Surgical Team Trips to Vietnam: Implementation of a Dedicated Cleft Palate Perioperative Program Improves Fistula Rates

BACKGROUND

ReSurge International is a nongovernmental organization that organizes surgical team trips to low- and middle-income countries. Cleft palate repair is commonly performed on these trips. A comprehensive cleft care program was implemented to help reduce postoperative palatal fistula rates.

METHODS

A retrospective review of all patients undergoing cleft palate repair surgery with ReSurge International in Vietnam from 2013 through 2019 was performed. The cleft care program was implemented in 2018. This intervention involved preoperative education of patients and close postoperative monitoring. Critically, this program also provided closer access to providers. Subsequent follow-up was performed by a ReSurge physician. Parent-reported outcomes were assessed preoperatively and postoperatively using 5-point Likert-like survey questions.

RESULTS

Two hundred three patients underwent cleft palate repair. The patients were older and of higher Veau classification than is usually seen in the United States. The palatal fistula rate in the preintervention group was 37.5% and 14.3% in the intervention group (P = 0.014). Patients without fistulas demonstrated improvements on parent-reported outcomes compared with those with fistulas, with food less likely to go up their nose (P < 0.001), less difficulty eating (P < 0.001), and more understandable speech (P = 0.015).

CONCLUSIONS

Implementation of a comprehensive cleft palate program reduced postoperative fistula rates by more than 50%. Improvements in parent-reported outcomes were observed after surgery among patients without fistulas. The blueprint for improved outcomes in these more complex patients includes enhanced perioperative patient counseling, close follow-up, and maintenance of communication with patients.

Does Time to Definitive Treatment Matter in Patients with Ductal Carcinoma in Situ?

Little is known about factors influencing time between diagnosis and definitive treatment in patients with ductal carcinoma in situ (DCIS). We sought to determine the factors influencing this delay time and implications on outcome. A retrospective review was performed of 127 patients with DCIS who were treated with definitive surgical excision at an academic center from 2000 to 2003. The mean time from diagnosis of DCIS to definitive surgical treatment was 39.5 days (range, 3 to 130 days). Age, race, tumor grade, and histopathologic features were not associated with time to definitive treatment ( P > 0.05). However, patients who opted for breast-conserving surgery had a shorter time to definitive treatment compared with patients treated with mastectomy (mean time 32.9 vs 53.9 days, P < 0.001). Of patients undergoing mastectomy, those who opted for reconstruction did not have a prolonged time to treatment (55.0 vs 52.4 days, P = 0.880). Increased time between diagnosis and treatment (greater than 39.5 days) was not associated with worse prognosis in terms of overall survival (five-year actuarial survival: 93.0 vs 97.6%, P = 0.322). No demographic or histopathologic factors were associated with increased time to definitive treatment, although patients treated with mastectomy tended to have a longer diagnosis-to-treatment interval. However, the delay time was not associated with worse outcome.

The versatile free medial sural artery perforator flap: An institutional experience for reconstruction of the head and neck, upper and lower extremities

BACKGROUND

The medial sural artery perforator (MSAP) flap is an increasingly versatile and reliable flap for soft tissue reconstruction. This study investigates complication rates and long-term outcomes of the MSAP flap.

METHODS

A retrospective review was performed on consecutive patients undergoing MSAP flap reconstruction at Chang Gung Memorial Hospital from 2006 through 2017. Patient demographics were assessed. Flap failure and wound complications were the outcome measures.

RESULTS

In the cohort of 246 patients that underwent a total of 248 MSAP flap reconstructions were identified. The average age was 47.5 years (range 15-76). Of the 248 flaps, 170 were used for reconstruction of the head and neck, 48 for upper extremity reconstruction, and 30 for lower extremity reconstruction. The average MSAP flap size was 5.2 × 11.8 cm. 31 (12.5%) of the flaps developed arterial occlusion, venous insufficiency, or a hematoma postoperatively requiring re-exploration. Nineteen were successfully salvaged, yielding an overall failure rate of 4.8%. Minor complications included the need for flap debridement in 18 cases (7.3%) and need for donor site debridement in eight cases (3.2%).

CONCLUSIONS

The MSAP flap can be used in a versatile fashion to reconstruct defects of the head and neck, upper extremity, and lower extremity with minimal complication rates.

