Associations of urban versus rural patient residence on outcomes after burn: A national inpatient sample database study.

INTRODUCTION: Burn patients in rural areas may encounter poorer outcomes associated with barriers to care; however, residence has not been studied in a large sample. The association between rural-versus-urban residence and outcomes after burn was examined using the National Inpatient Sample (NIS) database. METHODS: Using the 2019 NIS database, patients over 18 years with a primary diagnosis of burn or corrosive injury were included. Level of urbanization was categorized into six groups. Outcomes after burn such as in-hospital mortality, multifactorial shock, prolonged mechanical ventilation, length of stay, and total costs were analyzed after adjusting for demographic factors and hospital characteristics. RESULTS: We included 4671 records, which represented a weighted population of 23,085 patients. Rural residence was associated with higher percentage of prior transfer but not in-hospital mortality. Compared to the most urbanized counties, encounters from the most rural counties were associated with higher odds of shock (aOR:2.62, 99% CI: 1.04-6.56, p = 0.007). CONCLUSION: Burn encounters from less urbanized counties did not experience differences in mortality, rates of skin grafting, prolonged mechanical ventilation, length of stay, or overall costs. However, odds of shock were higher among the least urbanized counties. Despite improved triage and transportation systems across the US, disparities and challenges exist for burn patients from rural residence.

Analysis of gender representation, authorship inflation, and institutional affiliation in abstract acceptance: a 5-year study.

Purpose: Our goals were to characterize associations of author number, author gender, and institutional affiliation on ratings and acceptances of abstracts submitted to one surgical education conference over 5 years. Methods: We retrospectively reviewed all abstracts submitted between 2017 and 2021 to the annual meeting of the Association for Surgical Education (ASE). Abstract data included average rater scores, acceptance status, author lists, and institutional affiliations. We cross-referenced last author affiliation with top-40 National Institutes of Health (NIH)-funded institutions and used a gender determination software to code first and last author genders. Results: We analyzed 1,162 abstracts. Higher reviewer scores demonstrated positive, weak associations with more authors [r(1160) = 0.191, p < 0.001] and institutions [r(1160) = 0.182, p < 0.001]. Significantly higher scores were noted for abstracts with last authors affiliated with top-40 NIH-funded institutions [4.18 (SD 0.96) vs. 3.72 (SD 1.12), p < 0.001]. Women were first authors (51.8%) (n = 602) and last authors (35.4%) (n = 411) of the time. Abstracts were rated significantly higher with women rather than men as first authors [3.98 (SD 0.99) vs. 3.82 (SD 1.12), p = 0.011] or last [4.01 (SD 1.04) vs. 3.82 (SD 1.10), p = 0.005]. Across all years, abstracts were accepted more often as podium or plenary presentations when submitted by women first [n = 279, 59.7% (p = 0.002)] or last [n = 183, 38.4% (p = 0.095)] authors. Conclusion: Abstracts whose last authors were affiliated with top-40 NIH-funded institutions received significantly higher scores, possibly indicating increased tangible or intangible resources contributing to research efforts. Abstracts with women first and last authors scored higher and were more frequently invited for plenary and podium presentations.

Are We Speaking the Same Language? A Systematic Review on the Use of Consistent Language in Reporting Fat Necrosis in Autologous Fat Grafting of the Breast.

BACKGROUND: Autologous fat grafting is a widely adopted approach to optimize outcomes in breast reconstruction and augmentation. Although fat necrosis is a well-known consequence of autologous fat grafting, it remains inconsistently defined in the literature. In late 2014, the Food and Drug Administration released a draft guidance to restrict future autologous fat grafting-a statement that was permissively modified in late 2017. In the context of evolving guidelines and autologous fat grafting outcome data, the language and descriptions of fat necrosis are inconsistent in the literature. METHODS: Five databases were queried for studies reporting fat necrosis following autologous fat grafting for breast reconstruction or augmentation from inception to August 11, 2022. Studies were temporally stratified according to released FDA guidelines: pre-2015, 2015-2017, and 2018-2022. RESULTS: Sixty-one articles met inclusion criteria. Prior to 2015, 6 of 21 studies (28.6%) offered clear definitions of fat necrosis. In contrast, the 2015-2017 period demonstrated an absence of clear fat necrosis definitions (0/13 studies, p = 0.03). Though the 2018-2022 period exhibited a rise in annual publications compared with the pre-2015 period (5.4 vs. 1.9, respectively, p = 0.04), this was not matched by a rise in clear fat necrosis reporting (14.8% studies, p = 0.45). Across all periods, only 16.4% of articles offered clear definitions, which exhibited wide heterogeneity. CONCLUSION: Despite the increasing popularity of autologous fat grafting, fat necrosis remains inconsistently defined and described, especially in the context of changing FDA guidelines. This limits the reliable interpretation and application of the current literature reporting fat necrosis outcomes. LEVEL OF EVIDENCE IV: 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 .

