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Tian T, Moore AM, Ghareeb PA, Boulis NM, Ward PJ. A Perspective on Electrical Stimulation and Sympathetic Regeneration in Peripheral Nerve Injuries. Neurotrauma Rep 2024; 5:172-180. [PMID: 38463421 PMCID: PMC10924057 DOI: 10.1089/neur.2023.0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024] Open
Abstract
Peripheral nerve injuries (PNIs) are common and devastating. The current standard of care relies on the slow and inefficient process of nerve regeneration after surgical intervention. Electrical stimulation (ES) has been shown to both experimentally and clinically result in improved regeneration and functional recovery after PNI for motor and sensory neurons; however, its effects on sympathetic regeneration have never been studied. Sympathetic neurons are responsible for a myriad of homeostatic processes that include, but are not limited to, blood pressure, immune response, sweating, and the structural integrity of the neuromuscular junction. Almost one quarter of the axons in the sciatic nerve are from sympathetic neurons, and their importance in bodily homeostasis and the pathogenesis of neuropathic pain should not be underestimated. Therefore, as ES continues to make its way into patient care, it is not only important to understand its impact on all neuron subtypes, but also to ensure that potential adverse effects are minimized. This piece gives an overview of the effects of ES in animals models and in humans while offering a perspective on the potential effects of ES on sympathetic axon regeneration.
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Affiliation(s)
- Tina Tian
- Medical Scientist Training Program, Emory University, Atlanta, Georgia, USA
- Neuroscience Graduate Program, Laney Graduate School, Emory University, Atlanta, Georgia, USA
- Department of Cell Biology, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Amy M Moore
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Paul A Ghareeb
- Division of Plastic Surgery, Department of Surgery, Emory University, Atlanta, Georgia, USA
| | | | - Patricia J Ward
- Neuroscience Graduate Program, Laney Graduate School, Emory University, Atlanta, Georgia, USA
- Department of Cell Biology, School of Medicine, Emory University, Atlanta, Georgia, USA
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Brown CA, Ghanouni A, Williams R, Payne SH, Ghareeb PA. Safety and Efficacy of Liposomal Bupivacaine Supraclavicular Nerve Blocks in Open Treatment of Distal Radius Fractures: A Perioperative Pain Management Protocol. Ann Plast Surg 2023; 90:S332-S336. [PMID: 36752544 DOI: 10.1097/sap.0000000000003464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Distal radius fractures (DRFs) are common fractures requiring surgical fixation. The literature varies regarding opioid prescribing habits, opioid consumption, and postoperative pain scores. We hypothesized that the preoperative administration of a liposomal bupivacaine (LB) supraclavicular nerve block would be safe and effective in controlling postoperative pain. METHODS A standardized pain management protocol was implemented at a single institution from July 2021 to March 2022 for patients undergoing open reduction internal fixation of DRF. Protocol elements included a preoperative LB supraclavicular nerve block and a multimodal postoperative pain regimen. Primary clinical outcomes included postoperative pain scores and number of opioid tablets consumed. RESULTS Twenty patients underwent a newly implemented protocol. The average age was 56 years. Mean number of oxycodone 5-mg tablets consumed was 4.1 (median, 2.5), and mean visual analog scale pain score at first postoperative appointment was 2.8. There were no incidences of missed acute carpal tunnel postoperatively. When compared with an institutional historical control (n = 189), number of opioid pills prescribed was reduced by 60% (21.4 vs 8.6 tablets, P < 0.0001), and no patients had unscheduled health care contact because of uncontrolled pain (22% vs 0%, P < 0.016). CONCLUSIONS Liposomal bupivacaine supraclavicular nerve blocks are safe and effective in the treatment of postoperative pain after open reduction internal fixation of DRF. Patients consumed <5 oxycodone tablets on average, which is less than many recommend prescribed quantities (>20-30 tablets). Patients had low pain scores (2.8/10) at the first postoperative follow-up. To our knowledge, this is the first study demonstrating the utility of LB in this clinical setting.
