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Objective: The pathway to cardiothoracic surgery is often obscure for premedical students and aspiring applicants and requires navigating various known and unknown obstacles. Recognizing the challenges encountered on the path to a career in cardiothoracic surgery in the United States, we present this guide for students interested in the field to maximize success in their premedical, preclinical, and preresidency years. Methods: This is a joint collaboration between the Thoracic Surgery Residents Association and the Thoracic Surgery Medical Student Association. Drawing from firsthand experiences and insights gathered from numerous student applicants and current surgical residents, a comprehensive guide was constructed for students from the point of undergraduate school to advanced training options, including super-fellowship training. Results: Several intricacies to cardiothoracic surgery career planning were discussed, including differences between traditional and integrated/fast-track pathways, college and medical school selection, networking, performing during clinical rotations, extracurricular and research activities, building mentorship relationships, and pursuing alternate career and advanced training opportunities. Conclusions: For premedical students and aspiring applicants, the road to cardiothoracic surgery requires meticulous planning, grit, and thoughtful dedication. This document consolidates firsthand insights and advice from numerous aspiring and matched applicants to serve as a comprehensive guide for students seeking a career in cardiovascular and thoracic surgery.

Abstract Objective In‐office ablation of the posterior nasal nerve (PNN) has emerged as an effective treatment option for chronic rhinitis patients. This study explored questions patients commonly search online regarding this therapy and the quality of content available. Study Design A retrospective analysis of online search criteria and sources was performed with subsequent analysis of results. Setting Search and data acquisition was in September of 2023. Methods Most common search terms related to cryotherapy and radiofrequency neurolysis of the PNN were identified with associated People Also Ask (PAA) questions. Questions were categorized and organized into subtopics and sources evaluated using readability and quality metrics. Results A total of 255 unique PAA questions and 175 unique websites were identified. The most common subtopics were related to facts about chronic rhinitis (26.7%) and rhinitis treatment options (25.1%). Nearly a quarter (24.3%) of websites were from commercial sources. Quality metrics indicate difficult‐to‐read and low‐quality materials. Conclusion Existing online resources need improvement to provide patients material that is easier to read. Physicians counseling patients should be aware of these areas for adequate shared decision making.

Background: The relationship between preoperative bowel dysfunction and postoperative ileus has not been explored clinically. We hypothesized chronic partial obstruction, based on preoperative small bowel diameter, is associated with ileus after colon surgery. Methods: This was a retrospective case-control study of patients undergoing right colectomy or ileocolic resection with primary anastomosis. Patients who developed ileus were compared to those who did not. Results: Postoperative ileus occurred in 22 of 69 patients (32%). Preoperative small bowel dilation with maximum diameter >3 cm was present in 13 patients (19%) with 7 developing ileus (54%; p=0.06). In a multivariable model, small bowel dilation >3 cm (OR 4.6; 95% CI: 1.3-16.6) and preoperative weight loss >10 pounds (OR 9.8; 95% CI: 1.6-57.9) were independently associated with ileus. Conclusions: Colorectal surgery patients with preoperative bowel dilation have an increased risk of postoperative ileus. This knowledge can better inform patient expectations for recovery and help guide perioperative nutritional management, particularly with patient selection for parenteral nutrition.

Objective We hypothesize that Smad3 is a master regulator of fibrosis in the vocal folds (VFs) and RNA‐based therapeutics targeting Smad3 hold therapeutic promise. Delivery remains challenging. We previously described a novel synthetic peptoid oligomer, lipitoid L0, complexed with siRNA to improve stability and cellular uptake. An advantage of these peptoids, however, is tremendous structural and chemical malleability to optimize transfection efficiency. Modifications of L0 were assayed to optimize siRNA‐mediated alteration of gene expression. Methods In vitro, Smad3 knockdown by various lipitoid variants was evaluated via quantitative real‐time polymerase chain reaction in human VF fibroblasts. Cytotoxicity was quantified via colorimetric assays. In vivo, a rabbit model of VF injury was employed to evaluate the temporal dynamics of Smad3 knockdown following injection of the L0‐siRNA complex. Results In vitro, similar reductions in Smad3 expression were established by all lipitoid variants, with one exception. Sequence variants also exhibited similar nontoxic characteristics; no statistically significant differences in cell proliferation were observed. In vivo, Smad3 expression was significantly reduced in injured VFs following injection of L0‐complexed Smad3 siRNA at 1 day postinjection. Qualitative suppression of Smad3 expression persisted to 3 days following injury, but did not achieve statistical significance. Conclusions In spite of the chemical diversity of these peptoid transfection reagents, the sequence variants generally provided consistently efficient reductions in Smad3 expression. L0 yielded effective, yet temporally limited knockdown of Smad3 in vivo. Peptoids may provide a versatile platform for the discovery of siRNA delivery vehicles optimized for clinical application. Level of Evidence NA