Prior COVID-19 Infection Predisposes to Worse Outcomes After Autologous Breast Reconstruction: A Propensity Score-Matched Analysis.

BACKGROUND: Major shifts in health care systems worldwide have occurred because of coronavirus disease 2019 (COVID-19). With nearly half of all Americans now having a history of COVID-19 infection, there is a pressing need to better understand the importance of prior COVID-19 infection as a potential surgical risk factor. The aim of this study was to investigate the impact of a history of prior COVID-19 infection on patient outcomes after autologous breast reconstruction. METHODS: We performed a retrospective study using the TriNetX research database, which contains deidentified patient records from 58 participating international health care organizations. All patients who underwent autologous breast reconstruction between March 1, 2020, and April 9, 2022, were included and were grouped based on history of a prior COVID-19 infection. Demographic, preoperative risk factors, and 90-day postoperative complication data were compared. Data were analyzed by propensity score-matched analysis on TriNetX. Statistical analyses were performed by Fisher exact, χ2, and Mann-Whitney U tests as appropriate. Significance was set at P values of <0.05. RESULTS: Patients with a history of autologous breast reconstruction within our temporal study window (N = 3215) were divided into groups with (n = 281) and without (n = 3603) a prior COVID-19 diagnosis. Nonmatched patients with prior COVID-19 had increased rates of select 90-day postoperative complications, including wound dehiscence, contour deformities, thrombotic events, any surgical site complications, and any complications overall. Use of anticoagulant, antimicrobial, and opioid medications was also found to be higher in those with prior COVID-19.After performing propensity-score matching, each cohort consisted of 281 patients without statistically significant differences between any baseline characteristics. When comparing outcomes between matched cohorts, patients with a history of COVID-19 had increased rates of wound dehiscence (odds ratio [OR], 1.90; P = 0.030), thrombotic events (OR, 2.83; P = 0.0031), and any complications (OR, 1.52; P = 0.037). CONCLUSIONS: Our results suggest that prior COVID-19 infection is a significant risk factor for adverse outcomes after autologous breast reconstruction. Patients with a history of COVID-19 have 183% higher odds of postoperative thromboembolic events, warranting careful patient selection and postoperative management.

Food Security as a Predictor of Global Pediatric Postburn Mortality.

Food security (FS) is defined as access to sufficient and nutritious food. Children, especially those in low- and middle- income countries (LMICs), are disproportionately affected by low FS. We hypothesized high FS would be predictive of decreased pediatric postburn mortality in LMICs. Publicly-available, deidentified datasets were obtained from the World Health Organization's Global Burn Registry (GBR) and Economist Intelligence Unit's Global FS Index (GFSI). The GFSI calculates FS scores annually from intergovernmental organization data reviewed by a panel of experts. FS scores are reported on a 0 to 100 scale with 100 indicating the highest FS. Patients aged 0 to 19 yr were included; after linking GBR and GFSI datasets, countries with <100 burn patients were excluded. Data were analyzed with descriptive statistics and bivariate analyses. Multiple logistic regression controlling for confounders was used to quantify associations between mortality and FS score. Significance was set at P < 0.05. From 2016 to 2020, there were 2,246 cases including 259 deaths (11.5%) over nine countries. Those who died had a higher median age (7 [IQR 2, 15] vs 3 [2, 6] years, P < 0.001), higher proportion of females (48.6% vs 42.0%, P =0.048), and lower median FS score (55.7 [IQR 45.3, 58.2] vs 59.8 [IQR 46.7, 65.7], P < 0.001). Increasing FS score was associated with decreased odds of postburn mortality [multivariable odds ratio 0.78 (95% confidence interval 0.73 to 0.83), P < 0.001]. With the association between FS and mortality, international efforts to increase FS in LMICs may help improve pediatric burn patient survival.

Histologic evidence of brachial plexus compression sites at the thoracic inlet and variations in formation of the lower trunk in cadavers.

