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Excisional body contour surgery is the cornerstone treatment for skin laxity. Decision-making can be challenging when selecting the procedure. Dynamic definition liposculpture allows the surgeon to carve the underlying anatomy and provide more natural results, in which umbilical shape and position play a crucial role. The authors describe their experience using a decision-making algorithm as a tool to ease surgical planning for advanced excisional body contouring.Following the algorithm designed by the senior author regarding excisional body contouring procedures, the authors searched their database for patients who were classified according to skin laxity and navel location to undergo one of the following procedures: mixed technologies plus umbilical mobilization, mixed technologies plus sliding mini-abdominoplasty, mini-tummy tuck with muscular plication, full abdominoplasty, reverse bridge abdominoplasty, or reverse full abdominoplasty.A total of 563 women were consecutively operated on from February of 2014 to January of 2020. The six-procedure model algorithm helped the authors achieve very good results with low complication rates in patients with some grade of abdominal skin laxity. Most complications were reported as minor (9.6 percent). Major complications (3.9 percent) included three localized infections, four abnormal skin retractions, two cases of skin flap necrosis, and 13 cases of postoperative anemia.This algorithm helped the authors choose the best excisional technique based on patients' anatomical features by following skin geometry to enhance aesthetic outcomes. Further studies are needed to support the algorithm validation and aesthetic outcomes.Therapeutic, IV.

BACKGROUND Although abdominoplasty is a mainstay of the plastic surgeon, the safety of the Brazilian butt lift (BBL) has been questioned, effectively being prohibited in some countries. The central rationale for the safety concern over the BBL stems from a publication stating a mortality rate of one in 3000. The question remains: What is the real safety of these procedures? METHODS Focusing on mortality, literature searches were performed for BBL and for abdominoplasty. The 2017 Aesthetic Surgery Education and Research Foundation survey data and publication were examined and analyzed. Additional data from the American Association for Accreditation of Ambulatory Surgical Facilities were obtained independently. RESULTS Abdominoplasty and BBL appear to have similar safety based on mortality; however, the nature of their mortalities is different. Although most abdominoplasty deaths are secondary to deep venous thrombosis/pulmonary embolism-inherent circulatory thrombotic abnormality-BBL mortality is associated with iatrogenic pulmonary fat embolism. BBL mortality rates from more recent surveys on BBL safety demonstrate a mortality of one in 15,000. CONCLUSIONS Although deep venous thrombosis/pulmonary embolism will always remain an abdominoplasty risk, intraoperative BBL pulmonary fat embolism has the potential to be reduced dramatically with a better understanding of dynamic anatomy, surgical instrumentation, and technique. The authors are now presented with a better lens with which to view a more accurate safety profile of BBL surgery, including its place among other commonly performed aesthetic procedures.

Supplemental Digital Content is available in the text., Background: The optimal duration of antiplatelet therapy (APT) in patients at high bleeding risk with or without oral anticoagulation (OAC) after coronary stenting remains unclear. Methods: In the investigator-initiated, randomize, open-label MASTER DAPT trial (Management of High Bleeding Risk Patients Post Bioresorbable Polymer Coated Stent Implantation With an Abbreviated Versus Standard DAPT Regimen), 4579 patients at high bleeding risk were randomized after 1-month dual APT to abbreviated or nonabbreviated APT strategies. Randomization was stratified by concomitant OAC indication. In this subgroup analysis, we report outcomes of populations with or without an OAC indication. In the population with an OAC indication, patients changed immediately to single APT for 5 months (abbreviated regimen) or continued ≥2 months of dual APT and single APT thereafter (nonabbreviated regimen). Patients without an OAC indication changed to single APT for 11 months (abbreviated regimen) or continued ≥5 months of dual APT and single APT thereafter (nonabbreviated regimen). Coprimary outcomes at 335 days after randomization were net adverse clinical outcomes (composite of all-cause death, myocardial infarction, stroke, and Bleeding Academic Research Consortium 3 or 5 bleeding events); major adverse cardiac and cerebral events (all-cause death, myocardial infarction, and stroke); and type 2, 3, or 5 Bleeding Academic Research Consortium bleeding. Results: Net adverse clinical outcomes or major adverse cardiac and cerebral events did not differ with abbreviated versus nonabbreviated APT regimens in patients with OAC indication (n=1666; hazard ratio [HR], 0.83 [95% CI, 0.60–1.15]; and HR, 0.88 [95% CI, 0.60–1.30], respectively) or without OAC indication (n=2913; HR, 1.01 [95% CI, 0.77–1.33]; or HR, 1.06 [95% CI, 0.79–1.44]; Pinteraction=0.35 and 0.45, respectively). Bleeding Academic Research Consortium 2, 3, or 5 bleeding did not significantly differ in patients with OAC indication (HR, 0.83 [95% CI, 0.62–1.12]) but was lower with abbreviated APT in patients without OAC indication (HR, 0.55 [95% CI, 0.41–0.74]; Pinteraction=0.057). The difference in bleeding in patients without OAC indication was driven mainly by a reduction in Bleeding Academic Research Consortium 2 bleedings (HR, 0.48 [95% CI, 0.33–0.69]; Pinteraction=0.021). Conclusions: Rates of net adverse clinical outcomes and major adverse cardiac and cerebral events did not differ with abbreviated APT in patients with high bleeding risk with or without an OAC indication and resulted in lower bleeding rates in patients without an OAC indication. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03023020.

