α-Casozepine supplementation shows no effect on foals' growth and cortisol levels before and after weaning.

OBJECTIVE: The goal of this study was to determine whether oral administration of α-casozepine (Zylkene) supplementation decreases the risk of disease in foals, as measured through salivary cortisol levels, temperature, clinical signs of disease, and body weight before and after weaning. ANIMALS: 20 Thoroughbred foals were observed over 10 weeks, beginning 14 days prior to the time of weaning. METHODS: Experimental foals were randomly selected and given α-casozepine daily for 10 weeks, while the controls received a placebo with the same frequency as the experimental group. The average daily height and weight gain were calculated to examine the effects of α-casozepine before and after weaning. Salivary cortisol levels were also compared before versus after weaning. RESULTS: There was no statistically significant difference in average daily height/weight gain or cortisol levels between the α-casozepine group and the control before and after weaning. However, the α-casozepine group had numerically less of a decline in height and growth compared to the control. This suggests that with further study Zylkene may decrease losses in foal growth rate. CLINICAL RELEVANCE: The weaning process is one of the largest stressors in a young horse's life. This abrupt process can contribute to an increased risk of disease and even morbidity. Other major stressors including separation from the mare, diet change, and new social groups can also lead to animal health and welfare concerns, as well as economic losses in weanling foals. However, further study is required to determine the benefits of α-casozepine on equine stress and health.

Clinical aspects of spatially fractionated radiation therapy treatments.

PURPOSE: To provide clinical guidance for centers wishing to implement photon spatially fractionated radiation therapy (SFRT) treatments using either a brass grid or volumetric modulated arc therapy (VMAT) lattice approach. METHODS: We describe in detail processes which have been developed over the course of a 3-year period during which our institution treated over 240 SFRT cases. The importance of patient selection, along with aspects of simulation, treatment planning, quality assurance, and treatment delivery are discussed. Illustrative examples involving clinical cases are shown, and we discuss safety implications relevant to the heterogeneous dose distributions. RESULTS: SFRT can be an effective modality for tumors which are otherwise challenging to manage with conventional radiation therapy techniques or for patients who have limited treatment options. However, SFRT has several aspects which differ drastically from conventional radiation therapy treatments. Therefore, the successful implementation of an SFRT treatment program requires the multidisciplinary expertise and collaboration of physicians, physicists, dosimetrists, and radiation therapists. CONCLUSIONS: We have described methods for patient selection, simulation, treatment planning, quality assurance and delivery of clinical SFRT treatments which were built upon our experience treating a large patient population with both a brass grid and VMAT lattice approach. Preclinical research and patient trials aimed at understanding the mechanism of action are needed to elucidate which patients may benefit most from SFRT, and ultimately expand its use.

Longevity of Outcomes Following Reduction Mammoplasty.

Background: Reduction mammoplasty has been shown to provide wide-ranging benefits for patients including improved quality of life in terms of physical function and mental health. However, most existing studies have been limited to the 1-year postoperative period. The aim of this study was to investigate long-term outcomes after reduction mammoplasty. Methods: Patients who underwent reduction mammoplasty at a single institution were identified retrospectively and grouped into 3 categories based on time since surgery: (i) 5 to 10 years, (ii) 10 to 15 years, and (iii) more than 15 years. A telephone survey was administered to measure satisfaction and symptom relief following reduction mammoplasty. Results: A total of 124 patients completed the survey and were included in the study. The majority of patients in all 3 groups reported marked symptoms relief (75% vs 82% vs 82%, P = .84). Overall satisfaction after reduction mammoplasty was high in all 3 subgroups and did not significantly decrease over time (4.16 vs 3.97 vs 3.7, P = .216) despite high proportions of patients reporting an increase in breast size since surgery (40% vs 70% vs 51%, P = .0297). Conclusions: Overall, reduction mammoplasty has long-lasting benefits for patients with macromastia. Overwhelmingly, patients report satisfaction with the procedure and marked symptom relief that is sustained for as long as 15 years after surgery.

