The Future of Microsurgery: Vascularized Composite Allotransplantation and Engineering Vascularized Tissue.

Background: Microsurgical techniques have revolutionized the field of reconstructive surgery and are the mainstay for complex soft tissue reconstruction. However, their limitations have promoted the development of viable alternatives. This article seeks to explore technologies that have the potential of revolutionizing microsurgical reconstruction as it is currently known, reflect on current and future vascularized composite allotransplantation (VCA) practices, as well as describe the basic science within emerging technologies and their potential translational applications. Methods: A literature review was performed of the technologies that may represent the future of microsurgery: vascularized tissue engineering (VCA) and flap-specific tissue engineering. Results: VCA has shown great promise and has already been employed in the clinical setting (especially in face and limb transplantation). Immunosuppression, logistics, cost, and regulatory pathways remain barriers to overcome to make it freely available. Vascularized and flap-specific tissue engineering remain a laboratory reality but have the potential to supersede VCA. The capability of creating an off-the-shelf free flap matching the required tissue, size, and shape is a significant advantage. However, these technologies are still at the early stage and require significant advancement before they can be translated into the clinical setting. Conclusion: VCA, vascularized tissue engineering, and flap-specific bioengineering represent possible avenues for the evolution of current microsurgical techniques. The next decade will elucidate which of these three strategies will evolve into a tangible translational option and hopefully bring a paradigm shift of reconstructive surgery.

Turn Your Vision into Reality-AI-Powered Pre-operative Outcome Simulation in Rhinoplasty Surgery.

BACKGROUND: The increasing demand and changing trends in rhinoplasty surgery emphasize the need for effective doctor-patient communication, for which Artificial Intelligence (AI) could be a valuable tool in managing patient expectations during pre-operative consultations. OBJECTIVE: To develop an AI-based model to simulate realistic postoperative rhinoplasty outcomes. METHODS: We trained a Generative Adversarial Network (GAN) using 3,030 rhinoplasty patients' pre- and postoperative images. One-hundred-one study participants were presented with 30 pre-rhinoplasty patient photographs followed by an image set consisting of the real postoperative versus the GAN-generated image and asked to identify the GAN-generated image. RESULTS: The study sample (48 males, 53 females, mean age of 31.6 ± 9.0 years) correctly identified the GAN-generated images with an accuracy of 52.5 ± 14.3%. Male study participants were more likely to identify the AI-generated images compared with female study participants (55.4% versus 49.6%; p = 0.042). CONCLUSION: We presented a GAN-based simulator for rhinoplasty outcomes which used pre-operative patient images to predict accurate representations that were not perceived as different from real postoperative outcomes. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Challenges and pitfalls in diagnosing superior mesenteric artery syndrome: A case report.

Superior mesenteric artery syndrome is a rare condition that causes duodenal obstruction due to compression by the superior mesenteric artery and the aorta. It can be related to congenital or acquired factors that reduce the aortomesenteric angle and distance. The clinical presentation is nonspecific and often mimics other causes of upper gastrointestinal obstruction. The diagnosis requires a high index of suspicion and a correlation of clinical symptoms with radiographic findings. We report a case of a 17-year-old female patient who presented with chronic abdominal pain, vomiting, and weight loss. She was diagnosed with superior mesenteric artery syndrome based on an abdominal computed tomography scan that showed a reduced aortomesenteric angle of 30° and a reduced aortomesenteric distance of 7 mm. She was treated conservatively with anticoagulation therapy, dietary modification, and physical activity. She reported symptom improvement and weight gain after 2 weeks of treatment. This case illustrates the challenges and pitfalls in diagnosing superior mesenteric artery syndrome.

Medical education in Syria at a time of crisis: Analysis of the results of the knowledge-based National Medical Examination.

