Blood vessel occlusion with erythrocyte aggregates causes burn injury progression: microvasculature dilation as a possible therapy

Abstract

Other than radiation, caustic strong alkali insults, and massive over-reactive inflammation (pyoderma gangrenosum), injury progression after trauma is usually secondary to ischemia from decreased blood vessel perfusion. Impeded blood flow contributes to injury progression in a variety of disorders including venous stasis ulcers, arterial ulcers, diabetic ulcers, flap and graft necrosis, sickle cell disease, cryoglobulinemia and other vasculopathies, vasculitis, post-myocardial infarction, and post stroke. The cause of impeded blood flow in these disorders/diseases is well known.

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Adjuvant Therapy for Revision Rhinoplasty of Contracted Nose Using Polydeoxyribonucleotide and Invasive Bipolar Radiofrequency

Summary: Most cases of severely contracted nose require revision rhinoplasty and septoplasty, wherein preoperative and/or intraoperative expansion of nasal soft tissue is necessary for tension-free revision surgery. The present study aimed to evaluate the efficacy and safety of pre- and postoperative adjuvant therapy using polydeoxyribonucleotide (PDRN) and invasive, pulsed-type, bipolar, alternating current radiofrequency (RF) for revision surgery of a contracted nose. In total, 30 patients were treated with 16 sessions (8 preoperative sessions and 8 postoperative sessions) of intralesional injection of PDRN and invasive RF treatment using microneedle electrodes at 1-week intervals. One week after the final combined pretreatment using PDRN and invasive bipolar RF, the skin of contracted noses was sufficiently softened, and nasal skin mobility was notably improved in all the patients. During revision rhinoplasty and septoplasty, the contracted nasal skin in each patient was adequately released for proper covering of the nasal tip without tension. Postoperatively, 8 sessions of adjuvant therapy elicited marked clinical improvements in persistent nasal tip dimpling and contracture, septal deviation, and warping from the incomplete recovery of nasal contracture after revision surgery. In conclusion, our pre- and postoperative adjuvant therapies using PDRN and invasive bipolar RF remarkably improved the therapeutic outcomes of revision rhinoplasty and septoplasty for contracted skin of the nose without major side effects.

V-shaped Internal Nasal Vestibular Flap for Reconstruction of Iatrogenic Columellar Defect

Summary: Columella is an important structure in the center of the face, and its structural integrity has an important functional, social, and psychological role. Columella reconstruction can be very challenging for surgeons and the ideal technique remains elusive. This article describes a reconstruction technique in a young woman with columella necrosis due to nasal continuous positive airway pressure treatment. The method of reconstruction described here, with a V-shaped internal nasal vestibular flap and a cartilage grafts from lateral crura, is simple and easily reproducible, providing an optimal aesthetic result and in addition the donor site does not create a secondary deformity by disrupting normal anatomy.

An update of the Worldwide Integrated Assessment (WIA) on systemic insecticides. Part 3: alternatives to systemic insecticides

Abstract

Over-reliance on pesticides for pest control is inflicting serious damage to the environmental services that underpin agricultural productivity. The widespread use of systemic insecticides, neonicotinoids, and the phenylpyrazole fipronil in particular is assessed here in terms of their actual use in pest management, effects on crop yields, and the development of pest resistance to these compounds in many crops after two decades of usage. Resistance can only be overcome in the longterm by implementing methods that are not exclusively based on synthetic pesticides. A diverse range of pest management tactics is already available, all of which can achieve efficient pest control below the economic injury level while maintaining the productivity of the crops. A novel insurance method against crop failure is shown here as an example of alternative methods that can protect farmer's crops and their livelihoods without having to use insecticides. Finally, some concluding remarks about the need for a new framework for a truly sustainable agriculture that relies mainly on natural ecosystem services instead of chemicals are included; this reinforcing the previous WIA conclusions (van der Sluijs et al. Environ Sci Pollut Res 22:148-154, 2015).

Poor inter-rater reliability of hidradenitis suppurativa phenotypes

An Enhanced Recovery after Surgery Pathway for Microvascular Breast Reconstruction Is Safe and Effective

Background: The aim of this study was to develop, implement, and evaluate a standardized perioperative enhanced recovery after surgery (ERAS) clinical care pathway in microsurgical abdominal-based breast reconstruction. Methods: Development of a clinical care pathway was informed by the latest ERAS guideline for breast reconstruction. Key features included shortened preoperative fasting, judicious fluids, multimodal analgesics, early oral nutrition, early Foley catheter removal, and early ambulation. There were 3 groups of women in this cohort study: (1) traditional historical control; (2) transition group with partial implementation; and (3) ERAS. Narcotic use, patient-reported pain scores, antiemetic use, time to regular diet, time to first walk, hospital length of stay, and 30-day postoperative complications were compared between the groups. Results: After implementation of the pathway, the use of parenteral narcotics was reduced by 88% (traditional, 112 mg; transition, 58 mg; ERAS, 13 mg; P

Immediate Breast Reconstruction among Patients with Medicare and Private Insurance: A Matched Cohort Analysis

Background: By eliminating economic hurdles, the Women's Health and Cancer Rights Act of 1998 represented a paradigm shift in the availability of breast reconstruction. Yet, studies report disparities among Medicare-insured women. These studies do not account for the inherent differences in age and comorbidities between a younger privately insured and an older Medicare population. We examined immediate breast reconstruction (IBR) utilization between a matched pre- and post-Medicare population. Methods: Using the Nationwide Inpatient Sample database (1992–2013), breast cancer patients undergoing IBR were identified. To minimize confounding medical variables, 64-year-old privately insured women were compared with 66-year-old Medicare-insured women. Demographic data, IBR rates, and complication rates were compared. Trend over time was plotted for both cohorts. Result: A total of 21,402 64-year-old women and 25,568 66-year-old women were included. Both groups were well matched in terms of demographic type of reconstruction and complication rates. 72.3% of 64-year-old and 71.2 of % 66-year-old women opted for mastectomy. Of these, 25.5% (n = 3,941) of 64-year-old privately insured and 17.7% (n = 3,213) of 66-year-old Medicare-insured women underwent IBR (P

Complications following Nipple-Sparing Mastectomy and Immediate Acellular Dermal Matrix Implant-based Breast Reconstruction—A Systematic Review and Meta-analysis

