In defence of utterly indiscernible entities

Abstract

Are there entities which are just distinct, with no discerning property or relation? Although the existence of such utterly indiscernible entities is ensured by mathematical and scientific practice, their legitimacy faces important philosophical challenges. I will discuss the most fundamental objections that have been levelled against utter indiscernibles, argue for the inadequacy of the extant arguments to allay perplexity about them, and put forward a novel defence of these entities against those objections.

Free-style Capillary Perforator–Based Island Flaps for Reconstruction of Skin Cancer Defects of the Face, Body, and Extremities

Background The perforator flap concept has revolutionized reconstructive surgery. Recently, the attention has moved toward flaps based on capillary perforators, which have been usually neglected in the past as reliable perforators. The aim of this article is to report a series of freestyle capillary perforator–based island flap (c-PBIF) for reconstruction of skin cancer defects of the face, body, and extremities. Patients and Methods Between September 2015 and July 2017, 20 consecutive patients underwent c-PBIF reconstruction of facial, body, and limb defects after melanoma and nonmelanoma skin cancer excision. Perforators were detected by means of unidirectional Doppler, and the flaps were designed taking into account the laxity of the surrounding skin in order to allow primary closure of the donor site. The mean defect dimension was 3.75 × 4.43 cm (ranging from 1 × 2 to 4.5 × 8 cm). All but 1 procedure was performed under local anesthesia. Results Mean flap size was 5.37 × 9.97 cm (ranging from 1 × 3 to 6 × 8 cm). In all cases, flaps were based on visible capillary perforators with a caliber of approximately 0.5 mm. All flaps survived. One minor tip flap necrosis was experienced in the largest flap of the series, which was successfully managed with dressing changes. The final reconstructive outcomes were satisfactory both for the patients and surgeons. Conclusions Freestyle c-PBIF might represent a further method for local reconstruction of skin cancer defects of the face, body, and extremities, allowing a high tissue efficiency, reduced scarring, and expeditious reconstruction with pleasant outcomes. Further research is needed in order to explore the maximal perforasome potential of capillary perforators.

A Modification of an Established Method of Intercalary Extremity Bone Defect Reconstruction: The “Hemi-Capanna” Technique

Background Skeletal reconstruction of segmental defects of the appendicular skeleton is among the most challenging tasks in reconstructive surgery. A popular method of reconstruction of large osseous defects is the combination of massive allografts and vascularized bone transfer. We present and discuss our experience with a modification of the traditional Capanna technique in which the allograft is split in half longitudinally to provide for more space for postoperative fibula hypertrophy. Methods Patients who underwent reconstruction of segmental intercalary defects of the tibia using our modified technique were retrospectively identified. The following parameters were retrieved: patient age, race, sex, length of skeletal defect, recipient vessels, type of microsurgical anastomosis, union rate, complication rate, ambulation (yes/no), and follow-up (in months). Results Two male patients underwent reconstruction of the tibia via the modified "hemi-Capanna" technique. The tibia defect measured 12 and 13 cm, respectively. No intraoperative or postoperative complications were encountered. Osseous union was obtained in both patients who are both ambulatory. Conclusion The hemi-Capanna technique not only leaves more room for hypertrophy of the vascularized fibula, but also simplifies the technique of combining an allograft with vascularized bone transfer in reconstructions of segmental skeletal defects of the appendicular skeleton.

Publication Rates and Author Characteristics From 3 Plastic Surgery Journals in 2006 and 2016

Background Areas of surgical care in which, traditionally, plastic surgeons were exclusively involved are now routinely offered by other surgical specialists. Whether this shift in clinical responsibilities influenced publication rates of plastic surgeons remains unknown. The current article investigates the proportion of contributions in plastic surgery journals originating from authors with a plastic surgery background as well as publication rates and author demographics. Methods A cross-sectional sample study of every publication originating from Annals of Plastic Surgery, Journal of Plastic, Reconstructive and Aesthetic Surgery, and Plastic and Reconstructive Surgery was performed for 2006 and 2016. Data about the articles' methodological design and branch of plastic surgery as well as authors' country of origin, educational degree and specialty training were analyzed. Results From 1721 publications included, head and neck reconstruction was the branch of plastic surgery with the highest number of publications at 18% and most articles (30%) were retrospective cohort studies. From 3381 authors analyzed, a significant proportion originated from United States (34%). More than 85% of authors were physicians as opposed to other health care professionals. The specialty with the highest representation was plastic surgery at 72%, but the proportion decreased in all 3 journals by a mean rate of 3.8% in 2016. Conclusions A slight decrease in publication rates from plastic surgeons occurred in Annals of Plastic Surgery, Journal of Plastic, Reconstructive and Aesthetic Surgery, and Plastic and Reconstructive Surgery from 2006 to 2016. Publications rates and author characteristics in plastic surgery journals provide valuable insight on plastic surgeons' contribution to contemporary scientific literature.

An Evaluation of Reporting Guidelines and Clinical Trial Registry Requirements Among Plastic Surgery Journals

Background Ensuring that published studies are of the highest methodological quality is a critical step in plastic surgery's transition to a more evidence-based field. Reporting guidelines and reporting of clinical trial registration may serve as promising avenues of increasing the methodological quality in plastic surgery trials. Objective The objective of this study is to evaluate the rate at which plastic surgery journals require reporting guidelines, as well as the effect these policies have on adherence to reporting guidelines. Methods Using journal's "Instructions for Authors," we conducted a cross-sectional survey to evaluate journal policies regarding adherence to reporting guidelines and trial registration. We also examined whether trials published in journals referencing Consolidated Standards of Reporting of Trials (CONSORT) had higher rates of compliance with publishing a CONSORT flow diagram and whether journals with trial registration policies were more likely to contain registered trials than journals without these requirements. Results Of the 20 plastic surgery journals, 13 (65%) did not mention a single guideline within their instructions to authors. Furthermore, 10 (50%) did not mention policies regarding clinical trial registration. In addition, journals with policies regarding the CONSORT statement were more likely to publish trials with a CONSORT flow diagram, and journals with policies regarding clinical trial registry were more likely to publish trials reporting registration. Conclusion and Relevance Our study found that few plastic surgery journals mention reporting guidelines or trial registration in their instructions for authors. Our study also found that journal policies regarding guideline adherence and trial registration seem to be effective mechanisms toward improvement, and plastic surgery journals should consider adopting such policies.

The International Fellowship Program in Microsurgery at Uppsala University Hospital: A Paragon Throughout Europe

Personal reports with valuable information on plastic surgery fellowships from all over the world are about to accumulate in recent years. Whereas some institutions have rightly become widely renowned for their excellent microsurgery fellow training in Taiwan, Canada, United States, and Australia, less is known about European fellowships focusing on reconstructive microsurgery. As former fellow at the Department of Plastic and Maxillofacial Surgery at Uppsala University Hospital, Sweden, the author hereby presents a survey on a unique and exemplary 6-month microsurgical fellowship offering hands-on training, academic education, and not last personal development to ambitious candidates who pursue a career in reconstructive microsurgery.

Pectoralis Major Musculocutaneous Flap With a Midline Sternal Skin Paddle for Head and Neck Reconstruction: A New Design

Purpose The pectoralis major musculocutaneous (PMMC) flap is a classic flap for head and neck reconstruction, relatively unpopular with the advancement of microsurgery and free flaps. The classic parasternal paddle design provided a thick flap with a small rotation arch leaving objectionable scarring. Our new symmetric midsternal design overcomes these problems. Methods Chart review was done from the years 2000 to 2017. Flap skin paddle was placed symmetrically on both sides of the midsternal line. The pectoralis major (PM) muscle and aponeurosis were attached in the lateral half of the skin paddle. Most of PM muscle was elevated with the thoracoacromial vessel and dissected to the main trunk, where the PM muscle was cut and used for bulk. The flap was transferred to the neck and lower mandibular area. The flap was inset either supraclavicularly, covering the anterior neck, or subclavicularly, for intraoral/maxillary defects. Results Eight patients underwent head and neck reconstruction using the new design of PMMC flap between the years 2000 and 2017. The etiologies of the defect were radiation necrosis in 3 patients, repair of cutaneous fistulas in 3, recurrent hypopharyngeal cancer in 1, and recurrent tongue cancer in 1 patient. There were no flap losses or major complications. Conclusions With the advancement of free-flap techniques, the classic flaps have become less popular. Our new design supplements the PMMC flap by providing a thin pliable flap with a long pedicle and rotation arc, allowing a combination of different types of flaps to cover composite head and neck defects, especially in cases that lack a reliable recipient vessel due to radiation.

Discussion: A Matter of a ConundrumEvaluating the Impact of Resident Participation and the July Effect on Outcomes in Autologous Breast Reconstruction

No abstract available

Book Review: Handbook of Otolaryngology

No abstract available

Relational Anatomy of the Mimetic Muscles and Its Implications on Free Functional Muscle Inset in Facial Reanimation

Background The human smile is a complex coordinated activity of mimetic muscles predominantly recognizable by a superolateral pull at the commissure and elevation of the upper lip. The aim of this study was to revisit the muscles of facial expression responsible for these motions, evaluate their relational anatomy and orientation, and relate this to optimal positioning of free muscle transfer in smile reanimation. Methods Nineteen hemifaces from fresh cadaveric specimens were dissected. A subsuperficial muscular aponeurotic system skin flap was elevated to expose the zygomaticus major, zygomaticus minor, levator labii superioris, and levator labii superioris alaeque nasi. Muscle location, length, width, angle of pull, and any anatomic variation were noted. Results All specimens had zygomaticus major, levator labii superioris, and levator labii superioris alaeque nasi muscles present bilaterally. Conversely, the zygomaticus minor was present in only 10 of 19 hemifaces. There was no significant difference in muscle length, width, or line of pull between specimen sides. Of all the assessed muscles, the zygomaticus minor had the most transverse line of pull, at 31.6°; the zygomaticus major was more oblique with a line of pull of 55.5°; and the levator labii superioris and levator labii superioris alaeque nasi were oriented almost vertically with angles of 74.7° and 79.0°, respectively. Conclusions The mimetic muscle vector is quite vertical in comparison to the angle obtained by traditional dynamic smile reconstruction surgeries. A more vertical vector, especially at the upper lip, should be considered in smile reconstruction.

