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Potato is the third most important food crop in the world. Diverse pathogens threaten sustainable crop production but can be controlled, in many cases, through the deployment of disease resistance genes belonging to the family of nucleotide-binding, leucine-rich-repeat (NLR) genes. To identify effective disease resistance genes in established varieties, we have successfully established SMRT-AgRenSeq in tetraploid potatoes and have further enhanced the methodology by including dRenSeq in an approach that we term SMR-AgRenSeq-d. The inclusion of dRenSeq enables the filtering of candidates after the association analysis by establishing a presence/absence matrix across resistant and susceptible varieties that is translated into an F1 score. Using a SMRT-RenSeq-based sequence representation of the NLRome from the cultivar Innovator, SMRT-AgRenSeq-d analyses reliably identified the late blight resistance benchmark genes Rpi-R1 , Rpi-R2-like , Rpi-R3a , and Rpi-R3b in a panel of 117 varieties with variable phenotype penetrations. All benchmark genes were identified with an F1 score of 1, which indicates absolute linkage in the panel. This method also identified nine strong candidates for Gpa5 that controls the potato cyst nematode (PCN) species Globodera pallida (pathotypes Pa2/3). Assuming that NLRs are involved in controlling many types of resistances, SMRT-AgRenSeq-d can readily be applied to diverse crops and pathogen systems., Competing Interests: The authors declare that they have no competing interests., (© The Author(s) 2023. Published by Oxford University Press on behalf of Nanjing Agricultural University.)

The COVID-19 pandemic has catalyzed unprecedented scientific data and reagent sharing and collaboration, which enabled understanding the virology of the SARS-CoV-2 virus and vaccine development at record speed. The pandemic, however, has also raised awareness of the danger posed by the family of coronaviruses, of which 7 are known to infect humans and dozens have been identified in reservoir species, such as bats, rodents, or livestock. To facilitate understanding the commonalities and specifics of coronavirus infections and aspects of viral biology that determine their level of lethality to the human host, we have generated a collection of freely available clones encoding nearly all human coronavirus proteins known to date. We hope that this flexible, Gateway-compatible vector collection will encourage further research into the interactions of coronaviruses with their human host, to increase preparedness for future zoonotic viral outbreaks., Competing Interests: Conflicts of interest statement The author(s) declare no conflict of interest., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Genetics Society of America.)

Cellulite is characterized by dimpled contour alterations of the skin and is present in approximately 85% to 90% of postpubertal females. Although the pathophysiology of cellulite remains to be fully elucidated, experimental evidence indicates a multifactorial process involving the number and types of fibrous septae, microvascular dysfunction, subcutaneous inflammation, decreased dermal thickness with age, and fat deposition. Cellulite is a major cosmetic concern for many women, and a number of both noninvasive (eg, massage, cosmeceuticals, laser therapy) and minimally invasive techniques (eg, subcision, collagenase injection) have been evaluated to improve the appearance of the affected skin. However, evidence for many of these treatments is limited, largely due to the lack of a validated, convenient tool for the standardized evaluation of cellulite severity. Various imaging modalities have been employed to characterize cellulite severity and the impact of treatment, but only 2-dimensional and 3-dimensional digital photography have been adequately validated. However, in many cases, imaging findings do not correlate with subjective measures of cellulite severity. A number of cellulite rating scales have been developed; some provide only a qualitative measure, whereas others do not fully capture all clinically relevant aspects of cellulite, including the perspective of the patient. There remains an unmet need for global adoption of a validated scale that can be utilized easily by clinicians and patients in clinical and research settings. We propose features that should be included in an ideal rating scale for assessment of cellulite severity., (© 2020 The Aesthetic Society.)

Introduction: Despite the recent Department of Defense emphasis on traumatic brain injury (TBI) education and improvements in treatment, social, and attitudinal beliefs instilled in the military community hinder seeking medical assistance at the time of injury. This survey research presents injury reporting and care seeking behavioral patterns of service members (SMs) stationed in the Landstuhl catchment area in the context of TBI. This descriptive study investigated whether sociocultural factors influence health decision-making among SMs stationed abroad and how these compare to the SMs stationed in Fort Bliss and Fort Hood., Materials and Methods: A total of 969 of U.S. Army, Air Force, and Navy SMs completed a voluntary and anonymous 2- to 5-minute paper survey during the month of March 2019. As a result of illegibility and incompleteness, 15 survey responses were removed from the total sample., Results: Data analyses show three main findings about SMs in the Landstuhl catchment area: (a) older population (25-34, ≥48%; 18-24, 26.1%; +35, 25.4%) when compared to Fort Hood and Fort Bliss (≥48%; 18-24); (b) more years in service (7-13 years; 30.2%) versus 6 years or less in both Fort Hood and Fort Bliss (≥69%); (c) 54.8% of participants did not think TBI requires care versus 63.5% in both Fort Bliss and Fort Hood., Conclusion: Results suggest that TBI beliefs and influences are constant variables hindering health decision-making choices in the military population. Beliefs about thinking that the injury does not require care, fear to jeopardize the career, and knowledge about TBI and treatments vary among the respondents and all these components influence treatment-seeking behaviors. The findings provide a preliminary framework to further investigate the role of culture in reporting and seeking treatment behaviors among SMs., (© The Association of Military Surgeons of the United States 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: HEARTBiT is a whole blood-based gene profiling assay using the nucleic acid counting NanoString technology for the exclusionary diagnosis of acute cellular rejection in heart transplant patients. The HEARTBiT score measures the risk of acute cellular rejection in the first year following heart transplant, distinguishing patients with stable grafts from those at risk for acute cellular rejection. Here, we provide the analytical performance characteristics of the HEARTBiT assay and the results on pilot clinical validation., Methods: We used purified RNA collected from PAXgene blood samples to evaluate the characteristics of a 12-gene panel HEARTBiT assay, for its linearity range, quantitative bias, precision, and reproducibility. These parameters were estimated either from serial dilutions of individual samples or from repeated runs on pooled samples., Results: We found that all 12 genes showed linear behavior within the recommended assay input range of 125 ng to 500 ng of purified RNA, with most genes showing 3% or lower quantitative bias and around 5% coefficient of variation. Total variation resulting from unique operators, reagent lots, and runs was less than 0.02 units standard deviation (SD). The performance of the analytically validated assay (AUC = 0.75) was equivalent to what we observed in the signature development dataset., Conclusion: The analytical performance of the assay within the specification input range demonstrated reliable quantification of the HEARTBiT score within 0.02 SD units, measured on a 0 to 1 unit scale. This assay may therefore be of high utility in clinical validation of HEARTBiT in future biomarker observational trials., (© American Association for Clinical Chemistry 2020.)