OBJECTIVE: This study explored how the Syrian crisis, training conditions, and relocation influenced the National Medical Examination (NME) scores of final-year medical students. METHODS: Results of the NME were used to denote the performance of final-year medical students between 2014 and 2021. The NME is a mandatory standardised test that measures the knowledge and competence of students in various clinical subjects. We categorised the data into two periods: period-I (2014-2018) and period-II (2019-2021). Period-I represents students who trained under hostile circumstances, which refer to the devastating effects of a decade-long Syrian crisis. Period-II represents post-hostilities phase, which is marked by a deepening economic crisis. RESULTS: Collected data included test scores for a total of 18 312 final-year medical students from nine medical schools (from six public and three private universities). NME scores improved significantly in period-II compared with period-I tests (p < 0.0001). Campus location or relocation during the crisis affected the results significantly, with higher scores from students of medical schools located in lower-risk regions compared with those from medical schools located in high-risk regions (p < 0.0001), both during and in the post-hostilities phases. Also, students of medical schools re-located to lesser-risk regions scored significantly less than those of medical schools located in high-risk regions (p < 0.0001), but their scores remained inferior to that of students of medical schools that were originally located in lower-risk regions (p < 0.0001). CONCLUSION: Academic performance of final year medical students can be adversely affected by crises and conflicts, with a clear tendency to recovery upon crises resolution. The study underscores the importance of maintaining and safeguarding the infrastructure of educational institutions, especially during times of crisis. Governments and educational authorities should prioritise resource allocation to ensure that medical schools have access to essential services, learning resources, and teaching personnel.

Beyond the Operating Room: Exploring Gender Bias in Leadership Positions in German Plastic Surgery.

Background: Despite efforts to promote gender equity in medicine, gender disparities persist in various medical specialties, including plastic surgery. This study aimed to investigate the representation of female physicians in leadership positions in German plastic surgery departments. Methods: This cross-sectional study collected data about the physician workforce in the German plastic surgery field. The primary outcome was the proportion of female physicians in plastic surgery departments. Data were collected from 94 departments. The physician workforce was stratified based on gender and leadership. Results: We included 812 physicians working in different German plastic surgery departments. Of those, 76.8% were in leadership positions, and 35.1% were women. There was a significant association between being male sex and holding a leadership position (n = 158/188, 84% versus n = 30/188, 16%, P < 0.0001). This association persisted even after accounting for the academic grade of each physician in a multivariable regression model (OR 2.565; 95% confidence interval, 1.628-4.041). Conclusions: Women are significantly underrepresented in leadership positions in German plastic surgery, with only 16% of female physicians holding such positions. Furthermore, being male sex was significantly associated with holding a leadership position, even after adjusting for the academic grade. These findings emphasize the existence of gender bias in the selection process for leadership positions in plastic surgery.

Face the Future-Artificial Intelligence in Oral and Maxillofacial Surgery.

Artificial intelligence (AI) has emerged as a versatile health-technology tool revolutionizing medical services through the implementation of predictive, preventative, individualized, and participatory approaches. AI encompasses different computational concepts such as machine learning, deep learning techniques, and neural networks. AI also presents a broad platform for improving preoperative planning, intraoperative workflow, and postoperative patient outcomes in the field of oral and maxillofacial surgery (OMFS). The purpose of this review is to present a comprehensive summary of the existing scientific knowledge. The authors thoroughly reviewed English-language PubMed/MEDLINE and Embase papers from their establishment to 1 December 2022. The search terms were (1) "OMFS" OR "oral and maxillofacial" OR "oral and maxillofacial surgery" OR "oral surgery" AND (2) "AI" OR "artificial intelligence". The search format was tailored to each database's syntax. To find pertinent material, each retrieved article and systematic review's reference list was thoroughly examined. According to the literature, AI is already being used in certain areas of OMFS, such as radiographic image quality improvement, diagnosis of cysts and tumors, and localization of cephalometric landmarks. Through additional research, it may be possible to provide practitioners in numerous disciplines with additional assistance to enhance preoperative planning, intraoperative screening, and postoperative monitoring. Overall, AI carries promising potential to advance the field of OMFS and generate novel solution possibilities for persisting clinical challenges. Herein, this review provides a comprehensive summary of AI in OMFS and sheds light on future research efforts. Further, the advanced analysis of complex medical imaging data can support surgeons in preoperative assessments, virtual surgical simulations, and individualized treatment strategies. AI also assists surgeons during intraoperative decision-making by offering immediate feedback and guidance to enhance surgical accuracy and reduce complication rates, for instance by predicting the risk of bleeding.

Attitudes and factors influencing organ donation decision-making in Damascus, Syria: a cross-sectional study.