Availability and Safety of Osteotomy in Esthetic Rhinoplasty of East Asian Patients

Objective East Asians usually have short and flat noses and broad nasal bones. Therefore, rhinoplasty with dorsal augmentation and nasal osteotomy is often required. However, many surgeons are wary of performing nasal osteotomy in conjunction with augmentation with silicone. The authors sought to evaluate the availability and safety of osteotomy in esthetic rhinoplasty of East Asian patients. Methods In a clinical study, a retrospective chart review was performed for 227 patients who had undergone nasal osteotomy (paramedian oblique osteotomy plus percutaneous lateral osteotomy) and dorsal augmentation with silicone. Patient satisfaction after surgery was evaluated by the Rhinoplasty Outcome Evaluation test. In addition, a cadaveric study was conducted in which 5 fresh cadavers received different osteotomies on each side of the nose (right side: paramedian oblique and percutaneous lateral osteotomy; left side: medial oblique and intranasal continuous lateral osteotomy). Results In the clinical study, patients were satisfied with the outcome after esthetic rhinoplasty with nasal osteotomy (paramedian oblique osteotomy plus percutaneous lateral osteotomy) and augmentation with silicone. The results revealed a low complication rate. The average Rhinoplasty Outcome Evaluation test score significantly increased (P

The Effect of Postmastectomy Radiation Therapy on Breast Implants: Material Analysis on Silicone and Polyurethane Prosthesis

Introduction The pathogenic mechanism underlying capsular contracture is still unknown. It is certainly a multifactorial process, resulting from human body reaction, biofilm activation, bacteremic seeding, or silicone exposure. The scope of the present article is to investigate the effect of hypofractionated radiotherapy protocol (2.66 Gy × 16 sessions) both on silicone and polyurethane breast implants. Methods Silicone implants and polyurethane underwent irradiation according to a hypofractionated radiotherapy protocol for the treatment of breast cancer. After irradiation implant shells underwent mechanical, chemical, and microstructural evaluation by means of tensile testing, infrared spectra in attenuated total reflectance mode, nuclear magnetic resonance, and field emission scanning electron microscopy. Results At superficial analysis, irradiated silicone samples show several visible secondary and tertiary blebs. Polyurethane implants showed an open cell structure, which closely resembles a sponge. Morphological observation of struts from treated polyurethane sample shows a more compact structure, with significantly shorter and thicker struts compared with untreated sample. The infrared spectra in attenuated total reflectance mode spectra of irradiated and control samples were compared either for silicon and polyurethane samples. In the case of silicone-based membranes, treated and control specimens showed similar bands, with little differences in the treated one. Nuclear magnetic resonance spectra on the fraction soluble in CDCl3 support these observations. Tensile tests on silicone samples showed a softer behavior of the treated ones. Tensile tests on Polyurethane samples showed no significant differences. Conclusions Polyurethane implants seem to be more resistant to radiotherapy damage, whereas silicone prosthesis showed more structural, mechanical, and chemical modifications.

Severe Delayed Hemorrhage After Cosmetic Rhinoplasty in the Setting of Maxillary Vascular Malformation

Late epistaxis after rhinoplasty is a rare but potentially life-threatening occurrence. This case report concerns a 20-year-old woman who had severe epistaxis 5 and 10 days after a closed rhinoplasty with internal osteotomies and who ultimately required transcatheter arterial embolization for definitive control of the hemorrhagic source. Arterial hypervascularity, with signs of arteriovenous malformation, of the midface at the level of the piriform aperture and maxilla was seen on angiography.

Use of Single Drain the Way Forward in Implant-Based Breast Reconstruction

No abstract available

Neoumbilicoplasty With a Pedicled Deep Inferior Epigastric Perforator Island Flap

Management of the umbilicus is a common dilemma at the time of abdominoplasty and abdominal wall reconstruction. It is not uncommon for underlying pathologies, such as hernias and surgical scars, to result in a disfigured or obliterated native umbilicus or make the blood supply to the umbilical stalk unreliable. In these scenarios, the umbilicus is often sacrificed. Staged neoumbilical reconstruction may be offered and typically utilizes a small skin flap and full-thickness skin graft (Ann Plast Surg 2009;63:358–360). Our technique, in contrast, permits reconstruction of the neoumbilicus in the immediate setting utilizing normally discarded skin with a robust blood supply from a deep inferior epigastric artery perforator. In this series of 13 consecutive neoumbilicoplasties, the pedicled deep inferior epigastric artery perforator island flap provided reliable results and favorable aesthetic outcomes.

Use of a Vertical Muscle-Sparing Latissimus Dorsi Flap in Implant-Based Breast Reconstruction Without Position Change

Background The use of various latissimus dorsi (LD) flap types in combination with implants is a safe and reliable 1-stage breast reconstruction method. However, 1 or more positional changes are generally required during the procedure. We designed a vertical skin paddle that was centered along the midaxillary line and harvested the required LD muscle amount based on the thoracodorsal artery descending branch, thereby completing flap elevation, inset, and donor-site closure in the supine position following skin-sparing mastectomy. Methods Between July 2017 and September 2017, we enrolled patients who underwent breast reconstruction using the vertical muscle-sparing LD (ms-LD) flap with an implant. The vertical ms-LD flap was selected when the nipple-areolar complex could not be spared or when adjuvant radiation therapy was anticipated. Results Eleven patients were enrolled in the study. All patients underwent skin-sparing mastectomy (with excision of the nipple-areolar complex for oncological reason). The mean mastectomy specimen weight was 402.3 g. The average flap length and width were 15.2 and 5.5 cm, respectively. The mean implant size was 290 mL. The average operative time was 112 minutes. All surgical procedures were performed in the supine position, and the flap reached the most medial part of the breast without any tension in all cases. The mean follow-up length was 87 days, and no complications such as infection, partial flap loss, or donor-site seroma were observed. Conclusions Vertical ms-LD flaps can be harvested and utilized in direct-to-implant reconstructions when a skin paddle (or banking) is required, or when acellular dermal matrix use is precluded, or when additional soft tissue coverage is mandatory in high-risk patients not requiring intraoperative position changes. This technique can shorten the operation time and may reduce donor-site morbidity and associated complications.

Comparing Processed Nerve Allografts and Assessing Their Capacity to Retain and Release Nerve Growth Factor

Peripheral nerve gap injuries continue to present a clinical challenge to today's surgeons. One method of surgical repair, implantation of acellular allografts, has been developed with the aim of bridging the gap with a cadaveric graft after removal of its cellular components, thereby accelerating axonal regeneration and eliminating the need for immunosuppression in recipient patients. Although decellularizing allografts reduces rates of graft rejection, the same chemical processing modifies the neural microenvironment, removing neutrotrophic factors and modifying the complex extracellular matrix. In this study, we explore 3 common methods for producing acellular allografts. Extracellular matrix content remaining after processing was investigated and was found to be highly dependent on the decellularization method. In addition, scanning electron micrographs were obtained to evaluate the structural effects of the decellularization methods. Though the content and structure of these processed allografts will contribute to their effectiveness as nerve gap repair candidates, we demonstrate that it also affects their capacity to be supplemented/preloaded with the prototypical neurotrophin, nerve growth factor (NGF), essential to neuronal regeneration. Although all allografts had some capacity for retaining NGF in the first 24 hours, only Sondell-processed grafts retained NGF over the entire experimental period of 21 days. Future studies will include validating these processed and supplemented allografts as viable alternatives to traditional autograft nerve gap repair.

Evaluating the Impact of Resident Participation and the July Effect on Outcomes in Autologous Breast Reconstruction

Objective Although resident involvement in surgical procedures is critical for training, it may be associated with increased morbidity, particularly early in the academic year—a concept dubbed the "July effect." Assessments of such phenomena within the field of plastic surgery have been both limited and inconclusive. We sought to investigate the impact of resident participation and academic quarter on outcomes for autologous breast reconstruction. Methods All autologous breast reconstruction cases after mastectomy were gathered from the 2005–2012 American College of Surgeons National Surgical Quality Improvement Program database. Multivariable logistic regression models were constructed to investigate the association between resident involvement and the first academic quarter (Q1 = July-September) with 30-day morbidity (odds ratios [ORs] with 95% confidence intervals). Medical and surgical complications, median operation time, and length of stay (LOS) were also compared. Results Overall, 2527 cases were identified. Cases with residents (n = 1467) were not associated with increased 30-day morbidity (OR, 1.20; 0.95–1.52) when compared with those without (n = 1060), although complications including transfusion (OR, 2.08; 1.39–3.13) and return to the operating room (OR, 1.46; 1.11–1.93) were more frequently observed in resident cases. Operation time and LOS were greater in cases with resident involvement. In cases with residents, there was decreased morbidity in Q1 (n = 343) when compared with later quarters (n = 1124; OR, 0.67; 0.48–0.92). Specifically, transfusion (OR, 0.52; 0.29–0.95), return to operating room (OR, 0.64; 0.41–0.98), and surgical site infection (OR, 0.37; 0.18–0.75) occurred less often during Q1. No differences in median operation time or LOS were observed within this subgroup. Conclusions Our study reveals that resident involvement in autologous breast reconstruction is not associated with increased morbidity and offers no evidence for a July effect. Notably, our results suggest that resident cases performed earlier in the academic year, when surgical attendings may offer more surveillance and oversight, is associated with decreased morbidity.

Gastrocnemius Myocutaneous Flaps for Knee Joint Coverage

Introduction The gastrocnemius muscular flap has already proven its efficiency for soft tissue coverage in cases of knee joint exposure. However, it may be too small to cover large defects and has not the same aesthetic and mechanical properties as normal skin. Perforator fasciocutaneous flaps have recently been described in knee joint coverage with good results as they replace skin by skin, but they can be hard to harvest. Gastrocnemius flaps can be easily harvested with a planned skin paddle designed over the chosen muscle. This simple technique combines the advantages of muscular and fasciocutaneous flaps for knee joint area coverage. Perforator fasciocutaneous flap take a growing place in coverage of this localization in recent literature, but very few articles report the results of gastrocnemius myocutaneous flaps (MCFs). Methods All patients who underwent knee joint coverage with the use of a lateral or medial gastrocnemius MCFs between January 2012 and February 2017 in our university institution were included in this retrospective study. Results Sixteen gastrocnemius MCFs (10 medial and 6 lateral) were performed. The indication was posttraumatic in 5 cases, posttumoral in 5 cases, and after total knee prosthesis exposure in 6 cases. Skin paddles up to 15 cm in width and 18 cm in length were harvested. Complete healing was achieved in 15 days in all cases without suffering or nonunion. Three flaps were secondarily raised to allow total knee prosthesis reimplantation or arthrodesis, and 4 patients were treated with postoperative radiotherapy without complication. Conclusions In addition to its reliability and very easy harvesting, the gastrocnemius MCF allows a robust joint coverage and good skin resurfacing that makes eventual revision easier and allows early radiotherapy. Furthermore, skin paddle also increases the effective area of the flap. This technique should always be considered with the other classic alternatives.