Multiple umbilicoplasty techniques have been described, even more after the advent of full tummy tuck procedures and the neoumbilicoplasty (X-shaped incision) described by the authors in a previous report. The authors decided to upgrade the technique (H-wing incision) because the former procedure is associated with relatively common complications. The authors report a case series of an upgraded technique for neoumbilicoplasty (H-wing technique), comparing its outcomes with their previous standard procedure (X-shaped incision).The authors reviewed their records for neoumbilicoplasties performed between January of 2014 and December of 2019. The authors divided the procedures according to the surgical technique and performed a detailed analysis regarding timing, complications, uses, and quality standards according to patients' opinion through a nonstandardized survey.A total of 407 procedures were distributed between two techniques: X-shaped incision, 179 procedures; and H-wing technique, 228 procedures. The former was performed from January of 2014 to October of 2016 and the latter from September of 2016 to December of 2019. High satisfaction indexes were found for both procedures; however, fewer complications were seen in the H-wing group. The X-shaped incision is thought to generate a greater force of tension over the flaps compared to that from the H-wing technique, which consequently increased the risk of flap necrosis and flattening.The H-wing technique for neoumbilicoplasty decreases the risk of postoperative complications such as dehiscence, skin necrosis, and navel flattening, and maintains high aesthetic standards and satisfaction indexes among patients. The technique can be used after either lipoabdominoplasty or secondary procedures.

Intraoperative hemostasis should be performed with great caution because bleeding is a huge enemy of patient safety during surgery. Tranexamic acid is a lysine synthetic derivate that inhibits fibrinolysis and diminishes the bleeding by blocking the five lysine-binding sites for plasminogen. The authors compare the efficacy of tranexamic acid versus placebo as a hemostatic agent in liposculpture procedures.The authors conducted a multicenter, double-blind, randomized, controlled clinical trial in patients who were scheduled for liposculpture in three plastic surgery centers (Colombia and Mexico) between January of 2019 and February of 2020. One hundred forty-one patients were randomly assigned into three groups: intravenous (1 g of tranexamic acid), subcutaneous (1 g of tranexamic acid), and placebo (normal saline). Forty-seven patients were assigned to each group. There were 30 male patients and 111 female patients. The main outcome was to evaluate the amount of postoperative bleeding between groups. The primary outcome was measured by the hemoglobin point loss at day 1 (preoperative hemoglobin minus hemoglobin at day 1 postoperatively) and the hemoglobin (in milligrams per deciliter) point loss at day 5 (preoperative hemoglobin minus hemoglobin at day 5 postoperatively).The authors found the intravenous intervention group to have a greater hemoglobin level than the other two groups on both the first postoperative day ( p = 0.0001) and the fifth postoperative day ( p = 0.001). There were no statistical differences in hemoglobin values between the placebo and the subcutaneous intervention groups.Intravenous tranexamic acid is a good therapeutic choice to implement on liposculpture procedures to decrease postoperative bleeding.The preoperative use of intravenous tranexamic acid not only decreases the bleeding rate after liposuction procedures, but also allows greater lipoaspirate volumes when performing high-definition liposculpture. Further studies are required to support the effectiveness of tranexamic acid within the infiltration solution.Therapeutic, I.

Background Gluteal prominence is a unique characteristic that is widely acknowledged in female contouring but ignored in the male population. This study focuses on male gluteal aesthetics based on a muscular anatomical approach. Methods A retrospective review of gluteal contouring in men from January of 2012 to September of 2019 was conducted. Male body sculpting surgery in the gluteal area was performed in most cases. Patients were included according to preoperative assessment and the American Heart Association risk analysis. The gluteal area was divided into four main anatomical contouring zones and classified according to the procedure type. The follow-up period of 3 months to 6 years was included with photographs and medical assessment data. A nonstandardized satisfaction survey was performed postoperatively. Results The analysis included data from 374 consecutive gluteal dynamic definition liposculptures performed in men (mean age, 38.2 years; range, 20 to 66 years). Patients were treated according to the authors' new classification of deformities. Fat extraction, liposhifting, and fat grafting were performed on a regular basis to enhance and define the gluteal area. A satisfaction index of 92.5 percent was reported. Minor complications were reported: seroma, 0.2 percent; prolonged bruising, 1.3 percent; and swelling, 1.8 percent. No necrosis, burns, or infections were reported. Conclusions Men have been increasingly requesting improvement and definition of the buttocks, and our novel algorithm allows for a reliable method in this regard. The high satisfaction index supports the natural and athletic results accomplished with our new approach.

The abdominoplasty procedure poses a number of unique challenges. If the stigmata of the operation is to be avoided, careful planning and surgical execution are required. We describe our experience in full and mini abdominoplasties with a 360-degree approach, involving all muscular groups and body segments as described by high-definition liposculpture. Selective fat grafting is also safely performed in specific areas to improve projection and volume.

