and duplicated pseudogenes of glycolytic enzymes in many vertebrate model-organism genomes, including human, chimpanzee, mouse, rat, chicken, zebrafish, pufferfish, fruitfly, and worm (available at http://pseudogene.org/glycolysis/). We found that glycolytic pseudogenes are predominantly processed, i.e. retrotransposed from the mRNA of their parent genes. Although each glycolytic enzyme plays a unique role, GAPDH has by far the most pseudogenes, perhaps reflecting its large number of non-glycolytic functions or its possession of a particularly retrotranspositionally active sub-sequence. Furthermore, the number of GAPDH pseudogenes varies significantly among the genomes we studied: none in zebrafish, pufferfish, fruitfly, and worm, 1 in chicken, 50 in chimpanzee, 62 in human, 331 in mouse, and 364 in rat. Next, we developed a simple method of identifying conserved syntenic blocks (consistently applicable to the wide range of organisms in the study) by using orthologous genes as anchors delimiting a conserved block between a pair of genomes. This approach showed that few glycolytic pseudogenes are shared between primate and rodent lineages. Finally, by estimating pseudogene ages using Kimura's two-parameter model of nucleotide substitution, we found evidence for bursts of retrotranspositional activity approximately 42, 36, and 26 million years ago in the human, mouse, and rat lineages, respectively. CONCLUSION: Overall, we performed a consistent analysis of one group of pseudogenes across multiple genomes, finding evidence that most of them were created within the last 50 million years, subsequent to the divergence of rodent and primate lineages.

Surface area measurement of the female breast: phase I. Validation of a novel optical technique.

BACKGROUND: Breast shape is largely determined by the volume of tissue and surface area of the skin envelope. Values for breast surface area have never been published in the literature. The investigators have developed an inexpensive, noninvasive optical method to objectively measure breast volume and surface area, and its accuracy is determined. METHODS: An optical grid is projected onto the breast, and two images are captured to create a computerized three-dimensional model from which volume, surface area, and maximum vertical projection are calculated. RESULTS: To assess accuracy, simple geometric shapes (n = 22) were analyzed, and the actual volume, surface area, and maximum vertical projection were compared with the imaged values using least-squares linear regression. There was excellent correlation in all three parameters (r > 0.995, p < 10). The mean differences in volume, surface area, and maximum vertical projection were 28 +/- 28 ml (mean +/- SD), 2 +/- 9 cm, and 0.4 +/- 0.5 cm, respectively. Female breasts (n = 14) were then analyzed, and the actual volume and surface area were measured using plaster casts. Based on least-squares linear regression, there was excellent correlation between the imaged values and actual values (r > 0.992, p < 10), and the mean differences in volume and surface area were 32 +/- 22 ml and 3 +/- 11 cm, respectively. CONCLUSIONS: For the first time, an optical method has been demonstrated to measure volume and surface area with accuracy. When the method is applied to the breast, measurement errors are small and clinically insignificant. The ability to facilitate quantitative breast surgery will be investigated in future phases of this experiment.

Comparative analysis of processed ribosomal protein pseudogenes in four mammalian genomes.

BACKGROUND: The availability of genome sequences of numerous organisms allows comparative study of pseudogenes in syntenic regions. Conservation of pseudogenes suggests that they might have a functional role in some instances. RESULTS: We report the first large-scale comparative analysis of ribosomal protein pseudogenes in four mammalian genomes (human, chimpanzee, mouse and rat). To this end, we have assigned these pseudogenes in the four organisms using an automated pipeline and make the results available online. Each organism has a large number of ribosomal protein pseudogenes (approximately 1,400 to 2,800). The majority of them are processed (generated by retrotransposition). However, we do not see a correlation between the number of pseudogenes associated with a ribosomal protein gene and its mRNA abundance. Analysis of pseudogenes in syntenic regions between species shows that most are conserved between human and chimpanzee, but very few are conserved between primates and rodents. Interestingly, syntenic pseudogenes have a lower rate of nucleotide substitution than their surrounding intergenic DNA. Moreover, evidence from expressed sequence tags indicates that two pseudogenes conserved between human and mouse are transcribed. Detailed analysis shows that one of them, the pseudogene of RPS27, is likely to be a protein-coding gene. This is significant as previous reports indicated there are exactly 80 ribosomal protein genes encoded by the human genome. CONCLUSIONS: Our analysis indicates that processed ribosomal protein pseudogenes abound in mammalian genomes, but few of these are conserved between primates and rodents. This highlights the large amount of recent retrotranspositional activity in mammals and a relatively larger amount of it in the rodent lineage.

Genome-scale identification of nucleosome positions in S. cerevisiae.

The positioning of nucleosomes along chromatin has been implicated in the regulation of gene expression in eukaryotic cells, because packaging DNA into nucleosomes affects sequence accessibility. We developed a tiled microarray approach to identify at high resolution the translational positions of 2278 nucleosomes over 482 kilobases of Saccharomyces cerevisiae DNA, including almost all of chromosome III and 223 additional regulatory regions. The majority of the nucleosomes identified were well-positioned. We found a stereotyped chromatin organization at Pol II promoters consisting of a nucleosome-free region approximately 200 base pairs upstream of the start codon flanked on both sides by positioned nucleosomes. The nucleosome-free sequences were evolutionarily conserved and were enriched in poly-deoxyadenosine or poly-deoxythymidine sequences. Most occupied transcription factor binding motifs were devoid of nucleosomes, strongly suggesting that nucleosome positioning is a global determinant of transcription factor access.