Background: Acellular dermal matrix was introduced in breast reconstruction in 2001 and is gradually becoming a standard component for immediate breast reconstruction and nipple-sparing mastectomy. The reconstructive technique allows for improved aesthetic outcomes. However, there seems to be uncertainty regarding complication rates. The aim of this review was to systematically evaluate complication rates related to this method. Methods: This systematic review was conducted according to the recommendations outlined in the Cochrane Handbook for reviews and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Relevant databases were searched for in the literature concerning the use of acellular dermal matrix in implant-based nipple-sparing mastectomy and immediate breast reconstruction. All studies underwent detailed quality assessment. Summarized outcome rates were computed using meta-analysis. Results: Nine of 1,039 studies were eligible for inclusion yielding 778 procedures. The quality was acceptable for all included studies. The meta-analysis found the rate of skin necrosis to be 11%, nipple necrosis 5%, infection in 12%, hematoma in 1%, treated seroma in 5%, explantation 4%, and unplanned return to the operating room in 9%. Conclusion: The use of acellular dermal matrix in nipple-sparing mastectomy and implant-based breast reconstruction can be done with acceptable complication rates in selected patients. We recommend future studies to include specific definitions when reporting complication rates. Furthermore, future studies should elaborate on demographic characteristics of the included study samples and include predictor analysis to enhance knowledge of high risk patients.

Treatment Strategies for Hypopigmentation in the Context of Burn Hypertrophic Scars

Dyspigmentation in burn scars can contribute to the development of psychosocial complications after injury and can be detrimental to social reintegration and quality of life for burn survivors. Although treatments for skin lightening to treat hyperpigmentation have been well reviewed in the literature, skin-darkening strategies to treat hypopigmentation have not. The following potential treatment options in the context of burn hypertrophic scar will be discussed: use of the melanocyte-keratinocyte transplantation procedure, use of ectopic synthetic analogues of alpha-melanocyte stimulating hormone to initiate melanogenesis, and use of FK506 to induce melanogenesis. A proposed future direction of research in laser-assisted drug delivery of inducers of local melanin production, with the hope of developing a targeted, effective approach to dyspigmentation in hypertrophic scar is also discussed.

Earfold Implantable Clip System for Correction of Prominent Ears: Analysis of Safety in 403 Patients

Background: The Earfold system, a new treatment for the correction of prominent ears, consists of 3 components: the Earfold implant, the Earfold introducer, and the Prefold positioner. Methods: This is an interim report based on an ongoing analysis of safety in a series of patients treated for prominent ears with the Earfold implant between February 2013 and September 2014. Safety was assessed based on adverse event reports and the need for implant revision; follow-up is ongoing. Results: Seven surgeons used 1,200 Earfold implants to treat 403 patients (ages, 7–70 years; 63% male); the time since the initial implant procedure now ranges from 30 to 48 months. To date, 145 patients (36%) have returned for a follow-up visit (mean, 7.7 months [range, 1–34 months]). Adverse events requiring intervention have affected 39 of 403 (9.7%) patients; these include implant revisions (n = 17 [4.2%], most often due to implant visibility), skin erosion over the implant (n = 15 [3.7%]), and infection (n = 7 [1.7%]). Bleeding, recurrence of prominence, hematoma, deformity, or adverse scarring did not occur. Conclusions: This interim analysis has shown that Earfold prominent ear correction system is associated with relatively few adverse events that require intervention; a small number of patients experienced infection, implant extrusion, or implant visibility that required revision. Most adverse events were related to either patient selection or technical errors at implantation. It is expected that with continued use of Earfold by surgeons experienced in otoplasty, the adverse event incidence will decrease.

Incisional Negative Pressure Wound Therapy for Prevention of Wound Healing Complications Following Reduction Mammaplasty

Background: It has been proposed that negative pressure wound therapy (NPWT) applied prophylactically to a closed incision may decrease the incidence of wound complications. Patients undergoing reduction mammaplasty are at risk of wound complications such as delayed healing, infection, and dehiscence, and the bilateral nature of the surgery allows for a within-patient randomized study to evaluate incisional NPWT's effect in reducing healing complications. Methods: In this multicenter trial, 200 patients undergoing bilateral reduction mammaplasty were treated with PICO Single-Use NPWT System or standard wound-care dressings randomized to right or left breast for up to 14 days to enable within-patient comparison. Follow-up assessments were conducted to evaluate the difference in incision healing complications up to 21 days postsurgery. Healing complications (for the primary endpoint) were defined as delayed healing (incision not 100% closed by 7 days) and occurrence of dehiscence or infection within 21 days. Individual healing complications were assessed separately as secondary endpoints. Results: Significantly fewer healing complications (primary endpoint) were noted in NPWT-treated breasts [113 (56.8%)] versus standard care [123 (61.8%)]. The difference of 10 (5.0%) patients with fewer healing complications using NPWT was statistically significant (P = 0.004). NPWT also resulted in a significantly lower incidence of dehiscence (secondary endpoint) compared with standard care [32 patients (16.2%) versus 52 patients (26.4%)] by day 21, a relative reduction of 38% (P

Single-Stage Breast Reconstruction Using an All-In-One Adjustable Expander/Implant

Background: When tissue expansion is necessary in breast reconstruction, a single-stage approach is possible using adjustable expander/implants, with or without the use of acellular dermal matrix. We aimed to present the senior author's single-stage experience over a period of 12 years using combined expander/implants in breast reconstruction. Methods: This is a Single-institution, retrospective review of breast reconstruction with combined expander/implants from 2002 to 2014. Logistic regression was performed to evaluate the impact of multiple variables on long-term outcomes. Results: A total of 162 implants in 105 patients were included in this study. Mean follow-up time was 81.7 months (SD, ± 39.2; range, 15–151). Complication rates were as follows: 0.62% extrusion, 1.2% mastectomy flap necrosis, 1.2% hematoma, 1.9% dehiscence, 2.5% seroma, 4.9% infection, and 15.4% deflation. The following associations were identified by logistic regression: adjuvant radiotherapy and capsular contracture (P = 0.034), tumor size and deflation (P = 0014), and smoking history and infection (P = 0.013). Conclusions: Overall, 81% of breasts were successfully reconstructed in a single stage. Single-stage reconstruction using all-in-one expander/implants reduces costs by eliminating the need for a second procedure under general anesthesia and can achieve results comparable with other alloplastic reconstructions reported in the literature.