Acute kidney injury remains a common and significant contributor to perioperative morbidity. Acute kidney injury worsens patient outcomes, and anesthesiologists should make significant efforts to prevent, assess, and treat perioperative renal injury. The authors discuss the impact of renal injury on patient outcomes and putative underlying mechanisms, evidence underlying treatments for acute kidney injury, and practices that may prevent the development of perioperative renal injury. [ABSTRACT FROM AUTHOR]

Cecal diverticulitis is a rare condition in children that can present diagnostic and surgical challenges. Cecal diverticulitis has a similar presentation to appendicitis, but the surgical management is much different. We present a case of cecal diverticulitis in a 13-year-old Hispanic male who was initially treated nonoperatively, but ultimately underwent laparoscopic assisted ileocecectomy as definitive treatment. This is the only case report to describe a delayed surgical approach to this rare medical condition. We feel this approach has particular merit with respect to cecal diverticulitis as the possibility of diagnostic uncertainty is high. Cecal diverticulitis is a rare disease process, particularly in children. Patients predictably present with right lower quadrant abdominal pain in a manner similar to appendicitis. Imaging may reveal a phlegmon, perforation, bowel wall thickening, or nonspecific inflammatory changes. These imaging findings may not always indicate a clear diagnosis, especially if the appendix cannot be well visualized. Urgent operation may be ill advisable in this situation as the surgeon may encounter a hostile operative field with dense inflammatory changes resulting in an increased risk of ileostomy creation. We present a case of cecal diverticulitis managed safely with a delayed surgical approach. We feel a delayed surgical approach may provide an alternative option for patients with an uncertain diagnosis or surgeons who wish to avoid a potentially hazardous dissection. A delayed approach may also help to facilitate a minimally invasive approach.

Patients with polycystic liver disease are described in the literature as both recipient and donor for liver transplant. Due to well-preserved liver function, it is often difficult for these patients to receive an organ. Livers of these patients are often large and heavier than a normal organ. We describe two cases who had exceedingly large livers, weighing 14 and 19 kg. To the best of our knowledge and search, these are some of the heaviest explanted livers, and one of the patients incidentally received a liver from a donor with ADPKD. The aim of this report is to discuss the challenges and pitfalls of evaluating and listing, technical aspect of the transplant, possibility of transplanting a liver from a donor with a genetic cystic disease to a cystic disease recipient, and the related literature with some highlights on the facts from UNOS/OPTN data.

To characterize current evidence and current foci of perioperative clinical trials, we systematically reviewed Medline and identified perioperative trials involving 100 or more adult patients undergoing surgery and reporting renal end points that were published in high-impact journals since 2004. We categorized the 101 trials identified based on the nature of the intervention and summarized major trial findings from the five categories most applicable to perioperative management of patients. Trials that targeted ischemia suggested that increasing perioperative renal oxygen delivery with inotropes or blood transfusion does not reliably mitigate acute kidney injury (AKI), although goal-directed therapy with hemodynamic monitors appeared beneficial in some trials. Trials that have targeted inflammation or oxidative stress, including studies of nonsteroidal anti-inflammatory drugs, steroids, N-acetylcysteine, and sodium bicarbonate, have not shown renal benefits, and high-dose perioperative statin treatment increased AKI in some patient groups in two large trials. Balanced crystalloid intravenous fluids appear safer than saline, and crystalloids appear safer than colloids. Liberal compared with restrictive fluid administration reduced AKI in a recent large trial in open abdominal surgery. Remote ischemic preconditioning, although effective in several smaller trials, failed to reduce AKI in two larger trials. The translation of promising preclinical therapies to patients undergoing surgery remains poor, and most interventions that reduced perioperative AKI compared novel surgical management techniques or existing processes of care rather than novel pharmacologic interventions. [ABSTRACT FROM AUTHOR]