Background: Inferior vena cava (IVC) thrombosis is a rare form of venous thromboembolism (VTE). The optimal treatment strategies and outcomes are unclear in patients with this presentation. Objective: We aimed to compare baseline characteristics, treatment patterns and 24-month outcomes in IVC thrombosis patients (n=100) with lower extremity deep vein thrombosis (LEDVT) patients (n=7629). Methods: GARFIELD–VTE is a prospective, observational registry of 10868 patients with objectively diagnosed VTE from 415sites in 28 countries. Results: IVC thrombosis patients were younger (51.9 vs. 59.8years), more frequently had active cancer (26.0% vs. 8.9%) or history of cancer (21.0% vs. 12.2%), and less frequently had recent trauma or surgery than LEDVT patients. IVC thrombosis was more frequently treated with parenteral anticoagulants alone (35.1% vs. 15.9%), whereas patients with LEDVT more commonly received vitamin K antagonists (32.0% vs. 25.8%) or direct oral anticoagulants (49.0% vs. 35.1%). Thrombolysis (11.0% vs. 3.6%) and surgical/mechanical interventions (4.0% vs. 1.4%) were more frequent in IVC thrombosis. At 24-months, the rate per 100 person-years (95% confidence interval) of all-cause mortality was higher in patients with IVC thrombosis than LEDVT (13.28 [8.57–20.58] vs. 4.91 [4.55–5.3]); the incidence of cancer-associated mortality was comparable as was the incidence of VTE recurrence (4.11 [1.85–9.15] vs. 4.18 [3.84–4.55]). Major bleeding was slightly higher in IVC thrombosis (2.03 [0.66–6.31] vs. 1.66 [1.45–1.89]). Conclusion: In summary, IVC thrombosis patients have higher all-cause mortality rates than those with LEDVT, a finding only partly attributable to malignancy.

Abdominoplasty is a surgical technique for body contouring that has been shown to improve the patient's quality of life. It has become more common among male patients, so clear differences between procedures for men and women have to be stated. The authors present their experience with high-definition lipoabdominoplasty with transverse plication in men.Records of male patients undergoing transverse plication full abdominoplasty in addition to high-definition liposculpture were analyzed. A total of 24 consecutive cases were found between January of 2017 and June of 2019. Patient ages ranged from 24 to 60 years. Patients aged 18 years or younger were excluded. Body mass index ranged from 25 to 33 kg/m2. Photographic records were taken before and during follow-up at 2 days and 1, 3, 6, and 12 months after surgery.Male TULUA (transverse plication, no undermining, full liposuction, neoumbilicoplasty, and low transverse abdominal scar) with high-definition lipoabdominoplasty was successfully achieved in 24 cases. No major complications were reported. Six minor complications were reported (25 percent). Rectus abdominis diastases are less common in men compared to women, as pregnancy is the most determining factor in its development. Fat distribution is also a key difference when performing lipoabdominoplasty for the male or the female patient. The authors recommend a transverse plication of the abdominal wall, instead of a vertical one, as flap viability is preserved and enhanced muscular definition can be accomplished.Combining transverse plication with high-definition lipoabdominoplasty (transverse plication, no undermining, full liposuction, neoumbilicoplasty, and low transverse abdominal scar plus high-definition lipoabdominoplasty) is a safe and reproducible technique for the male patient. It offers higher aesthetic results in line with modern beauty ideals.Therapeutic, IV.

Background Male chest definition surgery and patients complaining of breast tissue overgrowth have been increasing in recent decades. After the authors' first report of pectoral etching in 2012, patients and surgeons became more aware about gynecomastia resection when performing pectoral enhancement. The authors present their experience with pectoral high-definition liposculpture in addition to inverted-omega incision resection for gynecomastia. Methods The authors reviewed their records on pectoral high-definition lipo sculpture between January of 2005 and October of 2019 in four surgical centers in Colombia. Inclusion criteria were as follows: men diagnosed with gynecomastia and body mass index less than or equal to 32 kg/m2, adequate skin elasticity, and general good health. Photographs were taken preoperatively and 1, 3, 6, and 12 months postoperatively. Follow-up ranged from 2 months to 3 years. Results Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). Ages ranged from 18 to 66 years. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. Minor complications (3.2 percent) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. Major complications (1.6 percent) included unilateral hematoma and localized infection. No necrosis, systemic infection, or muscle paralysis was reported. A nonstandardized survey showed a very high satisfaction index. Conclusion Gynecomastia treatment combining high-definition liposculpture to male breast tissue resection through a new, almost invisible incision allowed us to achieve an athletic and natural appearance of the male pectoral area with a very low rate of complications. Clinical question/level of evidence Therapeutic, IV.

The use of colchicine is associated with a significant reduction of cardiac adverse events in patients with coronary artery disease. Past small randomized trials with oral immunosuppressive or anti-inflammatory therapies have demonstrated a reduction of adverse clinical events after bare metal stent implantation. The potential role of adjunctive colchicine after bare-metal stent implantation, compared with drug-eluting stent alone, is unknown. The primary end point of the study will be to compare cost–effectiveness at 1 year of follow-up of coronary intervention with bare-metal stent implantation plus 1 mg of colchicine during 3 months versus percutaneous coronary intervention with drug-eluting stent implantation alone. ClinicalTrials.gov identifier: NCT04382443