BACKGROUND: In thoracic "outlet" syndrome (TOS), pathologic evidence is well documented for vascular but not neurologic compression. We hypothesized that histologic evidence of compression would be identified at sites where the upper trunk was impacted by the anterior scalene muscle and the lower trunk by anatomic anomalies or the first rib. The purpose of this study was to investigate this hypothesis in human cadavers. MATERIALS AND METHODS: Twenty-five cadavers' brachial plexuses were dissected and excised. Histologic and descriptive analysis was directed at juncture 1, the upper trunk and anterior scalene muscle, and juncture 2, C8 and T1 nerve roots (lower trunk) with the posterior border of the first rib. Measurements were obtained at the juncture of the T1 nerve root with the C8 nerve root in relationship to the first rib. RESULTS: Histologic analysis demonstrated epineurial and perineurial fibrosis, myelin thinning, and Renaut bodies at junctures 1 and 2. Lower trunk formation occurred on or lateral to the first rib in 66% of specimens, with asymmetry in 32% of cadavers. A muscle of Albinus was present in 18% of cadavers. A large dorsal scapular artery coursed through 36% of plexuses with a high, arched subclavian artery. CONCLUSIONS: We report histologic changes consistent with chronic compression of the upper and lower plexus in the thoracic inlet at hypothesized sites of brachial plexus compression that may correlate with clinical neck/shoulder (upper trunk) and "ulnar nervelike" (C8-T1/lower trunk) symptoms. Anatomic anomalies identified should alert the surgeon to variations of lower trunk formation at compression sites.

Facial Dermal Filler Injection and Vaccination: A 12-Year Review of Adverse Event Reporting and Literature Review.

BACKGROUND: Following authorization of 2 COVID-19 vaccines in December 2020, media attention increased towards postvaccine adverse events (AEs) in patients with facial dermal filler injections. OBJECTIVES: The purpose of this study was to characterize vaccine-related facial dermal filler AEs by scrutinizing the FDA's Manufacturer and User Facility Device Experience (MAUDE) database. METHODS: The MAUDE database was queried from January 1, 2011 to January 28, 2023 for facial dermal filler medical device reports (MDRs) discussing vaccination-related AEs. A PubMed (National Institutes of Health, Bethesda, MD) literature review on dermal filler AEs was then conducted. Data were analyzed with descriptive statistics. RESULTS: Of 10,637 MDRs identified, 33 were included. There were 25 MDRs (75.8%) related to COVID-19 vaccination. Hyaluronic acid-based fillers were described in 31 MDRs (93.9%). AEs were mostly reported within days postinjection (n = 7, 21.2%), but ranged from immediately (n = 2, 6.1%) to months (n = 6, 18.2%) postinjection. Most AEs were reported postvaccine (n = 17, 51.5%) vs postfiller (n = 14, 42.4%). In 26 reports (78.8%), AEs occurred at the site of filler injection. Most MDRs described inflammation/swelling (n = 21, 28.0%). The literature review returned 302 articles, of which 14 were included. Only 1 article (7.1%) was published in a plastic surgery journal. CONCLUSIONS: Although the pandemic brought attention to COVID-19 vaccine-related facial dermal filler AEs, this study shows a low incidence compared with the millions of vaccine and filler injections administered. Reactions with non-COVID-19 vaccines were also documented. Increased awareness may help providers counsel patients undergoing vaccination and dermal filler implantation.

Ultrasound as a Useful Tool for a Peripheral Nerve Surgeon: Examples in Clinical Practice.

BACKGROUND: Peripheral nerve surgeons often require additional imaging for examination, diagnostic testing, and preoperative planning. Point-of-care ultrasound (US) is a cost-effective, accessible, and well-established technique that can assist the surgeon in diagnosing and treating select peripheral nerve pathologies. With this knowledge, the properly trained surgeon may perform US-guided nerve blocks to help accurately diagnose and treat causes of neuropathic pain. We offer this paper, not as an exhaustive review, but as a selection of various peripheral nerve pathologies, which the senior author treats, and their associated US examination findings. Our goal is to encourage other peripheral nerve surgeons to incorporate US into their practices. METHODS: We provide various cases from our outpatient peripheral nerve clinic demonstrating relevant US anatomy. We also review techniques for US guided nerve blocks with relevant anatomic landmarks. RESULTS: US imaging successfully assisted in identification and injection techniques for various peripheral nerve pathologies in a surgeon's practice. Examples were presented from the neck, trunk, upper extremity, and lower extremity. CONCLUSION: Our review highlights the use of US by a peripheral nerve surgeon in an outpatient private practice clinic to diagnose and treat select peripheral nerve pathologies. We encourage reconstructive surgeons to add US to their arsenal of diagnostic tools.

The Use of Alloderm® Coverage to Reinforce Tissues in Two-Stage Tissue Expansion Placement in the Subcutaneous (Prepectoral) Plane: A Prospective Pilot Study.