Use of hyaluronic acid filler for enhancement of nipple projection following breast reconstruction: An easy and effective technique

Background

Breast reconstruction improves the psychological well-being of patients with breast cancer. Patients who complete nipple-areolar reconstruction are even more satisfied with their final reconstructive result. Nipple flattening is a common complication. We hypothesized that injectable soft-tissue filler can be used to augment nipple projection in patients who underwent breast reconstruction.

Methods

This is a retrospective study of patients who underwent breast reconstruction and desired an enhanced postoperative nipple projection. The patients underwent a single session of injection with a hyaluronic acid filler as an outpatient. The filler was injected intradermally at the base of the nipple until the desired nipple projection was obtained.

Results

Twelve patients and 22 breasts were included in this study. Enhanced nipple projection was observed in all cases, with an average increase of 3.0 mm in nipple height (range 2.5-4.5 mm). All injected nipples remained soft to the touch. All results were stable at a median of 7.5 months follow-up. No complications were observed.

Conclusions

The use of injectable fillers for enhanced nipple projection is a useful adjunct treatment in patients undergoing breast reconstruction. Advantages include the ability to obtain nipple projection in patients who opt to forgo nipple-areola reconstruction with local flaps, to augment reconstructed nipples in patients with thin mastectomy skin flaps especially following implant-based reconstruction, and to improve projection of the native nipple following nipple-sparing mastectomy. Another benefit of this adjunct treatment is that the injection is reversible. Filler injection is a safe and simple solution to the problem of insufficient nipple projection.

Cost-Effectiveness Analysis of Humanitarian Hand Surgery Trips According to WHO-CHOICE Thresholds

PURPOSE

Hand surgery outreach programs to low- and middle-income countries (LMICs) provide much-needed surgical care to the underserved populations and education to local providers for improved care. The cost-effectiveness of these surgical trips has not been studied despite a long history of such efforts. This study aimed to examine the economic impact of hand surgery trips to LMICs using data from the Touching Hands Project and ReSurge International. We hypothesized that hand surgery outreach would be cost-effective in LMICs.

METHODS

We analyzed data on the cost of each trip and the surgical procedures performed. Using methods from the World Health Organization (WHO-Choosing Interventions That Are Cost-Effective [WHO-CHOICE]), we determined whether the procedures performed during the outreach trips would be cost-effective.

RESULTS

For the 14 hand surgery trips, 378 patients received surgical treatment. Trips varied in the country where interventions were provided, the number of patients served, the severity of the conditions, and the total cost. The cost per disability-adjusted life-year averted ranged from United States (US)$222 to $1,525, all of which were very cost-effective according to WHO-CHOICE thresholds. The cost-effectiveness of global hand surgery was comparable to that of other medical interventions such as multidrug-resistant tuberculosis treatment in similar regions. We also identified a lack of standardized record keeping for these surgical trips.

CONCLUSIONS

Hand surgeries performed in LMICs are cost-effective based on WHO-CHOICE criteria. However, a standardized record-keeping method is needed for future research and longitudinal comparison. Understanding the economic impact of hand surgery global outreach is important to the success and sustainability of these efforts, both to allocate resources effectively and to identify areas for improvement.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic/Decision Analysis III.

The unusual presentation of a burn from methyl bromide exposure: A case report and review of the literature

Methyl bromide chemical burns are rare. Only two cases have been reported to date. The presentation of methyl bromide chemical burns is unusual. Patients with an acute exposure should be observed closely as the initial presentation can appear deceptively benign. The latency period lasts several hours prior to the development of chemical burn wounds. In this article, we review the literature on methyl bromide chemical burns and present our experience managing a patient with an extensive methyl bromide burn.

Propylene Glycol Poisoning From Excess Whiskey Ingestion: A Case of High Osmolal Gap Metabolic Acidosis

In this report, we describe a case of high anion gap metabolic acidosis with a significant osmolal gap attributed to the ingestion of liquor containing propylene glycol. Recently, several reports have characterized severe lactic acidosis occurring in the setting of iatrogenic unintentional overdosing of medications that use propylene glycol as a diluent, including lorazepam and diazepam. To date, no studies have explored potential effects of excess propylene glycol in the setting of alcohol intoxication. Our patient endorsed drinking large volumes of cinnamon flavored whiskey, which was likely Fireball Cinnamon Whisky. To our knowledge, this is the first case of propylene glycol toxicity from an intentional ingestion of liquor containing propylene glycol.