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Affiliation(s)
- Ciara A Brown
- From the Division of Plastic and Reconstructive Surgery
| | - Arian Ghanouni
- Department of Surgery, Emory University School of Medicine Atlanta, GA
| | - Rachel Williams
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | | | - Paul A Ghareeb
- Department of Orthopedic and Plastic Surgery, Emory University School of Medicine, Atlanta, GA
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Barr ML, Jain NS, Ghareeb PA, Benhaim P. Persistent Median Artery Thrombosis Causing a Bifid Median Nerve and Carpal Tunnel Syndrome: A Case Report. JBJS Case Connect 2022; 12:01709767-202212000-00005. [PMID: 36206366 DOI: 10.2106/jbjs.cc.22.00424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/07/2022] [Indexed: 06/16/2023]
Abstract
CASE In this report, we describe a 41-year-old woman with symptoms concerning for acute carpal tunnel syndrome. Operative exploration resulted in resection of an aneurysmal, thrombosed, persistent median artery seen on preoperative imaging and full recovery by the patient. CONCLUSION A persistent median artery is an uncommon congenital hand condition resulting from the failure of the median artery to regress, which can then travel through the carpal tunnel and be associated with a bifid median nerve, irritation of the nerve, and need for surgical exploration if it thromboses, which is rare. This should be considered in patients with acute median nerve compression, without other etiologies.
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Affiliation(s)
- Meaghan L Barr
- Division of Plastic and Reconstructive Surgery, University of California, Los Angeles
| | - Nirbhay S Jain
- Division of Plastic and Reconstructive Surgery, University of California, Los Angeles
| | - Paul A Ghareeb
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Emory University
| | - Prosper Benhaim
- Division of Plastic and Reconstructive Surgery, University of California, Los Angeles
- Department of Orthopaedic Surgery, University of California, Los Angeles
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Ghareeb PA, Daly C, Liao A, Payne D. Current Trends in the Management of Ballistic Fractures of the Hand and Wrist: Experiences of a High-Volume Level I Trauma Center. Hand (N Y) 2018; 13:176-180. [PMID: 28720003 PMCID: PMC5950967 DOI: 10.1177/1558944717697432] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Ballistic fractures of the carpus and hand are routinely treated in large urban centers. These injuries can be challenging due to many factors. Various treatment options exist for these complicated injuries, but there are limited data available. This report analyzes patient demographics, treatments, and outcomes at a large urban trauma center. METHODS All ballistic fractures of the hand and wrist of the patients who presented to a single center from 2011 to 2014 were retrospectively reviewed. Patient demographics, injury mechanism, treatment modalities, and outcomes were analyzed. RESULTS Seventy-seven patients were identified; 70 were male, and 7 were female. Average age of the patients was 29.6 years. Seventy-five injuries were low velocity, whereas 2 were high velocity. Sixty-seven patients had fractures of a metacarpal or phalanx, whereas 4 had isolated carpal injuries. Six had combined carpal and metacarpal or phalanx fractures. Thirty-six patients had concomitant tendon, nerve, or vascular injuries requiring repair. Sixty-three patients underwent operative intervention, with the most common intervention being percutaneous fixation. Sixteen patients required secondary surgery. Eighteen complications were reported. CONCLUSIONS The majority of patients in this report underwent early operative intervention with percutaneous fixation. Antibiotics were administered in almost all cases and can usually be discontinued within 24 hours after surgery. It is important to consider concomitant nerve, vascular, or tendon injuries requiring repair. We recommend early treatment of these injuries with debridement and stabilization. Due to lack of follow-up and patient noncompliance, early definitive treatment with primary bone grafting should be considered.
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Affiliation(s)
- Paul A. Ghareeb
- Emory University, Atlanta, GA, USA,Paul A. Ghareeb, 737 Brookridge Drive, Atlanta, GA 30306, USA.
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Hagopian TM, Ghareeb PA, Arslanian BH, Moosavi BL, Carlson GW. Breast necrosis secondary to vasopressor extravasation: management using indocyanine green angiography and omental flap closure. Breast J 2015; 21:185-8. [PMID: 25639475 DOI: 10.1111/tbj.12379] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Extravasation is a rare but serious complication of vasopressor administration. A 60-year-old female who underwent ascending and hemiarch repair of the aorta along with aortic valve replacement developed extensive right breast and chest wall necrosis after vasopressor extravasation from an internal jugular vein central line. The patient underwent a total mastectomy due to deep tissue necrosis detected by laser-assisted indocyanine green dye angiography, and eventually required omental flap reconstruction to obtain adequate sternal coverage. This case represents a previously unreported complication of internal jugular central line extravasation of vasopressors with resultant breast and chest wall necrosis, and highlights the utility of the omentum in chest wall reconstruction.