Epidemiology of Children With Multiple Complex Chronic Conditions in a Mixed Urban-Rural US Community.

OBJECTIVES: Children with multiple complex chronic conditions (MCCs) represent a small fraction of our communities but a disproportionate amount of health care cost and mortality. Because the temporal trends of children with MCCs within a geographically well-defined US pediatric population has not been previously assessed, health care planning and policy for this vulnerable population is limited. METHODS: In this population-based, repeated cross-sectional study, we identified and enrolled all eligible children residing in Olmsted County, Minnesota, through the Rochester Epidemiology Project, a medical record linkage system of Olmsted County residents. The pediatric complex chronic conditions classification system version 2 was used to identify children with MCCs. Five-year period prevalence and incidence rates were calculated during the study period (1999-2014) and characterized by age, sex, ethnicity, and socioeconomic status (SES) by using the housing-based index of socioeconomic status, a validated individual housing-based SES index. Age-, sex-, and ethnicity-adjusted prevalence and incidence rates were calculated, adjusting to the 2010 US total pediatric population. RESULTS: Five-year prevalence and incidence rates of children with MCCs in Olmsted County increased from 1200 to 1938 per 100 000 persons and from 256 to 335 per 100 000 person-years, respectively, during the study period. MCCs tend to be slightly more prevalent among children with a lower SES and with a racial minority background. CONCLUSIONS: Both 5-year prevalence and incidence rates of children with MCCs have significantly increased over time, and health disparities are present among these children. The clinical and financial outcomes of children with MCCs need to be assessed for formulating suitable health care planning given limited resources.

Performance on the Plastic Surgery In-Service Examination Can Predict Success on the American Board of Plastic Surgery Written Examination.

BACKGROUND: Originally developed for resident self-assessment, the Plastic Surgery In-Service Examination has been administered for over 45 years. The Accreditation Council for Graduate Medical Education requires that at least 70 percent of graduates pass the American Board of Plastic Surgery Written Examination on their first attempt. This study evaluates the role of In-Service Exam scores in predicting Written Exam success. METHODS: In-Service Exam scores from 2009 to 2015 were collected from the National Board of Medical Examiners. Data included residency training track, training year, and examination year. Written Exam data were gathered from the American Board of Plastic Surgery. Multivariate analysis was performed and receiver operating characteristic curves were used to identify optimal In-Service Exam score cut-points for Written Exam success. RESULTS: Data from 1364 residents were included. Residents who failed the Written Exam had significantly lower In-Service Exam scores than those who passed (p < 0.001). Independent residents were 7.0 times more likely to fail compared with integrated/combined residents (p < 0.001). Residents who scored above the optimal cut-points were significantly more likely to pass the Written Exam. The optimal cut-point score for independent residents was the thirty-sixth percentile and the twenty-second percentile for integrated/combined residents. CONCLUSIONS: Plastic Surgery In-Service Exam scores can predict success on the American Board of Plastic Surgery Written Exam. Residents who score below the cut-points are at an increased risk of failing. These data can help identify residents at risk for early intervention.

Socioeconomic Status, Race/Ethnicity, and Health Disparities in Children and Adolescents in a Mixed Rural-Urban Community-Olmsted County, Minnesota.

