Use of Biodegradeable Temporizing Matrix Dermal Template for Reconstruction of Upper Extremity Soft Tissue Defects with Associated Tendon Injury

In cases of complex upper extremity soft tissue defects with exposed bone or tendon, the surgeon needs to consider both restoration of stable soft tissue coverage and functional outcomes, which requires early motion and a wound bed suitable for tendon gliding. Often, local, regional, or free flaps are necessary; however, good outcomes have also been reported after staged reconstruction with a dermal template and split-thickness skin grafting. To our knowledge, staged reconstruction with a dermal template has not been described for soft tissue defects with an associated underlying tendon injury requiring tenorrhaphy. We have previously reported our experience with a synthetic dermal template [Novosorb BTM (Biodegradable Temporizing Matrix), Polynovo North America LLC. Carlsbad, Calif.] for the reconstruction of complex upper extremity defects with exposed tendon and showed that it consistently and reliably integrates even when these patients were treated with an early, active therapy protocol. As a result of these findings, we hypothesized that BTM could potentially be used over a tendon repair site without compromising functional outcomes. Here, we report on clinical outcomes for two patients with upper extremity injury where BTM was applied directly over a tendon repair or transfer site and resulted in stable soft tissue coverage with excellent tendon gliding. These early results show that this approach might be considered as an alternative to autologous tissue reconstruction in these patients and could reduce donor site morbidity associated with flap harvest.

A Photoactivated Protein Degrader for Optical Control of Synaptic Function

Hundreds of proteins determine the function of synapses, and synapses define the neuronal circuits that subserve myriad brain, cognitive, and behavioral functions. It is thus necessary to precisely manipulate specific proteins at specific sub-cellular locations and times to elucidate the roles of particular proteins and synapses in brain function. We developed PHOtochemically TArgeting Chimeras (PHOTACs) as a strategy to optically degrade specific proteins with high spatial and temporal precision. PHOTACs are small molecules that, upon wavelength-selective illumination, catalyze ubiquitylation and degradation of target proteins through endogenous proteasomes. Here we describe the design and chemical properties of a PHOTAC that targets Ca 2+ /calmodulin-dependent protein kinase II alpha (CaMKIIα), which is abundant and crucial for baseline synaptic function of excitatory neurons. We validate the PHOTAC strategy, showing that the CaMKIIα-PHOTAC is effective in mouse brain tissue. Light activation of CaMKIIα-PHOTAC removed CaMKIIα from regions of the mouse hippocampus only within 25 μm of the illuminated brain surface. The optically-controlled degradation decreases synaptic function within minutes of light activation, measured by the light-initiated attenuation of evoked field excitatory postsynaptic potential (fEPSP) responses to physiological stimulation. The PHOTACs methodology should be broadly applicable to other key proteins implicated in synaptic function, especially for evaluating their precise roles in the maintenance of long-term potentiation and memory within subcellular dendritic domains.

Venous Thromboembolism and Bleeding Events With Chemoprophylaxis in Abdominoplasty: A Systematic Review and Pooled Analysis of 1596 Patients

BACKGROUND

Many plastic surgeons avoid the administration of venous thromboembolism (VTE) chemoprophylaxis out of concern for surgical bleeding in abdominoplasty. Although previous studies have attempted to address the relationship between abdominoplasty and bleeding or VTE, poor reporting techniques remain a challenge. As a result, there has been a lack of reliable data to guide clinical practice.

OBJECTIVES

The authors sought to determine the prevalence of bleeding and VTE in abdominoplasty with and without chemoprophylaxis.

METHODS

A systematic review was performed following PRISMA guidelines utilizing PubMed, CINAHL, and Cochrane Central. Patient demographics, comorbidities, risk category (if available), bleeding events, VTE events, and chemoprophylaxis information were recorded.

RESULTS

Across 10 articles, 691 patients received chemoprophylaxis in the setting of abdominoplasty: 68 preoperatively, 588 postoperatively, and 35 received both; 905 patients did not receive chemoprophylaxis. A total of 96.8% of patients were female, 73% underwent concomitant liposuction, and none were clearly risk stratified. The overall incidence of VTE and bleeding was 0.56% (9/1596) and 1.6% (25/1596), respectively. Compared with no chemoprophylaxis, chemoprophylaxis was not associated with increased incidence of bleeding (1.3% [9/671] vs 0.91% [8/881], P = 0.417) or decreased incidence of VTE (0.87% [6/691] vs 0.33% [3/901], P = 0.187).