Predictors of Recurrence in Patients Diagnosed with Ductal Carcinoma In Situ

Although patients diagnosed with ductal carcinoma in situ (DCIS) enjoy a favorable prognosis, recurrence after definitive management does occur in a subset of these patients. Factors influencing the development of recurrence remain poorly understood. A retrospective chart review of 205 consecutive patients who presented to an academic breast center with DCIS from 2000 to 2003 was conducted under an Institutional Review Board-approved protocol. With a median follow-up of 8.5 years, 14 (6.8%) of the 205 patients who presented with DCIS between 2000 and 2003 had a recurrence of their DCIS. The median age of all patients at the time of diagnosis of their initial DCIS was 55.5 years (range, 35.8 to 88.9 years). Patients who experienced tumor recurrence were more likely to have Grade 3 DCIS on initial diagnosis compared with patients without recurrence (72.7 vs 35.4%, P = 0.032). The odds ratio of tumor recurrence for high-grade compared with low-grade DCIS was 4.39. Patient age, race, tumor size, tumor histologic subtype, or histopathologic features was not associated with recurrence. Patients with high-grade DCIS are more likely to recur than patients with low-grade DCIS, and this seems to be more predictive of recurrence than other clinicopathologic markers.

Predictors of recurrence in patients diagnosed with ductal carcinoma in situ

Although patients diagnosed with ductal carcinoma In Situ (DCIS) enjoy a favorable prognosis, recurrence after definitive management does occur in a subset of these patients. Factors influencing the development of recurrence remain poorly understood. A retrospective chart review of 205 consecutive patients who presented to an academic breast center with DCIS from 2000 to 2003 was conducted under an Institutional Review Board-approved protocol. With a median follow-up of 8.5 years, 14 (6.8%) of the 205 patients who presented with DCIS between 2000 and 2003 had a recurrence of their DCIS. The median age of all patients at the time of diagnosis of their initial DCIS was 55.5 years (range, 35.8 to 88.9 years). Patients who experienced tumor recurrence were more likely to have Grade 3 DCIS on initial diagnosis compared with patients without recurrence (72.7 vs 35.4%, P = 0.032). The odds ratio of tumor recurrence for high-grade compared with low-grade DCIS was 4.39. Patient age, race, tumor size, tumor histologic subtype, or histopathologic features was not associated with recurrence. Patients with high-grade DCIS are more likely to recur than patients with low-grade DCIS, and this seems to be more predictive of recurrence than other clinicopathologic markers.

Use of imiquimod for residual acral melanoma

Recent reports suggest that topical imiquimod cream is an effective treatment option for certain types of melanomas. No reports exist on the efficacy of using imiquimod cream to treat melanoma located on the plantar surface of the foot. We present two patients with a melanoma of the foot who had residual melanoma following surgical excision with acceptable margins. The patients were then treated with topical imiquimod for 8 weeks after which a repeat biopsy of the affected region showed no evidence of residual melanoma in situ. The use of topical imiquimod cream should be considered in the management of residual melanoma in situ of the plantar surface of the foot.

Niche Reconstructive Techniques for Complex Abdominal Wall Reconstruction: A Review

Abdominal wall defects resulting from recurrent hernias, trauma, and radiation necrosis are difficult and challenging to repair given the high rates of recurrence and surgical morbidity. Complex abdominal wall defects often require the transposition of autologous material to bridge the fascial gap. We present a review of niche reconstructive techniques that have been used in complex abdominal wall repair. The specific techniques reviewed include use of delayed and tunneled pedicled tensor fascia lata myofascial flap, de-epithelialized flap closure, free latissimus dorsi myocutaneous flap with or without innervation, and abdominal wall transplant. These niche surgical techniques have great potential to reduce recurrence rates when used in the proper setting for complex abdominal wall reconstruction. More studies are needed to evaluate the relative use of these techniques with the more widely established surgical methods of reconstruction.

Niche reconstructive techniques for complex abdominal wall reconstruction: a review

Abdominal wall defects resulting from recurrent hernias, trauma, and radiation necrosis are difficult and challenging to repair given the high rates of recurrence and surgical morbidity. Complex abdominal wall defects often require the transposition of autologous material to bridge the fascial gap. We present a review of niche reconstructive techniques that have been used in complex abdominal wall repair. The specific techniques reviewed include use of delayed and tunneled pedicled tensor fascia lata myofascial flap, de-epithelialized flap closure, free latissimus dorsi myocutaneous flap with or without innervation, and abdominal wall transplant. These niche surgical techniques have great potential to reduce recurrence rates when used in the proper setting for complex abdominal wall reconstruction. More studies are needed to evaluate the relative use of these techniques with the more widely established surgical methods of reconstruction.