OBJECTIVE: To characterize disparities in childhood health outcomes by socioeconomic status (SES) and race/ethnicity in a mixed rural-urban US community. METHODS: This was a retrospective population-based study of children 18 years and younger residing in Olmsted County, Minnesota, in 2009. The prevalence rates of childhood health outcomes were determined using International Classification of Diseases, Ninth Revision codes. Socioeconomic status was measured using the HOUsing-based SocioEconomic Status index (HOUSES), derived from real property data. Adjusting for age and sex, logistic regression models were used to examine the relationships among HOUSES, race/ethnicity, and prevalence of childhood health outcomes considering an interaction between HOUSES and race/ethnicity. Odds ratios were calculated using the lowest SES quartile and non-Hispanic white participants as the reference groups. RESULTS: Of 31,523 eligible children, 51% were male and 86% were of non-Hispanic white race/ethnicity. Overall, lower SES was associated with higher prevalence of bronchiolitis, urinary tract infection, asthma, mood disorder, and accidents/adverse childhood experiences (physical and sexual abuse) in a dose-response manner (P<.04). Prevalence rates of all childhood conditions considered except for epilepsy were significantly different across races/ethnicities (P<.002). Racial/ethnic disparities for asthma and mood disorder were greater with higher SES. CONCLUSION: Significant health disparities are present in a predominantly affluent, non-Hispanic white, mixed rural-urban community. Socioeconomic status modifies disparities by race/ethnicity in clinically less overt conditions. Interpretation of future health disparity research should account for the nature of disease.

The Effect of Sedation, Oral Examination, and Odontoplasty on Systemic Inflammation as Measured by Serum Amyloid A in the Adult Performance Horse.

Serum amyloid A (SAA) is one of the major acute phase proteins in horses. It serves as a marker for systemic inflammation and infection, as the concentration can increase 100- to even 1000-fold during systemic disease processes. The objective of this study was to evaluate the effect of sedation, oral examination, and odontoplasty on systemic inflammation as measured by SAA in the adult performance horse. This study included 32 clinically healthy adult performance horses. Blood samples were collected immediately prior to sedation, oral examination, and odontoplasty and 48 and 72 hours afterward. Serum amyloid A levels were measured directly after venipuncture using a commercially available stall-side lateral flow immunoassay test developed and validated for equine SAA levels. Serum amyloid A values were within normal limits for each of the time periods and there were no significant differences in SAA values between the time periods. The results of this study suggest that sedation, oral examination, and odontoplasty have no systemic inflammatory effects as measured by SAA.

Vasopressor magnitude predicts poor outcome in adults with congenital heart disease after cardiac surgery.

BACKGROUND: High levels of vasoactive inotrope support (VIS) after congenital heart surgery are predictive of morbidity in pediatric patients. We sought to discern if this relationship applies to adults with congenital heart disease (ACHD). METHODS: We retrospectively studied adult patients (≥18 years old) admitted to the intensive care unit after cardiac surgery for congenital heart disease from 2002 to 2013 at Mayo Clinic. Vasoactive medication dose values within 96 hours of admission were examined to determine the relationship between VIS score and poor outcome of early mortality, early morbidity, or complication related morbidity. RESULTS: Overall, 1040 ACHD patients had cardiac surgery during the study time frame; 243 (23.4%) met study inclusion criteria. Sixty-two patients (25%), experienced composite poor outcome [including eight deaths within 90 days of hospital discharge (3%)]. Thirty-eight patients (15%) endured complication related early morbidity. The maximum VIS (maxVIS) score area under the curve was 0.92 (95% CI: 0.86-0.98) for in-hospital mortality; and 0.82 (95% CI: 0.76-0.89) for combined poor clinical outcome. On univariate analysis, maxVIS score ≥3 was predictive of composite adverse outcome (OR: 14.2, 95% CI: 7.2-28.2; P < 0.001), prolonged ICU LOS ICU LOS (OR: 19.2; 95% CI: 8.7-42.1; P < 0.0001), prolonged mechanical ventilation (OR: 13.6; 95% CI: 4.4-41.8; P < 0.0001) and complication related morbidity (OR: 7.3; 95% CI: 3.4-15.5; P < 0.0001). CONCLUSIONS: MaxVIS score strongly predicted adverse outcomes and can be used as a risk prediction tool to facilitate early intervention that may improve outcome and assist with clinical decision making for ACHD patients after cardiac surgery.

The Architecture of Fat Grafting II: Impact of Cannula Diameter.