Background Currently, corporal perception has evolved among different ethnic groups and a tendency to change from a slim to an athletic shape has been influenced by geography, culture, race, gender, and social media. Although exercise improves health status, physical appearance does as well in the long term. Patients often opt for an immediate solution for which high-definition (HD) liposculpture has been the best choice. However, they differ on their preference regarding muscular definition. Objectives The authors presented a new therapeutic algorithm for HD liposculpture in harmony with body biotypes and patients’ preferences. Methods The authors reported their experience with 1772 consecutive patients, classified according to their body type in endomorph (217), ectomorph (195), and mesomorph (1360), and treated according to our new algorithm. Patients in general good health requesting HD liposculpture were included from June 2013 to September 2019. Pre- and postoperative photographs were taken to evaluate results. Results A total of 479 men and 1293 women were analyzed. Age ranged from 23 to 69 years in men and 18 to 57 years in women. Variable-degree HD liposculpture was successfully performed in all cases. Minor complications included port wound dehiscence (1.2%), seroma (4.1%), prolonged bruising (1.5%), and hyperchromia (10.4%). Superficial burns (0.7%), localized infection (0.4%), erratic skin adhesion (1%), and flap necrosis (0.4%) were also reported. A high-satisfaction index was reported in a nonstandardized patient survey. Conclusions The authors’ new algorithm helps in the decision-making for HD liposculpture according to variable degrees of muscle definition due to patients’ preferences. Level of Evidence: 4

OBJECTIVE The purpose of this research is to study the early stages of the Senhance learning curve to report how force feedback impacts learning rate. This serves as an exploratory investigation into assumptions that fellows and faculty will adjust faster to the Senhance in comparison with residents, and that force feedback will not hinder skill acquisition. DESIGN In this study, participants completed the peg transfer and precision cutting task from the Fundamentals of Laparoscopic Surgery (FLS) manual skills assessment five times each using the Senhance while instrument motion was tracked. SETTING This study took place in the Surgical Education and Activities Laboratory at Duke University Medical Center. PARTICIPANTS Participants for this study were residents, fellows, and faculty from Duke University Medical Center in general surgery and gynecology specialties (N = 16). RESULTS Postulated linear mixed effects models with participant level random effects showed significant improvement with additional attempts for the peg transfer task after adjusting for surgical experience and force feedback respectively for the primary FLS score metric. The secondary metric of total instrument path length also showed improvement (significant decreases) in path length with additional attempts after respectively adjusting for surgical experience and force feedback. CONCLUSIONS This study investigates the early stages of the learning curve of the Senhance. Exploratory modeling indicates that residents, fellows, and faculty surgeons rapidly adapt to the controls of the Senhance regardless of experience level and force feedback engagement. The results from this study may serve as motivation for future prospective studies that achieve sufficient statistical power with a larger sample size and strict experimental design.

Aim The present study aimed to assess the benefits of two-stent techniques for patients with DEFINITION criteria-defined complex coronary bifurcation lesions. Methods and results In total, 653 patients with complex bifurcation lesions at 49 international centres were randomly assigned to undergo the systematic two-stent technique (two-stent group) or provisional stenting (provisional group). The primary endpoint was the composite of target lesion failure (TLF) at the 1-year follow-up, including cardiac death, target vessel myocardial infarction (TVMI), and clinically driven target lesion revascularization (TLR). The safety endpoint was definite or probable stent thrombosis. At the 1-year follow-up, TLF occurred in 37 (11.4%) and 20 (6.1%) patients in the provisional and two-stent groups, respectively [77.8%: double-kissing crush; hazard ratio (HR) 0.52, 95% confidence interval (CI) 0.30–0.90; P = 0.019], largely driven by increased TVMI (7.1%, HR 0.43, 95% CI 0.20–0.90; P = 0.025) and clinically driven TLR (5.5%, HR 0.43, 95% CI 0.19–1.00; P = 0.049) in the provisional group. At the 1 year after indexed procedures, the incidence of cardiac death was 2.5% in the provisional group, non-significant to 2.1% in the two-stent group (HR 0.86, 95% CI 0.31–2.37; P = 0.772). Conclusion For DEFINITION criteria-defined complex coronary bifurcation lesions, the systematic two-stent approach was associated with a significant improvement in clinical outcomes compared with the provisional stenting approach. Further study is urgently warranted to identify the mechanisms contributing to the increased rate of TVMI after provisional stenting. Study registration http://www.clinicaltrials.com; Identifier: NCT02284750.