Latissimus Dorsi and Immediate Fat Transfer (LIFT) for Complete Autologous Breast Reconstruction

Background: Despite the popularity of latissimus dorsi (LD) flap in breast reconstruction, a breast implant is often necessary to achieve sufficient volume. Prior reports describe fat grafting to the LD flap as a secondary procedure to correct contour deformities and improve volume. Our institution has instituted autologous breast reconstruction with an LD flap and immediate fat transfer (LIFT). Methods: A retrospective review of all patients undergoing the LIFT procedure was undertaken. Patient age, total volume of fat transfer, length of follow-up, need for adjuvant therapy, and complications were recorded. The procedure begins with harvest of the LD flap and fat. Prior to disorigination of the latissimus muscle, fat is injected into the flap. Flap harvest is then completed and inset to create a breast mound. Results: Eighteen patients underwent LIFT procedures over 3 years with an average follow-up of 8.7 months (range, 2–24). Four breasts (22.2%) had previously received adjuvant radiation therapy. The mean total fat grafting volume was 515.5 mL (range, 325–730) per breast. The average estimated fat graft take was 66.8% (range, 50–80%). Four patients (22.2%) experienced complications. Conclusion: Autologous augmentation of the LD flap with lipotransfer has been used to avoid placement of an implant. We improve the technique by performing lipotransfer during index reconstruction. Furthermore, we perform lipotransfer prior to disorigination of the LD muscle to minimize trauma to the flap and increase the efficiency of fat grafting. Our experience demonstrates that this technique is a viable autologous alternative to microsurgical breast reconstruction.

Virtual Surgical Planning: The Pearls and Pitfalls

Objective: Over the past few years, virtual surgical planning (VSP) has evolved into a useful tool for the craniofacial surgeon. Virtual planning and computer-aided design and manufacturing (CAD/CAM) may assist in orthognathic, cranio-orbital, traumatic, and microsurgery of the craniofacial skeleton. Despite its increasing popularity, little emphasis has been placed on the learning curve. Methods: A retrospective analysis of consecutive virtual surgeries was done from July 2012 to October 2016 at the University of Montreal Teaching Hospitals. Orthognathic surgeries and free vascularized bone flap surgeries were included in the analysis. Results: Fifty-four virtual surgeries were done in the time period analyzed. Forty-six orthognathic surgeries and 8 free bone transfers were done. An analysis of errors was done. Eighty-five percentage of the orthognathic virtual plans were adhered to completely, 4% of the plans were abandoned, and 11% were partially adhered to. Seventy-five percentage of the virtual surgeries for free tissue transfers were adhered to, whereas 25% were partially adhered to. The reasons for abandoning the plans were (1) poor communication between surgeon and engineer, (2) poor appreciation for condyle placement on preoperative scans, (3) soft-tissue impedance to bony movement, (4) rapid tumor progression, (5) poor preoperative assessment of anatomy. Conclusion: Virtual surgical planning is a useful tool for craniofacial surgery but has inherent issues that the surgeon must be aware of. With time and experience, these surgical plans can be used as powerful adjuvants to good clinical judgement.

Suture Technique to Prevent Air Leakage during Negative-Pressure Wound Therapy in Fournier Gangrene

Background: The use of negative-pressure wound therapy (NPWT) for Fournier gangrene management is well documented; however, it is difficult to fixate GranuFoam dressings and maintain an airtight seal over the perineum area. We developed a simple method to facilitate GranuFoam fixation and improve airtight sealing. Methods: The Fournier's gangrene severity index (FGSI) score less than 9 was collected in from January 2015 to October 2016. All 13 patients underwent fasciotomy, and NPWT was applied directly on fasciotomy wounds after the debridement of infected tissue. Partial wound closure was performed, and a portion of GranuFoam was inserted to facilitate fixation. The seal check was converted to a 0–10 scale score that was recorded every 4 hours during NPWT. Patient profiles including medical history, FGSI, method of wound closure, and length of stay were collected in this study. Results: The median age of the patients was 62 (38–76) years. The mean FGSI score was 4.3 ± 3.1. The average duration of NPWT was 17.5 ± 11.5 days, and the average seal check score was 0.8 ± 0.5. No seal check alarms were noted during the study. Successful wound closure was achieved in all patients without using additional reconstruction methods such as skin grafting or muscle flap coverage. Conclusions: The present results suggest that partial wound-edge closure and in situ GranuFoam fixation improve the NPWT leaks in Fournier gangrene wounds. Furthermore, this method is simple to learn and can be useful in applying NPWT to anatomically difficult areas.

Enhanced Preoperative Deep Inferior Epigastric Artery Perforator Flap Planning with a 3D-Printed Perforasome Template: Technique and Case Report

Summary: Optimizing preoperative planning is widely sought in deep inferior epigastric artery perforator (DIEP) flap surgery. One reason for this is that rates of fat necrosis remain relatively high (up to 35%), and that adjusting flap design by an improved understanding of individual perforasomes and perfusion characteristics may be useful in reducing the risk of fat necrosis. Imaging techniques have substantially improved over the past decade, and with recent advances in 3D printing, an improved demonstration of imaged anatomy has become available. We describe a 3D-printed template that can be used preoperatively to mark out a patient's individualized perforasome for flap planning in DIEP flap surgery. We describe this "perforasome template" technique in a case of a 46-year-old woman undergoing immediate unilateral breast reconstruction with a DIEP flap. Routine preoperative computed tomographic angiography was performed, with open-source software (3D Slicer, Autodesk MeshMixer and Cura) and a desktop 3D printer (Ultimaker 3E) used to create a template used to mark intra-flap, subcutaneous branches of deep inferior epigastric artery (DIEA) perforators on the abdomen. An individualized 3D printed template was used to estimate the size and boundaries of a perforasome and perfusion map. The information was used to aid flap design. We describe a new technique of 3D printing a patient-specific perforasome template that can be used preoperatively to infer perforasomes and aid flap design.

