Does Brow Lift Add Risk to Blepharoplasty? Answers From a Multicenter Analysis of 6126 Patients Undergoing Aesthetic Eye Surgery.

BACKGROUND: Browlift is frequently combinedwith blepharoplasty; however, the literature is lacking on their combined effect on complication rates. OBJECTIVES: This study aims to evaluate major complication rates after blepharoplasty and brow lift and to determine if complication rates increase when blepharoplasty and brow lift were performed simultaneously. METHODS: A prospective cohort of patients who underwent cosmetic blepharoplasty, brow lift, or a combination of the 2 procedures between 2008 and 2013 was identified from the CosmetAssure Insurance database. The primary outcome was a postoperative major complication requiring emergency room evaluation, hospital admission, or reoperation within 30 days. Groups were compared with univariate analysis (significance, P < 0.05). RESULTS: A total of 6126 patients underwent aesthetic eye surgery, of which, 4879 (79.6%) underwent blepharoplasty, 441 (7.2%) brow lift, and 806 (13.2%) a combination the 2 procedures. Patients who underwent a combined procedure were older than patients who underwent isolated blepharoplasty or brow lift (55.5 ± 9.4 vs 54.6 ± 11.1 vs 53.3 ± 12.0 years; P < 0.01). In males, blepharoplasty was the most commonly performed procedure, followed by a combined procedure and brow lift (17.6% vs 12.9% vs 10.7%; P < 0.01). There were similar rates of smokers between the 3 groups (5.7% vs 8.0% vs 6.6%; P = 0.06). Between combined procedures, blepharoplasty, and brow lift there, were similar rates of major complications (0.4% vs 0.4% vs 0.7%; P = 0.65) and hematoma (0.2% vs 0.2% vs 0.5%; P = 0.49), which was the most common complication. CONCLUSIONS: Aesthetic eye surgery has a very low overall major complication rate (0.4%). When brow lift is combined with blepharoplasty, it poses no additional risk of major complications compared with either procedure alone.

Effects of sleepiness on clinical decision making among paramedic students: a simulated night shift study.

OBJECTIVE: Paramedics are at the forefront of emergency healthcare. Quick and careful decision making is required to effectively care for their patients; however, excessive sleepiness has the potential to impact on clinical decision making. Studies investigating the effects of night shift work on sleepiness, cognitive function and clinical performance in the prehospital setting are limited. Here, we aimed to determine the extent to which sleepiness is experienced over the course of a simulation-based 13-hour night shift and how this impacts on clinical performance and reaction time. METHODS: Twenty-four second year paramedic students undertook a 13-hour night shift simulation study in August 2017. The study consisted of 10 real-to-life clinical scenarios. Sleepiness, perceived workload and motivation were self-reported, and clinical performance graded for each scenario. Reaction time, visual attention and task switching were also evaluated following each block of two scenarios. RESULTS: The accuracy of participants' clinical decision making declined significantly over the 13-hour night shift simulation. This was accompanied by an increase in sleepiness and a steady decline in motivation. Participants performed significantly better on the cognitive flexibility task across the duration of the simulated night shift and no changes were observed on the reaction time task. Perceived workload varied across the course of the night. CONCLUSION: Overall, increased sleepiness and decreased clinical decision making were noted towards the end of the 13-hour simulated night shift. It is unclear the extent to which these results are reflective of practising paramedics who have endured several years of night shift work, however, this could have serious implications for patient outcomes and warrants further investigation.

Critical traumatic brain injury is associated with worse coagulopathy.