The utilization of electronic health records (EHR) has become essential in the daily activities of physicians for documentation and as an information source. However, the amount of time spent by residents utilizing the EHR has not been thoroughly evaluated, particularly within surgical specialties. This study aims to analyze EHR usage by general surgery residents and to assess the association between this use and case volume at a single academic institution.For general surgery residents in clinical years (CY) 1-5, de-identified login and logout time data between September 2016 and June 2017 were retrospectively extracted from the Epic EHR (Verona, WI). A binary time series was created for each resident to indicate and track over time whether he or she was utilizing the EHR system. Comparisons between categorical variables were performed with Fisher's exact test. Continuous variables were compared using Wilcoxon rank sum test. Longitudinal linear mixed-effects models were used to assess the EHR usage among the surgery residents. The association between EHR time and the number of operative cases logged was evaluated with Pearson's correlation coefficient.This study was performed by the Department of Surgery in conjunction with the Office of Graduate Medical Education at Duke University Health System.All active general surgery residents during the 2016-2017 academic year.Thirty-six general surgery residents (28 males, 8 females) spent a median of 2.4 hours per day and 23.7 hours per week using the EHR. CY2 had the highest median usage per week (28.9 hours), while CY3 had the lowest (16.7 hours) but no significant difference based on EHR usage was found among the analyzed CYs (p = 0.164). Residents spent significantly more time logged into the EHR during the week compared to weekends and during the day compared to nights (all p0.001). For the residency program as a whole, a median of 151.5 total work hours per day was dedicated to documentation. On average, interns on dedicated night rotations spent 7% of their login time outside regularly scheduled duty hours while interns on dedicated day rotations spent 27%. There was no overall correlation between monthly case logs and EHR usage (r = 0.06, p = 0.30); however, CY2 had a significant negative correlation (r = -0.2, p = 0.038).In the era of a maximum 80-hour work week, general surgery residents spend a substantial portion, at least 30%, of their time utilizing the EHR. One third of EHR usage by interns occurred outside the scheduled 12-hour shift, demonstrating the difficulties of completing paperwork as part of the scheduled work day. Additionally, the lack of correlation to case logs is likely due to an underestimation of the documentation burden associated with operating, which includes preparatory effort and operative notes. Ultimately, these quantitative EHR usage results will be correlated to burnout prior to implementing programs to improve efficiency and decrease the burden of charting.

BACKGROUND: The optimal duration of antiplatelet therapy in high-bleeding risk (HBR) patients with coronary artery disease treated with newer-generation drug-eluting bioresorbable polymer-coated stents remains unclear. DESIGN: MASTER DAPT (clinicaltrial.govNCT03023020) is an investigator-initiated, open-label, multicenter, randomized controlled trial comparing an abbreviated versus a standard duration of antiplatelet therapy after bioresorbable polymer-coated Ultimaster (TANSEI) sirolimus-eluting stent implantation in approximately 4,300 HBR patients recruited from ≥100 interventional cardiology centers globally. After a mandatory 30-day dual-antiplatelet therapy (DAPT) run-in phase, patients are randomized to (a) a single antiplatelet regimen until study completion or up to 5 months in patients with clinically indicated oral anticoagulation (experimental 1-month DAPT group) or (b) continue DAPT for at least 5 months in patients without or 2 in patients with concomitant indication to oral anticoagulation, followed by a single antiplatelet regimen (standard antiplatelet regimen). With a final sample size of 4,300 patients, this study is powered to assess the noninferiority of the abbreviated antiplatelet regimen with respect to the net adverse clinical and major adverse cardiac and cerebral events composite end points and if satisfied for the superiority of abbreviated as compared to standard antiplatelet therapy duration in terms of major or clinically relevant nonmajor bleeding. Study end points will be adjudicated by a blinded Clinical Events Committee. CONCLUSIONS: The MASTER DAPT study is the first randomized controlled trial aiming at ascertaining the optimal duration of antiplatelet therapy in HBR patients treated with sirolimus-eluting bioresorbable polymer-coated stent implantation. ispartof: AMERICAN HEART JOURNAL vol:209 pages:97-105 ispartof: location:United States status: published

There is no published literature regarding sub-Saharan health-care providers' understanding of stroke management patterns. Understanding current stroke management knowledge is important in formulating future education opportunities for providers to optimize patient outcomes. A cross-sectional survey of acute stroke diagnosis, hospital management, and secondary prevention questions was administered to health-care providers working in one large Kenyan acute referral hospital. Due to the prevalence of medical students (61.8%), an experienced-focused analysis contrasted students with more experienced providers. Providers (n=199) anonymously responded to the surveys. Among the acute diagnosis most respondents stated that stroke scales should always used (58.3% of respondents), 3h was the time period for alteplase (t-PA) (53.8% of respondents), and CT scan should be always be obtained prior to administration of anticoagulant therapy (61.3% of respondents). Neither VTE prophylaxis nor dysphagia/swallowing screening were considered to be done a majority of time. Secondary prevention results were variable. The respondent's level of clinical experience made the most difference in correctly answering the most appropriate IV Fluid to use in stroke patients (adjusted p=0.003) and the ideal initiation time for antithrombotic therapy (adjusted p=0.0017). Healthcare providers demonstrated a wide variability in their responses. Future efforts to improve stroke care in sub-Saharan Africa should include education and process improvement initiatives to focus on more specific aspects of stroke management based on the results from this survey.

Objective To compare second generation drug eluting stents (2DES) with first generation (1DES) for the treatment of patients (pts) with multiple coronary vessel disease (MVD). Background Although 2DES improved safety and efficacy compared to 1DES, MVD remains a challenge for percutaneous coronary interventions. Methods ERACI IV was a prospective, observational, and controlled study in pts with MVD including left main and treated with 2DES (Firebird 2, Microport). We included 225 pts in 15 sites from Argentina. Primary endpoint was the incidence of major adverse cardiovascular events (MACCE) defined as death, myocardial infarction (MI), cerebrovascular accident (CVA) and unplanned revascularization; and to compare with 225 pts from ERACI III study (1DES). PCI strategy was planned to treat lesions ≥70% in vessels ≥ 2.00 mm, introducing a modified Syntax score (SS) where severe lesions in vessels

Carpal tunnel syndrome (CTS) is known to develop post-stroke. Median nerve ultrasound (US) is an inex pensive, effective means of screening. In this prospective feasibility study, we compared the ability of the physical exam, the Boston Carpal Tunnel Questionnaire (BCTQ) and median nerve US to screen for carpal tunnel syndrome (CTS) within 72 hours of stroke onset. We enrolled 24 consecutive patients. Using US, 19 (79%, p = 0.0386) of the 24 patients screened positive for CTS on the paretic side and 20 (83%, p = 0.0042) on the nonparetic side. With clinical examination, only 11 out of 24 (46%) screened positive for CTS on the paretic side and 8 (33%) on the nonparetic side. The BCTQ did not predict CTS. US can be an effective screening tool post-stroke. Further research is needed to determine specificity and efficacy compared to electrodiagnostic testing in this population.

