Autologous Breast Reconstruction Skin Paddle Designs: Classification and Aesthetic Outcomes

Objective Present study was conducted to identify common mastectomy patterns and autologous skin paddle designs, to identify patient characteristics that influence these patterns, and assess aesthetic outcomes associated with each pattern.

Methods Autologous breast reconstructions over 5 years were reviewed. Mastectomy type and resultant skin paddle were categorized into four mastectomy type/skin paddle design groups based on the amount of native “Skin Spared” after mastectomy and the resultant flap skin paddle designed. Groups were designated as skin-sparing mastectomy 1 (SS1)/large elliptical skin paddle, skin-sparing mastectomy 2 (SS2)/small elliptical skin paddle, skin-sparing mastectomy 3 (SS3)/areola skin paddle, and skin-sparing mastectomy 4 (nipple-sparing mastectomy, SS4)/no skin paddle. Surveys were performed to validate the classification system and critique aesthetic outcomes.

Results A total of 89 autologous breast reconstructions were included. Radiotherapy was used in 45.6% of SS1 patients versus 29.2% in SS2 and 12.5% in SS3/SS4. Mean body mass index (BMI) was 30 in SS1/SS2 and 26 in SS3/SS4 mastectomy types (p = 0.045). Delayed reconstruction was performed in 96.5% SS1 versus 62.5% in SS2 and only 25% of SS3/SS4 (p < 0.0001). Physicians and Non-MD personnel correctly categorized 85.8 and 76.1% of skin paddle designs, respectively. Over 75% of those surveyed rated the reconstruction aesthetic outcome as “good-excellent” regardless of the pattern group.

Conclusions Patients in SS1/SS2 groups had a higher incidence of radiotherapy, delayed reconstruction, and higher BMI compared with the SS3/SS4 groups. The classification system is recognizable and may provide improved patient education and communication between healthcare providers. All mastectomy type/skin paddle designs received high aesthetic ratings.

Maternal and fetal outcomes in pregnancies complicated by the inherited aortopathy Loeys-Dietz syndrome

OBJECTIVE

Pregnancies in women with Loeys-Dietz syndrome (LDS) are rare and are typically documented in case reports only. Early reports suggested high rates of maternal complications during pregnancy and the puerperium, including aortic dissection and uterine rupture, but information on fetal outcomes was very limited.

DESIGN

A retrospective cohort study.

SETTING

Eight specialist UK centres.

SAMPLE

Pregnant women with LDS.

METHODS

Data was collated on cardiac, obstetric, and neonatal outcomes.

MAIN OUTCOME MEASURES

Maternal and perinatal outcomes in pregnancies complicated by LDS.

RESULTS

Twenty pregnancies in 13 women with LDS were identified. There was one miscarriage, one termination of pregnancy, and 18 livebirths. In eight women the diagnosis was known prior to pregnancy but only one woman had preconception counselling. In four women the diagnosis was made during pregnancy through positive genotyping, and the other was diagnosed following delivery. Five women had a family history of aortic dissection. There were no aortic dissections in our cohort during pregnancy or postpartum. Obstetric complications were common, including postpartum haemorrhage (33%) and preterm delivery (50%). In all, 14/18 (78%) of deliveries were by elective caesarean section, at a median gestational age at delivery of 37 weeks. Over half the infants (56%) were admitted to the neonatal unit following delivery.

CONCLUSION

Women with LDS require multidisciplinary specialist management throughout pregnancy. Women should be referred for preconception counselling to make informed decisions around pregnancy risk and outcomes. Early elective preterm delivery needs to be balanced against a high infant admission rate to the neonatal unit.

TWEETABLE ABSTRACT

Pregnancy outcomes in women with Loeys-Dietz syndrome.