Calcimycin Suppresses S100A4 Expression and Inhibits the Stimulatory Effect of Transforming Growth Factor β1 on Keloid Fibroblasts

Recent researches have indicated that S100A4 participates in tissue fibrosis, whereas calcimycin inhibits this process as a novel S100A4 transcription inhibitor. However, the relationship and mechanisms between calcimycin and S100A4 in keloid fibroblasts (KFs) remain unknown. The present research was aimed to evaluate the effect of calcimycin on S100A4 expression and pathogenesis in KFs. Keloid fibroblasts were cultured and exposed to different concentrations of calcimycin in the absence or presence of transforming growth factor β1 (TGF-β1). The results showed that the expression of S100A4 was significantly increased in keloid derived fibroblasts compared with normal skin fibroblasts. Calcimycin depressed S100A4 in a concentration- and time-dependent manner. Moreover, calcimycin suppressed TGF-β1–induced collagen type I, fibronectin, and α-smooth muscle actin expression and cell viability in cultured KFs. Furthermore, calcimycin modulated expression of TGF-β/Smad target genes Smad7 and phosphorylation of TGF-β1–induced Smad2/3. This research for the first time confirmed the presence of S100A4 in KFs. Calcimycin inhibits the expression of S100A4, as well as KF proliferation and migration and extracellular matrix (ECM) synthesis. Taken together, these results indicate that calcimycin might be a therapeutic candidate to keloid or other related fibrotic disorders.

Breast Reconstruction Among Commercially Insured Women With Breast Cancer in the United States

Introduction This study evaluated trends related to breast reconstruction and the factors associated with reconstruction. Methods Women with breast cancer aged 19 to 64 years who underwent a mastectomy procedure between July 1, 2011, and September 30, 2014, were identified from the MarketScan Commercial Claims and Encounters Database. The first date of surgical procedure during this period was defined as the index date. Continuous enrollment during the 12-month preindex and postindex period was required, and the patient sample was followed for 12 months postindex. Multivariable regression analysis was used to determine factors associated with having breast reconstruction. Results Among the 17,502 women undergoing mastectomy during the study period, 73% (n = 12,816) had breast reconstruction, with 66% (n = 11,613) having immediate and 7% (n = 1203) having delayed reconstruction. Overall reconstruction rates increased during the study period from 69.47% in the third quarter of 2011 to 75.72% in the third quarter of 2014. The most common type of immediate reconstruction involved the use of tissue expanders (with or without implant and autologous reconstruction) (~77%), followed by implant reconstruction (9.67%), autologous reconstruction (10.81%), and other reconstruction (2.52%). Acellular dermal matrix was commonly used with immediate tissue expander and immediate implant-based reconstruction, and its use increased during the study period. Demographic and treatment-related factors were found to be associated with reconstruction among women undergoing mastectomy. Conclusions In this commercial payor setting, most women undergoing mastectomy had breast reconstruction. Among women undergoing immediate reconstruction, tissue expander use was common. Several factors were shown to be associated with the decision to have breast reconstruction.

Terminalia bellirica (Gaertn.) Roxb fruit exerts anti-inflammatory effect via regulating arachidonic acid pathway and pro-inflammatory cytokines in lipopolysaccharide-induced RAW 264.7 macrophages

Abstract

Terminalia bellirica (Gaertn.) Roxb. (Family: Combretaceae), known as Bhibhitaki in Sanskrit and locally known as Behera in India, has been used for centuries in Ayurveda, a universal system of medicine in India. The dried fruit of T. bellirica is used for the treatment of several disorders. The present study aims to explore the anti-inflammatory effects of aqueous acetone extracts isolated from T. bellirica (AATB) in RAW 264.7 cell lines. The AATB was prepared from the fruits of T. bellirica. Different concentrations of AATB (6.25–100 μg/ml) were used for MTT assay. The anti-inflammatory effect of AATB was evaluated by using different assays such as total cyclooxygenase (COX), 5-lipoxygenase (5-LOX) activity, nitrate and reactive oxygen species (ROS) production. The mRNA level expression of COX-2, tumor necrosis factor alpha (TNF-α) and interleukin-6 (IL-6) were studied in LPS stimulated RAW 264.7 cells. AATB treatment significantly diminished the elevated levels of inflammatory markers. Moreover, AATB downregulated the mRNA level expression of TNF-α, IL-6 and COX-2 genes. The result of our study suggest the use of AATB and is able to reduce inflammatory conditions associated with various diseases.

Editorial Board

Table of Contents

Use of the 532-nm Q-switched neodymium-doped yttrium aluminum garnet laser for the treatment of recalcitrant repigmentation in vitiligo

Vitiligo is a disorder characterized by the development of depigmented patches and macules. Patients with extensive involvement may opt for complete depigmentation using monobenzyl ether of hydroquinone (MBEH).1 However, after depigmentation, a subset of patients note repigmentation that is significantly darker than their original skin tone and is resistant to treatment with MBEH.2 Here we present a vitiligo patient who had recalcitrant repigmentation after depigmentation with MBEH, which was responsive to treatment with the 532-nm Q-switched neodymium-doped yttrium aluminum garnet (QS Nd:Yag) laser.

Nevus anemicus: An island of sparing in the setting of drug-induced hypersensitivity

Nevus anemicus (NA) is an uncommon congenital finding characterized by a discrete area of hypopigmentation that remains stable in size throughout life. To our knowledge, generalized cutaneous eruption sparing NA in a mosaic fashion has never been reported in the literature. We report a case of erythrodermic drug-induced hypersensitivity syndrome (DIHS) in the setting of human herpes 6 virus (HHV-6) viremia, sparing NA.

Lipoid proteinosis: Unfamiliar skin findings delay diagnosis

Lipoid proteinosis (LP) is a rare, inherited condition that progresses gradually with multisystemic manifestations. Histopathologic characteristics can be understated, delaying the diagnosis if a high degree of suspicion is not present.

A novel AIRE gene mutation in a patient with autoimmune polyendocrinopathy candidiasis and ectodermal dystrophy revealed by alopecia areata

Autoimmune polyendocrinopathy candidiasis and ectodermal dystrophy (APECED) syndrome is an autosomal recessive syndrome caused by biallelic mutations in the autoimmune regulator AIRE gene.1 APECED is defined by at least 2 of the following conditions: hypoparathyroidism, chronic mucocutaneous candidiasis (CMC), and/or Addison disease.1 Dermatologic manifestations of APECED syndrome are poorly reported.

Use of reflectance confocal microscopy to diagnose occult basal cell carcinoma: 2 case reports

Clinical and dermoscopic diagnosis of facial pigmented and nonpigmented lesions is sometimes challenging. Face and scalp are chronic sun-exposed sites, and signs of photoaging1 can be associated with the development of precancerous or malignant lesions.2-4 Noninvasive imaging techniques such as reflectance confocal microscopy (RCM) allow us to better diagnose and monitor equivocal melanocytic and nonmelanocytic lesions, particularly on specific sites such as the face.5

Nivolumab-induced systemic vasculitis

Nivolumab is a fully human IgG4 monoclonal immune checkpoint inhibitor antibody that inhibits programmed cell death-1 receptor (PD-1), augmenting the host antitumor response.1 Nivolumab has been associated with immune-related adverse events (irAEs)2 such as colitis. In addition, various cutaneous adverse events have been reported and the 3 most common findings included lichenoid eruptions, eczema, and vitiligo.3 We report a patient with squamous cell carcinoma of the right maxillary sinus on nivolumab who had vasculitis of the jejunum and leukocytoclastic vasculitis of the skin successfully treated with high-dose systemic steroids and plasma exchange.

Severe recalcitrant morbilliform eruption from dual immune checkpoint blockade

Immune checkpoint inhibitors represent one of the newest and most promising therapies for malignancy, but they place patients at risk for autoimmune sequelae, including cutaneous eruptions. M7824, a novel bifunctional fusion protein currently in clinical trials, is directed against both programmed cell death ligand 1 (PD-L1) and transforming growth factor beta (TGF-β). It is well known that PD-1 checkpoint inhibition may lead to symptomatic cutaneous eruptions that most often can be effectively managed without discontinuation of antitumor therapy.

Immediate-type infliximab infusion reaction presenting as purpura

Immediate-type infliximab infusion reactions occur during or within 1 to 2 hours of an infusion and are well documented in the literature. The most common dermatologic manifestations of immediate-type infusion reactions include urticaria and erythematous rashes. We describe the case of an immediate-type infliximab infusion reaction presenting as purpura.

The importance of lymph node examination: Simultaneous diagnosis of hypopigmented mycosis fungoides and follicular B-cell lymphoma

Mycosis fungoides (MF) is the most common type of cutaneous T-cell lymphoma (CTCL). Its typical course is characterized by a progression of patches, plaques, and tumors. Follicular B-cell lymphoma, the second most common non-Hodgkin lymphoma (NHL), presents with lymphadenopathy and is characterized by a translocation between chromosomes 14 and 18, resulting in overexpression of the B-cell lymphoma (bcl)-2 gene. In most patients, the course of each of these lymphomas is indolent with slow progression.

Reverse Koebner phenomenon induced by the Mantoux test in erythrodermic psoriasis: A case report and literature review

The Koebner phenomenon (KP) was first described in patients with psoriasis.1 It was subsequently reported to occur with many dermatologic disorders.2 However, reverse KP, defined as the disappearance of lesions of a particular dermatosis at the injury site, is a rare condition with only a few reported cases.3-6

Piezogenic pedal papules treated successfully with deoxycholic acid injection

Piezogenic pedal papules (PPPs) were first described by Shelley and Rawnsley.1-3 As the name piezogenic suggests, lesions are generated by pressure (piesis), inducing herniation of footpad's fat through the dermis.1-4

Enhancement of the aesthetic outcome of scleroderma en coup de sabre with botulinum toxin injection

Linear scleroderma is a rare form of localized scleroderma. The involvement of the frontal or frontoparietal region with linear scleroderma is called en coup de sabre (ECDS). ECDS presents as linear sclerotic depressed groove appearing on the frontoparietal region. It is usually unilateral and extends from the forehead into the frontal scalp. Its paramedian location is more common than its median one. The sclerotic changes affect the soft tissue and muscles as well as adjacent structures.1 Linear scleroderma has diverse etiologies, and its pathogenic mechanism is still unclear.

Drug-induced dermatomyositis after lacosamide: A case report

Dermatomyositis (DM) is an autoimmune connective tissue disease characterized by cutaneous manifestations, muscle inflammation, and proximal muscle weakness. DM may develop in patients after an environmental insult initiates an autoimmune reaction in genetically predisposed individuals.1 Environmental triggers of DM cited in the literature include ultraviolet radiation, viruses, vaccines, medical devices, emotional stress, and drugs.2 Although the role of drug-induced DM is not well established, many drugs have been implicated in the development of DM.