Organ donation is vital to saving lives, but its success depends on people's willingness to donate organs. This descriptive cross-sectional survey aimed to investigate attitudes towards organ donation in Damascus, Syria. Understanding attitudes is crucial for the success of organ donation programs, especially in countries with similar settings. This study was a descriptive cross-sectional survey aimed at understanding patients' attitudes towards organ donation in Damascus, Syria. Data was collected through a carefully constructed validated survey through face-to-face interviews. 600 participants were randomly interviewed, 62.8% agreed to donate their organs after death, with helping others being the primary reason. Religious beliefs were the primary reason for organ refusal in males, while for females, it was lack of knowledge and religious beliefs. However, there were no significant differences between genders or educational level and age groups in the acceptance of organ donation. The percentage of those who agree to donate their organs after death encourages taking an effective step to build an integrated donation system, not just a center. Bearing in mind that there is no correlation with age, gender or even educational level, which means that the system may include different groups of society.

An Evidence-Based Approach to Anticoagulation Therapy Comparing Direct Oral Anticoagulants and Vitamin K Antagonists in Patients With Atrial Fibrillation and Bioprosthetic Valves: A Systematic Review, Meta-Analysis, and Network Meta-Analysis.

Direct oral anticoagulants (DOACs) are a newer class of anticoagulants that inhibit factor Xa or factor IIa and include drugs such as rivaroxaban, apixaban, edoxaban, betrixaban, and dabigatran. Although vitamin K antagonists (VKAs) have been traditionally used to prevent thromboembolic events, DOACs have gained popularity because of their faster onset and offset of action and reduced need for monitoring. This study aimed to provide more data for anticoagulants in patients with atrial fibrillation with bioprosthetic heart valves by incorporating all available trials to date. A search was performed across 5 electronic databases to identify relevant studies. We analyzed the data using a pooled risk ratio for categorical outcomes and used the I2 test to determine heterogeneity. The quality of randomized controlled trials was assessed using the Cochrane risk of bias assessment tool, and the National Institutes of Health tool was used for observational studies. Our study included a frequentist network meta-analysis (MA) of the aggregate data to obtain the network estimates for the outcomes of interest. We retrieved 28 studies with a total of 74,660 patients with bioprosthetic heart valves. Our MA significantly showed that DOACs decrease the risk of all-cause bleeding (risk ratio [RR] 0.80, 95% confidence interval [CI] 0.75 to 0.85, p >0.00001), stroke and systemic embolization (RR 0.89, 95% CI 0.80 to 0.99, p = 0.03), and intracranial bleeding outcomes (RR 0.62, 95% CI 0.45 to 0.86, p = 0.004) compared with VKA. In contrast, there was no significant difference between the compared groups in major bleeding (RR = 0.92, 95% CI 0.84 to 1.02, p = 0.10) and all-cause mortality outcomes (RR = 0.96, 95% CI 0.85 to 1.07, p = 0.43), respectively. In addition, the network MA results did not favor any of the studied interventions over each other (p <0.05) regarding all-cause bleeding, mortality, stroke and systemic embolization, and major bleeding outcomes. In conclusion, our study found that DOACs are more effective in reducing the risk of bleeding, stroke, systemic embolism, and intracranial bleeding than VKAs. However, no significant difference was observed in the incidence of gastrointestinal bleeding, major bleeding, thromboembolic events, and all-cause mortality. In addition, our network MA did not identify any specific DOAC treatment as more favorable than others.

Gender distribution and women leadership in German Otolaryngology, Head and Neck Surgery.