Leptin signaling and hyperparathyroidism: clinical and genetic associations

BACKGROUND

The role of leptin in mediating calcium-related metabolic processes is not well understood.

STUDY DESIGN

We enrolled patients with hyperparathyroidism undergoing parathyroidectomy in a prospective study to assess postoperative changes to serum leptin and parathyroid hormone levels and to determine the presence of LEPR (leptin receptor) polymorphisms. Patients undergoing hemithyroidectomy under identical surgical conditions were enrolled as controls. Wilcoxon signed-rank test was used to analyze changes in leptin. Pearson correlations and Bland-Altman methods were used to examine the between-subject and within-subject correlations in changes in leptin and parathyroid hormone levels. Five single-nucleotide polymorphisms in the LEPR gene were genotyped, and linear regression analysis was performed for each polymorphism.

RESULTS

Among the 71 patients included in the clinical study, after-surgery leptin levels decreased significantly in the parathyroid adenoma (p < 0.001) and parathyroid hyperplasia subgroups (p = 0.002) and increased in the control group (p = 0.007). On multivariate analysis, parathyroid disease subtype, baseline leptin levels, age, body mass index, and calcium at diagnosis was associated with changes in leptin. Among the 132 patients included in the genotyping analysis, under a recessive model of inheritance, single-nucleotide polymorphism rs1137101 had a significant association with the largest parathyroid gland and total mass of parathyroid tissue removed (p = 0.045 and p = 0.040, respectively). When analyzing obese patients only, rs1137100 and rs1137101 were significantly associated with total parathyroid size (p = 0.0343 and p = 0.0259, respectively).

CONCLUSIONS

Our results suggest a role for the parathyroid gland in regulating leptin production. Genetic contributions from the leptin pathway might predispose to hyperparathyroidism.

Does time to definitive treatment matter in patients with ductal carcinoma in situ?

Little is known about factors influencing time between diagnosis and definitive treatment in patients with ductal carcinoma in situ (DCIS). We sought to determine the factors influencing this delay time and implications on outcome. A retrospective review was performed of 127 patients with DCIS who were treated with definitive surgical excision at an academic center from 2000 to 2003. The mean time from diagnosis of DCIS to definitive surgical treatment was 39.5 days (range, 3 to 130 days). Age, race, tumor grade, and histopathologic features were not associated with time to definitive treatment (P > 0.05). However, patients who opted for breast-conserving surgery had a shorter time to definitive treatment compared with patients treated with mastectomy (mean time 32.9 vs 53.9 days, P < 0.001). Of patients undergoing mastectomy, those who opted for reconstruction did not have a prolonged time to treatment (55.0 vs 52.4 days, P = 0.880). Increased time between diagnosis and treatment (greater than 39.5 days) was not associated with worse prognosis in terms of overall survival (five-year actuarial survival: 93.0 vs 97.6%, P = 0.322). No demographic or histopathologic factors were associated with increased time to definitive treatment, although patients treated with mastectomy tended to have a longer diagnosis-to-treatment interval. However, the delay time was not associated with worse outcome.

Absence of aneuploidy and gastrointestinal tumours in a man with a chromosomal 2q13 deletion and BUB1 monoallelic deficiency

Chromosomal instability is a potentially critical step in the development of colorectal cancer. The budding uninhibited by benzimidazole 1 (BUB1) gene is a highly conserved protein that plays a critical role at the spindle assembly checkpoint during cell division. BUB1 mutations function in a dominant-negative fashion and have been implicated in causing dysfunctional kinetochore attachments, premature chromatid separation, accelerated mis-segregation of whole chromosomes and aneuploidy. BUB1 mutations have been observed in patients with colorectal cancers. We report a remarkable case of BUB1 haploinsufficiency owing to a 1.7 Mb deletion of chromosome 2q13 in a 54-year-old man with no prior history of carcinoma. These mutant alleles were observed in both tissue from the hand and peripheral blood. Aneuploidy was not observed on cytogenetic analysis. These findings highlight the insufficiency of BUB1 haploinsufficiency to directly stimulate tumourigenesis, and suggest that other factors may be more critical to this process.

Abstract P3-14-05: Recurrence in Patients Diagnosed with Ductal Carcinoma in Situ: Predictors and Prognostic Significance

Background: While patients diagnosed with ductal carcinoma in situ (DCIS) enjoy a favorable prognosis, recurrence after definitive management does occur in a subset of these patients. Factors influencing the development of recurrence, and the ultimate impact of this event on overall survival, remain poorly understood. We sought to determine clinicopathologic factors affecting recurrence and the prognostic role this plays in patients with DCIS.