OBJECTIVES: As thromboelastography (TEG) becomes the standard of care in patients with hemorrhagic shock (HS), an association between concomitant traumatic brain injury (TBI) and coagulopathy by TEG parameters is not well understood and is thus investigated. METHODS: Retrospective analysis of trauma registry data at a single level 1 trauma center of 772 patients admitted with head Abbreviated Injury Scale (AIS) score of 3 and TEG studies between 2014 and 2017. Patients were stratified to moderate-severe TBI by head AIS scores of 3 and 4 (435 patients) and critical TBI by head AIS score of 5 (328 patients). Hemorrhagic shock was defined by base deficit of 4 or shock index of 0.9. Statistical analysis with unpaired t tests compared patients with critical TBI with patients with moderate-severe TBI, and patients were grouped by presence or absence of HS. A comparison of TBI data with conventional coagulation studies was also evaluated. RESULTS: In the setting of HS, critical TBI versus moderate-severe TBI was associated with longer R time (p = 0.004), longer K time (p < 0.05), less acute angle (p = 0.001), and lower clot strength and stability (maximum amplitude [MA]) (p = 0.01). Worse TBI did not correlate with increased fibrinolysis by clot lysis measured by the percentage decrease in amplitude at 30 minutes after MA (p = 0.3). Prothrombin time and international normalized ratio failed to demonstrate more severe coagulopathy, while partial thromboplastin time was found to correlate with severity of TBI (p = 0.01). In patients with critical TBI, the presence of HS correlated with a statistically significant worsening of all parameters (p < 0.05) except for clot lysis measured by the percentage decrease in amplitude at 30 minutes after MA (LY-30). CONCLUSION: Thromboelastography demonstrates that, with and without hemorrhagic shock, critical TBI correlates with a significant worsening of traumatic coagulopathy in comparison with moderate/severe TBI. In HS, critical TBI correlates with impaired clot initiation, impaired clot kinetics, and impaired platelet-associated clot strength and stability versus parameters found in moderate-severe TBI. Hemorrhagic shock correlates with worse traumatic coagulopathy in all evaluated patient groups with TBI. Conventional coagulation studies underestimate TBI-associated coagulopathy. Traumatic brain injury-associated coagulopathy is not associated with fibrinolysis. LEVEL OF EVIDENCE: Prognostic/epidemiological, level IV; prognostic/epidemiological, level III.

Clinical Determinants of Dual Tasking in People With Premanifest Huntington Disease.

OBJECTIVE: Dual-tasking deficiencies are common in people with Huntington disease (HD) and contribute to reduced functional independence. To date, few studies have investigated the determinants of dual-tasking deficiencies in this population. The reliability of dual-tasking measures has also been poorly investigated in HD. The purpose of this study was to investigate the influence of clinical determinants on dual-tasking performance and to determine the association of disease burden outcomes on dual-tasking performance in individuals with premanifest HD. METHODS: Thirty-six individuals with premanifest HD and 28 age- and sex-matched healthy controls were recruited for this study. Participants performed 3 single-task (2 cognitive and 1 motor) and 2 dual-task assessments, comprising motor (postural stability) and cognitive (simple or complex mental arithmetic) components. In addition, participants performed a comprehensive clinical battery comprising motor, cognitive, mood, and sleep assessments as well as lifestyle and disease burden measures. RESULTS: Poorer sleep quality was associated with greater cognitive dual-task cost in individuals with premanifest HD. Compared with healthy controls, people with premanifest HD demonstrated an impaired capacity to dual task. Dual-task measures exhibited acceptable test-retest reliability in premanifest HD and healthy control groups. CONCLUSION: These results show that dual-tasking measures are sensitive and reliable in individuals with premanifest HD. Furthermore, poor sleep quality is associated with worse cognitive performance on dual tasks, which should be considered by rehabilitation specialists when examining and therapeutically managing dual-tasking problems in individuals with HD and other neurodegenerative populations in the future. IMPACT: This study adds important knowledge to the sparse literature on dual-tasking deficiencies in people with HD. When examining and therapeutically managing dual-tasking problems in this and other neurodegenerative populations, rehabilitation specialists should consider that people with premanifest HD may have an impaired capacity to dual task. Clinicians also should assess sleep quality, as poorer sleep quality is associated with worse cognitive performance on dual tasks in these individuals. LAY SUMMARY: If you have premanifest HD and poor quality of sleep, you may pay more attention to maintaining postural stability rather than performing arithmetic calculations to reduce the risk of falling.

Dual tasking impairments are associated with striatal pathology in Huntington's disease.