Screening for Atrial Fibrillation

Approximately 10% of ischemic strokes are associated with atrial fibrillation (AF) first diagnosed at the time of stroke. Detecting asymptomatic AF would provide an opportunity to prevent these strokes by instituting appropriate anticoagulation. The AF-SCREEN international collaboration was formed in September 2015 to promote discussion and research about AF screening as a strategy to reduce stroke and death and to provide advocacy for implementation of country-specific AF screening programs. During 2016, 60 expert members of AF-SCREEN, including physicians, nurses, allied health professionals, health economists, and patient advocates, were invited to prepare sections of a draft document. In August 2016, 51 members met in Rome to discuss the draft document and consider the key points arising from it using a Delphi process. These key points emphasize that screen-detected AF found at a single timepoint or by intermittent ECG recordings over 2 weeks is not a benign condition and, with additional stroke factors, carries sufficient risk of stroke to justify consideration of anticoagulation. With regard to the methods of mass screening, handheld ECG devices have the advantage of providing a verifiable ECG trace that guidelines require for AF diagnosis and would therefore be preferred as screening tools. Certain patient groups, such as those with recent embolic stroke of uncertain source (ESUS), require more intensive monitoring for AF. Settings for screening include various venues in both the community and the clinic, but they must be linked to a pathway for appropriate diagnosis and management for screening to be effective. It is recognized that health resources vary widely between countries and health systems, so the setting for AF screening should be both country- and health system-specific. Based on current knowledge, this white paper provides a strong case for AF screening now while recognizing that large randomized outcomes studies would be helpful to strengthen the evidence base.

Taxonomy of Individual Variations in Aesthetic Responses to Fractal Patterns

In two experiments, we investigate group and individual preferences in a range of different types of patterns with varying fractal-like scaling characteristics. In Experiment 1, we used 1/f filtered grayscale images as well as their thresholded (black and white) and edges only counterparts. Separate groups of observers viewed different types of images varying in slope of their amplitude spectra. Although with each image type, the groups exhibited the "universal" pattern of preference for intermediate amplitude spectrum slopes, we identified 4 distinct sub-groups in each case. Sub-group 1 exhibited a typical peak preference for intermediate amplitude spectrum slopes ("intermediate"; approx. 50%); sub-group 2 exhibited a linear increase in preference with increasing amplitude spectrum slope ("smooth"; approx. 20%), while sub-group 3 exhibited a linear decrease in preference as a function of the amplitude spectrum slope ("sharp"; approx. 20%). Sub-group 4 revealed no significant preference ("other"; approx. 10%). In Experiment 2, we extended the range of different image types and investigated preferences within the same observers. We replicate the results of our first experiment and show that individual participants exhibit stable patterns of preference across a wide range of image types. In both experiments, Q-mode factor analysis identified two principal factors that were able to explain more than 80% of interindividual variations in preference across all types of images, suggesting a highly similar dimensional structure of interindividual variations in preference for fractal-like scaling characteristics.

Derivation of Candidate Clinical Decision Rules to Identify Infants at Risk for Central Apnea

BACKGROUND AND OBJECTIVES

Central apnea complicates, and may be the presenting complaint in, bronchiolitis. Our objective was to prospectively derive candidate clinical decision rules (CDRs) to identify infants in the emergency department (ED) who are at risk for central apnea.

METHODS

We conducted a prospective observational study over 8 years. The primary outcome was central apnea subsequent to the initial ED visit. Infants were enrolled if they presented with central apnea or bronchiolitis. We excluded infants with obstructive apnea, neonatal jaundice, trauma, or suspected sepsis. We developed 3 candidate CDRs by using 3 techniques: (1) Poisson regression clustered on the individual, (2) classification and regression tree analysis (CART), and (3) a random forest (RF).

RESULTS

We analyzed 990 ED visits for 892 infants. Central apnea subsequently occurred in the hospital in 41 (5%) patients. Parental report of apnea, previous history of apnea, congenital heart disease, birth weight ≤2.5 kg, lower weight, and age ≤6 weeks all identified a group at high risk for subsequent central apnea. All CDRs and RFs were 100% sensitive (95% confidence interval [CI] 91%-100%) and had a negative predictive value of 100% (95% CI 99%-100%) for the subsequent apnea. Specificity ranged from 61% to 65% (95% CI 58%-68%) for CDRs based on Poisson models; 65% to 77% (95% CI 62%-90%) for CART; and 81% to 91% (95% CI 78%-92%) for RF models.