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Affiliation(s)
- Thomas M Hagopian
- Division of Plastic Surgery, Emory University School of Medicine, Atlanta, Georgia
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Affiliation(s)
- Ryan M Wilson
- University of Kentucky College of Medicine, Department of Plastic Surgery, Lexington, Kentucky
| | - Paul A Ghareeb
- Emory University School of Medicine Department of Surgery, Division of Plastic Surgery, Atlanta, Georgia
| | - W Thomas Mcclellan
- West Virginia University School of Medicine, Department of Surgery, Division of Plastic Surgery, Morgantown, West Virginia
| | - Ashley N Boustany
- University of Kentucky College of Medicine, Department of Plastic Surgery, Lexington, Kentucky, USA
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Wilson RM, Ghareeb PA, McClellan WT, Boustany AN. Biomechanical analysis of the FlatWire Figure 8 sternal fixation device. Plast Surg (Oakv) 2014; 22:188-190. [PMID: 25332648 PMCID: PMC4173867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
Abstract
OBJECTIVE To determine whether the FlatWire Figure 8 sternal fixation device (Penn United, USA) is mechanically superior to the current standard in sternotomy closure. DESCRIPTION Unstable sternal closure using traditional steel-wire cerclage can increase postoperative pain, bony cut-through and wound dehiscence. The authors present the Figure 8 sternal fixation device to minimize these complications. Biomechanical properties of the device were compared with conventional steel wire sternal repair. EVALUATION Using two constructs of both FlatWire and steel wire, pull-to-failure, Hertzian contact and cut-through were compared. Samples were tested to 500,000 cycles or failure. Cyclic comparisons were performed using log-rank t tests and Student's t tests for cut-through analysis. FlatWires were found to have superior biomechanical properties in all categories tested. CONCLUSION The FlatWire provides superior biomechanical properties compared with conventional steel wire, which may lead to reduced sternal wound complications.
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Affiliation(s)
- Ryan M Wilson
- University of Kentucky College of Medicine, Department of Plastic Surgery, Lexington, Kentucky
| | - Paul A Ghareeb
- Emory University School of Medicine Department of Surgery, Division of Plastic Surgery, Atlanta, Georgia
| | - W Thomas McClellan
- West Virginia University School of Medicine, Department of Surgery, Division of Plastic Surgery, Morgantown, West Virginia
| | - Ashley N Boustany
- University of Kentucky College of Medicine, Department of Plastic Surgery, Lexington, Kentucky, USA
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Wilson RM, Ghareeb PA, McClellan WT. Biomechanical analysis of the FlatWire Figure 8 sternal fixation device. Plast Surg (Oakv) 2014. [DOI: 10.4172/plastic-surgery.1000872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Dutton W, Ghareeb PA, McClellan WT. The lazy lateral incision: an innovative approach to the skin-sparing mastectomy. W V Med J 2013; 109:30-33. [PMID: 24371862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The skin-sparing mastectomy has many advantages over a simple mastectomy, including preservation of the native breast skin, inframammary fold, and improved aesthetics for immediate reconstruction. The traditional transverse elliptical access incision is anterior on the breast mound, requires a second incision for previous biopsy sites, and provides restricted access to the axilla. We describe a novel mastectomy incision that improves scar appearance, improves access to the axillary contents, and reduces skin flap retraction. This incision starts at the nipple-areolar complex and extends laterally in a curvilinear fashion toward the axilla incorporating the biopsy scar along the way. This simple sinusoidal design results in an aesthetically superior alternative to the traditional linear mastectomy incision.
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Ghareeb PA, Bourlai T, Dutton W, McClellan WT. Reducing pathogen transmission in a hospital setting. Handshake versus fist bump: a pilot study. J Hosp Infect 2013; 85:321-3. [PMID: 24144553 DOI: 10.1016/j.jhin.2013.08.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 08/27/2013] [Indexed: 11/24/2022]
Abstract
Handshaking is a known vector for bacterial transmission between individuals. Handwashing has become a major initiative throughout healthcare systems to reduce transmission rates, but as many as 80% of individuals retain some disease-causing bacteria after washing. The fist bump is an alternative to the handshake that has become popular. We have determined that implementing the fist bump in the healthcare setting may further reduce bacterial transmission between healthcare providers by reducing contact time and total surface area exposed when compared with the standard handshake.
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Affiliation(s)
- P A Ghareeb
- Department of Surgery, West Virginia University, School of Medicine, Morgantown, WV, USA.
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