BACKGROUND: Fat grafting has emerged as the treatment of choice for soft-tissue augmentation and reconstruction. Variability of volume retention remains the greatest challenge for this technique, often requiring multiple operations to achieve the desired volume. Graft that is placed greater than 2 mm from the recipient bed will undergo necrosis. Improved understanding of the architecture of fat within the recipient bed is paramount to improving outcomes. The impact of cannula diameter on graft architecture is unknown. METHODS: Fat was harvested by liposuction and stained with methylene blue. Stained fat was grafted into 4 × 2 × 1-cm sections of excised abdominal tissue with 12-, 14-, 16-, and 19-gauge Coleman cannulas at three different volumes: 0.1, 0.5, and 1.0 cc. Each tissue block was sectioned for stained graft visualization. The diameter of each deposit and percentage with a radius greater than 2 mm were recorded. RESULTS: With an injection volume of 0.1 cc, no fat deposits had a radius greater than 2 mm, regardless of cannula size. A graft volume of 0.5 cc created globules greater than 2 mm with larger cannulas (0 percent with 19-gauge, 2.9 percent with 16-gauge, 6.1 percent with 14-gauge, and 4.3 percent with 12-gauge). Injecting 1.0 cc resulted in a significant increase in the percentage of fat parcels expected to undergo central necrosis (16 percent with 19-gauge, 21 percent with 16-gauge, 26 percent with 14-gauge, and 44 percent with 12-gauge). CONCLUSIONS: Injection cannulas of 14-gauge or larger are more likely to create deposits with dimensions that may be susceptible to central necrosis when injecting 1.0 cc per pass. Smaller cannula sizes or lower volumes per pass should be considered. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

A "Fundamentals" Train-the-Trainer Approach to Building Pediatric Critical Care Expertise in the Developing World.

Pediatric Fundamental Critical Care Support (PFCCS) is an educational tool for training non-intensivists, nurses, and critical care practitioners in diverse health-care settings to deal with the acute deterioration of pediatric patients. Our objective was to evaluate the PFCCS course as a tool for developing a uniform, reproducible, and sustainable model for educating local health-care workers in the optimal management of critically ill children in the Republic of Georgia. Over a period of 18 months and four visits to the country, we worked with Georgian pediatric critical care leadership to complete the following tasks: (1) survey health-care needs within the Republic of Georgia, (2) present representative PFCCS lectures and simulation scenarios to evaluate interest and obtain "buy-in" from key stakeholders throughout the Georgian educational infrastructure, and (3) identify PFCCS instructor candidates. Georgian PFCCS instructor training included the following steps: (1) US PFCCS consultant and content experts presented PFCCS course to Georgian instructor candidates. (2) Simulation learning principles were taught and basic equipment was acquired. (3) Instructor candidates presented PFCCS to Georgian learners, mentored by PFCCS course consultants. Objective evaluation and debriefing with instructor candidates concluded each visit. Between training visits Georgian instructors translated PFCCS slides to the Georgian language. Six candidates were identified and completed PFCCS instructor training. These Georgian instructors independently presented the PFCCS course to 15 Georgian medical students. Student test scores improved significantly from pretest results (n = 14) (pretest: 38.7 ± 7 vs. posttest 62.7 ± 6, p < 0.05). A Likert-type scale of 1 to 5 (1 = not useful or effective, 5 = extremely useful or effective) was used to evaluate each student's perception regarding (1) relevance of course content to clinical work students rated as median (IQR): (a) relevance of PFCCS content to clinical work, 5 (4-5); (b) effectiveness of lecture delivery, 4 (3-4); and (c) value of skill stations for clinical practice, 5 (4-5). Additionally, the mean (±SD) responses were 4.6 (±0.5), 3.7 (±0.6), and 4.5 (±0.6), respectively. Training local PFCCS instructors within an international environment is an effective method for establishing a uniform, reproducible, and sustainable approach to educating health-care providers in the fundamentals of pediatric critical care. Future collaborations will evaluate the clinical impact of PFCCS throughout the Georgian health-care system.

Plastic and Reconstructive Surgeons' Knowledge and Comfort of Contralateral Prophylactic Mastectomy: A Survey of the American Society of Plastic Surgeons.