Microsurgical Engineering: Bilateral Deep Inferior Epigastric Artery Perforator Flap with Flow-Through Intraflap Anastomosis

Squamous cell carcinoma (SCC) of the head and neck affects a significant number of people around the world every year. Treatment generally entails surgical resection, radiotherapy, chemotherapy, or some combination of the three. Following resection, microsurgical reconstruction can provide definitive coverage, replace many tissue types simultaneously, and bring healthy tissue to irradiated wound beds. Microsurgical engineering, the manipulation and reorganization of native vascular tissue, can further augment the adaptability of free tissue transfer to complex, compromised wound beds. We present one such case. The patient described in the following report was treated for a recurrent SCC of the left face, which required extensive resection resulting in a complex, composite tissue defect with compromised vascular supply. Using the principals of microsurgical engineering, definitive coverage of the defect, with accept- able aesthetic result, was achieved via bipedicle, DIEP flap with flow-through intraflap anastomosis.

Quality Improvement in Facial Transplantation: Standard Approach for Novel Procedures

No abstract available

The Pedicled LICAP Flap Combined with a Free Abdominal Flap In Autologous Breast Reconstructions

Background: Previous surgery or slim body configuration can limit the size of the available abdominal flap in autologous breast reconstruction. However, redundant skin and subcutaneous tissue lateral to the mastectomy site can be utilized as the pedicled lateral intercostal artery perforator (LICAP) flap. This study evaluates the combination of a free abdominal flap and a pedicled LICAP flap to achieve increased breast size and improved cosmetic outcome. Methods: Patients undergoing secondary autologous breast reconstruction were included in a prospective study. The combination with a LICAP flap was used for women with insufficient abdominal flap tissue in relation to the desired breast size. The authors also assessed their modification of the original lateral thoracodorsal flap design to improve the aesthetic outcome. Results: In 109 patients, 121 free abdominal flaps were performed. The combination with a pedicled LICAP flap was used in 82 free abdominal flap reconstructions (68%). The LICAP flap provided additional volume and resulted in better projection and ptosis of the neo-mamma. The overall complication rate for the LICAP flaps was 26 %; all minor complications. Despite combining flaps, the majority of patients needed additional surgery to improve breast symmetry. Breast reduction of the native breast was the most common symmetrizing procedure. Conclusion: In selected patients with insufficient abdominal flap tissue, a combination of a free abdominal flap and a pedicled LICAP flap is a valuable option to increase breast size and cosmetic outcome. Additional symmetrizing surgery might still be necessary.

Free Flap Survival Despite Internal Jugular Vein Thrombosis in Head and Neck Reconstruction

Summary: Microvascular free tissue transfer is one of the most common techniques of reconstruction for complex head and neck surgical defects. Generally, venous thrombosis is more likely to occur than arterial thrombosis in vascular anastomosis. Thus, recipient veins must be chosen carefully. Although the internal jugular vein is preferred as a recipient vein by many microsurgeons, internal jugular vein thrombosis is a potential complication, as shown in our report. Therefore, we consider that the external jugular vein still is an option as a recipient for venous anastomosis and that it is better to perform multiple vein anastomoses with 2 different venous systems, such as the internal and external jugular systems, than anastomoses within the same venous system.

Hinge Flap with Triangular Extension for Reconstruction of Pharyngocutaneous and Laryngocutaneous Fistulas

Summary: Hinge flaps are commonly used for closure of a pharyngocutaneous fistula (PCF) or laryngocutaneous fistula. These flaps are employed to augment the wall of the pharynx or larynx, but the junction between the reconstructed and native lumens can eventually become narrow and irregular after reconstruction with standard hinge flaps. We devised a method of adding a triangular extension to the end of either or both flaps and used it to treat 3 patients. In 1 patient who developed a PCF (4 × 10 cm) after laryngectomy followed by radiotherapy, the fistula was closed with 2 hinge flaps. One flap had a caudal triangular extension. The residual skin defect was covered by a pedicled latissimus dorsi musculocutaneous flap. Another patient who developed a PCF (2.5 × 3 cm) after laryngectomy underwent 2-stage reconstruction using a buccal mucosal graft with a triangular extension, followed by 2 hinge flaps. A patient who developed an laryngocutaneous fistula (1 × 2 cm) after radiotherapy and subsequent partial laryngectomy underwent reconstruction using 2 hinge flaps, each of which had a triangular extension. The skin defect was covered by another flap. Postoperative CT or video fluoroscopic examination of swallowing showed a smooth lumen with no strictures in all 3 patients. The triangular extension of the hinge flap supplements the pharyngeal/laryngeal wall at the junction between the reconstructed and intact regions, thus avoiding postoperative stricture. Especially with PCF reconstruction, restoration of a smooth luminal surface minimizes dysphagia.

Successful Hand Replantation in a Case of Total Avulsion without Vein Graft

Summary: Replantation is the reattachment of a severed body part, with attempts to restore neurovascular and musculoskeletal integrity, function, and aesthetics. On September 7, 1964, the first extremity replantation—a completely amputated hand—by vascular anastomosis technique was successfully performed.1 Soon after, the first replantation of a complete thumb amputation using microvascular anastomosis in a human was successfully conducted by Komatsu et al.2 in 1968. The overall success rate of limb replantation surgery is around 83.2%.3 The mechanism of injury plays a role in the outcome; guillotine amputations—for example—carry a better prognosis than crush amputations.4 We present a case report of a 36-year-old male patient who presented with a total avulsion of the right hand with multiple fracture levels at the level of trans-carpal, distal radius extra-articulation fracture, and total avulsion of the hand. The patient was managed by a multidisciplinary team who were able to reattach his hand successfully with good functional outcome.