Objective: To determine the distribution of female physicians throughout the rank from resident to leadership positions in German Otolaryngology-Head and Neck Surgery (OHNS) departments. Methods: This cross-sectional study collected data about the physician workforce in the German OHNS.The primary outcome was the proportion of female physicians. Data were collected from 165 departments from January 2022 to February 2022. The physician workforce was stratified based on gender and leadership. Results: We included 2089 physicians from 165 departments of OHNS in German hospitals. Female residents and specialists outnumbered male peers (484/872 [55.5%] vs. 388/872 [44.5%] and 224/363 [61.71%] vs. 139/363 [38.29%], respectively). However, the women proportion decreased gradually with elevated hierarchical rank starting at the attending physician level to reaching its lowest extreme (14/165 [7.23%]) at the head of the department level. Holding a leadership position was associated with being male (n = 282 [85.2%] vs. n = 49 [14.8%], p < .0001). This persisted even after controlling the academic rank in a multivariable regression model (OR: 5.027, 95% CI: 3.536-7.146). The gap between the two genders in favor of men regarding leadership persisted in all kinds of hospitals. However, this disparity was lowest in university hospitals, (male: n = 83 [78.3%] vs. female: n = 23, [21.7%], p < .0001). Conclusions: Even though women outnumbered men in resident and specialist positions, they are still underrepresented in leadership positions in OHNS. Continuous surveillance is needed to watch the dynamic changes in the gap between the two genders and address it with more sex equality-supporting policies. Level of Evidence: IV.

A Comprehensive Review of the Current Monkeypox Outbreak.

Monkeypox is a zoonotic disease caused by an orthopoxvirus named monkeypox virus. The virus was identified in 1958, while the first human monkeypox case was discovered in 1970. Monkeypox caused a wide outbreak that was considered a global health emergency in July 2022. Monkeypox is transmitted through direct or indirect contact with the lesions and respiratory droplets. Animals can also transmit the disease if contacted without protection or if their products are consumed without proper processing. The disease presents as a prodromal period followed by the appearance of a rash filled with exudate. The rash appears initially on the face and then spreads to involve the genital area and the anus. Typically, the disease is mild and resolves spontaneously, but antiviral therapy with tecovirimat might be required. Monkeypox can be controlled by avoiding contact with the cases and vaccinating those at high risk for acquiring the infection and those at high risk for developing severe illness (immune deficient individuals, pregnant women, and children). Our review aims to comprehensively review the current literature regarding Monkeypox, including modes of transmission, pathogenesis, clinical presentation, diagnosis, treatment, preventive measures, and epidemiology.

Venous Thromboembolism Rates After Free Flap Reconstruction of the Head and Neck Region.

BACKGROUND: Venous thromboembolism (VTE) is a major concern for the postoperative hospitalized patient, especially after long and complex procedures. Cancer itself also contributes to the hypercoagulable state, further complicating the management of patients. Despite prophylaxis, breakthrough events can occur. We aimed to assess our institutional VTE and bleeding rates after free flap reconstruction of the head and neck (H&N) region and the factors associated with VTE events. METHODS: A retrospective review of the patients who underwent H&N free flap reconstruction at an academic center from 2012 to 2021 was performed from a prospectively maintained database. Data regarding patient demographics, medical history, surgical details, and overall outcomes were collected. Outcomes studied included postoperative 30-day VTE rates and major bleeding events. Patients who had a VTE event were compared with the rest of the cohort to identify factors associated with VTE. RESULTS: Free flap reconstruction of the H&N region was performed in 949 patients. Reconstruction after cancer extirpation for squamous cell carcinoma was the most common etiology (79%). The most common flap was thigh based (50%), followed by the fibula (29%). The most common postoperative VTE chemoprophylaxis regimen was enoxaparin 30 mg twice daily (83%). The VTE and bleeding rates over the 10-year period were 4.6% (n = 44) and 8.7% (n = 83), respectively. Body mass index (28.7 ± 5.8 vs 26.2 ± 6.6, P = 0.013) and pulmonary comorbidities were found to be significantly higher in patients who had a VTE event (43% vs 27%, P = 0.017). Patients with a VTE event had a prolonged hospital stay of 8 more days (19.2 ± 17.4 vs 11 ± 7, P = 0.003) and a higher incidence of bleeding events (27% vs 8%, P < 0.001). CONCLUSIONS: Postoperative VTE is a significant complication associated with increased length of hospitalization in patients undergoing free flap reconstruction of the H&N region. Institutional measures should be implemented on an individualized basis based on patient comorbidities to improve the postoperative VTE rates, while balancing the bleeding events.

Association between venous thromboembolism rates and different prophylactic anticoagulation regimens in patients undergoing free flap reconstruction of the head and neck region.