Background: Antimicrobial resistance (AMR) is a global threat to public health. e-Bug is an educational resource developed and promoted by a network of international partners. e-Bug seeks to reduce the spread of infection and use of antimicrobials in young people and the community, so helping to control AMR. This study aimed to explore how e-Bug is promoted by international partners and observe barriers to promotion, including the extent of education about antibiotics in schools., Methods: A total of 29 e-Bug partners were invited to complete online questionnaires on (i) methods they use to promote e-Bug; and (ii) antibiotic topics covered in the national curriculum in their countries., Results: Fourteen and 15 of 29 e-Bug partners across Europe and Palestine completed the promotional activities and curriculum questionnaires respectively. The most frequently reported methods of promotion included endorsement and collaboration with government and non-government sectors and involvement in national and global health awareness campaigns. Barriers to promotion included a lack of time and funding. The curriculum survey data showed variation in antibiotic education across Europe and Palestine, lack of antibiotic education for children under 11 years of age and little change in antibiotic topics included in the curriculum since 2006., Conclusions: Future and existing e-Bug partners should be encouraged to follow promotional activities reported in this paper, including ministry endorsement, educator training, international campaigns and youth programmes. We encourage all countries to increase antibiotic topics in the school curriculum across all ages., (© The Author(s) 2020. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy.)

The importance of nutrition support delivery to the severe burn-injured patient is well recognized, however, nutrition provision to the patient may be sub optimal in practice. The aim of this study was to conduct a prospective multi-center audit across Australia and New Zealand using the Joanna Briggs Institute Burns Node Nutrition audit criteria. Thirty-four patients with severe burn injury (≥20% TBSA in adults and ≥10% TBSA in children) were identified on admission or on referral to the Dietitian at the eight participating Burn Units between February 1, 2012 and April 30, 2012 for inclusion in the study. De-identified patient data was analyzed using the Joanna Briggs Institute, Practical Application of Clinical Evidence System. Compliance with individual audit criterion ranged from 33 to 100%. Provision of prescribed enteral feed volumes and weekly weighing of patients were highlighted as key areas for clinical improvement. Clinical audit is a valuable tool for evaluating current practice against best evidence to ensure that quality patient care is delivered. The use of the Joanna Briggs Institute Burns Node audit criteria has allowed for a standardized multi-center audit to be conducted. Improving nutrition support delivery in burn patients was identified as a key area requiring ongoing clinical improvement across Australia and New Zealand. Clinician feedback on use of the audit criteria will allow for future refinement of individual criterion, and presentation of results of this audit has resulted in a review of the Bi-National Burns Registry nutrition quality indicators.

Background: Phosphatidylcholine and deoxycholate (PC-DC) injections are a popular nonsurgical method to eliminate unwanted fat. The safety and efficacy of this approach is uncertain., Objective: The authors evaluate the effects of PC-DC treatments on body composition, adipocyte function, and mechanisms responsible for fat loss., Methods: This randomized, open-label study enrolled 13 women with a body mass index (BMI) ≤30 kg/m(2) and lower abdominal subcutaneous fat suitable for small-volume liposuction. Patients were randomized by the final digit of their Social Security numbers and received between 2 and 4 PC-DC treatments, spaced 8 weeks apart. One side below the umbilicus was injected with PC-DC. The contralateral, control side received no treatment. Adipose tissue biopsies were performed on the treated side at baseline, 1 week after the first treatment, and 8 weeks after the final treatment. The primary outcome was change in adipose tissue thickness at baseline and 8 weeks after the final treatment., Results: Seven women completed the study. Treatment with PC-DC significantly reduced the thickness of the anterior subcutaneous abdominal fat (P = .004). Adipose tissue showed rapid increases in crown-like structures, macrophage infiltration, and reduced expression of leptin, hormone-sensitive lipase, adipose tissue triglyceride lipase, and CD36. Plasma C-reactive protein, lipid profile, and plasma glucose concentrations were unchanged., Conclusions: PC-DC injections can effectively reduce abdominal fat volume and thickness by inducing adipocyte necrosis. These treatments do not appear to increase circulating markers of inflammation or affect glucose and lipid metabolism.

Objective: The outcome of patients with solitary kidney undergoing on-pump cardiac surgery is unknown. We sought to assess the in-hospital mortality and complications in these patients compared with patients with normal renal function., Methods: This is a retrospective review of prospectively collected data over an 8-year period of all patients who underwent cardiac surgery. Our cohort consisted of 3363 consecutive patients divided into: solitary kidney (n=31, 0.9%) and normal kidneys (n=3332, 99.1%). Postoperative complications and in-hospital mortality were analysed., Results: Solitary kidney patients had higher incidence of renal failure (26% vs 5%, p-value<0.001), higher incidence of gastrointestinal complications (10% vs 1%, p-value 0.009) and higher blood transfusions (74% vs 43%, p-value<0.001) compared with patients with normal kidneys. There was an increased length of both intensive care unit stay (3.8 vs 2.2 days, p-value 0.031) and hospital stay (15.6 vs 8.5 days, p-value 0.026) among patients with solitary kidney compared with normal kidney patients. Multivariate analysis showed that solitary kidney is an independent predictor of postoperative renal failure (odds ratio (OR) 7.1 (95%CI 3.1-16.6)), gastrointestinal complications (OR 8.5 (95%CI 2.5-29.4)) and blood transfusion (OR 3.8 (95%CI 1.6-9.0)) after adjusting for age and gender. In-hospital mortality, however, was similar in both groups., Conclusion: Although solitary kidney patients have similar short-term mortality as normal kidney patients, the rates of postoperative renal failure, gastrointestinal complications and blood transfusion are significantly higher among solitary kidney patients. Our findings have important clinical implications and prior knowledge of such entity with appropriate risk stratification at admission could help in reducing the risk of these potential complications., (Copyright © 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Smoking is reported to increase the risk of arrhythmias. However, there are limited data on its effects on arrhythmias following coronary artery bypass graft (CABG). This is a retrospective review of a prospective database of all CABG patients over an eight-year period. Our cohort (n=2813) was subdivided into: current (n=1169), former (n=837), and non-smokers (n=807). Predictors of arrhythmias following CABG in relation to smoking status were analysed. Atrial arrhythmias occurred in 942 patients (33%). Ventricular arrhythmias occurred in 48 patients (2%) and high-grade atrioventricular block occurred in five patients (0.2%). Arrhythmias were lower in current smokers than former and non-smokers (29% vs. 40% vs. 39%, respectively P<0.001). Logistic regression analysis showed 30% arrhythmia risk reduction in smokers compared to non-smokers [odds ratio (OR) 0.7, 95% confidence intervals (CI) 0.5-0.8] and this effect persisted after accounting for potential confounders while former smokers had the same risk as non-smokers (OR 1.04, CI 0.9-1.3). There were no significant differences in mortality. Smokers are less prone to develop arrhythmias following CABG. This paradox effect is lost in former smokers. This effect is possibly due to a lower state of hyper adrenergic stimulation observed in smokers than non-smokers following the stress of surgery.