Development of immunochromatographic assays for the detection of imidacloprid in soil chemical barrier

Abstract

A soil chemical barrier is the most important and common way to control termites; fast and on-site detection methods are significant tools to verify pesticide content meeting the standard requirements. In this study, conventional and enhanced immunochromatographic assays (ICAs) containing two test lines (TLs) were developed to semi-quantitatively detect imidacloprid in soil chemical barrier, and detection results were quantified by a smart phone. According to the results, the disappearance concentrations of first TL (TL-1) and second TL (TL-2) in an enhanced ICA and conventional ICA were 5 and 20 ng/mL and 20 and 80 ng/mL with the naked eye. The sensitivity of TL-2 was four times that of TL-1 in both ICAs, consistent with the maximum and minimum concentration differences for imidacloprid in Jiangsu province's "the technical regulation of assay and evaluation on chemical soil barrier of termite prevention treatment in buildings". The results of TLs can be used to judge whether the amount of imidacloprid in soil chemical barrier meets the standard. Enhanced and conventional ICAs were available for further quantitative testing with a smart phone, and the limit of detection (LOD) was 0.74 and 3.17 ng/mL, respectively. Moreover, some soil chemical barrier samples from several areas in Wuxi, Jiangsu province, were used to test by ICAs and high-performance liquid chromatography (HPLC), and the results of ICAs correlated well with HPLC.

S-incorporated TiO 2 coatings grown by plasma electrolytic oxidation for reduction of Cr(VI)-EDTA with sunlight

Abstract

The plasma electrolytic oxidation (PEO) technique was used to prepare photocatalytic S-TiO₂ coatings on Ti sheets; the incorporation of the S ions was possible from the electrolyte for modifying the structural and optics characteristics of the material. In this work, substrates of Ti (ASME SB-265 of 20 × 20 × 1 mm) were used in a PEO process in 10 min, using constant voltage pulses of 340 V with frequency of 1 kHz and duty cycles of 10% and of 30%. Solutions with H₂SO₄ (0.1 M) and CH₄N₂S (52 and 79 mM) were used as electrolytes. X-ray diffraction, scanning electron microscopy, and energy dispersive spectroscopy (EDS) were utilized to analyze the surface morphology, crystalline phase, and chemical composition of the samples. According to the results, the catalyst coatings had microporous structure and contained anatase-rutile TiO₂ nanocrystalline mixture, until 73.2% rutile and 26.8% anatase in the samples grown with 30% duty cycle and the lowest concentration of CH₄N₂S. From the EDS measurements, the incorporation of sulfur ions to the coatings was 0.08 wt%. 99.5% reduction efficiency of Cr(VI)-EDTA with sunlight was observed after 2 h; it was determined by diphenyl carbazide spectrophotometric method. These coatings have potential for effective sunlight heterogeneous photoreduction of this toxic, cumulative, and non-biodegradable heavy metal that contaminates the soil and water and is a serious risk to sustainability, ecosystems, and human health.

Colloidal mobilization from soil and transport of uranium in (sub)-surface waters

Abstract

An analytical methodology was developed to characterize the colloidal distribution of trace elements of interest in environmental waters sampled in a same site and enables the different colloidal distributions from waters to be compared. The purpose was to provide consistent information related to the origin and nature of colloids responsible for the transport of trace element(s). The work was motivated by the observed enhanced mobility of uranium in soil. The colloidal size continuum was investigated by a multi-technique approach involving asymmetric flow field-flow fractionation (AF4) coupled with ultraviolet spectroscopy (UV), multi angle light scattering (MALS), and atomic mass spectrometry (ICPMS). To take into consideration the size and shape variability specific to each sample, the size distributions were established from the gyration radii measured from MALS, also considering the size information from standard nanospheres fractionated by AF4. A new parameter called "shape index" was proposed. It expresses the difference in hydrodynamic behavior between analytes and spherical particles taken as reference. Under AF4 diffusion conditions, it can be considered as an evaluator of the deviation from the sphericity of the fractionated analytes. AF4-UV-MALS-ICPMS enabled the dimensional and chemical characteristics of the colloidal size continuum to be obtained. As a "proof of concept", the developed methodology was applied at a field scale, in a reference study site. In order to have a "dynamic understanding", the investigation was based on the joint characterization of colloids from surface waters and soil leachates from static and dynamic processes. In the water samples of the study site, the continuum of gyration radius ranged from a few nanometers up to 200 nm. Colloids containing iron, aluminum, and organic carbon were involved in the uranium transport in the soil column and surface waters. The colloidal uranium concentration in the surface water increased from the upstream location (approximately 13 ng (U) L⁻¹) to the downstream location (approximately 60 ng (U) L⁻¹).

CME Part II Psoriasis: Which Therapy for Which Patient Focus on special populations and chronic infections

Publication date: Available online 11 July 2018

Source: Journal of the American Academy of Dermatology

Author(s): Shivani B. Kaushik, Mark G. Lebwohl

Abstract

Despite the availability of several new systemic agents for psoriasis treatment, it can be challenging to choose the right therapy in certain patient populations. There are few up-to-date reviews on systemic drugs for moderate to severe psoriasis in pregnant and pediatric patients and in patients with concomitant chronic infections such as hepatitis, HIV and latent tuberculosis. These groups are usually excluded from clinical trials and much of the available evidence is based on anecdotal case reports and case series. Being a chronic disease, psoriasis requires long-term treatment and there are concerns of adverse maternal-fetal outcomes, long term side-effects in children and reactivation of latent infections with use of systemic agents in these patients. Part 2 of this CME article will provide insights for choosing appropriate systemic agents for treating moderate-to-severe psoriasis in pregnant and pediatric patients and in the setting of chronic infections such as hepatitis, HIV and latent tuberculosis.

CME Part I Psoriasis: Which Therapy for Which Patient Psoriasis comorbidities and preferred systemic agents

Publication date: Available online 11 July 2018

Source: Journal of the American Academy of Dermatology

Author(s): Shivani B. Kaushik, Mark G. Lebwohl

Abstract

Psoriasis is a systemic inflammatory disease associated with increased risk of comorbidities such as psoriatic arthritis, Crohn disease, malignancy, obesity and cardiovascular diseases. All these factors have a significant impact on the decision to use one therapy over another. The past decade has seen a paradigm shift in our understanding of the pathogenesis of psoriasis which has led to identification of new therapeutic targets. Several new drugs have gained FDA approval, expanding the psoriasis armamentarium but still a large number of patients continue to be untreated or undertreated. Treatment regimens for psoriasis patients should be tailored to meet specific needs based on disease severity, impact on quality of life, response to previous therapies and presence of comorbidities. Part 1 of this CME article will focus on specific comorbidities and provide insights to choose appropriate systemic treatment in patients with moderate to severe psoriasis.

Detection, extinguishing, and monitoring of a coal fire in Xinjiang, China

Abstract

Coal fire is a global catastrophe. Xinjiang suffers the most severe coal fire in China and even in the world. Coal firefighting work has been being conducted for decades in Xinjiang. In this paper, coal fire detection, extinguishing, and monitoring approaches that were derived from coal firefighting experience are introduced in detail by taking the Fifth Fire Area (FFA) of the Heshituoluogai coal fire for instance. We first introduce the geology and fire situation in the FFA. Before developing efficient strategies to extinguish it, magnetic and self-potential methods are adopted to delineate the extent of the fire. A composite index is proposed to better indicate the fire. The comprehensive coal firefighting method is illustrated in detail, which consists of surface cooling, excavation and leveling, borehole drilling, borehole water injection and grouting, and loess backfill. The subsequent temperature and CO monitoring records show that the fire is extinguished successfully without burnback. The methodology presented here provides guidance and reference for putting out other coal fires around the world.

Enhanced biodiesel industry wastewater treatment via a hybrid MBBR combined with advanced oxidation processes: analysis of active microbiota and toxicity removal

Abstract

In the present study, a multistage route is proposed for the treatment of biodiesel industry wastewater (BWW) containing around 1000 mg L⁻¹ of total organic carbon (TOC), 3500 mg L⁻¹ of chemical oxygen demand (COD), and 1325 mg L⁻¹ of oil and grease. Initially, BWW aerobic biodegradability was assessed via Zhan-Wellens biodegradability test to confirm the appropriate treatment route. Then, a hybrid moving bed bioreactor (MBBR) system was chosen as the first treatment stage. The hybrid MBBR achieved 69 and 68% removal of COD and TOC removals, respectively, and provided great conditions for biomass growth. The bacterial community present in the hybrid MBBR was investigated by PCR-DGGE and potential biodegraders were identified such as: members of Desulfuromonadales, Nocardioidaceae and Pseudomonadaceae. Since biodegradation in the hybrid MBBR alone was unable to meet quality requirements, advanced oxidation processes, such as Fenton and photo-Fenton, were optimized for application as additional treatment stages. Physicochemical properties and acute toxicity of BWW were analyzed after the multistage routes: hybrid MBBR + Fenton, hybrid MBBR + photo-Fenton and hybrid MBBR + UV-C_254nm/H₂O₂. Hybrid MBBR + Fenton or photo-Fenton showed overall COD removal efficiencies greater than 95% and removed acute toxicity, thus being appropriate integrated routes for the treatment of real BWW.

Graphical abstract

ᅟ

Defending a Common World: Hannah Arendt on the State, the Nation and Political Education

Abstract

For a long time, one of the most important tasks for education in liberal democracies has been to foster the next generation in core democratic values in order to prepare them for future political responsibilities. In spite of this, general trust in the liberal democratic system is in rapid decline. In this paper, the tension between the ambitions of liberal-democratic educational systems and contemporary challenges to central democratic ideas is approached by reconsidering Hannah Arendt's critique of political education. This will be done informed by her analysis of the tension between the concepts of state and nation. By showing how education, depending on its role as a tool of the state or the nation, may be a fundamental requirement for the establishment of a common world or the most effective tool for its destruction, the paper argues for the need to understand Arendt's educational thinking in light of her wider political analysis. Rather than downplaying the provocative aspects of her critique, the paper argues for the need to use it as a starting point for thinking again how education may become an emancipatory undertaking capable of disarming contemporary threats to human plurality and freedom.