Changes in Sunken Eyes Combined with Blepharoptosis after Levator Resection

Background: This study aims to report the changes in sunken eyes combined with blepharoptosis after levator resection. Methods: Analysis involved 60 eyes from 32 patients with sunken eyes combined with blepharoptosis. Advancement of the levator aponeurosis and the Müller's muscle complex (levator resection) was performed in these patients. Area of upper eyelid sulcus (AES) was defined as the area of the upper eyelid shadow. The digital images were converted to black and white using image-processing software (Adobe Photoshop), and the AES was calculated using ImageJ software. In addition, margin reflex distance, eyebrow height (EBH), and AES were measured before and 3 months after surgery to assess the changes in the eyelids. Results: Preoperative AES was significantly correlated to age (P

Efficacy of Vancomycin-based Continuous Triple Antibiotic Irrigation in Immediate, Implant-based Breast Reconstruction

Background: Single irrigation of the peri-implant space with a cefazolin-based triple antibiotic solution is a routine antibiotic prophylaxis measure during implant-based breast augmentation and reconstruction. Cefazolin, however, is less efficacious against resistant Staphylococcus species, which are the predominant bacterial species isolated from the peri-implant space. Vancomycin is effective against resistant Staphylococcus species and may be a more appropriate prophylactic agent. The availability of single-injection long-acting anesthetic agents allows the novel use of the elastomeric infusion pump for continuous irrigation of antibiotic solution into the peri-implant space. The efficacy of continuous irrigation with a vancomycin-based solution is evaluated here. Methods: Study patients (N = 163; group 1) who underwent immediate, direct-to-implant breast reconstruction received continuous infusion of a vancomycin-based triple antibiotic solution. Patients also received a single injection of liposomal bupivacaine in the pectoralis major/minor muscles for pain control. A historic control group (N = 113; group II) received ropivacaine local anesthetic via the infusion pump and a single intraoperative irrigation of the peri-implant space with the vancomycin-based triple antibiotic solution. Incidence of postsurgical infection during the 6 weeks after surgery was compared between the groups. Results: Group I patients had a statistically significant lower incidence of infections (1.9%) than group II patients (6.4%) (P = 0.007). There were no vancomycin-related adverse effects. Conclusions: Continuous breast irrigation with a vancomycin-based triple antibiotic solution is a safe and effective accompaniment for immediate implant reconstruction. Use of intramuscular anesthetic injection for postoperative pain control allows the elastomeric infusion pump to be available for local tissue antibiotic irrigation.

A Modified Bilhaut–Cloquet Procedure for Zigzag Thumb Polydactyly Types III and IV

Background: A review of the English literature over the least 43 years revealed only a total of 53 cases of Wassel types III, IV, and VII treated by the Bilhaut–Cloquet (B–C) procedure. Furthermore, the detailed results and range of motion were only given in 2 series (a total of 9 cases). Methods: Four cases of Wassel types III and IV thumb duplications with zigzag deformity were treated with a modified B–C procedure. The main modification was minimal central resections at the joints aiming for joint preservation to improve the postoperative range of motion of the new thumb. Results: The results showed an excellent overall functional score (Tada score of 5 of 5 in all cases). The mean range of motion at the metacarpophalangeal joint was excellent (60°), but the mean at the interphalangeal joint was only 20°. Cosmetically, all thumbs were "too wide" and a panel of 3 hand surgeons scored the cosmetic result (0–10 scoring system) between 5.7 and 6.7. No secondary procedures were done, and all parents were "very satisfied" despite the wide thumbs and split nails. This was attributed to the presence of an ugly preoperative zigzag appearance, and hence the comparative postoperative appearance was satisfactory. Conclusion: The modified B–C procedure gives a satisfactory function, but the cosmetic outcome is suboptimal.

Arsenite removal from contaminated water by precipitation of aluminum, ferrous and ferric (hydr)oxides

Abstract

Several methods to remove arsenic from water have been considered, including co-precipitation with Fe and Al (hydr)oxides. Such compounds are considered very effective to remove As from contaminated water due to strong bindings between them. Three Fe:Al molar ratios (100:0, 80:20, and 60:40) were used to synthesize aluminum, ferrous, and ferric (hydr)oxides by precipitation in water highly contaminated with arsenite (50 and 500 mg L⁻¹). The method was very efficient for all treatments (> 93%) at the beginning of the incubation period, excepted the one with 60:40 Fe(II):Al molar ratio at the higher As concentration (500 mg L⁻¹) in which gibbsite was identified in precipitated phases. In spite of the high efficiency, however, the threshold for drinking water was not attained, mainly to the higher As concentration, even 84 days after precipitation. At this high concentration of arsenite, even the required threshold for effluent discharge was not attained in some treatments. The sludge resulting from treatments with higher As concentration were considered hazardous according to results from leaching test and corroborated by BCR extractions. Arsenic associated with Al and adsorbed phases were also assessed by extractions with NH₄F and KH₂PO₄, respectively. In general, the presence of Al increased the efficiency as well as the stability of the sludge resulting from Fe (II) treatments, but did not affect Fe (III) treatments, which were more efficient for As removal.

Cochlear dead regions: Using the Threshold Equalising Noise (TEN) test to improve the assessment of potential cochlear implant candidates – The Oxford experience

Abstract

The Threshold Equalising Noise (TEN) test can be used to detect cochlear dead regions

Patients with cochlear dead regions may gain limited benefit from conventional amplification

The TEN test can be used to assess selected cochlear implant candidates who do not meet pure tone audiometry criteria for implantation

Our patients with cochlear dead regions had good outcomes following cochlear implantation

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Mytilus galloprovincialis (Lamarck, 1819) spermatozoa: hsp70 expression and protamine-like protein property studies

Abstract

In this work, we describe results of the reproductive health monitoring studies in Mytilus galloprovincialis following spermatozoa hsp70 expression and protamine-like protein properties. Mussels control (ctr) were released within cages for 30 days in three different marine sites near Naples (Campania, Italy): Bagnoli south (BAs) and Bagnoli north (BAn), both close to a disposal metallurgical factory and in Capo Miseno (CM). Studies of hsp70 gene expression carried out, by RT-qPCR, in mussel spermatozoa have shown varied expression levels, particularly 5, 13, and 15-fold more than ctr in CM, BAs, and BAn, respectively, indicating highest involvement of stress proteins in spermatozoa of mussels in Bagnoli. In order to evaluate the possible risk on Mytilus galloprovincialis sustainability loss, electrophoretic analyses were performed on protamine-like proteins (PL) of collected spermatozoa. The results showed that CM PL were apparently unaltered with respect to ctr PL, while BAs and BAn PL appeared in part in the form of peptides and in part as bands with low mobility. Further, CM and BAs PL showed, by electrophoretic mobility shift assay, a decrease in DNA binding ability and a change in their DNA binding mode. The results of this investigation show the usefulness of the study of alterations of spermatozoa hsp70 expression and protamine-like protein properties for eco-toxicological evaluation using Mytilus galloprovincialis as a bioindicator.