BACKGROUND: Recent findings suggest that individuals with Huntington's disease (HD) have an impaired capacity to execute cognitive and motor tasks simultaneously, or dual task, which gradually worsens as the disease advances. The onset and neuropathological changes mediating impairments in dual tasking in individuals with HD are unclear. The reliability of dual tasking assessments for individuals with HD is also unclear. OBJECTIVES: To evaluate differences in dual tasking performance between individuals with HD (presymptomatic and prodromal) and matched controls, to investigate associations between striatal volume and dual tasking performance, and to determine the reliability of dual tasking assessments. METHODS: Twenty individuals with HD (10 presymptomatic and 10 prodromal) and 20 healthy controls were recruited for the study. Individuals undertook four single and dual task assessments, comprising motor (postural stability or force steadiness) and cognitive (simple or complex mental arithmetic) components, with single and dual tasks performed three times each. Participants also undertook a magnetic resonance imaging assessment. RESULTS: Compared to healthy controls, individuals with presymptomatic and prodromal HD displayed significant deficits in dual tasking, particularly cognitive task performance when concurrently undertaking motor tasks (P < 0.05). The observed deficits in dual tasking were associated with reduced volume in caudate and putamen structures (P < 0.05),however, not with clinical measures of disease burden. An analysis of the reliability of dual tasking assessments revealed moderate to high test-retest reliability [ICC: 0.61-0.99] for individuals with presymptomatic and prodromal HD and healthy controls. CONCLUSIONS: Individuals with presymptomatic and prodromal HD have significant deficits in dual tasking that are associated with striatal degeneration. Findings also indicate that dual tasking assessments are reliable in individuals presymptomatic and prodromal HD and healthy controls.

The effects of multidisciplinary rehabilitation on neuroimaging, biological, cognitive and motor outcomes in individuals with premanifest Huntington's disease.

BACKGROUND: Huntington's disease (HD) is a chronic, progressive neurodegenerative condition for which there are currently no proven disease-modifying therapies. Lifestyle factors have been shown to impact on the age of disease onset and progression of disease features. We therefore investigated the effects of a nine-month multidisciplinary rehabilitation intervention on neuroimaging, biological and clinical disease outcomes in individuals with premanifest HD. METHODS: 31 individuals with premanifest HD participated in the study. Eighteen participants underwent a nine-month multidisciplinary rehabilitation intervention comprising aerobic and resistance exercise, computerised cognitive training, dual-task training and sleep hygiene and nutritional guidance. The remaining 13 participants were allocated to a standard care control group. Neuroimaging, biological, cognitive, motor and cardiorespiratory fitness data was collected. RESULTS: Participants displayed good adherence (87%) and compliance (85%) to the intervention. Maintenance of the shape of the right putamen was observed in the intervention group when compared to the control group. The intervention group displayed significant improvements in verbal learning and memory, attention, cognitive flexibility and processing speed following the intervention when compared to the control group. Performance on the mini-social cognition and emotional assessment (mini-SEA) was maintained in the intervention group, but decreased in the control group. No changes were observed in serum neurofilament light protein levels, postural stability outcomes or cardiorespiratory fitness. CONCLUSION: This study adds to the accumulating body of literature to suggest that multidisciplinary rehabilitation is of clinical benefit for individuals with HD. Large randomised controlled trials are necessary to determine the extent to which benefits occur across the spectrum of the disease.

Comparative Antimicrobial Activity of Commercial Wound Care Solutions on Bacterial and Fungal Biofilms.