Water quality guideline values for aluminium, gallium and molybdenum in marine environments

Abstract

Revised water quality guideline values (WQGVs) are presented for the metals aluminium (Al), gallium (Ga) and molybdenum (Mo) in receiving marine environments. These elements are commonly found in elevated concentrations in alumina refinery waste streams, yet current WQGVs fail to accurately assess the environmental risk. Here, chronic biological effects data we have generated over the course of several years were combined with toxicity data from the open literature to construct species sensitivity distributions (SSDs) which enabled the computation of revised WQGVs for Al, Ga and Mo in marine environments. These procedures are in accordance with internationally recommended derivation procedures, and newly computed WQGVs may be incorporated in regulatory frameworks aimed at sustainable exploitation of environmental resources and ongoing protection of the marine estate. Where the available datasets allowed such distinction, separate SSDs were constructed for temperate and tropical environments and zone-specific WQGVs derived. Extrapolated from the SSDs, WQGVs of 56 μg Al L⁻¹, 800 μg Ga L⁻¹ and 3.88 mg Mo L⁻¹ (in the 0.45-μm filtered fraction) for 95% species protection were recommended for implementation in both temperate and tropical receiving environments. Currently, there is insufficient validation to separate the tropical from the temperate data and in most cases, application of the generic WQGVs is recommended.

L’érysipèle du pénis et du scrotum

Publication date: Available online 11 July 2018

Source: Annales de Dermatologie et de Vénéréologie

Author(s): J.-N. Dauendorffer, P. Mongiat Artus, M. Janier, M. Bagot, S. Fouéré

Tesla and the Violet Ray

The beginnings of electrotherapy can be traced back to the Victorian era in the late 19th century. During this period, physicians experimented with applying electrical currents to the human body. Among the early pioneers of electrotherapy were the French physician Jacques Arsène d'Arsonval and the genius inventor and engineer, Nikola Tesla. The electrotherapy circuits produced from Tesla's research were not initially intended for medical applications. Tesla publicized the product during his various lectures and captured the attention of 2 French physicians, Paul Marie Oudin and Jacques-Arsène d'Arsonval.

Revised Mohs Surgery Appropriate Use Criteria for Superficial BCC

This Viewpoint discusses the process of reevaluating Mohs surgery appropriate use criteria for primary superficial basal cell carcinoma.

Osteopenia and Multiple Fractures in an Infant With Harlequin Ichthyosis

This case report describes the occurrence of osteopenia and multiple fractures in an infant with harlequin ichthyosis.

Framework for Caring for Older Patients With Skin Disease

This Viewpoint describes principles of geriatric science that allow for more appropriate dermatological care for the US population of patients older than 65 years.

Prevalence of Skin Cancer Examination Among Indoor Tanning Bed Users

This study uses weighted national survey data to examine the prevalence of skin cancer examinations among users of indoor tanning beds.

The Future of JAMA Dermatology

I am deeply humbled to be selected to serve as Editor in Chief of JAMA Dermatology. The fundamental role of an editor in chief is to review, select, and publish the articles that best help clinicians practice more safely and effectively. The opportunity to illuminate the aspects of our field that deserve spotlight is a task both daunting and delightful. I am committed to do a deep dive into dermatology to identify what is most significant, what is most fascinating, what is most problematic, and to find opportunities to improve and elevate the practice of dermatologists. My ultimate goal is to ensure that dermatologists deliver the best patient care possible, and I consider it an incredible honor to be able to contribute to the specialty through this work.

Missing Affiliation

In the Brief Report titled "Early Genetic Diagnosis of Neurofibromatosis Type 2 From Skin Plaque Plexiform Schwannomas in Childhood," published in the March 2018 issue of JAMA Dermatology, Dr Plana's affiliation at Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain, was missing. This article has been corrected online.

Topical Sirolimus to Treat Tuberous Sclerosis Complex

Tuberous sclerosis complex (TSC) causes the formation of hamartomatous tumors in multiple organs. Facial angiofibromas frequently arise during childhood and can be a source of patient distress owing to bleeding and effects on appearance. The standard treatment is surgical, delivered by multiple modalities, including lasers, shave excision, dermabrasion, electrosurgery, or cryosurgery. These approaches are effective but can create concerns about the potential for scarring, pain, anesthesia risk, postoperative recovery, and the need for repeated procedures delivered in the office or operating room. Consequently, there has been interest in the development of a topical therapy for home use that is painless and nonscarring. In this issue, Koenig and collaborators show that topical 0.1% or 1.0% sirolimus (rapamycin) applied once daily is safe and effective for treating facial angiofibromas. This is welcome news for many with TSC. Furthermore, these results are expected to fuel investigations into other uses for sirolimus in dermatology. The story of how topical sirolimus became a treatment option for TSC is based in scientific discoveries of its molecular target and that target's role in relevant diseases.

Disseminated Asymptomatic Papules Over the Body

A woman in her 30s had a 15-year history of generalized asymptomatic papules on her arms, trunk, legs, neck, and face; examination revealed skin-colored to red-brown papules distributed over her trunk, extremities, neck, forehead, and periocular regions. What is your diagnosis?

2018 Update of Hyaluronidase Use in Aesthetic Dermatology

Hyaluronidase has become an essential tool in cosmetic dermatology as an eraser of unwanted hyaluronic acid (HA) filler. The purpose of this Editorial is to update the reader on the evidence supporting the use of hyaluronidase in (1) the emergency treatment of vascular occlusion from accidental injection of HA into a blood vessel and (2) the more common case of removing small amounts of HA that are simply unwanted, which is the purpose of the study published by Alam and colleagues in this issue of JAMA Dermatology.

Demographic, Academic, and Publication Factors Associated With Academic Dermatology Career Selection

This cohort study examines associations between demographic, academic, and publication factors and dermatology trainees' initial choice of academic vs private practice careers.

Effectiveness of Low Doses of Hyaluronidase to Remove Hyaluronic Acid Filler Nodules

This parallel-group, randomized clinical trial assesses the effectiveness and dose-related effect of small quantities of hyaluronidase vs saline to treat hyaluronic acid filler nodules in healthy women.

Problematic End Points in a Keratinocyte Carcinoma Chemoprevention Trial

To the Editor Treatment with topical fluorouracil, 5%, compared with placebo reduced risk of surgically treated squamous cell carcinoma (SCC) and Mohs surgery for keratinocyte carcinoma (KC) for 1 year, according to a randomized clinical trial (RCT) report. However, because neither of these outcomes was prespecified, these findings should be interpreted very cautiously and should not sway clinical practice.

Topical Rapamycin in Patients With Facial Angiofibromas

This randomized clinical trial examines the efficacy and safety of topical rapamycin therapy for treatment of patients with tuberous sclerosis complex–related facial angiofibromas.

Striking White Hair

Poliosis is a patch of white hair with decreased or absent melanin located in areas with hair growth, such as the scalp and eyebrows. This condition most commonly occurs on the scalp. If poliosis occurs on the scalp, it is referred to as a mallen streak. The term mallen streak originated from author Catherine Cookson's The Mallen Trilogy book series, which had characters in the same family with this trait. In addition, poliosis has also been depicted in movies as a sign of malice and sin. In the 1939 film The Return of Doctor X, the main character has a mallen streak that further characterizes his deceitfulness. Other films that have characters with poliosis include Bride of Frankenstein and Sweeney Todd: The Demon Barber of Fleet Street.

Sirolimus Gel vs Placebo for Facial Angiofibromas in Patients With Tuberous Sclerosis Complex

This randomized clinical trial assesses the efficacy and safety of sirolimus gel, 0.2% vs placebo for treatment of angiofibromas and skin lesions in adult and pediatric patients with tuberous sclerosis complex.

July 2018 Issue Highlights

Contributions by MC1R Variants to Melanoma Risk in Males and Females

This case-control study evaluates the association of melanocortin-1-receptor (MC1R) with melanoma risk in males vs females, adjusting for risk factors such as age, pigmentation, phenotype, signs of skin damage, and sun exposure.

Solitary Asymptomatic Tumor in the Axilla

A woman in her 60s presented with a solitary, indolent, erythematous plaque in the right axilla and also reported a slowly growing subcutaneous node with progressive infiltration of the overlying skin. What is your diagnosis?

Association of Lichen Planopilaris With Dyslipidemia

This cohort study evaluates the association between lichen planopilaris, hyperlipidemia, and metabolic syndrome.

Dermatology Procedures Billed by Advanced Practice Professionals, 2012-2015

This longitudinal study uses Medicare data from 2012 through 2015 to review the trends in scope and volume of dermatology procedures performed by advanced practice professionals such as nurse practitioners and physician assistants.

Skin Cancer Detection In Vivo With Reflectance Confocal Microscopy Performed by a Novice Reader

This study evaluates the learning curve, diagnostic accuracy, and challenges for a novice reader of reflectance confocal microscopy for determining a diagnosis of skin cancer.

Economic Analysis of a Noninvasive Molecular Pathologic Assay for Pigmented Skin Lesions

This economic analysis assesses the costs of use of the pigmented lesion assay vs visual and histopathologic assessment in model inputs of patients with primary pigmented lesions suggestive of melanoma.

Myths, Truths, and Clinical Relevance of Comedogenicity Product Labeling

This Viewpoint evaluates the meaning of the noncomedogenic label and the need for an objective assay for assessment of facial products.

An Atrophic and Spiny Eruption of the Palms

A woman presented with a pruritic and burning hyperpigmented eruption on the bilateral palms; examination revealed well-marginated brown atrophic patches on the bilateral palms extending focally onto the volar aspect of the wrist and surmounted by spiny keratotic pits in the palmar creases. What is your diagnosis?

Correction to: Rational social and political polarization

In the original publication of the article, the Acknowledgement section was inadvertently not included. The Acknowledgement is given in this Correction.

Modal epistemology made concrete

Abstract

Many philosophers since Hume have accepted that imagining/conceiving a scenario is our prime guide to knowing its possibility. Stephen Yablo provided a more systematic criterion: one is justified in judging that p is possible if one can imagine a world which one takes to verify p. I defend a version of Yablo's criterion against van Inwagen's moderate modal scepticism. Van Inwagen's key argument is that we cannot satisfy Yablo's criterion because we are not in a position to spell out far-fetched possible scenarios in relevant detail. Van Inwagen's argument can be applied to the use of conceivability for everyday possibility claims, leaving us with the spectre of pervasive modal scepticism. In order to answer the sceptical threat, I combine van Inwagen's main example with general considerations about the nature of metaphysical modality to motivate a version of Yablo's criterion and show that it does not lead to scepticism. One structural condition of p being metaphysically possible is that it coheres with a complete reality. This condition gives rise to Yablo's criterion. However, for the criterion to be of any avail, we have to disregard details we are not in a position to specify. To account for our practice of doing so, I use Yablo's distinction between imagining a world as determinate and imagining it determinately. I present a condition when we may simply disregard details as determinate. The condition results from integrating analogical reasoning into the conceivability test.