CONCLUSIONS

The prevalence of bleeding in abdominoplasty was low. Chemoprophylaxis was not associated with increased risk of bleeding or decreased risk of VTE, though the lack of risk stratification and heterogeneity of the cohort precludes firm conclusions. This study underscores the importance of utilizing validated risk-stratification tools to guide perioperative decision-making.

LEVEL OF EVIDENCE: 4

An In-Depth Analysis of Research Output in Successful Integrated Plastic Surgery Match Applicants and Factors Associated With Matching at Top-Ranked Programs

OBJECTIVE

With USMLE Step I score reports becoming pass/fail, research output may become a more important factor for applicants in the integrated plastic surgery match. The authors aim to assess the research output of successful applicants and bibliometric variables associated with matching at higher tier programs.

DESIGN

A search of peer-reviewed publications up to or during September before the matriculant's match year was performed using PubMed, Google Scholar, and Scopus for each resident. Bibliometric variables were analyzed including those associated with matching at higher tier Doximity reputation/research programs.

SETTING

University of Pennsylvania (Philadelphia, Pennsylvania).

PARTICIPANTS

Integrated plastic surgery interns for the 2019 to 2020 and 2020 to 2021 academic years (n = 301).

RESULTS

Three hundred one matriculants at 73 programs produced a total of 731 manuscripts. The mean number of publications and H-index per applicant was 2.43 ± 3.84 and 1.01 ± 1.30, respectively. The average and maximum journal impact factor was 2.8 ± 1.81 and 4.66 ± 5.59, respectively. H-index, total publications, plastic surgery-related and unrelated publications, and first-author studies were all associated with matching into both a higher ranked reputation and research tier program, respectively (p < 0.05). Highest impact factor publications were associated with matching at top tier research programs only (p < 0.05). Among students from US News Top 40 and non-Top 40 medical schools, total publications and first-author publications remained associated with matching at a higher tier reputation and research program (p < 0.05). However, plastic surgery-related publications were significantly linked to matching into a higher tier program for matriculants from non-Top 40 medical schools only (p < 0.05).

CONCLUSIONS

Research productivity, particularly total publications and first-author publications, is associated with an increased likelihood of matching at a higher tier integrated plastic surgery residency. Regardless of their medical school's US News rank, students may gain a competitive edge in the match with increased research output.

The effect of an oxytocin washout period on blood loss at cesarean delivery

Objectives Prolonged oxytocin exposure may result in increased blood loss during delivery. Our objective was to determine whether an oxytocin rest period before cesarean delivery had an impact on blood loss. Methods We performed a retrospective cohort study of women who underwent primary cesarean delivery after oxytocin augmentation. The primary outcome was change between pre- and postoperative hematocrit (Hct) in women with less than 60-min oxytocin rest period (<60 min) and greater than 60-min rest period (>60 min). Results There was no difference in demographic characteristics (age, BMI, or gestational age at delivery) between the two groups. Women in the >60 min group had a higher cumulative dose and longer duration of oxytocin administration. There was no significant difference in change in Hct between the two groups when controlling for these factors. Conclusions We did not find a significant correlation between the duration of the oxytocin rest period and blood loss. Oxytocin washout periods of greater than 60 min may not result in decreased blood loss at cesarean delivery, and thus, women may not benefit from such oxytocin washout periods.

Gliomatosis cerebri and Rasmussen's encephalitis: Two different entities causing refractory epilepsy. Comparison through two clinical cases

BACKGROUND AND IMPORTANCE

Rasmussen's Encephalitis (RE) is a chronic and progressive childhood disease caused by an inflammatory disorder that affects a cerebral hemisphere. On the other hand, Gliomatosis Cerebri (GC) is a rare primary neoplastic glial process with a diffuse and infiltrative growth.

CLINICAL PRESENTATION

We present two clinical cases with a history of continuous focal epilepsy refractory to antiepileptic drugs. They share similar clinical and radiologic features, but a different histopathological diagnosis. A brain biopsy was needed to distinguish GC from a RE.

CONCLUSION

The debut of a drug-resistant epilepsy with focal seizures and an ipsilateral progressive hemiparesis suggests the diagnosis of RE. However, there are other entities such as GC, which, despite its rarity, should be considered in the differential diagnosis. So, in some cases, histological diagnosis is needed.

The Role of Inflammatory Cytokines in Cardiac Arrest

Introduction:

Post-cardiac arrest syndrome (PCAS) is characterized by systemic ischemia/reperfusion injury, anoxic brain injury, and post-arrest myocardial dysfunction superimposed on a precipitating pathology. The role of inflammatory cytokines in cardiac arrest remains unclear.

Aims:

We aimed to describe, with an emphasis on clinical applications, what is known about the role of inflammatory cytokines in cardiac arrest.