BACKGROUND: Venous Thromboembolism (VTE) is a serious complication after free tissue transfer to the head and neck (H&N). However, an optimal antithrombotic prophylaxis protocol is not defined in the literature. Enoxaparin 30 mg twice daily (BID) and heparin 5000 IU three times daily (TID) are among the most commonly used regimens for chemoprophylaxis. However, no studies compare these two agents in the H&N population. METHODS: A cohort study of patients who underwent free tissue transfer to H&N from 2012 to 2021 and received either enoxaparin 30 mg BID or Heparin 5000 IU TID postoperatively. Postoperative VTE and hematoma events were recorded within 30 days of index surgery. The cohort was divided into two groups based on chemoprophylaxis. VTE and hematoma rates were compared between the groups. RESULTS: Out of 895 patients, 737 met the inclusion criteria. The mean age and Caprini score were 60.6 [SD 12.5] years and 6.5 [SD 1.7], respectively. 234 [31.88%] were female. VTE and hematoma rates among all patients were 4.47% and 5.56%, respectively. The mean Caprini score between the enoxaparin (n = 664) and heparin (n = 73) groups was not statistically significant (6.5 ± 1.7 vs.6.3 ± 1.3, p = 0.457). The VTE rate in the enoxaparin group was significantly lower than in the heparin group (3.9% vs. 9.6%; OR: 2.602, 95% CI: 1.087-6.225). Hematoma rates were similar between the two groups (5.5% vs. 5.6%; OR: 0.982, 95% CI: 0.339-2.838). CONCLUSIONS: Enoxaparin 30 mg BID was associated with a lower VTE rate while maintaining a similar hematoma rate compared to heparin 5000 units TID. This association may support the use of enoxaparin over heparin for VTE chemoprophylaxis in H&N reconstruction.

Outcomes of KTP Laser Ablation in Glottic Neoplasms: A Systematic Review and Meta-Analysis.

OBJECTIVES: To evaluate the safety and clinical effectiveness of transoral laser microsurgery (TLM) with potassium-titanyl-phosphate (KTP) laser ablation for glottic neoplasms. DATA SOURCE: MEDLINE via PubMed, SCOPUS, Web of Science, and Cochrane Library. REVIEW METHODS: A systematic review and meta-analysis of studies assessing the safety and efficacy of KTP laser therapy in patients with early-stage glottic neoplasms. RESULTS: Eight studies were included. After an average follow-up of 3.3 years, the overall survival and disease-free survival for patients who underwent KTP were 90.7% (95% CI 85%-96.5%) and 98.5% (95% CI 97.3%-99.8%), respectively. In the single-arm meta-analysis, the pooled estimate of recurrence was 7.7% (95% CI 3.4%-12%). The overall voice handicap index (VHI) estimate attributed to KTP in the single-arm meta-analysis was 6.76 (95% CI [3.05, 10.48]) and 5.21 (95% CI [2.86, 7.56]) within 6 months and after a one-year follow-up, respectively. CONCLUSION: KTP laser ablation is a safe and effective method for treating patients with early glottic neoplasms. Laryngoscope, 133:1806-1814, 2023.

Deep Learning Applications in Surgery: Current Uses and Future Directions.

Deep learning (DL) is a subset of machine learning that is rapidly gaining traction in surgical fields. Its tremendous capacity for powerful data-driven problem-solving has generated computational breakthroughs in many realms, with the fields of medicine and surgery becoming increasingly prominent avenues. Through its multi-layer architecture of interconnected neural networks, DL enables feature extraction and pattern recognition of highly complex and large-volume data. Across various surgical specialties, DL is being applied to optimize both preoperative planning and intraoperative performance in new and innovative ways. Surgeons are now able to integrate deep learning tools into their practice to improve patient safety and outcomes. Through this review, we explore the applications of deep learning in surgery and related subspecialties with an aim to shed light on the practical utilization of this technology in the present and near future.

Dermatological assessment of thick-skinned patients before rhinoplasty-what may surgeons ask for?

Rhinoplasty is considered a very challenging surgery since minimal changes of this central area of the face may significantly impact a person's appearance and self-awareness. This is even more challenging in thick-skinned patients because results are less predictable, and changes to the osseocartilaginous framework (OCF) may not be sufficiently visible due to the blanket effect of the thick skin. Furthermore, pre-existing skin conditions may exacerbate following surgery. Therefore, managing patients with extremely thick skin or patients who suffer from pre-existing dermatological conditions such as rosacea or acne requires a synergy of surgeons and dermatologists to achieve optimal results. In this article, we review the most significant pre- and post-surgical regimens that surgeons and dermatologists should apply in selected patients to achieve optimal results after rhinoplasty.