Improvements in infection prevention practices over the past several decades have enhanced outcomes following aesthetic surgery. However, surgical site infections (SSI) continue to result in increased morbidity, mortality, and cost of care. The true incidence rate of SSI in aesthetic surgery is unknown due to the lack of a national surveillance system, but studies of SSI across surgical specialties have suggested that many of these infections are preventable. Patient-related factors-including obesity, glycemic control, and tobacco use-may contribute to the development of SSI following aesthetic surgery. In terms of SSI prevention, proper handwashing and surgical skin preparation are integral. Furthermore, the administration of prophylactic antibiotics has been shown to reduce SSI following many types of surgical procedures. Unfortunately, there are few large, randomized studies examining the role of prophylactic antibiotics in aesthetic surgery. The authors review the medical literature, discuss the risks of antibiotic overutilization, and detail nonpharmacological methods for reducing the risk of SSI.

Wegener's granulomatosis (WG) is a systemic vasculitic condition that commonly affects the lung and kidneys. With improvement in medical therapy, airway complications are increasingly encountered and are difficult to manage. Here, we present a case whereby a patient presenting with airway complication is successfully treated with surgery.

Learning Objectives: The reader is presumed to have a broad understanding of aesthetic surgical procedures. After studying this article, the participant should be able to: 1. Explain the microbiology of Staphylococcus species and discuss antibiotic resistance development in Staphylococcus species and assess how clinical outcomes are affected. 2. Identify the epidemiology of Staphylococcus carriers and the impact on the clinical practice and regulation. Practice effective measures that prevent surgical site infections. 3. Practice screening for and decolonizing of patients with methicillin-resistant Staphylococcus aureus (MRSA). Physicians may earn 2.5 AMA PRA Category 1 Credit by successfully completing the examination based on material covered in this article. The examination begins on page 245. As a measure of the success of the education we hope you will receive from this article, we encourage you to log on to the Aesthetic Society website and take the preexamination before reading this article. Once you have completed the article, you may then take the examination again for CME credit. The Aesthetic Society will be able to compare your answers and use this data for future reference as we attempt to continually improve the CME articles we offer. ASAPS members can complete this CME examination online by logging on to the ASAPS Members-Only Website (http://www.surgery.org/members) and clicking on "Clinical Education" in the menu bar. Staphylococcus aureus is the most common cause of surgical site infections (SSI), with both methicillin-sensitive and methicillin-resistant strains causing these infections. The incidence of methicillin-resistant S aureus (MRSA) has increased in the US over the past decade, largely due to the emergence of community-acquired MRSA (CA-MRSA). This article reviews the microbiology and epidemiology of methicillin-sensitive S aureus (MSSA) and MRSA, risk factors for surgical site infections among plastic surgery patients, the evidence supporting preoperative screening and decolonization measures to prevent surgical site infections caused by MRSA, recommendations for anti-microbial prophylaxis, and treatment recommendations for surgical site infections. Other proven methods of reducing SSI, including maintenance of normothermia during surgery, glucose control, cessation of nicotine use, and not shaving the surgical site preoperatively are discussed.

Objective: We sought to assess the clinical implication and prognostic significance of maximum standardised uptake value (SUV(max)) of primary non-small cell lung cancer (NSCLC) staged by integrated PET-CT., Methods: A retrospective review was carried out on 176 consecutive patients with histologically proven NSCLC who underwent staging with integrated PET-CT prior to curative intent surgical resection. SUV(max) of primary NSCLC were measured and correlated with tumour characteristics, lymph node involvement, surgical stage, type of surgical resection and survival following resection., Results: SUV(max) was significantly higher in centrally located tumours, tumours > or =4.0 cm, squamous cell subtype, poorly differentiated tumours, advanced T stage, advanced nodal stage, pleural invasion, and patients requiring complex surgical resection. SUV(max) value of 15 was the best discriminative cut-off value for survival generated by log-rank test. When patients were stratified based on this value, those with SUV(max) >15 were more likely to have centrally located tumours, squamous cell subtype, advanced T stage, advanced nodal stage, advanced American Joint Committee on Cancer (AJCC) stage, larger tumour size and required more advanced surgical resections than a simple lobectomy. Overall survival was significantly longer for patients with SUV(max) < or =15 than those with SUV(max) >15. Furthermore, nodal stage specific survival following resection (i.e. non-N2 and N2) were significantly better in patients with SUV(max) < or =15 than SUV(max) >15., Conclusion: SUV(max) correlates with tumour characteristics, surgical stage and prognosis following resection. SUV(max) may be a useful preoperative tool, in addition to other known prognostic markers, in allocating patients with potentially poor prognosis preoperatively to neoadjuvant chemotherapy prior to resection in order to improve their overall survival. Prospective and randomised trials are warranted.