BACKGROUND: Biofilms represent a complex milieu of matrix-enclosed microorganisms, which can significantly contribute to the pathology of chronic wounds. In this study, we compare the activity of 3 commercial antimicrobial wound care solutions, Vashe (HOCl based), PhaseOne (HOCl based), and Sulfamylon (mafenide acetate), for their in vitro activity against bacterial and fungal biofilms. METHODS: Reference and clinical isolates of 6 Gram-negative bacterial species (36 total strains), 3 Gram-positive bacteria (21 strains), and 3 Candida species (9 strains) were used to create biofilms. Various working concentrations of the 3 antiseptic agents were incubated with the biofilms in microwell plates; they were monitored from 1 minute to 24 hours to compare bacterial and fungal viability through colony forming unit analysis. RESULTS: Vashe and PhaseOne displayed excellent bactericidal and fungicidal activity, whereas Sulfamylon demonstrated minimal activity against the biofilms tested. With the exception of Candida albicans, all biofilms were eliminated at either 1 or 10 minutes using Vashe and PhaseOne solutions. In most cases, mafenide was unable to eliminate both bacterial and fungal biofilms, even with 24 hours of treatment. CONCLUSIONS: Biofilms represent a major clinical challenge, with no clear consensus for treatment of chronic wounds or prosthetic devices. Our results suggest that hypochlorous acid-based wound solutions such as Vashe and PhaseOne are more efficacious than mafenide in eliminating bacterial and fungal biofilms. Further studies are necessary to investigate and compare the in vivo efficacy of these products in clinical care.

Reducing Expansion Visits in Immediate Implant-Based Breast Reconstruction: A Comparative Study of Prepectoral and Subpectoral Expander Placement.

BACKGROUND: The numerous office visits required to complete expansion in implant-based breast reconstruction impact patient satisfaction, office resources, and time to complete reconstruction. This study aimed to determine whether prepectoral compared to subpectoral immediate implant-based breast reconstruction offers expedited tissue expansion without affecting complication rates. METHODS: Consecutive patients who underwent immediate implant-based breast reconstruction with tissue expanders from January of 2016 to July of 2017 by a single surgeon were grouped into subpectoral (partial submuscular/partial acellular dermal matrix) or prepectoral (complete acellular dermal matrix coverage), and reviewed. The primary outcomes were total days and number of visits to complete expansion. Groups were compared by univariate analysis with significance set at p < 0.05. RESULTS: In total, 101 patients (subpectoral, n = 69; prepectoral, n = 32) underwent 184 immediate implant-based breast reconstructions (subpectoral, n = 124; prepectoral, n = 60). There was no difference in age, body mass index, smoking, or diabetes between the groups (all p > 0.05). Follow-up was similar between groups (179.3 ± 98.2 days versus 218.3 ± 119.8 days; p = 0.115). Prepectoral patients took fewer days to complete expansion (40.4 ± 37.8 days versus 62.5 ± 50.2 days; p < 0.001) and fewer office visits to complete expansion (2.3 ± 1 .7 versus 3.9 ± 1.8; p < 0.001), and were expanded to greater final volumes than subpectoral patients (543.7 ± 122.9 ml versus 477.5 ± 159.6 ml; p = 0.017). Between prepectoral and subpectoral reconstructions, there were similar rates of minor complications (25 percent versus 18.5 percent; p = 0.311), readmissions (5 percent versus 2.4 percent; p = 0.393), seromas (8.3 percent versus 5.6 percent; p = 0.489), reoperations for hematoma (3.3 percent versus 1.6 percent; p = 0.597), and explantations (5 percent versus 2.4 percent; p = 0.393). CONCLUSION: This novel analysis demonstrates that prepectoral immediate implant-based breast reconstruction can facilitate expansion to higher total volumes in nearly half the office visits compared to subpectoral placement in similar populations without increasing complication rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Quadruple Perforator Flaps for Primary Closure of Large Myelomeningoceles: An Evaluation of the Butterfly Flap Technique.

INTRODUCTION: Myelomeningocele is the most common open neural tube defect. A quadruple rotation-VY advancement flap (butterfly flap) was recently reported for closure of large myelomeningocele defects; however, no series has been reproduced to evaluate this technique. The objective of this study was to describe our experience with this technique. MATERIALS AND METHODS: We reviewed all infants born with large myelomeningocele defects who underwent butterfly flap closure over a 2-year period. Demographics, defect size, operative details, and complications were used to generate descriptive statistics. RESULTS: From June 2015 to January 2018, 7 infants met inclusion criteria. Mean defect width was 52% ± 0.11 of the back, representing 21% ± 0.09 of the total back area. Only 1 child had central breakdown. All patients had some peripheral skin dehiscence that occurred on postoperative day 12 ± 7, and these were treated with outpatient wound care. Four patients returned to the operating room for dehiscence electively. There were no incidences of total flap loss. There were no cases of meningitis or myelomeningocele dehiscence. All patients had successful closure of their myelomeningocele without the use of skin grafts. CONCLUSIONS: The butterfly flap is able to close large myelomeningocele defects and has the potential to improve contour. There are minor wound-healing complications, but in the rare event of central dehiscence, quadruple rotation-VY advancement flaps can be re-advanced. In all cases, a large myelomeningocele was successfully reconstructed with robust full-thickness flaps, and there was no need for skin grafting of donor sites.