The Role of Autologous Fat Grafting in Rhinoplasty.

Rhinoplasty is one of the most popular aesthetic surgeries worldwide and often includes grafting techniques to achieve optimal results. One of these grafting techniques is autologous fat transfer, which has been used to increase volume, camouflage irregularities, and/or improve the quality of the nasal skin-soft tissue envelope. Moreover, minimally invasive approaches for altering the nasal appearance have recently increased and become known as "liquid" or "nonsurgical rhinoplasty." These nonsurgical approaches include altering the nasal appearance with filler injection to induce volumetric changes in lieu of extensive surgery. The use of fat grafting as a filler is favorable to achieve well-balanced aesthetic results without compromising the nasal skin-soft tissue envelope. This capability is partly because of the regenerative potential of fat grafts, serving to improve the quality of surrounding soft tissues. In contrast, commercial injectable fillers are inert. This article highlights the role of fat grafting in surgical and nonsurgical rhinoplasty to provide surgeons with an overview of the potential of these vastly abundant, biocompatible, and cost-effective grafts.

Depression, anxiety and related factors among Syrian breast cancer patients: a cross-sectional study.

INTRODUCTION: Breast cancer represents a traumatic experience with a psychological burden. The prevalence of psychological distress (which include depression and anxiety) among breast cancer patients is estimated to be 15 to 54%, but studies have shown that applying some psychological treatments has contributed to decreasing depression and anxiety. So, it is crucial to diagnose and treat patients with the appropriate means. After reviewing the literature, no studies discussed depression and anxiety among Syrian breast cancer patients. METHODS: A cross-sectional study in Al-Bairouni hospital in Damascus, Syria carried out using face-to-face interviews based on a structured questionnaire. All breast cancer patients were included, except who refused to participate, and responses with missing data were excluded. The questionnaire consisted of 2 sections: the first included Socio-demographic characteristics, and the other evaluated patients' depression using PHQ-2 and GAD-2 scales. Data were gathered using the Kobo toolbox app and then entered into an Excel sheet. RESULTS: Five hundred patients were interviewed. 35.6% of the patients had a GAD-2 score greater than or equal to 3.00, while 35% had a PHQ-2 score greater than or equal to 3.00. There is a significant negative relationship between the age of the patient and the GAD-2 score and PHQ-2 score, which means the older the patient is, the lower the GAD-2 and PHQ-2 scores are. A multivariable regression model showed that younger (age ≤ 45 years) and being widowed were associated with being positive for further evaluation for generalized anxiety disorder. Similarly, patients younger than 45 are significantly associated with the need for further evaluation for major depressive disorder (MDD). Social status had a stronger association with the need for further assessment for MDD, with divorced women showing the strongest association, followed by widowed and married women compared to single women. CONCLUSION: This study showed high anxiety and depression among breast cancer patients. The patient's age and social status were significant factors in determining the need for further psychological assessment. In General, Younger patients showed higher levels of depression and anxiety, the size of the tumor did not show significant association with psychological distress.

Assessment of BMI and Venous Thromboembolism Rates in Patients on Standard Chemoprophylaxis Regimens After Undergoing Free Tissue Transfer to the Head and Neck.