Probabilistic risk assessment of the effect of acidified seawater on development stages of sea urchin ( Strongylocentrotus droebachiensis )

Abstract

Growing evidence indicates that ocean acidification has a significant impact on calcifying marine organisms. However, there is a lack of exposure risk assessments for aquatic organisms under future environmentally relevant ocean acidification scenarios. The objective of this study was to investigate the probabilistic effects of acidified seawater on the life-stage response dynamics of fertilization, larvae growth, and larvae mortality of the green sea urchin (Strongylocentrotus droebachiensis). We incorporated the regulation of primary body cavity (PBC) pH in response to seawater pH into the assessment by constructing an explicit model to assess effective life-stage response dynamics to seawater or PBC pH levels. The likelihood of exposure to ocean acidification was also evaluated by addressing the uncertainties of the risk characterization. For unsuccessful fertilization, the estimated 50% effect level of seawater acidification (EC50_SW ) was 0.55 ± 0.014 (mean ± SE) pH units. This life stage was more sensitive than growth inhibition and mortality, for which the EC50 values were 1.13 and 1.03 pH units, respectively. The estimated 50% effect levels of PBC pH (EC50_PBC ) were 0.99 ± 0.05 and 0.88 ± 0.006 pH units for growth inhibition and mortality, respectively. We also predicted the probability distributions for seawater and PBC pH levels in 2100. The level of unsuccessful fertilization had 50 and 90% probability risks of 5.07–24.51 (95% CI) and 0–6.95%, respectively. We conclude that this probabilistic risk analysis model is parsimonious enough to quantify the multiple vulnerabilities of the green sea urchin while addressing the systemic effects of ocean acidification. This study found a high potential risk of acidification affecting the fertilization of the green sea urchin, whereas there was no evidence for adverse effects on growth and mortality resulting from exposure to the predicted acidified environment.

Behavioral and mutagenic biomarkers in tadpoles exposed to different abamectin concentrations

Abstract

It is known that pesticides such as abamectin (ABA) present cytotoxic effects on target organisms; however, the effects from ABA on non-target organisms such as amphibians are poorly understood. The aim of the current study is to investigate whether the exposure of Lithobates catesbeianus tadpoles to different abamectin concentrations [12.5, 25, and 50% of the median lethal concentration (LC₅₀)] leads to behavioral and morphological changes and/or generates possible cytotoxic effects. The aggregation test showed that tadpoles exposed to the highest ABA concentrations did not respond to the stimulus from non-familial and unrelated co-specific species. On the other hand, there was no difference in the total number of crossings in the central line of the herein adopted apparatus between groups; it suggests that ABA did not affect animal locomotion in the aforementioned test, although changes in the normal swimming pattern of tadpoles exposed to the pesticide were recorded in the swimming activity test. In addition, the herein exposed animals did not respond to the predatory stimulus in the antipredator response test; this result suggests defensive response deficit caused by the pesticide. With respect to their oral morphology, tadpoles exposed to ABA presented the lowest scores for mandibular pigmentation and structures, as well as for dentition condition. Finally, it was possible seeing that the exposure to ABA, even at the lowest concentration (12.5% of the LC₅₀), resulted in nuclear changes in the erythrocytes of the animals; these changes became evident in the increased number of micronuclei and in other nuclear abnormalities. Thus, besides confirming the cytotoxic potential of ABA in amphibians, the current study corroborates the hypothesis that the exposure to the herein investigated pesticide leads to behavioral and morphological changes in tadpoles, fact that may negatively reflect on the survival, as well as on natural populations of these individuals.

Introduction

Preface

Concerning the Apperception of Robot-Assisted Childcare

Abstract

This essay looks askance at how robot-assisted childcare is constructed in the public domain of the Internet. Complex interactions of rhetorical manoeuvres, narratives and postnarrativity, and semiotic slippages may channel the apperception of this application of robotics. The prospect of robots in childcare roles is exceptionally contentious, for it connotes interference with the child-caregiver attachment bond. The industry's response to psychology-informed concerns is to 'rebrand' the product as a robot companion for a child or as a home robot for the family. A technocentric bias in information disseminated online creates an illusion of expertise and may endorse technology-driven morality.

Effects of high fluoride content in livestock drinking water on milk samples of different cattle in endemic area of Pakistan: risk assessment for children

Abstract

Fluoride in trace quantity is beneficial for human beings, serving to strengthen the apatite matrix of skeletal tissues and teeth, whereas high intake causes adverse impacts. In the present study, the effect of fluoride-contaminated drinking water of livestock on the milk samples of different cattle, belonging to a fluoride-endemic area (Tharparkar, Pakistan), was studied. In milk samples of different cattle (cows, camels, sheep, and goats), free and bound fluoride forms and its total (free (F⁻) + bound (F⁻)) contents were measured by ion-selective electrode. The concentration of fluoride in drinking water of livestock was also analyzed, as found in the range of 11.8–33.5 mg/L. The concentration of total fluoride in the milk samples of sheep, goats, cows, and camels were observed in the range of 1.72–2.43, 1.40–2.03, 0.835–1.41, and 0.425–0.897 mg/L, respectively. The resulted data indicated that the concentration of fluoride was higher in the milk samples of smaller cattle (sheep and goat), as compared to cow and camel. The fluoride in milk samples of all cattle appeared dominantly in free form. The percentage values of bound fluoride in the milk samples of sheep, goats, and cows were found to be 6.76, 11.6, and 19.7% in total, respectively, while in camel milk, the percentage was below the detection limit. The estimated daily intake of fluoride contents on consuming different types of milk by children age ranged 1.0 to 3.0 years was evaluated.