CONCLUSIONS

All candidate CDRs had a negative predictive value of 100% for subsequent central apnea.

Dose-dependent modulation of myogenesis by HGF: implications for c-Met expression and downstream signalling pathways

Hepatocyte growth factor (HGF) regulates satellite cell activation, proliferation, and differentiation. We analyzed the dose-dependent effects of HGF on myogenesis. Murine C2C12 and human donor-derived skeletal muscle myoblasts were treated with 0, 2, or 10 ng/ml HGF followed by assessment of proliferation and differentiation. HGF (2 ng/ml) significantly promoted cell division, but reduced myogenic commitment and fusion. Conversely, 10 ng/ml HGF reduced proliferative capability, but increased differentiation. c-Met expression analysis revealed significantly decreased expression in differentiating cells cultured with 2 ng/ml HGF, but increased expression in proliferating cells with 10 ng/ml HGF. Mitogen-activated protein kinase (MAPKs: ERK, JNK, or p38K) and phosphatidylinositol-3-kinase (PI3K) inhibition abrogated the HGF-stimulated increase in cell number. Interestingly, PI3K and p38 kinase facilitated the negative effect of HGF on proliferation, while ERK inhibition abrogated the HGF-mediated decrease in differentiation. Dose-dependent effects of HGF are mediated by changes in c-Met expression and downstream MAPK and PI3K signalling.

Approaches to describing inter-rater reliability of the overall clinical appearance of febrile infants and toddlers in the emergency department

Objectives. To measure inter-rater agreement of overall clinical appearance of febrile children aged less than 24 months and to compare methods for doing so.

Study Design and Setting. We performed an observational study of inter-rater reliability of the assessment of febrile children in a county hospital emergency department serving a mixed urban and rural population. Two emergency medicine healthcare providers independently evaluated the overall clinical appearance of children less than 24 months of age who had presented for fever. They recorded the initial ‘gestalt’ assessment of whether or not the child was ill appearing or if they were unsure. They then repeated this assessment after examining the child. Each rater was blinded to the other’s assessment. Our primary analysis was graphical. We also calculated Cohen’s κ, Gwet’s agreement coefficient and other measures of agreement and weighted variants of these. We examined the effect of time between exams and patient and provider characteristics on inter-rater agreement.

Results. We analyzed 159 of the 173 patients enrolled. Median age was 9.5 months (lower and upper quartiles 4.9–14.6), 99/159 (62%) were boys and 22/159 (14%) were admitted. Overall 118/159 (74%) and 119/159 (75%) were classified as well appearing on initial ‘gestalt’ impression by both examiners. Summary statistics varied from 0.223 for weighted κ to 0.635 for Gwet’s AC2. Inter rater agreement was affected by the time interval between the evaluations and the age of the child but not by the experience levels of the rater pairs. Classifications of ‘not ill appearing’ were more reliable than others.

Conclusion. The inter-rater reliability of emergency providers’ assessment of overall clinical appearance was adequate when described graphically and by Gwet’s AC. Different summary statistics yield different results for the same dataset.