Diffusion tensor tractography to visualize axonal outgrowth and regeneration in a 4-cm reverse autograft sciatic nerve rabbit injury model.

BACKGROUND: Diffusion tensor tractography (DTT) has recently been shown to accurately detect nerve injury and regeneration. This study assesses whether 7-tesla (7T) DTT imaging is a viable modality to observe axonal outgrowth in a 4 cm rabbit sciatic nerve injury model fixed by a reverse autograft (RA) surgical technique. METHODS: Transection injury of unilateral sciatic nerve (4 cm long) was performed in 25 rabbits and repaired using a RA surgical technique. Analysis of the nerve autograft was performed at 3, 6, and 11 weeks postoperatively and compared to normal contralateral sciatic nerve, used as control group. High-resolution DTT from ex vivo sciatic nerves were obtained using 3D diffusion-weighted spin-echo acquisitions at 7-T. Total axons and motor and sensory axons were counted at defined lengths along the graft. RESULTS: At 11 weeks, histologically, the total axon count of the RA group was equivalent to the contralateral uninjured nerve control group. Similarly, by qualitative DTT visualization, the 11-week RA group showed increased fiber tracts compared to the 3 and 6 weeks counterparts. Upon immunohistochemical evaluation, 11-week motor axon counts did not significantly differ between RA and control; but significantly decreased sensory axon counts remained. Nerves explanted at 3 weeks and 6 weeks showed decreased motor and sensory axon counts. DISCUSSION: 7-T DTT is an effective imaging modality that may be used qualitatively to visualize axonal outgrowth and regeneration. This has implications for the development of technology that non-invasively monitors peripheral nerve regeneration in a variety of clinical settings.

Image once, print thrice? Three-dimensional printing of replacement parts.

OBJECTIVE: The last 20 years has seen an exponential increase in 3D printing as it pertains to the medical industry and more specifically surgery. Previous reviews in this domain have chosen to focus on applications within a specific field. To our knowledge, none have evaluated the broad applications of patient-specific or digital imaging and communications in medicine (DICOM) derived applications of this technology. METHODS: We searched PUBMED and CINAHL from April 2012 to April 2017. RESULTS: 261 studies fulfilled the inclusion criteria. Proportions of articles reviewed: DICOM (5%), CT (38%), MRI (20%), Ultrasonography (28%), and Bio-printing (9%). CONCLUSION: There is level IV evidence to support the use of 3D printing for education, pre-operative planning, simulation and implantation. In order to make this technology widely applicable, it will require automation of DICOM to standard tessellation language to implant. Advances in knowledge: Recent lapses in intellectual property and greater familiarity with rapid prototyping in medicine has set the stage for the next generation of custom implants, simulators and autografts. Radiologists may be able to help establish reimbursable procedural terminology.

Plantar Fat Grafting and Tendon Balancing for the Diabetic Foot Ulcer in Remission.

We report on the use of free fat grafting as a means of redistributing normal and shear stress after healing of plantar diabetic foot wounds. Although fat augmentation (lipofilling) has been described previously as an approach to supplement defects and prevent atrophy, including use as an adjunct to wound healing and to mitigate pain in the foot, we are unaware of any reports in the medical literature that have described its use in the high-risk diabetic foot in remission. An active 37-year-old man with type 2 diabetes and neuropathy presented with gangrene of his fifth ray, which was amputated. He subsequently developed a chronic styloid process ulceration that progressed despite treatment. We performed a tibialis anterior tendon transfer and total contact casting. He went on to heal but with residual fat pad atrophy and recalcitrant preulcerative lesions. We then used autologous fat grafting for the plantar atrophy. The patient was able to successfully transition to normal shoe gear after 4 weeks with successful engraftment without complication or recurrence of the wound at 6 weeks. This therapy may provide a promising adjunct to increase ulcer-free days to the patient in diabetic foot remission.