Importance: Venous thromboembolism (VTE) is a severe complication after free tissue transfer to the head and neck (H&N). Enoxaparin 30 mg twice daily (BID) is a common regimen for chemoprophylaxis. However, differences in enoxaparin metabolism based on body weight may influence its efficacy and safety profile. Objective: To assess the association between BMI and postoperative VTE and hematoma rates in patients treated with prophylactic enoxaparin 30 mg BID. Design, Setting, and Participants: This was a retrospective review of a prospectively collected cohort from 2012 to 2022. Postoperative VTE, hematoma, and free flap pedicle thrombosis were recorded within 30 days of index surgery. The setting was a tertiary academic referral center. Participants included patients undergoing H&N reconstruction with free flaps that received fixed-dose subcutaneous enoxaparin 30 mg BID postoperatively. Statistical analysis was conducted from April to May 2022. Main Outcomes and Measures: Outcomes include incidence of VTE, hematoma, and flap pedicle thrombosis events within 30 days of the surgery. Univariate and multivariable regression models were used to evaluate associations between BMI and other patient factors with these outcomes. Results: Among the 765 patients included, 262 (34.24%) were female; mean (SD) age was 60.85 (12.64) years; and mean (SD) BMI was 26.36 (6.29). The rates of VTE and hematoma in the cohort were 3.92% (30 patients) and 5.09% (39 patients), respectively. After adjusting for patient factors, BMI was the only factor associated with VTE (OR, 1.07; 95% CI, 1.015-1.129). Obesity (BMI >30) was associated with increased odds of VTE (OR, 2.782; 95% CI, 1.197-6.564). Hematoma was not associated with BMI (OR, 0.988; 95% CI, 0.937-1.041). Caprini score of at least 9 was not associated with VTE (OR, 1.259; 95% CI, 0.428-3.701). Conclusions and Relevance: This cohort study found that obesity was associated with an increased risk of VTE in patients after microvascular H&N reconstruction and while on standard postoperative chemoprophylaxis regimens. This association may suggest insufficient VTE prophylaxis in this group and a potential indication for weight-based dosing.

The pathway to residency in Germany: a survey study to identify factors that impact an international medical graduate from Syria.

BACKGROUND: The German health care system has recently become an attractive destination for international medical graduates, particularly from developing countries such as Syria. However, there are no studies about the factors that influence the successful entry into the German healthcare system at trainee level.  METHOD : An anonymous cross-sectional survey was distributed electronically to Syrian medical graduates who successfully entered residency training in Germany. Collected data included demographics and factors that influence entering the residency, such as proven German proficiency and clinical experience in the home country. Hypothesis testing was used to assess the difference between the variables. RESULTS: A total of 109 participants responded to the survey. Twenty-three (21.1%) subjects completed a medical residency in Syria before moving to Germany, and 46 (42.2%) had no previous clinical experience before moving to Germany. The proven German proficiency of the participants upon arrival in Germany was less than B1 in 39 (35.8%), B1 in 37 (33.9%), and B2 in 33 (30.3%) cases. None of the participants had a language level beyond B2, and 18 (16.5%) had no German knowledge. The median of months spent in Germany till residency for those with B1 or B2 certificates before moving to Germany (10.5 (6.25-16) months and 8 (5-11) months, respectively) differed significantly from those with German-language skills belowB1 ((21 (14-29) months, p < .001). Residency in the home country was not associated with a difference in the median of the months in Germany till entering residency, p = 0.84. CONCLUSION: A crucial factor influencing the successful entry to the German medical system at the trainee level is the ability to speak German, measured in levels based on the Common European Framework of Reference for languages. A high language skill level is a crucial factor associated with a decrease in time in Germany till entering residency for an international medical applicant. In contrast, previous work experience is not influencing the entry into the German labor market.

Leiomyosarcoma of the Nasal Cavity.

Leiomyosarcoma (LMS) in the sinonasal tract (SNT) is a rarity that has been firstly described in 1958. Since then, there have been only a few articles about this entity. Most of the data available about LMS in the SNT is derived from case reports. We believe that our case will support the data set and help guiding the management of this rare condition. A 84-year-old female presented with nasal airway obstruction on the left side. She experienced several episodes of epistaxis from her left nostril, what made her to seek medical care. A rhinoscopy revealed an obstructing mass in the left nasal cavity. Computed tomography (CT) scan of the paranasal sinuses revealed a homogenous mass occupying the left nasal cavity, bone destruction of the left middle, and inferior nasal turbinates. An infiltration of the left nasolacrimal duct was also present. The patient refused to undergo open surgery and the mass was removed during an endoscopic approach. The histopathological analysis combined with immunohistochemistry was consistent with LMS. The resection margins were positive for tumor cells. A staging with CT-neck-thorax, abdomen ultrasound, and MRI of the head ruled out metastases. She underwent a second endoscopic tumor resection surgery with positive resection margins and obtained adjuvant radiotherapy. On 9 months of follow-up, there was no recurrence or metastases.