We present a case of pyoderma gangrenosum (PG) mimicking a lung carcinoma. A 52-year-old woman presented with an unremitting cough. Computed tomography revealed a cavitating lung lesion. Bronchoscopy and biopsy were interpreted as squamous cell carcinoma. Following a staging mediastinoscopy, a sleeve lobectomy and chest-wall resection was performed. The pulmonary histopathological features suggested Wegener's granulomatosis; no malignancy was found. Three months postoperatively, wound breakdown led to dermatological review. A clinical diagnosis of cutaneous PG was made on the basis of the classic appearance of the surgical wounds and an ulcer on the upper back that had been present before surgery. The patient has been consistently negative for cytoplasmic-staining antineutrophil cytoplasmic antibodies, which supports the diagnosis of PG with cutaneous and pulmonary involvement. Lung manifestations of PG are rare. PG is amenable to systemic therapy. Pulmonary PG is a rare but important differential diagnosis that is not familiar to many physicians and surgeons in this type of presentation.

We present a case of an unusual presentation of a rare primary cardiac tumour. There are no more than 50 previously reported cases of primary cardiac paraganglioma in the world literature and only a small proportion of these involve the right side of the heart. Diagnosis is difficult and surgical management is varied and complex.

We collected cigarette butts in a range of residential areas, to assess differences in the length of unburnt tobacco in the butts, and in proportions of roll-your-own (RYO) cigarettes. Two high, two medium, and two low deprivation areas, as classified by deciles of the New Zealand Deprivation Index, were selected for the Wellington region. Collected butts were systematically classified and measured. A mixed model of analysis, treating location clusters nested within deprivation level areas as a random effect, was used to assess differences in mean length of unburnt tobacco in the butts. A total of 6,262 cigarette butts and separate filters were collected, of which 3,509 (56.0%) were measurable manufactured cigarette butts, 1,069 were unmeasurable manufactured butts, 1,450 were RYO butts, and 236 were RYO filters. The RYO butts were not measured because of the extent of their degradation. The unburnt tobacco lengths in manufactured cigarette butts were significantly shorter in the most deprived areas, relative to the least deprived areas (p = .035). Deformed manufactured cigarette butts (i.e., that potentially were stubbed out) showed the same pattern (p = .011 between the most and least deprived areas). We found no significant difference between deprivation areas in the proportion of RYO material found. The shorter mean unburnt tobacco length in the most deprived areas is consistent with more intensive smoking among smokers in those areas. This finding is consistent with other evidence of increased price sensitivity among poorer smokers, and with basic economic theory. Further evidence on observed smoking behavior in the field is necessary to better interpret these preliminary findings.

Background: The number of cosmetic surgical and nonsurgical procedures performed in the United States has increased by 500% over the past 10 years. Most studies of psychosocial functioning following aesthetic procedures have reported high levels of patient satisfaction and improved functioning; however, nearly all these studies focused only on changes during the first posttreatment year., Objective: This paper reports on the 2-year results of a prospective, multi-site investigation of postoperative satisfaction and changes in psychosocial status following cosmetic surgery., Methods: One hundred patients from 8 surgical practices completed psychometric measures of body image, depressive symptoms, and self-esteem before surgery. Patients completed the same measures again at 3, 6, 12, and 24 months postoperatively. In addition, they reported their postoperative satisfaction as well as self-rated attractiveness at the 4 postoperative assessment points., Results: Patients reported improvements in their overall appearance and body image, the appearance of and their degree of dissatisfaction with the feature altered by surgery, and the frequency of negative body image emotions in specific social situations through 24 months after surgery. These improvements were first evident at 3 months postoperatively and were maintained, without deterioration, through 2 years following surgery., Conclusions: Patients reported high rates of satisfaction and improvements in body image within the first 3 months of cosmetic surgery. These improvements were well maintained through the first 2 postoperative years.

Objective: We sought to assess the incidence, pattern and predictors of occult mediastinal lymph node involvement (N2) in non-small cell lung cancer patients with negative mediastinal uptake of 2-deoxy-2-[(18)F]-fluoro-d-glucose ((18)FDG) on integrated positron emission tomography-computerised tomography (PET-CT)., Methods: All patients who underwent surgical resection in our unit over a 30-month period were reviewed (n=215). All patients had preoperative PET-CT prior to lung resection as an adjunct to a dedicated chest CT. Diabetic patients, patients who received neoadjuvant chemotherapy and those with positive mediastinal nodes on PET-CT (N2/N3) were excluded from this study. The population of interest was 153 non-small cell cancer patients (NSCLC), all of which had no FDG uptake in the mediastinum. No preoperative mediastinoscopy was carried out in this group and all underwent curative intent surgical resection. The pathological results were retrospectively reviewed and correlated with CT and integrated PET-CT findings., Results: The incidence of occult N2 disease in NSCLC patients with negative mediastinal uptake of (18)FDG on PET-CT was 16% (25 of 153). The highest incidence of occult N2 involvement was in American thoracic society (ATS) 7 (16 of 25 patients, 64%) followed by ATS 4 (seven patients of 25, 28%). In univariate analysis, the following were significant predictors of occult N2 disease: centrally located tumours (P=0.049), right upper lobe tumours (P=0.04), enlarged lymph nodes (>1cm) on CT (P=0.048) and PET positive uptake in N1 nodes (P=0.006). In multivariate analysis, the following were independent predictors of occult N2 disease: centrally located tumours, right upper lobe tumours and PET positive uptake in N1 nodes (P<0.05)., Conclusions: In NSCLC patients who are clinically staged as N2/N3 negative in the mediastinum by integrated PET-CT, 16% will have occult N2 disease following resection. Patients with the following: centrally located tumours, right upper lobe tumours and positive N1 nodes on PET should have preoperative cervical mediastinoscopy to rule out N2 nodal involvement, especially in ATS stations 7 and 4 as the incidence of occult nodal metastasis in these nodes is high. This study has potential implications in decision-making and planning best treatment approach.

Acute renal failure requiring continuous renal replacement therapy post cardiac surgery carries a high mortality. Most studies have focused on patients with impaired renal function preoperatively but little is known about predictors of such a complication in patients with preoperatively normal renal function. This is a retrospective review of a prospective collected database. A total of 1609 patients underwent cardiac surgery over a 4-year period. Dialysis was required in 47 patients (2.9%). Univariate analysis identified the following as significant risk factors: age, female gender, chronic obstructive pulmonary disease, congestive cardiac failure, creatinine clearance, Euro, Parsonnet and Cleveland clinic scores, body mass index, non-isolated CABG, cardiopulmonary bypass time, extubation time and pulmonary complications (P<0.05). Multivariate analysis identified EuroSCORE, congestive cardiac failure, insulin-dependent diabetes, emergency surgery, postoperative extubation time and pulmonary complications as independent risk factors (P<0.05). In-hospital mortality and length of stay (P<0.0001) were higher in dialysis group. Acute renal failure requiring dialysis post cardiac surgery is associated with a higher mortality and prolonged hospital stay. By identifying higher risk patients, early planned preventative measures should be readily available to both reduce the incidence of such a complication and improve utilisation of hospital resources.