PURPOSE: Two-stage tissue expander (TE) to implant breast reconstruction is commonly performed by plastic surgeons. Prepectoral implant placement with acellular dermal matrix (ADM, e.g., AlloDerm®) reinforcement is evidenced by minimal postoperative pain. However, the same is not known for TE-based reconstruction. We performed this study to explore the use of complete AlloDerm® reinforcement of breast pocket tissues in women undergoing unilateral or bilateral mastectomies followed by immediate, two-stage tissue expansion in the prepectoral plane. METHODS: Patients (n = 20) aged 18-75 years were followed prospectively from their preoperative consult to 60 days post-TE insertion. The pain visual analog scale (VAS), Patient Pain Assessment Questionnaire, Subjective Pain Survey, Brief Pain Inventory-Short Form (BPI-SF), postoperative nausea and vomiting (PONV) survey, BREAST-Q Reconstruction Module, and short-form 36 (SF-36) questionnaires were administered. Demographic, intraoperative, and 30- and 60-day complications data were abstracted from medical records. After TE-to-implant exchange, patients were followed until 60 days postoperatively to assess for complications. RESULTS: Pain VAS and BPI-SF pain interference scores returned to preoperative values by 30 days post-TE insertion. Static and moving pain scores from the Patient Pain Assessment Questionnaire returned to preoperative baseline values by day 60. The mean subjective pain score was 3.0 (0.5 standard deviation) with seven patients scoring outside the standard deviation; none of these seven patients had a history of anxiety or depression. Median PONV scores remained at 0 from postoperative day 0 to day 7. Patient-reported opioid use dropped from 89.5% to 10.5% by postoperative day 30. BREAST-Q: Sexual well-being scores significantly increased from preoperative baseline to day 60 post-TE insertion. Changes in SF-36 physical functioning, physician limitations, emotional well-being, social functioning, and pain scores were significantly different from preoperative baseline to day 60 post-TE insertion. Five participants had complications within 60 days post-TE insertion. One participant experienced a complication within 60 days after TE-to-implant exchange. CONCLUSIONS: We describe pain scores, opioid usage, patient-reported outcomes data, and complication profiles of 20 consecutive patients undergoing mastectomy followed by immediate, two-stage tissue expansion in the prepectoral plane. We hope this study serves as a baseline for future research.

Is Antibiotic Prophylaxis Necessary in Small (≤20% TBSA) Burn Excisions? A Retrospective Study.

Background: This study investigates the effect of prophylactic perioperative antibiotic use on patients with small burns [≤20% total body surface area (TBSA)] on rates of infection, graft loss, or readmission. Methods: A retrospective chart review was conducted on patients admitted to our institution's burn center between January 2020 and July 2021. Patients were included if they had a 20% or less TBSA burn with 1 or more operating room visit for burn excision and were excluded if a preoperative infection was present. Data were gathered regarding patient demographics, burn mechanism, burn characteristics, and outcome measures including infection, graft loss, and readmission. Statistical analysis was conducted by Mann-Whitney U and Fisher exact tests, and P values reported at two-sided significance of less than 0.05. Results: There were no significant differences in age, body mass index, TBSA, percent third-degree burn, or comorbidities between patients who received (n = 29) or did not receive (n = 47) prophylactic perioperative antibiotics. There was a nonsignificant trend toward higher length of stay in the prophylactic antibiotic group, possibly driven by a nonsignificant trend toward higher rates of flame injuries in this group. There was no difference in infection (P = 0.544), graft loss (P = 0.494), or 30-day readmission (P = 0.584) between the two groups. Conclusion: This study finds no significant difference in postoperative infection, graft loss, or 30-day readmission in two similar patient cohorts who received or did not receive prophylactic perioperative antibiotics for acute excision of small (≤20% TBSA) burns.

Quantifying Breast Cancer-Driven Fiber Alignment and Collagen Deposition in Primary Human Breast Tissue.

Solid tumor progression is significantly influenced by interactions between cancer cells and the surrounding extracellular matrix (ECM). Specifically, the cancer cell-driven changes to ECM fiber alignment and collagen deposition impact tumor growth and metastasis. Current methods of quantifying these processes are incomplete, require simple or artificial matrixes, rely on uncommon imaging techniques, preclude the use of biological and technical replicates, require destruction of the tissue, or are prone to segmentation errors. We present a set of methodological solutions to these shortcomings that were developed to quantify these processes in cultured, ex vivo human breast tissue under the influence of breast cancer cells and allow for the study of ECM in primary breast tumors. Herein, we describe a method of quantifying fiber alignment that can analyze complex native ECM from scanning electron micrographs that does not preclude the use of replicates and a high-throughput mechanism of quantifying collagen content that is non-destructive. The use of these methods accurately recapitulated cancer cell-driven changes in fiber alignment and collagen deposition observed by visual inspection. Additionally, these methods successfully identified increased fiber alignment in primary human breast tumors when compared to human breast tissue and increased collagen deposition in lobular breast cancer when compared to ductal breast cancer. The successful quantification of fiber alignment and collagen deposition using these methods encourages their use for future studies of ECM dysregulation in human solid tumors.