TERT promoter mutations are associated with poor prognosis and cell immortalization in meningioma

Abstract

Background

Meningiomas are mostly benign tumors tending to progress to higher-grade lesions. Mutations in the telomerase reverse transcriptase (TERT) gene promoter are comparably rare in meningioma, but were recently suggested to predict risk of recurrence and progression. Here we have analyzed a cohort of World Health Organization grades I–III meningiomas regarding the impact of TERT promoter mutations on patient prognosis and in vitro cell propagation feasibility.

Methods

From 110 meningioma patients, 128 tissue samples were analyzed for the TERT promoter mutations C228T and C250T by direct sequencing. Of the 128 samples, 121 were tested for cell propagation in vitro. Telomerase activity, TERT mRNA expression, and telomere lengths were investigated by telomeric repeat amplification protocol assay, reverse transcription PCR, and quantitative PCR, respectively. Impact of the E-twenty-six (ETS) transcription factor inhibitor YK-4–279 on cell viability and TERT promoter activity was analyzed.

Results

TERT promoter mutations were found in 5.5% of all samples analyzed and were associated with a significantly upregulated telomerase activity and TERT mRNA expression (P < 0.0001 both). Regarding telomere lengths, no significant difference between the TERT promoter wild-type and mutated subgroups was detected. Patients with TERT promoter mutated tumors exhibited significantly shorter overall survival (P = 0.0006; 53.8 vs 115.6 mo). The presence of TERT promoter mutations but not telomerase activity or TERT mRNA expression predicted indefinite cell growth in vitro. TERT promoter mutated meningioma cells were hypersensitive against the ETS transcription factor inhibitor YK-4–279, inducing a distinct downregulation of TERT promoter activity.

Conclusion

TERT promoter mutations drive meningioma aggressiveness, resulting in reduced patient survival, but might also open novel therapeutic options for progressive disease.

Long-term experience with setup and implementation of an IHE-based image management and distribution system in intersectoral clinical routine

Abstract

Purpose

Sharing of medical data is crucial for the proper treatment of patients as it could reduce the risk of duplicated medical tests and speed up the care process if all documents are readily available. Despite great technical progress, sharing patient data while maintaining full control over the process in an intersectoral (in Germany, this describes the different actors in the healthcare system consisting of clinic, ambulatory care, etc.) setting remains a particular challenge. This paper focuses on the successful implementation of a privacy compliant, standards-based image-management component of a personal electronic health record.

Methods

Over a 5-year period, a sharing system based on readily available IHE profiles constructed around XDS has been built. It was necessary to create interfaces for the existing hospital sub-systems to become part of the network. Specifically, the imaging workflow had to be adapted to allow for fast and easy access to DICOM images utilizing a flexible web-based image viewer. In addition to the standard XDS workflow, an Imaging Cache was established which combines the Imaging Document Source and Consumer to guarantee fast and streaming-based access to all images in the network observing the high security standards of the hospital network.

Results

The authors of this paper have proven that it is possible to build a fast and reliable sharing system based on IHE profiles using most of the transactions of XDS-I with some adaptions to the clinical workflow. Primary hospital systems were enabled by building adapters to overcome lack of IHE compatibility. The established system embraces the existing security mechanisms in hospital networks while connecting patients and referring physicians from outside in a secure and convenient manner.

Conclusions

A state-of-the-art sharing system that is used in a productive clinical environment has been established and is ready to grow with more partners. The system is the basis for an elaborated interdisciplinary collaboration where data, and in particular images, can now be shared between medical professionals.

Sub-muscular Breast Augmentation Using Tumescent Local Anesthesia

Abstract

Background

Tumescent local anesthesia (TLA) consists of infiltration of saline solution with lidocaine and epinephrine into the tissues to obtain regional anesthesia and vasoconstriction. The use of TLA in augmentation mammoplasty has been described for sub-glandular positioning. We describe a modified TLA technique for primary sub-muscular breast augmentation reporting our experience during the past 7 years.

Methods

From 2010 to 2017, 300 patients underwent bilateral primary sub-muscular breast augmentation under TLA and conscious sedation. The tumescent solution was prepared with 25 mL of 2% lidocaine, 8 mEq of sodium bicarbonate, and 1 mL of epinephrine (1 mg/1 mL) in 1000 mL of 0.9% saline solution. Firstly, the solution was infiltrated between the pectoral fascia and the mammary gland, secondarily, during surgery, under the pectoralis major muscle.

Results

The average amount of tumescent solution infiltrated while performing TLA was 740 mL per breast. No signs of adrenaline or lidocaine toxicity were reported and conversion to general anesthesia was never required. In all patients, no pain nor discomfort was reported during the pre-operating infiltration and surgical procedure. We reported a major complication rate of 3.3% (4 hematomas and 6 seromas) and a minor complication rate of 6.0% (8 implant dislocation and 10 dystrophic scars formation).

Conclusions

TLA represents a safe and efficacious technique for performing breast augmentation surgery with sub-muscular implant positioning. This technique guarantees good pain control during and after surgery and has low incidence of postoperative side effects. Patients subjected to sub-muscular breast augmentation with TLA were satisfied.

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.

Combination Therapies for Obesity

Metabolic Syndrome and Related Disorders, Ahead of Print.

What Can Diabetes-Associated Genetic Variation in TCF7L2 Teach Us About the Pathogenesis of Type 2 Diabetes?

Metabolic Syndrome and Related Disorders, Ahead of Print.

How Do We Teach High-Value Radiology?

Abstract

Purpose of Review

The healthcare environment is under tremendous flux and the rate of change is continuously increasing. Calls have been made and efforts are underway to transform medical education. In this article, trends, key drivers, and resources for both global medical education and some specific to radiology are discussed.

Recent Findings

Great strides have been made to begin shifting focus towards high-value healthcare delivery through both non-traditional methods and innovation. We are not alone in this journey; resources are readily offered by instrumental key drivers of medical education with collaboration and sharing as valuable tools at our disposal.

Summary

Despite initial progress, barriers persist to achieving meaningful and sustainable changes in medical education. We must commit our resources and empower our current and future medical providers to lead the way in providing high-value healthcare for our patients. An awareness of trends and driving forces in healthcare and medical education is necessary for radiologists to be relevant and vital contributors to the healthcare team.

Increased risk of incident psoriasis in end‐stage renal disease patients on chronic hemodialysis: A nationwide population‐based cohort study

The Journal of Dermatology, EarlyView.

Low caregiver health literacy among pediatric food-allergic patients is associated with poorer food allergy management knowledge

Publication date: Available online 11 July 2018

Source: The Journal of Allergy and Clinical Immunology: In Practice

Author(s): Maureen Egan, H. Shonna Yin, Matthew Greenhawt, Julie Wang

Comparison of efficacy of aminolaevulinic acid photodynamic therapy versus adapalene gel plus oral doxycycline for treatment of moderate acne vulgaris ‐ a simple, blind, randomized, and controlled trial

Photodermatology, Photoimmunology &Photomedicine, Volume 0, Issue ja, -Not available-.

Fungal keratitis: an overview of clinical and laboratory aspects

Mycoses, Volume 0, Issue ja, -Not available-.

Genetic diversity of Pneumocystis jirovecii from a cluster of cases of pneumonia in renal transplant patients: cross‐sectional study

Mycoses, Volume 0, Issue ja, -Not available-.

Monitoring chemotherapy‐induced alopecia with trichoscopy

Journal of Cosmetic Dermatology, EarlyView.

The evaluation of psychiatric comorbidity, self‐injurious behavior, suicide probability, and other associated psychiatric factors (lonileness, self‐esteem, life satisfaction) in adolescents with acne: A clinical pilot study

Journal of Cosmetic Dermatology, EarlyView.

An atypical persistent eruption of Adult‐onset Still’s disease with Neutrophilic Urticarial Dermatosis‐like dermal features: a case report and review of the literature

Journal of Cutaneous Pathology, Volume 0, Issue ja, -Not available-.

Linoleate-enriched diet increases both linoleic acid esterified to omega hydroxy very long chain fatty acids and free ceramides of canine stratum corneum without effect on protein-bound ceramides and skin barrier function

Abstract

Few studies have investigated the influence of increased amounts of dietary linoleic acid on the epidermal lipid biochemistry and TEWL in healthy subject. The influence of dietary linoleic acid on canine stratum corneum (SC) lipids was studied by feeding two groups of five dogs differential amounts of linoleic acid (LA) for three months. SC was harvested by tape stripping and lipids were analyzed by thin-layer chromatography and mass spectrometry. The dogs that were fed the higher concentration of LA showed high increases in the contents of both linoleic acid and free ceramides in the SC, whereas the protein-bound ceramide content was unchanged. Acylacids that represent the esterified form of linoleic acid in omega hydroxy very long chain fatty acids (ω-OH VLCFA) accounted for most of the elevation of LA, whereas the concentration of the free form was not significantly changed. Corroborating the absence of change in the protein-bound ceramides content of healthy dogs SC, TEWL was nearly unaffected by the linoleic acid-enriched diet.

Corrigendum to “Evaluation of Complication Rates after Breast Surgery Using Acellular Dermal Matrix: Median Follow-Up of Three Years”

Kardiale Mortalität bei Radio- und/oder Chemotherapie der Brust

Spätfolgen nach onkologischer Chirurgie

Zusammenfassung

Hintergrund

Die onkologische Chirurgie erfordert oft ausgedehnte und radikale Eingriffe, die mit einem breiten Spektrum möglicher operationsbedingter Spätfolgen einhergehen.

Ziel der Arbeit

Dieser Übersichtsartikel soll wesentliche Spätfolgen onkologischer Chirurgie zusammenfassen und Präventions- und Therapieansätze aufzeigen. Beispielhaft werden Spätfolgen viszeralonkologischer Operationen am oberen und unteren Gastrointestinaltrakt sowie am Pankreas diskutiert.

Methoden

Es erfolgte eine selektive Literaturrecherche und Zusammenfassung der aktuellen Evidenz.

Ergebnisse

Das Erreichen des bestmöglichen onkologischen Ergebnisses geht häufig mit einer erhöhten postoperativen Morbidität sowie bleibenden Funktionseinschränkungen und permanenten Einbußen der Lebensqualität einher. Spätfolgen sind oft spezifisch für den jeweiligen Eingriff, wobei chronische Schmerzsyndrome und eine eingeschränkte gesundheitsbezogene Lebensqualität mit hoher Prävalenz organ- und eingriffsübergreifend auftreten. Häufige Spätfolgen nach onkologischer Chirurgie des oberen Gastrointestinaltrakts sind persistierende Beschwerden bei der Nahrungsaufnahme, postprandiale Störungen sowie respiratorische Einschränkungen. Nach Eingriffen am Pankreas steht aufgrund des Parenchymverlusts die endokrine- und exokrine Pankreasinsuffizienz im Vordergrund. Im Bereich des unteren Gastrointestinaltrakts sind persistierende Stuhlveränderungen, Defäkationsprobleme, Anastomosen- und Stomakomplikationen sowie Störungen der Blasen- und Sexualfunktion von Relevanz.