Data Sources:

A PubMed literature review was performed for relevant articles. Only articles in English that studied cytokines in patients with cardiac arrest were included.

Results:

Cytokines play a crucial role in the pathogenesis of PCAS. Following cardiac arrest, the large release of circulating cytokines mediates the ischemia/reperfusion injury, brain dysfunction, and myocardial dysfunction seen. Interleukins, tumor necrosis factor, and matrix metalloproteinases all play a unique prognostic role in PCAS. High levels of inflammatory cytokines have been associated with mortality and/or poor neurologic outcomes. Interventions to modify the systemic inflammation seen in PCAS continue to be heavily studied. Currently, the only approved medical intervention for comatose patients following cardiac arrest is targeted temperature management. Medical agents, including minocycline and sodium sulfide, have demonstrated promise in animal models.

Conclusions:

The role of inflammatory cytokines for both short- and long-term outcomes is an important area for future investigation.

[X-linked adrenoleukodystrophy with an atypical radiological pattern]

INTRODUCTION

X-linked adrenoleukodystrophy (X-ALD) is the most frequent peroxisomal disease. It is due to a mutation in the ABCD1 gene. The loss of functioning of ABCD1 triggers ineffective beta oxidation of very long-chain fatty acids, which gives rise to an accumulation of these fatty acids. The typical alteration revealed in neuroimaging scans in the cerebral form is symmetrical periventricular demyelination with posterior location.

CASE REPORT

We report the case of a 10-year-old boy with right spastic hemiparesis and subacute cognitive impairment. Magnetic resonance imaging of the brain showed symmetrical involvement of the white matter in the left frontoparietotemporal region, and calcifications were observed in the computerised axial tomography scan. X-ALD was confirmed by means of the elevated levels of very long-chain fatty acids, and a pathogenic variant was found in the ABCD1 gene.

CONCLUSIONS

Symmetrical demyelination with calcifications has rarely been reported in X-ALD, and these findings could delay diagnosis. This exceptional presentation should always be taken into consideration in children with subacute onset of motor symptoms and cognitive or behavioural regression.

A statistical algorithm showing coenzyme Q10 and citrate synthase as biomarkers for mitochondrial respiratory chain enzyme activities

Laboratory data interpretation for the assessment of complex biological systems remains a great challenge, as occurs in mitochondrial function research studies. The classical biochemical data interpretation of patients versus reference values may be insufficient, and in fact the current classifications of mitochondrial patients are still done on basis of probability criteria. We have developed and applied a mathematic agglomerative algorithm to search for correlations among the different biochemical variables of the mitochondrial respiratory chain in order to identify populations displaying correlation coefficients >0.95. We demonstrated that coenzyme Q10 may be a better biomarker of mitochondrial respiratory chain enzyme activities than the citrate synthase activity. Furthermore, the application of this algorithm may be useful to re-classify mitochondrial patients or to explore associations among other biochemical variables from different biological systems.

Automated detection of the factor V Leiden mutation using the LCx microparticle enzyme immunoassay

The factor V Leiden mutation, a G-->A transition at position 1691 in exon 10 of the gene that codes for factor V, produces an Arg506Gln substitution and is the most common genetic risk factor for venous thrombosis. We have developed a rapid, sensitive, and specific method to detect the factor V Leiden mutation in genomic DNA from whole blood by PCR amplification and microparticle enzyme immunoassay detection using the Abbott LCx instrument. We compared this automated method with the standard procedure using restriction endonuclease digestion of PCR products followed by gel electrophoresis in blinded experiments. In 130 patients (from Veterans Affairs medical centers) with deep venous thromboses, including 24 heterozygotes with the factor V Leiden mutation, there was complete agreement between the two methods. The assay was also able to distinguish heterozygotes from homozygotes. This method, which carries a low potential for cross-contamination of samples, should be a useful routine test for the factor V Leiden mutation in clinical laboratories with sufficient demand for molecular diagnostic assays using the LCx instrument.

GB virus C/hepatitis G virus infection: a favorable prognostic factor in human immunodeficiency virus-infected patients?