Illustration of Cost Saving Implications of Lower Extremity Nerve Decompression to Prevent Recurrence of Diabetic Foot Ulceration.

The US diabetic foot ulcer (DFU) incidence is 3-4% of 22.3 million diagnosed diabetes cases plus 6.3 million undiagnosed, 858 000 cases total. Risk of recurrence after healing is 30% annually. Lower extremity multiple nerve decompression (ND) surgery reduces neuropathic DFU (nDFU) recurrence risk by >80%. Cost effectiveness of hypothetical ND implementation to minimize nDFU recurrence is compared to the current $6.171 billion annual nDFU expense. A literature review identified best estimates of annual incidence, recurrence risk, medical management expense, and noneconomic costs for DFU. Illustrative cost/benefit calculations were performed assuming widespread application of bilateral ND after wound healing to the nDFU problem, using Center for Medicare Services mean expense data of $1143/case for unilateral lower extremity ND. Calculations use conservative, evidence-based cost figures, which are contemporary (2012) or adjusted for inflation. Widespread adoption of ND after nDFU healing could reduce annual DFU occurrences by at least 21% in the third year and 24% by year 5, representing calculated cost savings of $1.296 billion (year 3) to $1.481 billion (year 5). This scenario proffers significant expense reduction and societal benefit, and represents a minimum 1.9× return on the investment cost for surgical treatment. Further large cost savings would require reductions in initial DFU incidence, which ND might achieve by selective application to advanced diabetic sensorimotor polyneuropathy (DSPN). By minimizing the contribution of recurrences to yearly nDFU incidence, ND has potential to reduce by nearly $1 billion the annual cost of DFU treatment in the United States.

Early two-stage repair of clefts in holoprosencephaly.

UNLABELLED: Holoprosencephaly (HPE) presents with a spectrum of severity, but in its totality is the most common malformation of the embryonic forebrain occurring 1 in 10,000 to 1 in 20,000 live births. Due to the poor prognosis, treatment of mid-face clefts in HPE patients have classically been addressed in a delayed fashion after 1-year of age. Improvements in the ability to manage medical complications associated with HPE along with an increased understanding and lower mortality rates in less severe forms have challenged these previous practiced routines. Accompanied by advances in understanding of HPE and identification of genes responsible for sporadic forms, we are able to better guide timing of surgical intervention. We present a patient with lobar HPE and a type IV facial deformity treated with early repair of the median facial cleft. We believe this treatment strategy was safe, given her relatively good prognosis. We propose that patients with HPE displaying less severe neural non-cleavage may be good candidates for earlier two-stage intervention. SUMMARY: The historically poor prognosis of patients with holoprosencephaly (HPE) has led to midline facial clefts have being addressed in a delayed fashion after 1-year of age. Improvements in the ability to manage medical complications associated with HPE and lower mortality rates in less severe forms have challenged these previous practiced routines. Additionally, the identification of genes responsible for sporadic forms of HPE can better guide timing of surgical intervention and improve developmental outcomes. We present a patient with lobar HPE and a type IV facial deformity treated with an early two-stage repair of the median facial cleft. We propose patients with HPE displaying less severe neural non-cleavage may be good candidates for earlier intervention.

Palliative reconstructive surgery may improve quality of life in high functioning noncurable head and neck oncologic patients.