Schlussfolgerung

Herausforderung der onkologischen Chirurgie ist es, die Balance zwischen erforderlicher Radikalität und postoperativer Morbidität zu finden.

Lineäre, irregulär konfigurierte Pigmentierungen am gesamten Integument

Against the iDoctor: why artificial intelligence should not replace physician judgment

Abstract

Experts in medical informatics have argued for the incorporation of ever more machine-learning algorithms into medical care. As artificial intelligence (AI) research advances, such technologies raise the possibility of an "iDoctor," a machine theoretically capable of replacing the judgment of primary care physicians. In this article, I draw on Martin Heidegger's critique of technology to show how an algorithmic approach to medicine distorts the physician–patient relationship. Among other problems, AI cannot adapt guidelines according to the individual patient's needs. In response to the objection that AI could develop this capacity, I use Hubert Dreyfus's analysis of AI to argue that attention to the needs of each patient requires the physician to attune his or her perception to the patient's history and physical exam, an ability that seems uniquely human. Human physician judgment will remain better suited to the practice of primary care despite anticipated advances in AI technology.

Erratum zu: Therapie des kutanen malignen Melanoms im Kopf-Hals-Bereich

Erratum zu:

MKG-Chirurg 2018.

https://ift.tt/2KOU6BY

In der Legende zu Abb. 1a wurde leider ein sinnentscheidendes Komma vergessen.

Die richtige Abbildungslegende ist hier dargestellt:

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The ubiquitous hospital polyethylene pinny: an ideal temporary wound cover

Abstract

Background

Daily plastic surgery ward rounds involve regular complex wound monitoring to direct management. As a tertiary service, our patients are often located on different wards that lack a full gamut of dressings. We propose the use of a novel, expedient, temporary dressing for wound coverage and review the literature on the subject matter.

Methods

Our trauma team trialled the use of standard polyethylene aprons' inner surface as temporary cover for open wounds. Microbiology wound swabs were taken from the unfolded apron prior to use, and sent for routine culture. Twenty-one consecutive patients were recruited to the trial. All patients were asked to rate the dressing on pain and comfort.

Results

No bacterial growth was reported. The average price of each apron is 3 pence and patients reported that their use was comfortable, painless and quick. The plastic apron was popular with our outreach nursing team (responsible for applying full dressings post ward round) who reported always finding one with ease.

Conclusions

Polyethylene aprons are widely available in all clinical areas. We found no evidence that they are colonised with or harbour bacteria at the point when taken from the roll. They are inexpensive, easy to handle, waterproof and in our experience, do not adhere to wounds. In addition, no specialty specific knowledge or training is required for their use. We believe these qualities make the polyethylene apron an ideal temporary dressing.

Level of Evidence: Level IV, therapeutic study

Comparison of the microstructures and properties of different microcannulas for HA injection

BACKGROUND: Microcannulas are used for hyaluronic acid and other fillers injection and reduce the side effects and complications. There are several microcannulas manufactured by different manufacturers but the differences between microcannulas haven't been carefully investigated. OBJECTIVE: To compare the microstructures and properties of different microcannulas by several trials and provide guidance for clinical application. METHODS: In this study, 9 kinds of microcannulas, from different manufacturers were chose. Scanning electron microscope(SEM) was used to obtain high-definition image of microstructures, chemical composition analyzers were used to test the chemical composition for the microcannulas' tips and universal testing machine was used to measure mechanical properties. Injection speed test recorded the time spent for the weight pushed hyaluronic acid out during different microcannulas. Vessel piercing force test was conducted to simulate the process of puncturing the vessels in vitro. RESULTS: The SEM images showed the differences in the tips and inner surfaces which may relate to the characteristics. Most microcannulas' chemical composition met the American Society for Testing Material(ASTM) standards basically. For mechanical properties, the elastic modulus and the yield strength were obviously different. The injection speed test showed the speed of difference microcannulas through same force was discrepant more than 7 times. The vessel piercing test showed which microcannula was most difficult to puncture the aorta and which was the easiest. CONCLUSION: The results indicated there are significant differences between different microcannulas. The differences are instructive to physician to select suitable microcannulas to improve the injection effect and reduce discomfort and complications. Financial disclosure: The authors have no financial interest to declare in relation to the content of this article. Acknowledgement: none Corresponding author: Wang Hang, Sichuan Univ, West China Sch Stomatol, Dept Oral & Maxillofacial Surg, 14,3rd Sect,RenMin Nan Rd, Chengdu 610041, Peoples R China. Tel: +86 13980888813, E-mail:dr.hangwang@hotmail.com ©2018American Society of Plastic Surgeons

Immediate local and systemic hypersensitivity due to etanercept and adalimumab

Publication date: Available online 10 July 2018

Source: The Journal of Allergy and Clinical Immunology: In Practice

Author(s): Katharina Hansel, Leonardo Bianchi, Marta Tramontana, Anna Balato, Emanuele Scala, Jacopo Brozzi, Luca Stingeni

Common food flavors are safe in patients with urticaria or atopic dermatitis

Publication date: Available online 10 July 2018

Source: The Journal of Allergy and Clinical Immunology: In Practice

Author(s): Viktor Schnabel, Peter Schupp, Carsten Gutgesell, Andrea Braun, Michael P. Schön, Thomas Fuchs, Timo Buhl

The Differential Use of Bilobed and Trilobed Transposition Flaps in Cutaneous Nasal Reconstructive Surgery

Background: Bilobed and trilobed transposition flaps are versatile random pattern transposition flaps which reliably restore nasal symmetry, topography, light reflex, contour and are frequently used in cutaneous nasal reconstructive surgery. We wish to compare the characteristics of bilobed and trilobed flaps in cutaneous reconstructive surgery and to identify scenarios for their differential use. Methods: A retrospective chart review over 7 years of consecutive patients reconstructed with a bilobed or trilobed flap after Mohs micrographic surgery was performed. Statistical analysis of patient and surgery characteristics, anatomic distribution, postprocedural events and need for revisions after both flap types was conducted. Results: One hundred eleven patients with bilobed flaps and 74 patients with trilobed flaps were identified. Bilobed flaps are significantly more frequently used on the inferior nasal dorsum and on the sidewall whereas trilobed flaps are significantly more frequently used on the nasal tip and infratip. No significant difference in postprocedural events (complications, erythema, trapdoor, etc) was noted between the two flap types. Conclusion: Bilobed and trilobed transposition flaps are versatile repairs for nasal reconstruction. Trilobed flaps may be used to repair defects in a more distal nasal location than bilobed flaps. Regardless of flap type, complications are rare. Conflicts of interest: none declared Funding sources: none Presented at: American College of Mohs Surgeons Annual Meeting 2017 in San Francisco, CA Corresponding author/Reprint requests: Nathaniel J. Jellinek, MD, 1672 South County Trail, Suite 101, East Greenwich, RI, 02818, (401)-885-6647 (phone), (401)-885-6639 (fax), email: winenut15@yahoo.com ©2018American Society of Plastic Surgeons

Increasing nerve autograft length increases senescence and reduces regeneration

Background: Nerve grafting with an autograft is considered the gold standard. However, the functional outcomes of long (>3cm) nerve autografting are often poor. We hypothesized that a factor contributing to these outcomes is the graft microenvironment, where long compared to short autografts support axon regeneration to different extents. Methods: A rat sciatic nerve defect model was used to compare regeneration within short (2cm) and long (6cm) isografts. Axon regeneration and cell populations within grafts were assessed using histology, retrograde labeling of neurons regenerating axons, immunohistochemistry, qRT-PCR, and electron microscopy at 4 and/or 8 weeks. Results: At 8 weeks for distances of both 1 and 2cm from the proximal coaptation (equivalent regenerative distance), long isografts had reduced numbers of regenerated fibers compared to short isografts. Similarly, the number of motoneurons regenerating axons was reduced in the presence of long isografts compared to short isografts. Considering the regenerative microenvironments between short and long isografts, cell densities and general populations within both short and long isografts were similar. However, long isografts had significantly greater expression of senescence markers, which included senescence associated β-galactosidase, p21, and p16, as well as distinct chromatin changes within Schwann cells. Conclusions: This study shows that axon regeneration is reduced within long compared to short isografts, where long isografts contained an environment with an increased accumulation of senescent markers. While autografts are considered the "gold standard" for grafting, these results demonstrate that we must continue to strive for improvements in the autograft regenerative environment. Financial Disclosure Statement: The authors have the following to disclose: None Presented at: American Society for Surgery of the Hand 2016 meeting in Austin, Tx and the Plastic Surgery Research Council 2017 meeting in Durham, NC. Disclosures: None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. Acknowledgements: This work was supported in part by the National Institutes of Neurological Disorders and Stroke of the National Institutes of Health (NIH) under award number R01 NS086773 to Washington University and in part by the Plastic Surgery Foundation under award ID 346670 to Wood through Washington University. The content is solely the responsibility of the authors and does not represent the views of the NIH, the Plastic Surgery Foundation, or Washington University. Corresponding author: Matthew D. Wood, PhD, Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, Campus Box 8238, 660 South Euclid Avenue, St. Louis, MO 63110, USA. woodm@wudosis.wustl.edu ©2018American Society of Plastic Surgeons

Outcomes of Corticosteroid Treatment for Trigger Finger by Stage.