To investigate a possible influence of GB virus C (GBV-C) in immunocompromised patients, the prevalences of GBV-C RNA and anti-E2 antibody in 197 human immunodeficiency virus (HIV)-infected patients and in 120 control blood donors were studied. GBV-C RNA was detected in 33 of 197 HIV-infected patients (16.8%) compared with 1 in 120 blood donors (0.8%) (P < .001). Previous exposure to GBV-C (anti-E2 antibody-positive) was shown in 56.8% of HIV patients and in 9% of blood donors. GBV-C viremia was not associated with hepatitis. Despite approximately equal duration of HIV infection in all subgroups, the CD4 cell counts were significantly higher in GBV-C-viremic patients (344 cells/microL) compared with exposed (259 cells/microL) and unexposed (170 cells/microL) patients (P = .017 and P < .001). Furthermore, Kaplan-Meier analysis demonstrated significantly better cumulative survival in GBV-C RNA-positive HIV-infected patients, suggesting that GBV-C might be a favorable prognostic factor in HIV disease.

Antibody to GBV-C second envelope glycoprotein (anti-GBV-C E2): is it a marker for immunity?

The clinical significance of GB virus C (GBV-C E2) antibody is under investigation. The prevalence rates of GBV-C RNA and antibody to GBV-C E2 glycoprotein were determined in a population of 123 Egyptian anti-hepatitis C virus (HCV)-positive patients with chronic liver disease (CLD) who had not been treated previously with interferon. Sera were tested for GBV-C RNA by the LCx assay (Abbott Laboratories, North Chicago, IL), and for GBV-C E2 antibody by enzyme immunoassay. GBV-C RNA was present in 11.4% of patients. GBV-C E2 antibody was detected in 55.9% of GBV-C RNA-negative patients and in 2.2% of GBV-C RNA-positive patients (P = 0.006). GBV-C RNA was associated significantly with a history of schistosomiasis (relative risk [RR] = 5.83, 95% confidence interval [CI] 1.99-17.14, P < 0.005) but not with parenteral risk factors. The presence of GBV-C E2 antibody was not associated with age, gender, parenteral risk factors, schistosomal infection, or HCV viremia. The HCV genotype and level of viremia were similar in GBV-C anti-E2-positive and negative patients. There was a trend toward more severe histological disease with anti-E2 seropositivity (RR = 1.45, 95% CI 0.89-2.45, P = 0.11), an association which was independent of the evidence of schistosomiasis. It is concluded that GBV-C infection is common among HCV-infected Egyptian patients with CLD due to HCV infection. A significant negative correlation between the GBV-C viremia and GBV-C E2 antibody suggests that an antibody response is associated with viral clearance. This antibody response presumably occurs spontaneously, as none of the patients had received antiviral therapy. The unexpected association between GBV-C RNA and schistosomiasis suggests that nonparenteral or occult parenteral routes of GBV-C infection are likely to be important.

Real-time detection of DNA hybridization and melting on oligonucleotide arrays by using optical wave guides

The challenge of the Human Genome Project is to increase the rate of DNA sequence acquisition by two orders of magnitude to complete sequencing of the human genome by the year 2000. The present work describes a rapid detection method using a two-dimensional optical wave guide that allows measurement of real-time binding or melting of a light-scattering label on a DNA array. A particulate label on the target DNA acts as a light-scattering source when illuminated by the evanescent wave of the wave guide and only the label bound to the surface generates a signal. Imaging/visual examination of the scattered light permits interrogation of the entire array simultaneously. Hybridization specificity is equivalent to that obtained with a conventional system using autoradiography. Wave guide melting curves are consistent with those obtained in the liquid phase and single-base discrimination is facile. Dilution experiments showed an apparent lower limit of detection at 0.4 nM oligonucleotide. This performance is comparable to the best currently known fluorescence-based systems. In addition, wave guide detection allows manipulation of hybridization stringency during detection and thereby reduces DNA chip complexity. It is anticipated that this methodology will provide a powerful tool for diagnostic applications that require rapid cost-effective detection of variations from known sequences.

Deletion detection in the dystrophin gene by multiplex gap ligase chain reaction and immunochromatographic strip technology

The purpose of this study is to demonstrate the value of a multiplex amplification and readout system. The validation was done using as a model system the detection of deletions in nine possible dystrophin exons: 4, 8, 12, 17, 19, 44, 45, 48, and 51. The amplification system was gap ligase chain reaction, adapted to amplify selected regions of multiple exons simultaneously. The amplified products were read out with an immunochromatographic methodology, adapted from that used in the Abbott product line commercialized under the name Test Pack Plus. In each amplification, the beta-globin gene was incorporated and served as a procedural control. The complete process takes < 3 hr from DNA sample to result. The procedure is therefore rapid and simple, as well as being potentially very cost effective. The combination of these two technologies is shown to be a useful tool for the determination of deletions in the nine exons of the dystrophin gene. The results of a 100-patient sample study showed concordance with cDNA and PCR in current use. Equivalent performance at two sites was shown.