First Report of Meloidogyne marylandi Infecting Bermudagrass in Oklahoma

Meloidogyne marylandi is a nematode commonly associated with turfgrasses and has been reported to occur in Texas and Arkansas (1,3). In the fall of 2013, a stand of ultradwarf bermudagrass (Cynodon dactylon × C. transvaalensis) plants in a sand-based, research putting green in Stillwater, Oklahoma, exhibited symptoms of decline. Roots of the affected plants had small galls and upon staining of the root system, numerous egg masses were evident. Egg masses were collected, placed in water, and the morphology of 20 hatched, second-stage juveniles were examined. The characteristics of the juveniles were: body length averaged 393.1 ± 19.87 (range: 361 to 425) μm, mean width averaged 16.6 ± 0.7 (15.6 to 17.8) μm, stylet lengths averaged 12.1 ± 0.7 (10.4 to 12.9) μm, dorsal gland orifice from stylet base averaged 2.9 ± 0.4 (2.5 to 3.6) μm, tail lengths averaged 53.7 ± 3.8 (46.2 to 60.4) μm, and the hyaline region of the tails averaged 10.4 ± 1.1 (8.4 to 12.7) μm. Genomic DNA was extracted from six females that were removed from roots. Amplification and sequencing of the mitochondrial DNA region between COII and 16S rRNA genes was performed with primers 1RNAF (5'-TACCTTTGACCAATCACGCT-3') and CO11R (5'-GGTCAATGTTCAGAAATTTGTGG-3') as previously described (2). A PCR product approximately 510 bp in length was obtained and sequenced at the Oklahoma State University Core Facility. Sequences were compared with those in NCBI's nucleotide database using BLAST and had 97% identity with two sequences from M. marylandi (KC473862.1 and KC473863.1) and the next most similar species being M. graminis (JN241898.1) with 83% identity. To our knowledge, this is the first report of the root-knot nematode M. marylandi in Oklahoma. As bermudagrass becomes more commonly used for putting greens in the turfgrass transition zone, M. marylandi may become a more common and damaging pathogen in the region. References: (1) A. A. Elmi et al. Grass For. Sci. 55:166, 2000. (2) M. A. McClure et al. Plant Dis. 96:635, 2012. (3) J. L. Starr et al. Nematrop. 37:43, 2007.

Effects of an exogenous protease on the fermentation and nutritive value of corn silage harvested at different dry matter contents and ensiled for various lengths of time

The objective of this experiment was to evaluate the effects of adding an experimental protease to corn plants harvested at different maturities on silage fermentation and in vitro ruminal starch digestibility (IVSD). Corn plants were harvested at maturities resulting in plants with 31 or 40% dry matter (DM). Plants were chopped, kernel processed, and treated with (1) only a 0.1 M phosphate buffer (pH 5.5, 5% vol/wt of fresh forage), (2) buffer with protease to obtain a final concentration of 20mg of protease/kg of wet forage, and (3) buffer with protease to obtain a final concentration of 2,000 mg of protease/kg of wet forage. Treated forages (about 500 g) were ensiled in nylon-polyethylene pouches and stored between 21 and 23°C for 0, 45, 90, and 150 d. Data were analyzed as a 2 × 3 × 4 factorial arrangement of treatments, with the main effects of harvest DM, dose of protease, days of ensiling, and their interactions. The treatment with the highest dose of protease resulted in more robust fermentations across harvest DM with higher concentrations of lactic and acetic acids compared with untreated silage. Concentrations of soluble protein (% of crude protein) increased with time of ensiling, regardless of DM content at harvest. However, averaged over both harvest DM contents, it increased by 37% for silages treated with the high dose of protease compared with an average 11% increase for untreated silages and silage treated with the low dose of protease, between d 0 and 45. Averaged over both harvest DM contents, the concentration of soluble protein peaked in silages treated with the high dose of protease after 45 d of ensiling, whereas it peaked at d 90 in untreated silages and silage treated with the low dose of protease. Similar changes occurred in the concentration of NH3-N due to length of ensiling and treatment with protease. In fresh forages, the concentration of starch for early- and late-harvested forages was similar, but IVSD was lower in the latter. After 45 d of ensiling, IVSD was highest in both early- and late-harvested silages that were treated with the high level of protease. After 150 d of ensiling, IVSD was similar among silages treated with protease, regardless of DM at harvest. Treating corn plants with a high dose of an experimental protease at harvest accelerated proteolysis during ensiling, resulting in corn silages with levels of IVSD after 45 d of ensiling that were only obtained in untreated corn silages after 150 d of ensiling.