Background: Despite limited oncologic benefit, contralateral prophylactic mastectomy (CPM) rates have increased in the United States over the past 15 years. CPM is often accompanied by breast reconstruction, thereby requiring an interdisciplinary approach between breast and plastic surgeons. Despite this, little is known about plastic surgeons' (PS) perspectives of CPM. The purpose of this study was to assess PS practice patterns, knowledge of CPM oncologic benefits, and perceptions of the CPM decision-making process. Methods: An electronic survey was sent to 2,642 members of the American Society of Plastic Surgeons (ASPS). Questions assessed demographics, practice patterns, knowledge of CPM oncologic benefits, and perceptions of the CPM decision-making process. Results: ASPS response rate was 12.5% (n = 329). Most responders worked in private practice (69%), were male (81%) and had been in practice for ≥15 years (60%). The median number of CPM reconstructions performed per month was 2-4. Fifty-five percent of PS reported routine attendance at a breast multidisciplinary conference. Responders reported CPM discussion was most likely to be initiated by the patient (51%) followed by the breast surgeon (38%), and plastic surgeon (7.3%). According to PS, the most common reason patients choose CPM is a perceived increased contralateral cancer risk (86%). Most plastic surgeons (63%) assessed the benefits of CPM as worth the risk of additional surgery and the majority (53%) estimated the complication rate at 2X the risk of unilateral surgery. The majority (61%) of PS estimated risk of contralateral cancer in an average risk patient between <2 and 5% over 10 years, which is consistent with data reported from the current literature. Most plastic surgeons (87%) reported that there was no evidence or limited evidence for breast cancer specific survival benefit with CPM. A minority of PS (18.5%) reported discomfort with a patient's choice for CPM. Of those surgeons reporting discomfort, the most common reasons for their reservations were a concern with the risk/benefit ratio of CPM and with lack of patient understanding of expected outcomes. Common reasons for PS comfort with CPM were a respect for autonomy and non-oncologic benefits of CPM. Discussion: To our knowledge, this is the first survey reporting PS perspectives on CPM. According to PS, CPM dialogue appears to be patient driven and dominated by a perceived increased risk of contralateral cancer. Few PS reported discomfort with CPM. While many PS acknowledge both the limited oncologic benefit of CPM and the increased risk of complications, the majority have the opinion that the benefits of CPM are worth the additional risk. This apparent contradiction may be due to an appreciation of the non-oncologic benefits CPM and a desire to respect patients' choices for treatment.

Epidemiology and Outcomes of Pediatric Multiple Organ Dysfunction Syndrome.

OBJECTIVE: To summarize the epidemiology and outcomes of children with multiple organ dysfunction syndrome as part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development multiple organ dysfunction syndrome workshop (March 26-27, 2015). DATA SOURCES: Literature review, research data, and expert opinion. STUDY SELECTION: Not applicable. DATA EXTRACTION: Moderated by an experienced expert from the field, issues relevant to the epidemiology and outcomes of children with multiple organ dysfunction syndrome were presented, discussed, and debated with a focus on identifying knowledge gaps and research priorities. DATA SYNTHESIS: Summary of presentations and discussion supported and supplemented by the relevant literature. CONCLUSIONS: A full understanding the epidemiology and outcome of multiple organ dysfunction syndrome in children is limited by inconsistent definitions and populations studied. Nonetheless, pediatric multiple organ dysfunction syndrome is common among PICU patients, occurring in up to 57% depending on the population studied; sepsis remains its leading cause. Pediatric multiple organ dysfunction syndrome leads to considerable short-term morbidity and mortality. Long-term outcomes of multiple organ dysfunction syndrome in children have not been well studied; however, studies of adults and children with other critical illnesses suggest that the risk of long-term adverse sequelae is high. Characterization of the long-term outcomes of pediatric multiple organ dysfunction syndrome is crucial to identify opportunities for improved treatment and recovery strategies that will improve the quality of life of critically ill children and their families. The workshop identified important knowledge gaps and research priorities intended to promote the development of standard definitions and the identification of modifiable factors related to its occurrence and outcome.