Simultaneous analysis of mutant and normal alleles for multiple cystic fibrosis mutations by the ligase chain reaction

The ligase chain reaction (LCR) involves repetitive cycles of ligation of two adjacent pairs of oligonucleotides to form longer ligated products in a template-dependent manner. This study demonstrates the application of LCR for analysis of multiple small mutations. We adapted the technology for the simultaneous determination of the normal and mutant alleles in a competition format, as well as multiple mutations in a multiplex format. For these purposes, we used mutations causing cystic fibrosis, namely the delta F508, W1282X, and G551D mutations. Blunt ligation was compared to a strategy with a single base gap on one or both strands to be filled by thermostable polymerase prior to ligation. Blunt or gap strategies worked well for detection of the delta F508 mutation. Detection of the W1282X mutation worked well with a blunt strategy when high K+ concentration (180-220 mM) was used to reduce template-independent ligation. For reliable detection of the G551D mutation, we used mismatches in the oligonucleotides 2-5 bp away from the ligation site and hot start of the reaction to achieve allele specificity. Excellent discrimination of mutations was achieved using competitive LCR with six oligonucleotides (two common on one side of the mutation plus two wild type and two mutant on the opposite side with the mutation site at the end adjacent to the common oligonucleotides) and with multiplex-competitive LCR using 12 oligonucleotides to detect both alleles for two mutations in a single tube.(ABSTRACT TRUNCATED AT 250 WORDS)

Characteristics of the external quality assessment (EQA) scheme for haematology in Spain

Ensuring reliable results of the tests which are performed in large haematology laboratories is essential because of the problems resulting from the use of complex automated instruments and the ever increasing workload. The Spanish Haematology EQA Scheme started in 1984 with 56 laboratories, a number which rose to 332 in 1989. The general scheme follows the guidelines established by the International Committee for Standardization in Haematology (ICSH) with participants from Public Health (57.9%) and Private (42.1%) laboratories. Surveys are performed monthly and on each occasion the following samples are prepared and sent by the Organizing Center (Haematology Laboratory Department, Hospital Clinic i Provincial of the University of Barcelona): whole blood for full blood counts (FBC), platelet suspensions (or equine total blood) and lyophilized plasma for prothrombin time (PT), partial thromboplastin time (PTT) and fibrinogen (F). After preparation, control materials are sent to participant laboratories where the requested tests are performed and the results reported back to the Organizing Center for statistical analysis. For result evaluation, laboratories are divided into four to eight groups depending on the methodologies used. Individuals results are assessed against a consensus value (mean) deviation index (DI) from the mean, coefficient of variation (CV) and Youden diagram for all results and groups of each parameter. Between 58.3 and 74.5% of laboratories responded. For WBC, the CV improved from 17 to 7%, for platelets from 34.4 to 24.3%. For coagulation tests CV was 18.1% for PT, 16% for PTT, and 26% for fibrinogen.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of the first program of external quality control in hematology of the Spanish Hematology and Hemotherapy Association. Experience of 1 year's activity]

The External Quality Control Programme in Haematology (EQCP-H) comprises a monthly remittance of two whole-blood control samples for evaluating red cell count (RBC), white cell count (WBC), platelet count (PC), haematocrit (HT), haemoglobin rate (HB) and red cell indices (MCV, MHC, MCHC), as well as lyophilized plasma for prothrombin time (PT), partial thromboplastin time (PTT) and fibrinogen (F) determination. The participant laboratories were classified for each determination in accordance with the methods used. The evaluation was made on the basis of 1986 data, the number of participants being 230, from Public Health (54%) and private 46%) laboratories. A mean (means) or target value, along with the standard deviation (SD), was obtained for the results received in the Organising Centre for each parameter. In order to find deviation of individual results with respect to means, a deviation index (DI) was calculated with regard to the whole group and to those laboratories using the same methods. The graphic evaluation of the results was plotted on a Youden diagram. The active participation was 58.3 +/- 5.7%, ranging from 33% (PC) to 74% (RBC, HB, HT and MCV). Upon evaluating the whole programme, stress was laid on the global variation coefficient (VC%) attained for each parameter and those pertaining to the analytical systems employed, grouped in accordance with the methodological principles. Global VC% ranged between 3.6% (HB) and 31.9% (PTT), and the values corresponding to the analytical procedure used were below 4% for RBC, HB, MCV and MCHC in automatic systems and also for HB and MCV in semiautomatic systems. Although the working period of EQPC-H is too short to draw definitive conclusions on the improvement it may induce in the methodological quality, the high VC% values found for WBC, PC and manual determination of HB, along with the unacceptable values for PT, PTT and F, should be stressed.