Graphical abstract

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Associations between respiratory health and ambient air quality in Canakkale, Turkey: a long-term cohort study

Abstract

Few epidemiological studies investigating the association between air pollution and health are available in Turkey. The aim of this cohort-type study is to examine the relationships between ambient air quality, respiratory diseases, and decreases in pulmonary function over a year in three different towns in Canakkale: Canakkale Central town (region I), Lapseki town center (region II), and Can town (region III). Region III had four different sub-regions, which were Can town center (region III-A), and the villages located around Can town, namely Durali (region III-B), Kulfal (region III-C), and Yuvalar (region III-D). In the first stage of the study, a detailed questionnaire was completed by the participants (n = 1152) in face-to-face interviews and pulmonary function test (PFT) was performed. In the second stage of the study, PFT measurements were repeated 1 year after the first stage. Particulate matter, SO₂, NO₂, and ozone were gathered from air quality monitoring stations located in the centers of the three regions. The most polluted area was region III, while region I and region II were the least polluted areas. The risk of pulmonary function decline throughout a year was 2.1 times higher in region III, 2.4 times higher both in regions III-B and III-C, and 1.6 times higher for smokers in all regions. In the present study, ambient air quality was worse in region III (industrialized region), which influenced PFT scores and the prognostics for chronic respiratory diseases. The findings of this study should be considered for future investment plans in this region related to human and environmental health needs.

Intermittent flux from a sand filter for household wastewater and integrated solute transfer to the vadose zone

Abstract

Depending on the actual number of soil-based on-site wastewater treatment system (OWTS) in an area, on-site sanitation may be a significant source of pollutants and a threat to groundwater. Even in the case of a system functioning correctly, here, a sand filter substituted for the in-situ soil, as the treated effluent may reach to the water table, it is necessary evaluating in situ how much the sand and underneath soil respectively contribute to pollutant removal. On the plot of a household in a small rural community, the functioning of a real scale OWTS was monitored for 1.5 years. This system, composed of a septic tank connected to a 5 × 5 m² and 0.7-m thick aerobic sand filter was equipped with soil hydrodynamic probes (water content and matrix potential) during construction. By using the instantaneous profile method of water content, the intermittent infiltrated flux was determined across the sand-pack according to position and time. Treated water infiltrates into underneath soil acting as post-treatment. Quality of interstitial liquid from the sand and the soil was analysed each month on a 12-h pumping sample obtained through porous plates. Results of water fluxes and concentrations provide an estimate of the annual flux to the vadose zone and groundwater of metals, nutrients and some organic micro-pollutants (parabens and triclosan) through the OWTS and subsoil.

Removal of helminth eggs by centralized and decentralized wastewater treatment plants in South Africa and Lesotho: health implications for direct and indirect exposure to the effluents

Abstract

Wastewater may contain contaminants harmful to human health; hence, there is the need for treatment before discharge. Centralized wastewater treatment systems are the favored treatment options globally, but these are not necessarily superior in reduction of pathogens as compared to decentralized wastewater treatment systems (collectively called DEWATS). This study was therefore undertaken to assess the soil-transmitted helminth (STH) and Taenia sp. egg reduction efficiency of selected anaerobic baffled reactors and planted gravel filters compared to centralized wastewater treatment plants in South Africa and Lesotho. The risk of ascariasis with exposure to effluents from the centralized wastewater treatment plants was also assessed using the quantitative microbial risk assessment (QMRA) approach. Eggs of Ascaris spp., hookworm, Trichuris spp., Taenia spp., and Toxocara spp. were commonly detected in the untreated wastewater. The DEWATS plants removed between 95 and 100% of the STH and Taenia sp. eggs, with centralized plants removing between 67 and 100%. Helminth egg concentrations in the final effluents from the centralized wastewater treatment plants were consistently higher than those in the WHO recommended guideline (≤ 1 helminth egg/L) for agricultural use resulting in higher risk of ascariasis. Therefore, in conclusion, DEWATS plants may be more efficient in reducing the concentration of helminth eggs in wastewater, resulting in lower risks of STH infections upon exposure.

Effect of water motion and microhabitat preferences on spatio-temporal variation of epiphytic communities: a case study in an artificial rocky reef system, Laoshan Bay, China

Abstract

Epiphytic fauna community structure is mainly determined by macro-scale environmental characteristics (e.g., water motion), whereas the influences of, and interaction with, micro-scale habitat-forming species are not well known. In order to explore the effects of water motion and functional macroalgal group on the community structure of epiphytic faunas, macroalgae and epiphytic faunas from four isolated artificial rocky reefs with different levels of hydrodynamic conditions were investigated in Laoshan Bay of China. A total of 32 macroalgal species and 22 faunal species were recorded on the surveys. The biomass and abundance of macroalgae and epiphytic faunas showed significant variations among stations and months. The biomass and abundance of epiphytic faunas were highest at outer Huangshankou station (H1) with medium hydrodynamic force. The lowest biomass of epiphytic faunas occurred at inner Huangshankou station (H3) with highest level of water motion, while the lowest abundance of epiphytic faunas occurred at Liepo station (L) with lowest level of water motion. Results showed that medium water motion level contributed to increasing biodiversity of epiphytic faunas. Epiphytic communities generally presented higher biomass and abundance in summer than in spring or autumn, which indicated temperature could be the ecological driver for temporal variation of epiphytic communities. The epiphytic faunas showed distinct preferences to structural morphology of macroalgae which forms suitable habitat for these organisms. This study suggests that artificial rocky reefs are of great significance to restore and maintain coastal biodiversity, and appropriate physical disturbance promote community reestablishment.

Should de-escalation of bone-targeting agents be standard of care?

Correction to: The argument from almost indiscernibles

Abstract

In pages 3005 (abstract), 3006 and 3019, there is a sentence that begins: "If the premise lacks support, the argument does not establish the possibility of almost indiscernibles…"

Kinetic release of arsenic after exogenous inputs into two different types of soil

Abstract

The mobility of arsenic (As) in soil depends on its sorption/desorption processes on soil particles. Plant uptake locally lowers As concentration in soil pore water, which would trigger resupplies of As from soil solid phase. To better understand the fate of As in soil system after its inputs into soil and its subsequent dynamic processes, diffusive gradients in thin films (DGT) technique along with DGT-induced fluxes in soils (DIFS) model were introduced to study the kinetic information of As in soils, including its response time (T_C) and resupply rate constant (k₋₁). To achieve a series of soils with gradient As level, two different types of soils with similar As level (total As in soil JL is 7.4 mg kg⁻¹, while in soil BJ is 6.5 mg kg⁻¹) were collected and amended with exogenous As. Then, DGT deployments were carried out following a period of 90-day soil incubation. The simulated T_C values in non-amended soil JL and soil BJ were 0.036 and 0.001 s⁻¹, respectively. The difference may due to the properties of these two soils, including pH values and contents of adsorption materials, such as Fe and Al compounds. After As inputs into soils, the intrinsic rate of As release from the solid phase to the solution phase in As-amended JL soil was much higher than that in non-amended soil. While for soil BJ, a decreasing trend was observed after As spiking. The redistribution of As may responsible for the different variation trends of As kinetics in these two soils after As spiking. The results indicated that the distribution coefficient of As (K_d) in soil was mainly affected by soil Olsen-P content due to an ubiquitous competition between P and As on soil particles.