OBJECTIVE: Identify predictors of adverse events and highlight areas for quality improvement for children who underwent laryngeal or tracheal dilation, without prior tracheostomy placement. STUDY DESIGN: Cross-sectional analysis using a US national database. SETTING: American College of Surgeons (ACS) National Surgical Quality Improvement Program® (ACS NSQIP® - pediatric), years 2012 – 2015. SUBJECTS AND METHODS: Patients aged 18 years and less were included. Patients without prior tracheostomy placement were identified using 2017 current procedural terminology (CPT) codes: 31528, 31529, and 31630. RESULTS: We identified a total of 160 children who met inclusion criteria. 43 (26.9%) patients experienced an adverse event. Mortality was observed postoperatively in one patient (0.6%), one day after the operation. Younger age, increased number of days from hospital admission to operation, and increased number of days from operation to discharge were noted to be associated with adverse events. Lastly, the risk of adverse events appears to be mitigated by concurrent other laryngeal procedures. CONCLUSIONS: There is a high rate of adverse events reported with airway dilation in children. Unplanned reoperations and hospital readmissions are highlighted areas for quality improvement. Airway dilation in children appears to avoid tracheostomy and open laryngotracheoplasty in most cases for at least 30 days postoperatively. Further investigation may be helpful to understand if younger age and delayed operative intervention contributes to increased adverse events.

A 79-year-old female was admitted with sudden onset dyspnea, mild oppressive chest pain, and severe anxiety disorder. Patient had history of hypertension, dyslipidemia, smoking, and chronic obstructive pulmonary disease. On admission blood pressure was 160/90 and heart rate was 130 bpm. Transthoracic echocardiography (TE) and contrast tomography showed a thin septum with an abnormal left and right ventricular contraction with an “apical ballooning” pattern and mild increase of cardiac enzymes. At the 4th day of admission, the patient presented symptoms and signs of congestive heart failure and developed cardiogenic shock. EKG showed an inversion of T waves in all precordial leads. In a new TE, a ventricular septal perforation (VSP) in the apical portion of the septum was seen. Coronary angiogram showed angiographically “normal” coronary arteries. With a diagnosis of VSP in takotsubo cardiomyopathy, a percutaneous procedure to repair the VSP was performed 11 days after admission. The VSP was closed with an Amplatzer device. TE performed 24 hours after showed significant improvement of ventricular function and good apposition of the Amplatzer device. Three days later she was discharged from the hospital. To our knowledge, this is the first reported case of a VSP in a TCM repaired percutaneously with an occluder device.

Laser was being used in medicine soon after its invention. However, it has been possible to excise hard tissue with lasers only recently, and the Er:YAG laser is now established in the treatment of damaged teeth. Recently experimental studies have investigated its use in bone surgery, where its major advantages are freedom of cutting geometry and precision. However, these advantages become apparent only when the system is used with robotic guidance. The main challenge is ergonomic integration of the laser and the robot, otherwise the surgeon's space in the operating theatre is obstructed during the procedure. Here we present our first experiences with an integrated, miniaturised laser system guided by a surgical robot. An Er:YAG laser source and the corresponding optical system were integrated into a composite casing that was mounted on a surgical robotic arm. The robot-guided laser system was connected to a computer-assisted preoperative planning and intraoperative navigation system, and the laser osteotome was used in an operating theatre to create defects of different shapes in the mandibles of 6 minipigs. Similar defects were created on the opposite side with a piezoelectric (PZE) osteotome and a conventional drill guided by a surgeon. The performance was analysed from the points of view of the workflow, ergonomics, ease of use, and safety features. The integrated robot-guided laser osteotome can be ergonomically used in the operating theatre. The computer-assisted and robot-guided laser osteotome is likely to be suitable for clinical use for ostectomies that require considerable accuracy and individual shape.

Despite of the long history of medical application, laser ablation of bone tissue became successful only recently. Laser bone cutting is proven to have higher accuracy and to increase bone healing compared to conventional mechanical bone cutting. But the reason of subsequent better healing is not biologically explained yet. In this study we present our experience with an integrated miniaturized laser system mounted on a surgical lightweight robotic arm.; An Erbium-doped Yttrium Aluminium Garnet (Er:YAG) laser and a piezoelectric (PZE) osteotome were used for comparison. In six grown up female Gottingen minipigs, comparative surgical interventions were done on the edentulous mandibular ridge. Our laser system was used to create different shapes of bone defects on the left side of the mandible. On the contralateral side, similar bone defects were created by PZE osteotome. Small bone samples were harvested to compare the immediate post-operative cut surface.; The analysis of the cut surface of the laser osteotomy and conventional mechanical osteotomy revealed an essential difference. The scanning electron microscopy (SEM) analysis showed biologically open cut surfaces from the laser osteotomy. The samples from PZE osteotomy showed a flattened tissue structure over the cut surface, resembling the "smear layer" from tooth preparation.; We concluded that our new finding with the mechanical osteotomy suggests a biological explanation to the expected difference in subsequent bone healing. Our hypothesis is that the difference of surface characteristic yields to different bleeding pattern and subsequently results in different bone healing. The analyses of bone healing will support our hypothesis.