Methods: A retrospective chart review of 205 consecutive patients who presented to an academic breast center with DCIS from 2000 to 2003 was conducted under an IRB-approved protocol. Non-parametric statistical analyses comparing patients who recurred to those who did not were then performed using SPSS Statistical Software.

Results: With a median follow-up of 8.5 years, 14 (6.8%) of the 205 patients who presented with DCIS between 2000–2003 had an invasive or in situ recurrence. The median age of all patients at the time of diagnosis of their initial DCIS was 55.5 years (range; 35.8–88.9). 51 (24.9%) had possible (albeit not definitive) microinvasion on their initial specimen. The majority were grade 2 (91; 44.4%), and 99 (48.3%) had comedo histology. The median size of DCIS on the initial excision was 10 mm (range; 0.1–80). All patients underwent definitive surgery to negative margins. The mean time to recurrence was 4.7 years (range; 1.1–10.6). On bivariate analysis, histologic grade of DCIS was the only factor that was significantly correlated with the risk of recurrence. Patients with grade 3 DCIS were more likely to develop a recurrence compared to those with grade 2 or grade 1 DCIS (12.3% vs. 3.3% vs. 0%, respectively, p = 0.032). Patient age, race, extent of DCIS, and histologic subtype were not associated with recurrence (see table below). 5-year actuarial overall survival was no different between those who developed a recurrence and those who did not (92.9 vs. 95.7%, p = 0.171).

The pK(a) values of acidic and basic residues buried at the same internal location in a protein are governed by different factors

The pK(a) values of internal ionizable groups are usually very different from the normal pK(a) values of ionizable groups in water. To examine the molecular determinants of pK(a) values of internal groups, we compared the properties of Lys, Asp, and Glu at internal position 38 in staphylococcal nuclease. Lys38 titrates with a normal or elevated pK(a), whereas Asp38 and Glu38 titrate with elevated pK(a) values of 7.0 and 7.2, respectively. In the structure of the L38K variant, the buried amino group of the Lys38 side chain makes an ion pair with Glu122, whereas in the structure of the L38E variant, the buried carboxyl group of Glu38 interacts with two backbone amides and has several nearby carboxyl oxygen atoms. Previously, we showed that the pK(a) of Lys38 is normal owing to structural reorganization and water penetration concomitant with ionization of the Lys side chain. In contrast, the pK(a) values of Asp38 and Glu38 are perturbed significantly owing to an imbalance between favorable polar interactions and unfavorable contributions from dehydration and from Coulomb interactions with surface carboxylic groups. Their ionization is also coupled to subtle structural reorganization. These results illustrate the complex interplay between local polarity, Coulomb interactions, and structural reorganization as determinants of pK(a) values of internal groups in proteins. This study suggests that improvements to computational methods for pK(a) calculations will require explicit treatment of the conformational reorganization that can occur when internal groups ionize.

A buried lysine that titrates with a normal pKa: role of conformational flexibility at the protein-water interface as a determinant of pKa values

Previously we reported that Lys, Asp, and Glu residues at positions 66 and 92 in staphylococcal nuclease (SNase) titrate with pK(a) values shifted by up to 5 pK(a) units in the direction that promotes the neutral state. In contrast, the internal Lys-38 in SNase titrates with a normal pK(a). The crystal structure of the L38K variant shows that the side chain of Lys-38 is buried. The ionizable moiety is approximately 7 A from solvent and ion paired with Glu-122. This suggests that the pK(a) value of Lys-38 is normal because the energetic penalty for dehydration is offset by a favorable Coulomb interaction. However, the pK(a) of Lys-38 was also normal when Glu-122 was replaced with Gln or with Ala. Continuum electrostatics calculations were unable to reproduce the pK(a) of Lys-38 unless the protein was treated with an artificially high dielectric constant, consistent with structural reorganization being responsible for the normal pK(a) value of Lys-38. This reorganization must be local because circular dichroism and NMR spectroscopy indicate that the L38K protein is native-like under all conditions studied. In molecular dynamics simulations, the ion pair between Lys-38 and Glu-122 is unstable. The simulations show that a minor rearrangement of a loop is sufficient to allow penetration of water to the amino moiety of Lys-38. This illustrates both the important roles of local flexibility and water penetration as determinants of pK(a) values of ionizable groups buried near the protein-water interface, and the challenges faced by structure-based pK(a) calculations in reproducing these effects.