BACKGROUND: Treatment recommendations for palliative patients are guided by functional status and individual needs. The projected success of palliative procedures relies on estimating the risk: benefit ratio, which weighs the expected improvement in life quality to the frailty, metabolic status, and the individual's ability to heal after surgery. Terminal patients have less time in which to judge outcomes; therefore, the timeframe in which we assess these metrics should be modified according to prognosis. We emphasize efficiency over simplicity for reconstructive palliative surgery. METHODS: We reviewed the literature and supply a representative case to contribute our experiences for the palliative reconstructive surgeon to use in the evaluation and treatment of incurable patients. RESULTS: Palliative reconstructive surgery carries higher perioperative risk than standard reconstructive surgery; however, aggressive surgical management can improve quality of life. We find the Palliative Performance Scale-a functional, prognostic tool-to be a helpful metric for preoperative evaluation. CONCLUSIONS: Reconstructive palliative surgery can improve quality of life in dying patients (ie, pain, wound hygiene, and so on) and may even improve survival. We advocate prioritizing efficiency in completing the reconstructive process, which may not be the simplest or least invasive.

Reduction of pain via platelet-rich plasma in split-thickness skin graft donor sites: a series of matched pairs.

In the past decade, autologous platelet-rich plasma (PRP) therapy has seen increasingly widespread integration into medical specialties. PRP application is known to accelerate wound epithelialization rates, and may also reduce postoperative wound site pain. Recently, we observed an increase in patient satisfaction following PRP gel (Angel, Cytomedix, Rockville, MD) application to split-thickness skin graft (STSG) donor sites. We assessed all patients known to our university-based hospital service who underwent multiple STSGs up to the year 2014, with at least one treated with topical PRP. Based on these criteria, five patients aged 48.4±17.6 (80% male) were identified who could serve as their own control, with mean time of 4.4±5.1 years between operations. In both therapies, initial dressing changes occurred on postoperative day (POD) 7, with donor site pain measured by Likert visual pain scale. Paired t-tests compared the size and thickness of harvested skin graft and patient pain level, and STSG thickness and surface area were comparable between control and PRP interventions (p>0.05 for all). Donor site pain was reduced from an average of 7.2 (±2.6) to 3 (±3.7), an average reduction in pain of 4.2 (standard error 1.1, p=0.0098) following PRP use. Based on these results, the authors suggest PRP as a beneficial adjunct for reducing donor site pain following STSG harvest.

A passing glance? Differences in eye tracking and gaze patterns between trainees and experts reading plain film bunion radiographs.

Eye tracking and gaze pattern studies have been used to evaluate human behavior for decades. This is because of its ability to reveal conscious and subconscious behaviors when subjects are tasked with observation, decision making, and surgical performance. Many have popularized the use of this technology for radiographic assessment while evaluating radiologist behaviors, but little has been described for surgeon behavior patterns when evaluating preoperative deformities by radiograph. Because the radiographic assessment strongly influences surgical selection, the present study was designed to evaluate the differences between groups of novice and experienced surgeons' gaze patterns when tasked to describe hallux valgus deformities. The subjects were asked to rate the deformity as "none," "mild," "moderate," or "severe." Using an externally mounted eye tracking system, our study assessed saccades, fixations, overall time spent per radiograph, and the subjects' chosen bunion rating. Both the novice and advanced groups of foot and ankle surgeons were tasked to evaluate 25 total anteroposterior radiographs from patients who presented with a primary complaint of bunion pain. These patients were chosen at random, such that all participating surgeons had no previous patient familiarization. Statistically significant differences were observed with regard to the activity and rating of the moderate bunion films. The experience of surgeons does appear to modify gaze behavior with respect to time and attention, such that less overall time spent per image is needed by the advanced group, with improved efficiency. Future academic curriculum and training techniques could be developed to reflect these potential technical differences in search behavior, diagnostic technique, and surgical selection strategy.

A heads-up display for diabetic limb salvage surgery: a view through the google looking glass.

Although the use of augmented reality has been well described over the past several years, available devices suffer from high cost, an uncomfortable form factor, suboptimal battery life, and lack an app-based developer ecosystem. This article describes the potential use of a novel, consumer-based, wearable device to assist surgeons in real time during limb preservation surgery and clinical consultation. Using routine intraoperative, clinical, and educational case examples, we describe the use of a wearable augmented reality device (Google Glass; Google, Mountain View, CA). The device facilitated hands-free, rapid communication, documentation, and consultation. An eyeglass-mounted screen form factor has the potential to improve communication, safety, and efficiency of intraoperative and clinical care. We believe this represents a natural progression toward union of medical devices with consumer technology.