Despite documented superiority of positron emission tomography over other investigative modalities in the preoperative staging of non-small cell lung cancer, a proportion of patients will have an inaccurate staging of their mediastinal nodes. The aim of this retrospective review is to analyse the clinicopathological factors responsible for inaccurate nodal staging by integrated PET-CT. A total of 100 consecutive patients with histologically proven non-small cell lung cancer underwent staging with PET-CT prior to lung resection. Thirty-three patients, inaccurately staged by PET-CT, were analysed. Univariate analysis identified the following as significant in causing inaccurate nodal staging: history of tuberculosis (P=0.039) and non-insulin dependant diabetes (P=0.014). In multivariate analysis, we have identified the following as independent factors in causing inaccurate staging of mediastinal lymph nodes: rheumatoid arthritis, non-insulin dependent diabetes, history of tuberculosis, presence of atypical adenomatous hyperplasia and pneumonia (P<0.05). The highest rate of inaccuracy in mediastinal nodal staging was in nodal station 4 (11%, P=0.01) followed by station 7 (10%, P=0.02) and station 9 (3.5%, P=0.01). Interpretation of PET-CT staging of the mediastinum in patients with a history of the above should be with caution, as the incidence of false upstaging and down staging in these subgroups is high. Vigilance of such factors may improve the accuracy of PET-CT in staging mediastinal lymph nodes. Histological confirmation should always be sought.

Positron emission tomography (PET) has become widely available in staging non-small cell lung cancer (NSCLC) and despite its high accuracy, false positive staging remains a problem. We report a rare case where such false positive staging caused a dilemma in optimal management.

While inadvertent perioperative hypothermia has received serious attention in many surgical specialties, few discussions of hypothermia have been published in the plastic surgery literature. This article reviews the physiology of thermoregulation, describes how both general and regional anesthesia alter the normal thermoregulatory mechanisms, indicates risk factors particularly associated with hypothermia, and discusses the most effective current methods for maintaining normothermia. Hypothermia is typically defined as a core body temperature of /=36.5 degrees C is maintained. Unless preventive measures are instituted, inadvertent hypothermia occurs in 50% to 90% of surgical patients, even those undergoing relatively short procedures lasting one to one-and-a-half hours. During either general or regional anesthesia, a patient's natural behavioral and autonomic responses to cold are unavailable or impaired, and the combination of general and neuraxial anesthesia produces the highest risk for inadvertent perioperative hypothermia. Unless hypothermia is prevented, the restoration of normothermia can take more than 4 hours once anesthesia is stopped. Consequences of hypothermia are serious and affect surgical outcomes in plastic surgery patients. Potential complications include morbid cardiac events, coagulation disorders and blood loss, increased incidence of surgical wound infection, postoperative shivering, longer hospital stays, and increased costs associated with surgery. Measures for preventing hypothermia are emphasized in this article, especially those proven most effective in prospective and controlled clinical studies. Perhaps the most important step in maintaining normothermia is to prewarm patients in the preoperative area with forced-air heating systems. Intraoperative warming with forced-air and fluid warming are also essential. Other strategies include maintaining an ambient operating room temperature of approximately 73 degrees F (22.8 degrees C), covering as much of the body surface as possible, and aggressively treating postoperative shivering. None of these measures can be adequately employed unless a patient's core body temperature is monitored throughout the perioperative period. Prevention of perioperative hypothermia is neither difficult nor expensive. Proper preventive measures can reduce the risk of complications and adverse outcomes, and eliminate hours of needless pain and misery for our patients.

The study was designed to determine whether the development of atrial fibrillation is associated with post-operative left ventricular dysfunction and subsequent left atrial stretch. We recruited 133 patients with well preserved pre-operative left ventricular function undergoing bypass surgery. Brain natriuretic peptide was measured at baseline, 24 and 48 h after the onset of cardiopulmonary bypass, and patients were monitored for 72 h after surgery. Atrial fibrillation occurred in 65 patients. Median 48 h brain natriuretic peptide levels were greater in the atrial fibrillation group (440 pg/ml (AF) and 319 pg/ml (non AF) P=0.001). As atrial fibrillation can cause an elevation in brain natriuretic peptide we divided the subjects into early atrial fibrillation (<48 h) and late (>48 h). In those with early atrial fibrillation there was no difference in the 24 h brain natriuretic peptide levels (381 pg/ml and 365 pg/ml P=0.73). In those with late atrial fibrillation the median 48 h brain natriuretic peptide level was greater than in the control group (405 pg/ml and 319 pg/ml, respectively, P=0.02). Brain natriuretic peptide levels rise significantly following bypass surgery. This increase was more evident in those who develop late atrial fibrillation which may suggest a role for atrial stretch in this arrhythmia.