Pulmonary foreign-body granulomatous embolization has been described secondary to crystal precipitation in total parenteral nutrition (TPN) as well as when pharmaceutical tablets are crushed and injected intravenously. Extensive granulomatous embolization may cause pulmonary hypertension and death due to acute cor pulmonale. We report the case of a 34-year old woman who had been receiving TPN post-operatively secondary to complications of a paraesophageal hernia repair. During and following receiving TPN, she experienced episodes of hypoxia, tachycardia, fever, and hypotension. Computed tomography scans of the thorax showed centrilobular nodules, tree-in-bud and ground-glass opacities, as well as findings of pulmonary hypertension. Following an episode of hypoxia she was found unresponsive and died despite resuscitative efforts. Microscopic examination of the lungs following post-mortem examination revealed occlusive granulomatous inflammation of the pulmonary arterial vasculature by crystalline material. The morphologic and histochemical patterns of the crystals were suggestive of microcrystalline cellulose, a finding that was confirmed by energy dispersive X-spectroscopy and infrared spectroscopy. Ancillary tests did not support that the crystalline material was the result of TPN precipitation. Foreign-body granulomatous embolization leading to acute core pulmonale may occur as a complication of both intravenous injection of oral medications as well as of TPN crystallization. The source of crystalline material may be difficult to discern based solely on morphological assessment or by histochemical staining. Ancillary studies such as energy dispersive X-spectroscopy or infrared spectroscopy should be performed to definitively discern the two entities.

Transcatheter Aortic Valve Replacement (TAVR) is performed in patients who are poor surgical candidates. Many patients have inadequate femoral access, and alternative access sites have been used such as the transapical approach discussed in this paper. We present an elderly and fragile patient not suitable for surgery for unacceptable high risk, including poor ventricular function, previous myocardial infarction with percutaneous coronary intervention, pericardial effusion, and previous cardiac surgery with replacement of mechanical mitral valve. Transapical aortic valve replacement with a second-generation self-expanding JenaValve is performed. The JenaValve is a second-generation transapical TAVR valve consisting of a porcine root valve mounted on a low-profile nitinol stent. The valve is fully retrievable and repositionable. We discuss transapical access, implantation technique, and feasibility of valve implantation in this extremely high surgical risk patient.

Objective Identify predictors of adverse events for children who underwent endoscopic sinus surgery for treatment of orbital complications associated with sinusitis. Study Design Cross-sectional analysis of a US national database. Setting American College of Surgeons National Surgical Quality Improvement Program (NSQIP), pediatric version (2012-2015). Subjects and Methods Patients were identified with a combination of codes from the International Classification of Diseases, Ninth Revision and 2014 Current Procedural Terminology. Our primary outcome measure was adverse events, which were compared with clinical risk factors to examine for any associations. Results A total of 57 patients were included for analysis. No significant relationship was identified between 30-day postoperative adverse events and age, sex, race, body mass index, prematurity, history of asthma, steroid use (within 30 days), and preoperative white blood cell count. There was a statistically significant increase in adverse events for those patients who underwent delayed surgery ( P < .0001). No serious adverse events related to death, sepsis, nerve injury (eg, visual loss), or other organ space infections (eg, intracranial infection) were identified. After controlling for age group and race, delayed operative intervention was a significant clinical predictor of adverse events (odds ratio = 25.65; 95% CI, 3.86-170.45; P = .0008). We observed unplanned reoperation and readmission rates of 5.3% and 7%, respectively. Conclusions Endoscopic surgical drainage for infectious orbital complications of sinusitis in children appears to be safe. Serious or significant adverse events were uncommon. Areas for improvement include limiting and reducing unplanned reoperations and readmissions.

Background The vascularized free fibula epiphyseal transfer provides an option for the preservation of limb lengthening after resection of the proximal humerus in pediatric sarcoma patients. The purpose of this study was to provide a long-term follow-up of longitudinal growth patterns and outcomes after free fibula epiphyseal transfer in upper extremity reconstruction. Methods A retrospective review of 4 patients who underwent free fibula epiphyseal transfer after oncologic resection of the proximal humerus for osteosarcoma was performed. Oncologic details that could affect outcomes were included in the review: primary tumor pathology, location of malignancy, and presence of recurrence. Details on the reconstruction included longitudinal growth of the flap from the time of implantation to the most recently available radiograph and postoperative complications. The length of the fibula over time was measured from the humeral head to the olecranon process. Results All patients were alive at the start of this study. The average longitudinal growth rate of the free fibula epiphyseal transfer was 0.54 ± 0.18 cm/y, and patients demonstrated satisfactory and consistent longitudinal bone growth and hypertrophy over time. All 4 patients suffered from a complication of postoperative fibula graft fracture, and 1 of 4 patients experienced unremitting peroneal nerve damage. All patients demonstrated normal wrist and hand motion with a normal arc of elbow flexion and extension. Conclusion This study demonstrates that the vascularized fibula epiphyseal transfer offers the ability to preserve longitudinal limb growth and hypertrophy throughout adolescence.