Comparison of patient (POEM), observer (EASI, SASSAD, TIS) and corneometry measures of emollient effectiveness in children with eczema: findings from the COMET feasibility Trial

Abstract

Background

Eczema affects ~20% of children but multiple different outcome measures have hampered research into the effectiveness of different treatments.

Objectives

To compare the change in scores and correlations within and between five measures of eczema severity: Patient Orientated Eczema Measure (POEM), Eczema Area Severity Index (EASI), Six Area Six Sign Atopic Dermatitis (SASSAD), Three Item Severity (TIS), and skin hydration (corneometry).

Methods

Data from a feasibility trial that randomised young children with eczema to one of four emollients were used. Participants were followed for three months (84 days). Descriptive statistics (by emollient over time) and Spearman's correlation coefficients comparing scores at each time-point and absolute change (between adjacent time-points) for each outcome measure were calculated.

Results

197 children, mean age (SD) of 21.7 (12.8) months, were randomised. POEM and TIS appeared to capture a range of eczema severity at baseline but only POEM had close approximation to normal distribution. Mean POEM, EASI, SASSAD and TIS scores improved month-by-month, with POEM showing the greatest sensitivity (effect size 0.42). Correlations within POEM, EASI, SASSAD and TIS were moderate-to-good, decreasing over time. Correlations between measures were strongest for EASI, SASSAD and TIS. By contrast, corneometry scores were more variable, correlated less well over time, and were poorly correlated with the other measures.

Conclusions

Except for corneometry, all measures appear to change in relation to emollient use over time and correlate well with themselves. POEM demonstrated the greatest range of scores at baseline and change in eczema severity over the first 28 days.

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Cost-effectiveness of omalizumab for the treatment of Chronic Spontaneous Urticaria

Summary

Background

Chronic spontaneous urticaria (CSU) is a skin disease, with itchy hives and / or angioedema that last for at least 6 weeks without an obvious external trigger.

Objectives

The objective of this study was to determine the cost-effectiveness of omalizumab relative to standard of care (SoC; up to 4 times the daily dose of H1-antihistaminics) for the Netherlands from a societal perspective.

Methods

The Markov model used consisted of five health states based on Urticaria Activity Score over seven days (UAS7). Model settings and characteristics of the Dutch patient population were based on an online survey among clinical experts and were validated during an expert committee meeting. Transition probabilities were derived from the GLACIAL trial. Healthcare consumption, quality of life (using EQ-5D) and productivity losses were derived from a burden of illness study (ASSURE-CSU) among 93 Dutch patients. Healthcare consumption and productivity losses were valued using the Dutch costing manual. Comparator treatment was SoC, consisting of (up dosed) antihistamines. A ten-year time horizon was used.

Results

The incremental cost-effectiveness ratio (ICER) of omalizumab versus SoC was €17,502 per quality adjusted life year (QALY) gained. Productivity costs played an important role in the value of the ICER; discarding productivity costs resulted in an ICER of €85,310 per QALY.

Conclusions

Omalizumab is cost-effective compared to SoC. The outcomes of this study were used to establish omalizumab as third-line treatment in the Dutch treatment guidelines for CSU.

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A randomized split-scalp study comparing Calcipotriol assisted MAL-PDT with Conventional MAL-PDT for the treatment of Actinic Keratosis

Summary

Background

Topical photodynamic therapy (PDT) is an approved treatment for actinic keratosis (AK). To enhance the efficacy of PDT for AKs, physical (ablative lasers and microneedling) and chemical (pro-differentiating drugs) pretreatments have been suggested.

Objectives

To compare the efficacy and safety of the combination of topical calcipotriol (CAL) before methylaminolevulinate (MAL)-PDT for AKs of the scalp versus conventional MAL-PDT in a randomized controlled-clinical trial.

Materials and Methods

Twenty patients with multiple AKs on the scalp were randomized to receive conventional MAL - PDT with previous curettage on one side of the scalp and CAL – assisted MAL-PDT applied once a day for fifteen days before the illumination with red light-emitting diode (37J/cm²) on the other side. After three months, patients were evaluated for the clearance of AKs, side effects and histopathology before and after the procedure. Protoporphyrin IX (PpIX) fluorescence was measured before and after illumination on both sides.

Results

All twenty patients completed the study. Overall AK clearance was 92.07% and 82.04% for CAL-PDT and conventional PDT respectively (p< 0.001). The AKs grade I showed similar response rate of 92.83% and 87.29% (p=0.055) respectively for CAL and MAL-PDT sides. However, AKs grade II showed more improvement on the CAL-PDT side (89.55%) compared with MAL-PDT (62.90%) (p<0.001). Before illumination, PpIX fluorescence intensity was higher on the CAL-assisted side (p=0.048). The treatment was more painful on the CAL-PDT side, although well tolerated. The mean VAS score was 5.40±1.43 on the CAL-PDT side and 3.95±0.69 on the conventional MAL-PDT side (p=0.001). Side effects such as erythema (p=0.019), edema (p=0.002), crusts (p<0.001) were more pronounced on the CAL-assisted side. Histopathological analyses were obtained from five patients and both sides showed improved keratinocyte atypia following PDT, with a slight more improvement on CAL- assisted side.

Conclusion

CAL-assisted PDT proved to be safe and more effective than conventional MAL-PDT for the treatment of AKs on the scalp. CAL pretreatment increased PpIX accumulation within the skin and may have enhanced the efficacy in this first human trial. As this is the first CAL-assisted PDT study in human skin, further and larger trials are needed to corroborate our findings.

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