Learning Objectives: The reader is presumed to have a broad understanding of plastic surgical procedures and concepts. After studying this article, the participant should be able to: Physicians may earn 1 AMA PRA Category 1 credit credit by successfully completing the examination based on material covered in this article. The examination begins on page 176. ASAPS members can also complete this CME examination online by logging onto the ASAPS Members-Only Web site (http://www.surgery.org/members) and clicking on "Clinical Education" in the menu bar. Little has been published about venous thromboembolism (VTE) complications in plastic surgery. The authors investigated the recent literature, particularly literature reviews and meta-analyses of clinical studies, in order to outline strategies for prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE) applicable to plastic surgery patients. Major risk factors for VTE include trauma, a prior history of VTE, older age, use of oral contraceptives or hormone replacement therapy, and prolonged travel. Although the frequency of VTE among plastic surgery patients is estimated to be from less than 1% to 2% of cases, in fact many of our patients are at moderate to high risk of VTE. Moreover, the actual frequency of VTE among plastic surgery patients is probably higher than we know, because up to two thirds of cases are asymptomatic. Mechanical methods of VTE prophylaxis include graduated compression stockings (GCSs), intermittent pneumatic compression (IPC) devices, and venous foot pumps (VFPs). They are recommended primarily for patients with a high risk of bleeding or as an adjunct to chemoprophylaxis. Intermittent pneumatic compression devices were found to be more effective than passive compression using GCSs. For plastic surgery patients, IPC devices or VFPs are recommended for any procedure that lasts more than 1 hour, and for all patients receiving general anesthesia. Use should begin 30 to 60 minutes before surgery. Low-molecular-weight heparin (LMWH) is the most widely used form of DVT/PE prophylaxis. Other forms of chemoprophylaxis are coming onto the market or under development. In particular, fondaparinux, an indirect FXa inhibitor, was approved in 2004 for VTE prophylaxis in orthopedic surgery. Studies have indicated that it is significantly more effective than LMWH after joint replacement, hip fracture surgery, and in cancer patients. Other drugs in development include idraparinux, another indirect FXa inhibitor, direct FXa inhibitors, and several direct thrombin inhibitors. Plastic surgeons have generally been reluctant to use antithrombotic agents because of the increased risk of bruising or hematoma and the possible need for blood transfusion. However, numerous studies have found little or no increase in the frequency of clinically important bleeding associated with their use. Some plastic surgeons now routinely use chemoprophylaxis in patients undergoing abdominoplasty, combined procedures, or procedures lasting more than 4 hours. The authors also recommend postoperative chemoprophylaxis in circumferential body contouring, thighplasty, surgery requiring open space dissection, transverse rectus abdominus muscle (TRAM) procedures, and surgical procedures likely to contribute to venous stasis or compression. It is impractical and expensive to screen every patient for asymptomatic DVT. A patient history focusing specifically on VTE risk factors should be performed within a few weeks of surgery. Patient education should include information about the symptoms of DVT and PE (including the fact that most patients with VTE are asymptomatic) and a full explanation of the risks and benefits of anticoagulant prophylaxis.

Background: Although several studies have investigated patient satisfaction and changes in body image following aesthetic plastic surgery, few have investigated more specific dimensions of body image, including dysphoric emotions that occur in specific social situations or body image quality of life. In addition, few studies have investigated changes in body image that may occur in concert with changes in more general areas of psychosocial functioning, such as depressive symptoms and self-esteem., Objective: This prospective, multi-site study investigated postoperative satisfaction and changes in psychosocial status following cosmetic surgery., Methods: One hundred patients recruited from 8 geographically diverse surgical practices completed psychometric measures of body image, depressive symptoms, and self-esteem prior to surgery. Seventy-two patients completed the 3-month postoperative assessment, 67 completed the 6-month assessment, and 63 completed the 12-month assessment. All statistical tests on changes after surgery were conducted using the sample of 72 patients who completed the 3-month assessment. A Last Observation Carried Forward analysis was used to account for patients who did not complete the subsequent follow-up assessments. In addition, they reported their postoperative satisfaction as well as self-rated attractiveness at the 3 postoperative assessment points., Results: Eighty-seven percent of patients reported satisfaction with their postoperative outcomes. Patients also reported significant improvements in their overall appearance, as well as the appearance of the feature altered by surgery, at each of the postoperative assessment points. Patients experienced significant improvements in their overall body image, their degree of dissatisfaction with the feature altered by surgery, and the frequency of negative body image emotions in specific social situations. All of these improvements were maintained 12 months after surgery., Conclusions: These results add to a growing body of literature documenting improvements in body image following cosmetic surgery.

The authors point out that dimethyl sulfoxide (DMSO) increases tissue perfusion and may effectively treat or prevent ischemia in flaps. They recommend application of topical DMSO every 4 to 6 hours, until blood flow improves, to areas that show signs of ischemia or less than adequate perfusion. Other potential cosmetic surgery uses of DMSO include areas of skin care, pain relief, and treatment of keloids.

Background: The first Online Breast Augmentation Survey (Aesthetic Surg J 2004;24:117-135) reported on women who had undergone or who were considering breast augmentation with regard to motivation for surgery, patient satisfaction with results, and other issues. The Food and Drug Administration and others have also raised questions concerning informed consent, follow-up, health insurance, and related issues dealing with breast augmentation., Objective: An Online Breast Augmentation Follow-Up Survey was designed to collect data from women who had undergone breast augmentation with regard to informed consent, follow-up, complications and problems following breast augmentation, and health insurance., Methods: The survey comprised 56 questions, many of which were presented in a multiple-part format. Women who visited the Web site www.implantinfo.com and who had undergone breast augmentation were invited to participate in the survey. An independent research firm, Industry Insights, Inc. (Columbus, OH), assisted with the final design and collected and analyzed the data., Results: The survey was posted from April 8-June 30, 2003. Surveys were submitted by 1350 women. Ninety-two percent of respondents said that surgeons asked them to return for regular follow-up during the first postoperative year. Ninety percent said they would return to the original surgeon if a problem developed. Almost all respondents (94%) said that they had been informed by the surgeon, the surgeon's staff, or both of specific problems or complications that might be associated with breast implants and augmentation; 89% said that the information they received was adequate. Eighty percent said they complied with the surgeon's recommendations for follow-up visits, although compliance declined after the first postoperative year. The survey also showed that most women who undergo breast augmentation seek out information about the procedure before surgery from independent sources, in most cases from Web sites. Eighty-eight percent of respondents said they were involved in some way in deciding on implant size; 88% said they were satisfied with breast size after surgery. Fourteen percent of respondents reported additional implant-related surgery after the original augmentation., Conclusions: Our data indicate that almost all patients are advised to return for follow-up visits, that most comply with their surgeons' recommendations for follow-up in the first postoperative year, and that the main reason for noncompliance is an absence of problems with implants. The survey also indicates that patients receive adequate informed consent from the surgeon or the surgeon's staff and that they also seek out information on their own. Finally, the data suggest that women who have undergone augmentation have a realistic appreciation of the problems involved and are willing to tolerate minor complications.