In a recent issue of the Journal , Park et al. [(1)][1] published the 10-year follow-up results of the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty versus Surgical Revascularization) study in patients with

Background: There is a select group of women for whom mini-abdominoplasty techniques combined with 3-dimensional liposculpture and fat grafting can effectively correct postpartum deformities. Objective: The authors describe a multilayer and 360-degree approach, dynamic definition mini-abdominoplasty (DDM), to create athletic definition and contour and to restore a feminine appearance postpartum. Methods: A total of 181 consecutive women ages 20 to 56 years underwent DDM between January 2005 and May 2012. Patients who were a minimum of 6 months postpartum and in good health, with a body mass index below 30, were considered for inclusion in the study. Fat grafting was performed in select cases in the buttocks, deltoids, and/or calves. A satisfaction index (SI) was estimated based on patient survey responses. Results: An overall SI of 91.5% was achieved. No major complications were reported. Twenty-nine minor complications included postoperative anemia, seroma, and infection in the surgical wound. In most patients, the postpartum abdomen was restored to an aesthetic and even athletic appearance. Athletic definition to the rectus, arms, trunk, thighs, and buttocks was also achieved. No burns or flap necrosis were reported. Conclusions: Dynamic definition mini-abdominoplasty is safe and reproducible. It serves as a viable alternative to a full abdominoplasty in selected cases and for women who wish to restore an athletic and feminine appearance after childbirth. Level of Evidence: 4 ![Graphic][1] [1]: /embed/inline-graphic-1.gif

Cervical spine injury (CSI) studies have identified different factors contributing to CSI, but none compares the incidence and pattern of injury of patients arriving at the Emergency Department (ED) by private vehicle (PV).We compared the characteristics and injury patterns in CSI patients who were transported to the ED via Emergency Medical Services (EMS) versus PV.We conducted a three-hospital retrospective review of patients with CSI from January 1, 2000 to December 31, 2007. We excluded transfers and follow-up visits. Using a standardized data collection form, we reviewed demographics, mode of transport, mechanism of injury, imaging results, injury type and level, and neurologic deficits. Means and proportions were compared using t-tests and chi-squared as appropriate.Of 1174 charts identified, 718 met all study criteria; 671 arrived by EMS and 47 by PV. There was no difference between groups in age or gender. Ground-level fall was more likely in PV patients (32%, 95% confidence interval [CI] 20-46% vs. 6%, 95% CI 4-9%), whereas motor vehicle collision was less likely (32%, 95% CI 20-46% vs. 67%, 95% CI 63-70%). PV patients more often sustained a stable injury (66%, 95% CI 52-78% vs. 40%, 95% CI 36-44%), and were more often triaged to a lower-acuity area (25%, 95% CI 15-40% vs. 4%, 95% CI 3-6%). The incidence of neurologic deficit was similar (32%, 95% CI 20-46% vs. 24%, 95% CI 21-28%), though more PV patients had spinal cord injury without radiographic abnormality (21%, 95% CI 12-35% vs. 5%, 95% CI 4-7%).A small proportion of patients with CSI present to the ED by PV. Although most had stable injuries, a surprising number had unstable injuries with neurologic deficits, and were triaged to lower-acuity areas in the ED.

BACKGROUND Although percutaneous coronary intervention (PCI) with first-generation drug-eluting stents (DES-1) did not show a benefit in terms of death rate and myocardial infarction (MI) compared to bypass surgery (coronary artery bypass graft [CABG]), DES platforms have seen a remarkable improvement in the last few years, and a significant increase in their safety and efficacy was observed in randomized controlled trials and observational studies in comparison with DES-1 in patients with coronary artery disease (CAD). One-year results from the ERACI IV registry using a second-generation DES (DES-2) demonstrated significantly greater efficacy and safety in patients with multiple vessel CAD, including diabetics, compared to DES-1. Long-term results are yet unknown. METHODS The ERACI IV registry was a multicenter, prospective and controlled open-label study conducted in 9 sites in Argentina during 2013 and 2014, which evaluated a DES-2 for the treatment of patients with multiple vessel CAD including unprotected left main disease (ULMD) and diabetes. The primary endpoint was to compare the composite of death of any cause, MI and cerebrovascular accident (CVA) as hard endpoints with ERACI III DES-1 arm. Secondary endpoints included each component of the primary endpoint and target vessel revascularization (TVR) as major adverse cardiovascular events (MACCE) and stent thrombosis. We include a modified Syntax Score (SS) taking in account functional revascularization, treating lesions ≥70% in vessels ≥ 2.00 mm, whereas severe lesions in vessels < 2.0 mm and intermediate lesions were not rated. RESULTS Baseline characteristics were similar between groups, with higher numbers of diabetics and 3-vessel/ULMD (P=0.02 and P=0.003, respectively) in ERACI IV. At 34.7 months' follow-up, the incidence of the composite of death/MI/CVA between ERACI IV and ERACI III (4.9% vs. 13.7%, P