Epidemiology of Pediatric Critical Illness in a Population-Based Birth Cohort in Olmsted County, MN.

OBJECTIVES: Investigations of pediatric critical illness typically focus on inpatient cohorts drawn from wide referral areas and diverse healthcare systems. Cohorts amenable to investigating the full spectrum of critical illness as it develops within a community have yet to be studied in the United States. Our objective was to provide the first epidemiologic report of the incidence and presentation of pediatric critical illness within a U.S. population-based birth cohort. DESIGN: Retrospective cohort study. SETTING: A geographically defined community (Olmsted, MN) with medical record linkage across all health systems. All ICU services are provided within a single children's hospital. PATIENTS: A birth cohort of children (n =9,441) born 2003-2007 in Olmsted County, MN. MEASUREMENTS AND MAIN RESULTS: During the study period, there were a total of 15,277 ICU admissions to Mayo Clinic Children's Hospital. A total of 577 birth cohort children accounted for 824 of these admissions during the 61,770 person-years of follow-up accumulated. Incidence of first-time ICU admission was 9.3 admits per 1,000 person-years. Admission rates were highest in the first year of life and then declined steadily. Respiratory problems were among the most common reasons for admission at any age and diagnoses reflect changes in health risk factors as children grow and develop over time. After 1 year old, a majority of children admitted have preexisting chronic comorbidities and/or prior ICU stays. In-hospital mortality occurred exclusively in children admitted prior to 5 days of age (n = 4). Seven children died after hospital discharge. CONCLUSIONS: This is the first report characterizing critical illness within a population-based birth cohort of U.S. children. The results demonstrate the changing incidence, presentation, and healthcare requirements associated with critical illness across the developmental spectrum as a population of children ages.

Total and free cortisol responses and their relation to outcomes after cardiopulmonary bypass in infants.

BACKGROUND: Hypothalamic-pituitary-adrenal (HPA) axis dysfunction may be partially responsible for the hemodynamic instability experienced by infants after cardiopulmonary bypass (CPB). We report the full spectrum of the HPA response surrounding CPB for infant congenital cardiac surgery. METHODS: We enrolled 84 infants who received 1 mg/kg of dexamethasone before initiation of CPB. Total cortisol (TC), free cortisol (FC), adrenocorticotropic hormone (ACTH), and corticosteroid-binding globulin (CBG) were measured at 3 time points: immediately before CPB (TP1), on intensive care unit arrival (TP2), and at 24 hours after surgery (TP3). A 1-µg ACTH stimulation test was performed at each time point to evaluate adrenal responsiveness. RESULTS: Sixty-eight infants completed all study procedures. Levels of TC, FC, CBG, and ACTH decreased significantly between the preoperative and 24-hour postoperative measurements. There were no significant associations between preoperative FC responses and clinical outcomes after adjusting for weight and Risk-Adjusted Scores for Congenital Heart Surgery. Infants with subnormal TC responses to ACTH stimulation (<9 µg/dL) at TP2 had greater fluid requirements (P < .001) and greater chest tube output (P < .001) during the first 24 hours, as well as longer length of stay (LOS) (P = .007). Except for LOS, these differences persisted for infants with subnormal stimulation tests at TP3. CONCLUSIONS: We observed a significant decline in all aspects of the HPA axis throughout the first 24 hours after infant CPB. TC and FC levels were not associated with clinical outcomes. Subnormal (Δ <9 µg/dL) TC response to cosyntropin stimulation during the postoperative period was associated with increased fluid resuscitation and greater LOS.

Assessing health disparities in children using a modified housing-related socioeconomic status measure: a cross-sectional study.