Background: Some medical equipment manufacturers and surgeons have asserted that certain types of cannulas and other components of liposuction systems enhance the efficiency of fat aspiration., Objective: A laboratory experiment was designed to evaluate the effect of each component of a standard liposuction system on the rate of fat aspiration. A clinical investigation of the effectiveness of a vented (Turbo) cannula versus that of a standard cannula was also undertaken., Methods: The equipment used for the experiment included cannulas of varying lengths and diameters, provided with different tip geometries, suction tubes of 2 diameters, graduated canisters, and a vacuum pump. Applesauce was used as a simulated aspirant because its consistency appears similar to that of a mixture of fat and infiltrate. The time required to aspirate 1500 mL of material, with the pump set at maximum vacuum and the temperature and barometric pressure held constant, was measured., Results: Aspiration rates for the laboratory experiment with Becker, Keel Cobra Accelerator III, and Mercedes tip geometries were similar. In general, clinical aspiration rates were significantly lower than the laboratory rates. A higher aspiration rate was obtained with the vented Turbo cannula than with the conventional cannula., Conclusions: Cannula-tip geometry has a minimal effect on the rate of aspiration; however, use of a tip less than 4 mm in diameter can cause clogging with fibrous tissue and significantly decrease the rate of aspiration. Aspiration is directly proportional to cannula and suction-tubing diameter and inversely proportional to cannula and suction-tubing length. Vented cannulas can enhance aspirate flow and efficiency. Further research is needed to investigate the significance of the fat fragmentation process and the development of fluids to simulate infiltrate/fat solutions in laboratory experiments.

Background: Data have been lacking to answer many questions raised in the clinical literature and by the US Food and Drug Administration with regard to patient satisfaction with breast implants, informed consent, the impact of augmentation on quality of life, repeat operations, and other issues related to breast augmentation., Objective: The authors conducted an online survey of women with and without breast implants to collect data on key issues related to breast augmentation., Methods: A survey including 177 questions was posted on the Web site www.implantinfo.com for 6 months, from August 2001 to February 2002. The survey was aimed at women who had undergone augmentation and those who were considering augmentation but had not yet undergone surgery. The raw data were analyzed by Data Harbor (Chicago, IL), an independent data management and technology development company with experience in managing large, complex medical databases., Results: The survey was completed by 4011 women, including 2273 who had received breast implants and 1738 who were considering augmentation. Among the key findings: More than half of the women who had undergone breast augmentation and those who were considering the procedure thought about the decision for at least 3 years before proceeding. Most women who underwent breast augmentation (88%) were satisfied with the results, and 93% said they would recommend the procedure to friends or family members. Nearly all women who received implants thought the surgery improved their overall appearance (92%) and self-confidence (82%) but said it did not result in significant changes in their marriage/dating activities, careers, or social lives. At least 92% said their surgeons had answered their questions and listened to their concerns, and more than 75% said they remembered being informed of the risks of surgery. The percentage of women with breast pain was greater among women with implants than among those without. However, other physical symptoms, such as those associated with rheumatologic diseases, were more common among women considering augmentation. Respondents with implants did not smoke at levels higher than comparable women in the general population and were not major consumers of alcohol., Conclusions: The Online Breast Augmentation Survey provides a wealth of previously unavailable data on women who have undergone or who are considering breast augmentation. The data indicate that women consider breast augmentation carefully, that they are well informed by their physicians before surgery, and that they are generally happy with the results.

Lipostabil, advertised as an injectable product for eliminating fat, has been available for 3 decades in Europe, South America, and South Africa for the treatment of numerous medical conditions. The author outlines what is known about the aesthetic applications of Lipostabil and explores the important questions that remain unanswered.

We have analyzed the human mineralocorticoid receptor (hMR) gene in 14 families with autosomal dominant or sporadic pseudohypoaldosteronism (PHA1), a rare form of mineralocorticoid resistance characterized by neonatal renal salt wasting and failure to thrive. Six heterozygous mutations were detected. Two frameshift mutations in exon 2 (insT1354, del8bp537) and one nonsense mutation in exon 4 (C2157A, Cys645stop) generate truncated proteins due to premature stop codons. Three missense mutations (G633R, Q776R, L979P) differently affect hMR function. The DNA binding domain mutant R633 exhibits reduced maximal transactivation, although its binding characteristics and ED(50) of transactivation are comparable with wild-type hMR. Ligand binding domain mutants R776 and P979 present reduced or absent aldosterone binding, respectively, which is associated with reduced or absent ligand-dependent transactivation capacity. Finally, P979 possesses a transdominant negative effect on wild-type hMR activity, whereas mutations G633R and Q776R probably result in haploinsufficiency in PHA1 patients. We conclude that hMR mutations are a common feature of autosomal dominant PHA1, being found in 70% of our familial cases. Their absence in some families underscores the importance of an extensive investigation of the hMR gene and the role of precise diagnostic procedures to allow for identification of other genes potentially involved in the disease.

Background: Because of concerns that exposure to povidone-iodine (Betadine) may lead to early breast implant failure, the Food and Drug Administration announced in 2000 that any contact between implants and Betadine is contraindicated. The evidence cited by the Food and Drug Administration primarily referred to Betadine added to saline implant filler solution and not to povidone-iodine used for pocket irrigation., Objective: Thirteen explanted Mentor saline solution-filled devices that had been exposed to Betadine pocket irrigation during implantation were studied for any loss of implant shell integrity., Methods: The 13 explants had been in place 1 week to 55 months, and none had intraluminal Betadine exposure. Twelve of the 13 explants were intact when removed, and one had leaked through the anterior valve. All were examined for any signs of patch-shell delamination. The mechanical properties of tensile strength, percent elongation, force-to-break, tear resistance, and patch bond strength were also measured., Results: No shell delamination or disruption of the sealing patch bond was found in any of the 13 explants placed in Betadine-irrigated pockets. In addition, the measured mechanical properties of the explants exceeded American Society for Testing and Materials requirements, with the exception of the textured explants (n = 2), which failed to meet the minimum elongation standards., Conclusions: We found no evidence of patch or shell delamination in Mentor implants that had extraluminal contact with Betadine irrigation and were later explanted. We believe that the lower mechanical properties of the two textured implants are probably related to the texturing process rather than to Betadine pocket irritation. (Aesthetic Surg J 2002;22:438-445.).