Background: While steroid injection remains a common first-line treatment of trigger fingers, clinical experience suggests that not all trigger fingers respond the same. The purpose of this study was to utilize a classification system for trigger finger that is simple, reproducible, and produces clearly definable, clinically relevant cutoff points to determine if responsiveness to steroid injection correlates to clinical staging. Methods: This was a prospectively-collected longitudinal study of trigger finger patients separated into four stages of severity. Each subject received a single injection of 6 mg dexamethasone acetate. One-month outcomes were analyzed to evaluate efficacy of steroid injection. These outcomes were further stratified based on baseline characteristics and stage of triggering Results: A total of 99 digits and 69 subjects were included. Two variables were found to be significant in predicting response to initial injection: 1. multiple affected digits, and 2. stage severity. Patients with multiple involved fingers were 5.8 times more likely to have no resolution of symptoms compared with those with a single affected finger. For every level of stage increase, the odds doubled for having no resolution of symptoms. Conclusions: Steroid injection remains a viable first-line option for patients presenting with mild triggering (Stage 1 and 2). For more severe triggering (Stage 3 and 4) or multiple affected digits, success of steroid injection is significantly lower at one month. For the latter patients, surgery may be a more reasonable initial treatment. Presented at: The American Association of Plastic Surgeons Annual Meeting, Austin, TX, 2017 Financial Disclosure Statement: Funded by a 2012 PSF/AAHS research grant Products Mentioned: N/A Corresponding Author: Robert A. Weber, MD, 2401 S. 31st St. Temple, TX, USA. E-mail address: Robert.Weber@BSWHealth.org ©2018American Society of Plastic Surgeons

Treatment of Apert hand syndrome: Strategies for achieving a 5-digit hand

Background: Apert hand reconstruction requires complex surgical planning. The purpose of this study is to describe our 8 year surgical experience with Apert syndrome hand reconstruction, and provide specific surgical strategies for achieving a 5-digit hand in Upton type I and II hands. Methods: A retrospective analysis of consecutive Apert patients who underwent web space releases between 2007 and 2015 was performed. Demographic, surgical, and outcome data were verified through medical records, clinical photographs, radiographic images, and patient interviews. Results: A total of 41 Apert patients (23 [56.1%] male and 18 [43.9%] female) were treated at our Hospital since 2007. A 5-digit hand was achieved in all patients (100%) with Upton type I and II hands, and in 8 patients (72.7%) with Upton type III hands. A 4-digit hand was obtained in 3 of 11 patients (27.3%) with Upton type III hands. Four (25%) of 20 patients with Upton type I hands, 3 (30%) of 10 patients with Upton type II hands, and 6 (54.5%) of 11 patients with Upton type III hands, required subsequent revision for aesthetic reasons. Conclusion: Upton type III hands have demonstrated higher revision rates than type I and II hands, regardless of whether a 4 or 5-digit hand is obtained. Treatment strategies for Apert hands based on hand type are offered to guide 4-web-space release in all patients with Upton type I and II hands. Funding: None Conflict of interest: The authors have no personal financial or institutional interest in any of the drugs, materials, or devices described in this article. Corresponding author: Cassio Eduardo Raposo-Amaral, MD, PhD, Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Av. Adolpho Lutz, 100, Caixa Postal: 6028, Campinas, São Paulo 13084-880, Brazil. E-mail: cassioraposo@hotmail.com ©2018American Society of Plastic Surgeons

Aesthetic Comparison of Two Different Types of Webspace Reconstruction for Finger Syndactyly

Background: Syndactyly reconstruction incorporates techniques of applying skin grafts or dorsal advancement flaps without the use of skin grafts. Comparative outcome studies of these two approaches are lacking. Our study compares the long-term aesthetic outcomes of these two flap techniques. Methods: Forty-five patients were included in our study. The methods of reconstruction used were a dorsally-based rectangular flap with skin graft from the groin and a dorsal pentagonal advancement flap without skin grafting. Eighteen independent raters completed a Visual Analogue Scale (VAS) as well as a unique classification scale to subjectively assess aesthetic outcomes. We used univariate analyses to determine which variables significantly influenced the outcome score. We then used multivariable regression models to compare the two flap types. Results: Dorsally-based rectangular flaps with skin graft had statistically significantly better VAS scores and greater odds of receiving an 'Excellent' rating when compared to dorsal pentagonal advancement flaps. Conclusions: Despite the use of skin graft and their associated donor-site morbidity, dorsal rectangular flaps may offer better overall aesthetic outcomes for patients. Future comparative studies should incorporate functional and patient-reported outcomes to better assess the optimal reconstruction type. Financial Disclosure Statement: This publication was supported in part by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (2 K24-AR053120-06). The consent is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Corresponding Author: Kevin C. Chung MD, MS, Section of Plastic Surgery, University of Michigan Health System, 2130 Taubman Center, SPC 5340, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5340, Kecchung@med.umich.edu, Phone 734-936-5885, Fax 734-763-5354 ©2018American Society of Plastic Surgeons

Re-establishment of Lymphatic Drainage after Vascularized Lymph Node Transfer in a Rat Model

Background: Vascularized lymph node transfer (VLNT) has recently received attention as a potential surgical treatment for lymphedema. Despite good results in some series, the mechanism and benefits of VLNT have yet to be fully understood. This study aimed to investigate the re-establishment of drainage into transferred lymph nodes following VLNT in a rat model. Methods: Seven rats underwent VLNT. The operation performed on each rat consisted of two parts. First, the left groin lymph node basin with superficial epigastric vessels was harvested as a free flap. Second, the flap was re-attached in the left groin of the rat via end-to-end microvascular anastomoses. Anastomosis patency was assessed immediately post-op and at the time of animal sacrifice. The rats were evaluated for re-establishment of lymphatic flow into the transplanted nodes at 1 month intervals for at least 6 months post-op. This was accomplished non-invasively by injecting the rats in their flanks with fluorescent indocyanine green (ICG) which was detected using a PDE infrared camera. Results: Anastomoses were patent in all 7 rats immediately postop. No ICG uptake was seen in the transplanted lymph node basins in the first 2 months post-op in any of the rats. In 5 of 7 rats, however, ICG uptake was demonstrated in the transplanted lymph node basin by 6 months (average 13 weeks). Conclusions: We report uptake of ICG in 5 of 7 rats at an average of 13 weeks following lymph node transplantation, consistent with the re-establishment of lymphatic drainage into the transplanted nodes. Financial Disclosure Statement: None of the authors have any conflicts of interest nor disclosures. No funding was received for this article. Portions presented at: American Society for Reconstructive Microsurgery (ASRM) 2017 in Waikoloa, Hawaii Northeastern Society of Plastic Surgeons (NESPS) 2016 in Baltimore, MD Acknowledgments: We would like to thank Yanping Sun, PhD and Christopher Damoci from the Small Animal Imaging Shared Resource (SAISR) division of the Herbert Irving Comprehensive Cancer Center at Columbia University for their assistance in obtaining our MRI studies. Corresponding author: Jeffrey A. Ascherman, MD, Herbert Irving Pavilion, 161 Fort Washington Avenue Suite: 511, New York, NY 10032, jaa7@cumc.columbia.edu ©2018American Society of Plastic Surgeons

Facial implants; controversies an d criticism, a comprehensive review of the current literature.

BACKGROUND: Polyethylene (Medpor) and Silicone are two of the most popular materials used today for facial skeleton implantation. Previous studies have identified common complications with the use of these implants, but patient follow up has been short. This review of literature examines complications and patient follow up in cases using Medpor and Silicone implants for reconstructive and aesthetic surgeries of the mid and lower face over the last 20 years. METHOD: A literature search was conducted through the PUBMED database. Key words used were ("Mandible Implants" or "Malar Implants" or "Chin Implants") AND ("Reconstruction" or "Augmentation") AND ("Medpor" or "Silicone"). RESULT: There were 9 studies with 626 patients in the Medpor group and 5 studies with 365 patients for Silicone. Silicone had a higher incidence of infections and displacements. Medpor showed a higher incidence of prominence problems. Exposure/extrusion rates were low for both implants. Chin and mandibular implants were the safest, while malar implants had a high incidence of prominence problems. The average follow up for Medpor was 36.6 months and 24 months for Silicone. There were wide ranges of follow up times, from 2 weeks up to 15 years. A limited number of articles included an averaged time within their ranges. Reported follow ups were not linked to specific complications. CONCLUSION: Medpor implantation is more common than Silicone. Complications rates are low with the use of both materials. Patient follow up is deficient and hasn't improve in the last 20 years, raising questions on the reliability of complications rates. FD - None of the authors have financial disclosures. Corresponding author: Yoel Rojas, MD1, Department of Plastic Surgery, Nassau University Medical Center, East Meadow, NY 11554 ©2018American Society of Plastic Surgeons

A simple dynamic strategy to deliver stem cells to decellularized nerve allografts

Background: The addition of adipose-derived Mesenchymal Stromal Cells (MSCs) to decellularized nerve allografts may improve outcomes of nerve reconstruction. Prior techniques used for cell seeding are traumatic to both the MSCs and nerve graft. An adequate, reliable and validated cell seeding technique is an essential step for evaluating the translational utility of MSC-enhanced decellularized nerve grafts. The purpose of this study was to develop a simple seeding strategy with an optimal seeding duration. Methods: A dynamic bioreactor was used to seed rat and human MSCs separately onto rat and human decellularized nerve allografts. Cell viability was evaluated by MTS assays and cellular topology after seeding was determined by SEM microscopy. Cell density and distribution were determined by LIVE/DEAD assays and Hoechst staining at 4 different time points (6, 12, 24 and 72 hours). The validity and reliability of the seeding method were calculated. Results: Cells remained viable at all time points, and MSCs exhibited exponential growth in the first 12 hours of seeding. Seeding efficiency increased significantly from 79.5% at 6 hours to 89.2% after 12 hours of seeding (p = 0.004). Both intra-rater (r = 0.97) and inter-rater reliability (r = 0.92) of the technique were high. Conclusions: This study describes and validates a new method to effectively seed decellularized nerve allografts with MSCs. This method is reproducible, distributes cells homogenously over the graft and does not traumatize the intra-neural architecture of the allograft. Utilization of this validated seeding technique will permit critical comparison of graft outcomes. Financial Disclosure Statement: Funding for this study was received from the Mayo Clinic Center for Regenerative Medicine Acknowledgements: We thank the American Donor Services for providing fresh human cadaveric motor nerves. We also thank Drs. Anthony Windebank, Allan Dietz, Amel Dudakovic and Roman Thaler for their expertise and guidance. Presentations: Part of this work was presented at the Annual Meeting of the American Society for Peripheral Nerve, Hawaii, United States, January 13th, 2017. Author Contributions: Nadia Rbia: contributed to the conception, analysis, interpretation of the data, as well as drafting of the manuscript for submission.Liselotte F. Bulstra: contributed to the conception, analysis, interpretation of the data, as well as the drafting of the manuscript for submission. Allen T. Bishop: contributed to the conception and interpretation of data, as well as edited the manuscript. Andre J. van Wijnen: contributed to the conception and interpretation of data, as well as edited the manuscript. Alexander Y. Shin: contributed to the conception and interpretation of data, as well as the acquisition of funding and editing of this manuscript. Corresponding Author: Alexander Y. Shin, M.D., Professor of Orthopedic Surgery, Professor of Neurosurgery, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, Phone: 507-284-0475, Email: shin.alexander@mayo.edu. ©2018American Society of Plastic Surgeons