OBJECTIVES: Socioeconomic status (SES) is a well-established risk factor for many health outcomes. Recently, we developed an SES measure based on 4 housing-related characteristics (termed HOUSES) and demonstrated its ability to assess health disparities. In this study, we aimed to evaluate whether fewer housing-related characteristics could be used to provide a similar representation of SES. STUDY SETTING AND PARTICIPANTS: We performed a cross-sectional study using parents/guardians of children aged 1-17 years from 2 US Midwestern counties (n=728 in Olmsted County, Minnesota, and n=701 in Jackson County, Missouri). PRIMARY AND SECONDARY OUTCOME MEASURES: For each participant, housing-related characteristics used in the formulation of HOUSES (assessed housing value, square footage, number of bedrooms and number of bathrooms) were obtained from the local government assessor's offices, and additional SES measures and health outcomes with known associations to SES (obesity, low birth weight and smoking exposure) were collected from a telephone survey. Housing characteristics with the greatest contribution for predicting the health outcomes were added to formulate a modified HOUSES index. RESULTS: Among the 4 housing characteristics used in the original HOUSES, the strongest contributions for predicting health outcomes were observed from assessed housing value and square footage (combined contribution ranged between 89% and 96%). Based on this observation, these 2 were used to calculate a modified HOUSES index. Correlation between modified HOUSES and other SES measures was comparable to the original HOUSES for both locations. Consistent with the original HOUSES formula, the strongest association with modified HOUSES was observed with smoking exposure (OR=0.24 with 95% CI 0.11 to 0.49 for comparing participants in highest HOUSES vs lowest group; overall p<0.001). CONCLUSIONS: The modified HOUSES requires only 2 readily available housing characteristics thereby improving the feasibility of using this index as a proxy for SES in multiple communities, especially in the US Midwestern region.

The Architecture of Fat Grafting: What Lies beneath the Surface.

BACKGROUND: Fat grafting is a powerful procedure limited by unpredictable volume loss. Grafted tissue survives via plasmatic imbibition until neovascularization occurs; therefore, fat that is deposited more than 0.2 cm from capillaries will undergo central necrosis. This study aims to determine the architecture of fat deposits within the recipient bed following fat grafting. METHODS: Fat was harvested by liposuction and stained with methylene blue. Stained fat was grafted into 4 × 4 × 2-cm sections of pannus tissue at graft-to-recipient volume ratios ranging from 1:10 to 1:1. Each tissue block was sectioned for stained graft visualization. The diameter of each deposit and the percentage with a radius greater than 0.2 cm were recorded. RESULTS: Average tunnel diameter was 0.20 ± 0.01 cm at a graft-to-recipient ratio of 1:10, 0.25 ± 0.01 cm at 1:8, 0.26 ± 0.01 cm at 1:6, 0.31 ± 0.01 cm at 1:4, 0.40 ± 0.01 cm at 1:2, and 0.57 ± 0.02 cm at 1:1. All comparisons reached statistical significance (p ≤ 0.05) except 1:8 versus 1:6 (p = 0.96). The percentage of fat parcels with a radius greater than 0.2 cm was 3.0 percent at 1:10, 5.3 percent at 1:8, 9.5 percent at 1:6, 20.9 percent at 1:4, 42.0 percent at 1:2, and 68.3 percent at 1:1. All percentage comparisons were significant except 1:10 versus 1:8 (p = 0.15). CONCLUSION: As the total volume transferred increases, grafted deposits coalesce to form larger globules, particularly at ratios beyond 1:4, likely contributing to central necrosis and subsequent volume loss. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Duration and magnitude of vasopressor support predicts poor outcome after infant cardiac operations.