Objective: To determine the expression of molecular markers of prostanoid/fatty acid signalling in leucocytes of patients with systemic sclerosis (SSc)., Methods: Gene expression in patient leucocytes was analysed using real-time fluorescence reverse transcriptase polymerase chain reaction for tumour necrosis factor alpha (TNF-alpha), thromboxane synthase (TXAS, CYP5A), prostacyclin synthase (CYP8A), monocyte chemoattractant protein-1 (MCP-1), peroxisome proliferator-activated receptors (PPAR) alpha, delta and gamma, low-density lipoprotein-associated lipoprotein lipase A(2) (LDL-PLA(2)), apolipoprotein E (apoE) and cholesterol 27-hydroxylase (CYP27)., Results: Both TNF-alpha and TXAS showed an increase in mean expression in the diseased group (6.3-fold and 5.6-fold respectively, P<0.0001). These two markers, along with CYP27, PPARgamma and apoE, provided predictive markers for the development of carotid artery disease within the SSc patient population., Conclusion: The elevated levels of TNF-alpha and thromboxane seen in SSc patient sera are paralleled by increases in the expression of the appropriate genes in leucocytes. This method will allow us to screen for a large number of candidate markers of disease in order to increase our understanding of the processes underlying the pathology of SSc.

Helicobacter pullorum has been isolated from the feces and livers of poultry and is associated with human gastroenteritis. Discrimination of this organism from other enterohepatic Helicobacter species and Campylobacter species has proven difficult. H. pullorum from both avian and human clinical sources has DNA sequence homology and cytotoxic activity that represent a new member of the cytolethal distending toxin (CDT) family of bacterial toxins. CDT is a potential virulence factor in H. pullorum that may serve as a distinguishing phenotype and aid in identification of this organism in veterinary and human clinical samples.

Restrictions ordered by the U.S. Food and Drug Administration on the use of silicone gel-filled breast implants, as well as patient and surgeon dissatisfaction with the aesthetic results sometimes attained with saline solution-filled implants, have prompted new interest in developing alternative implant filler materials, including triglycerides. Soybean oil-filled breast implants are now in various stages of testing and use in the United States, Europe, and Canada. This article reports on experience with Trilucent breast implants (prefilled with soybean oil) by one plastic surgeon in Sweden. A total of 96 patients (191 implants) underwent primary augmentation or replacement augmentation mammaplasty between October 1995 and June 1997. Data have been analyzed for all 96 patients with a mean follow-up period of 15 months and for 67 patients (133 implants) with a mean follow-up of 18 months. The significant findings of the study include the absence of systemic reactions or unusual local complications, the low incidence (2.3%) of symptomatic capsular contracture (grades III and IV) among the 67 patients at the 18-month postoperative time point, and high patient satisfaction with the aesthetic results. The mammographic radiolucency of soybean oil-filled implants was also demonstrated. At the 18-month follow-up point, the only negative observations were the presence of skin wrinkling in 3% of the breasts and implant palpability in 46% of the breasts. These findings are in general agreement with preliminary data from the European clinical trials of Trilucent breast implants.

Numerous manufacturers are marketing topical creams, claiming that they improve or eliminate unwanted fat or cellulite in a short period of time. The active ingredient in most of these creams is theophylline, and claims have been made that it initiates lipolysis by binding to adipocyte beta-adrenergic receptors. The creams are applied with vigorous massage to facilitate absorption and apply mechanical stress to the fat cells. The efficacy of these creams is largely untested. This prospective randomized study was conducted to determine whether there is scientific evidence that application of these creams alone can eliminate unwanted fat or cellulite. Eleven women with normal body weight as defined by insurance tables applied either Skinny Dip(TM) or a placebo to one thigh and one half of the abdomen for 8 weeks. Each subject was examined, photographed, weighed, and measured by a study monitor on a weekly basis. There were no statistically significant differences in appearance, abdominal circumference, thigh circumference, or skin fold measurements among subjects using the active agent (Skinny Dip(TM)) or the placebo. This study failed to support the efficacy of topically applied lipolytic creams in eliminating unwanted fat manifesting as a localized bulge or cellulite presenting as a dimpling of the skin.

The major components of daily energy expenditure may change during aging. A review of current estimates of energy requirements leads to the conclusion that direct estimates of daily energy expenditure are desirable to confirm the validity of the present recommendations. A more extensive examination of the metabolic and nutritional significance of the major food fuel sources is necessary to further define human energy needs.

In this short review some aspects of body protein and amino acid metabolism during ageing in human subjects have been explored. The picture that emerges is a progressive diminution of total body protein with ageing, due largely to a decline in the size of the skeletal muscle mass. These changes are accompanied by a shift in the overall pattern of whole body protein synthesis and breakdown, with muscle mass estimated to account for about 30% of whole body protein turnover in the young adult, as compared with a lower value of 20% or less in the elderly subject. The metabolic significance and possible functional implications of this alteration in the quantitative contribution by muscle to whole body amino acid and protein dynamics have been considered. The determination of requirements for individual essential amino acids and for total protein has been discussed, and it is evident that the data are limited and often contradictory. However, elderly individuals are more likely to be influenced by various biological, environmental and social factors, the effects of which would be generally to increase protein needs above those for younger adults. Thus, in practice, the protein needs of elderly people are probably higher than for the young. The decline in energy intake, together with its possible consequences for reduced dietary protein utilization, will also tend to increase the protein need of elderly subjects, compared with that for physically more active young adults. Until more data become available, it is recommended for food planning purposes that an appropriate protein allowance could be 12-14% of the total energy intake, for mixed protein sources characteristic of the diets of industrialized countries or the more affluent sectors of populations in developing countries. Energy intake should be at a level that meets the estimates proposed by FAO/WHO/UNU for older persons. Tentative recommendations are made herein that intakes of specific indispensable (essential) amino acids, per unit of protein need, should be similar to those for the young school-age child and they should be higher than those currently judged by international authorities (i.e. FAO/WHO/UNU) to be sufficient for maintenance of protein nutritional status in the adult. In view of (i) the increasing proportion of older individuals within technically advanced populations together with the need of this group for health care and (ii) the important role played by diet and food habits in health maintenance, and in the aetiology or progression of degenerative disease, it is vitally necessary to improve upon the current state of knowledge concerning protein and amino acid metabolism and nutrition during the later phases of our lives.