BACKGROUND: The vasoactive inotrope score (VIS) is a sum of the total vasopressor dose at a single point in time. Incorporating duration and magnitude of vasopressor requirements during the postcardiac surgical period could improve VIS sensitivity for predicting poor outcome. METHODS: This is a retrospective review of 244 infants (aged ≤365 days) who underwent cardiopulmonary bypass during congenital cardiac operations from 2002 to 2011. The VIS was calculated hourly for the first 72 hours. Poor outcome was defined as prolonged mechanical ventilation (≥6 days) or intensive care length of stay (≥12 days). First, the association between the maximum VIS (maxVIS) in the first 48 postoperative hours and poor outcome was confirmed for our study population. Next, postoperative intervals and VIS values that were significantly associated with poor outcome were identified and incorporated into a formula, termed the VISindex, which was compared with the traditional maxVIS. RESULTS: The VISindex demonstrated improved sensitivity for predicting prolonged mechanical ventilation (VISindex: area under the curve [AUC], 0.85; 95% confidence interval [CI], 0.79 to 0.90; maxVIS: AUC, 0.80; 95% CI, 0.75 to 0.86) and intensive care unit length of stay (VISindex: AUC, 0.84; 95% CI, 0.79 to 0.89; maxVIS: AUC, 0.77; 95% CI, 0.71 to 0.83) after cardiac operations in infants. CONCLUSIONS: Incorporating magnitude and duration of postoperative vasopressor support into the VIS improves its sensitivity for predicting poor outcome.

Management of lower ureteric stones: a prospective study.

OBJECTIVE: To discuss the current concepts in lower ureteric stone management. MATERIAL AND METHODS: Between October 2008 and November 2010, 190 patients of both sexes and of different age groups with lower ureteric stones, underwent in situ extracorporeal shock wave lithotripsy (ESWL) (48 cases), ureterorenoscopy (URS) (120 cases) and open stone surgery (OSS) (22 cases). The patients' clinical and radiological findings, as well as stone characteristics, were reviewed and correlated with the stone-free status. RESULTS: In the ESWL group, the operative time was 43.13 +22.5 min; the average number of sessions/patients was 1.5 sessions; the average number of SW/patients was 4500 SW/patients; the average energy was 16.5 kV; the average stone burden was 7.8/mm; the overall stone-free rate was 75% (36/48); and the average radiation exposure time was 3.5 min. In the URS group, the operative time was 49.21 +16.09 min; the average stone burden was 10.81mm; the overall stone-free rate was 97.5% (117/120); the average hospital stay was 3.99 days; and the average radiation exposure time was 0.75 min. In the OSS group, the operative time was 112.38 +37.1 min; the overall stone-free rate was 100% (22/22); and the average hospital stay was 9.74 days. CONCLUSION: In the management of patients with lower ureteral stones, URS, SWL and OSS were considered acceptable treatment options. This recommendation was based on the stone-free results, morbidity and retreatment rates for each therapy.

Dexamethasone levels predict cortisol response after infant cardiopulmonary bypass.

OBJECTIVES: We sought to evaluate whether there is variability in blood dexamethasone levels after a standard 1 mg/kg dose of dexamethasone administered before infant cardiopulmonary bypass. We hypothesized that postoperative dexamethasone drug levels are highly variable, and that the infant stress response is related inversely to the amount of dexamethasone measured in the blood. METHODS: Thirty-two infants (age, ≤365 days) received 1 mg/kg of dexamethasone before cardiopulmonary bypass (CPB) initiation. Blood was analyzed for cortisol, adrenocorticotropin, and interleukin (IL)-6, IL-8, and IL-10 levels after anesthesia induction, after CPB, after intensive care unit (ICU) arrival, and 4, 8, 12, and 24 hours after surgery. Patients were grouped as high dexamethasone (≥15 µg/dL) or low dexamethasone (<15 µg/dL) based on their level at ICU arrival. RESULTS: Dexamethasone levels varied significantly between the high (n = 22) and low (n = 10) dexamethasone groups throughout the entire postoperative course and were correlated highly with cortisol response. Patients with high dexamethasone levels had postoperative cortisol levels that were lower than their pre-CPB baseline cortisol levels. Cortisol levels remained low throughout the first 24 postoperative hours even after dexamethasone levels neared zero. There were no significant differences between groups in the duration of mechanical ventilation or ICU length of stay. CONCLUSIONS: Dexamethasone levels are highly variable at ICU arrival, despite standardized 1 mg/kg dosing before CPB initiation.