Objectives The aim of this study was to compare outcomes of transcatheter intervention (TI) versus surgical intervention (SI) for paravalvular leak (PVL). Background Data comparing the treatment of PVL with TI and SI are limited. Methods A retrospective cohort study was conducted comparing baseline characteristics, procedural details, and 1-year survival in consecutive patients who underwent TI or SI for moderate or greater PVL from 2007 to 2016. The primary outcome was a composite of death, reintervention for PVL, or readmission for congestive heart failure–related symptoms at 1 year. Results Of 114 patients, 56 underwent TI and 58 underwent SI. PVL locations were mitral, aortic, and pulmonary in 69 (60.5%), 39 (34.2%), and 6 (5.3%) patients, respectively. At baseline, TI patients were older (age 71 vs. 62 years; p = 0.010) and had fewer cases of active endocarditis (0.0% vs. 25.9%, p < 0.001) than SI patients. The TI group had a shorter post-operative stay (4 vs. 8 days; p < 0.001), a shorter intensive care unit stay (0 vs. 3 days; p < 0.001), and fewer readmissions at 30 days (8.9% vs. 25.9%; p = 0.017). There were no differences in the primary endpoint (TI 33.9% vs. SI 39.7%; p = 0.526) or 1-year survival (TI 83.9% vs. SI 75.9%; p = 0.283) between groups. Conclusions In this study, TI for PVL closure had comparable 1-year clinical outcomes with SI, even after adjusting for differences in baseline characteristics, with less in-hospital morbidity and 30-day rehospitalization. Although further study is needed, these findings support the increased implementation of TI for PVL closure at experienced institutions. [ABSTRACT FROM AUTHOR]

The goal of surgery in the multimodal treatment of pleural malignancies such as malignant pleural mesothelioma (MPM) or Non-small cell lung cancer with pleural spread (p-NSCLC) is to achieve a macroscopic compete resection (MCR). We have investigated the use of intraoperative photodynamic therapy to reduce the rate of local recurrence following MCR using a variety of photosensitizers, including porfimer sodium and HPPH. With lung sparing MCR and intraoperative PDT, patients with locally advanced, epithelial MPM experience median overall progression free and overall survival of 13 and 36 months, respectively. Similarly, patients with p-NSCLC experience median progression free and overall survival of 10 and 23 months, respectively. The results with MCR and PDT are highly encouraging. Nevertheless, a subset of patients treated with this approach experience aggressive local or systemic relapse of pleural disease within the first 12 months. In this study, we combine analysis of clinical data and pre-clinical models to examine the hypothesis that surgically mediated Inflammation affects outcomes following intraoperative PDT. In studies of clinical samples from patients with MPM undergoing surgery and intraoperative PDT, we found that increases in pro-inflammatory cytokines plasma levels from surgery prior to PDT experience earlier tumor recurrences than patients who did not experience a pro-inflammatory reaction to surgery. We have developed a preclinical model of surgically-mediated tumor injury (TI) that mimics these cytokine increases. Although PDT decreases tumor recurrences following partial debulking of tumors, we noted that TI reduces the efficacy of subsequently delivered PDT when compared to PDT of intact, size matched tumors. Mechanistically, this appears to involve surgically-mediated influx of myeloid derived suppressor cells into the tumor. Further analyses including RNAseq of clinical tumor samples and immunophenotyping of tumors and tumor draining lymph nodes in the TI model provide additional evidence to support the surgical inflammation hypothesis. Taken together, these results demonstrate that PDT can be safely and effectively adapted to treat the entire pleural surface and that PDT combined with multimodality, surgically based therapy demonstrates remarkably good patient outcomes. However, surgically induced inflammation impairs the full potential benefit of PDT. [ABSTRACT FROM AUTHOR]

Background. Although traumatic rupture of the thoracic aorta (TRA) has traditionally been considered a surgical emergency, there exists a small patient population for whom nonoperative management may be appropriate. The short- and long-term consequences of patients managed in a nonoperative fashion remain unclear.Methods. A review of patients admitted with TRA over a period of 16 years was performed. Patients who did not undergo operative repair within 24 hours of injury and diagnosis comprised the study group.Results. One hundred forty-five patients were admitted with TRA. Of these, 30 underwent a period of nonoperative management. The mean age of the study patients was 44 ± 21 years, 80% were male, and the mean Injury Severity Score (ISS) was 34 ± 9. Fifteen patients underwent delayed operation (DELAY group) at more than 24 hours after injury and diagnosis and 15 patients never underwent repair (NON-OP group). The median time to operation in the DELAY group was 3 days (range 2 to 90). Three patients exhibited progression of TRA within 5 days of injury and of these, 2 died. A total of 3 deaths occurred in the DELAY group (1 rupture and 2 intraoperative arrests). The fifteen NON-OP patients were significantly older (mean age 52 ± 22 versus 36 ± 18 years; p = 0.03), tended to be more severely injured (mean ISS 36 ± 9 versus 32 ± 8; p = 0.2), and had more premorbid risk factors than the DELAY patients. Five NON-OP patients died, all because of severe head injuries. On long-term follow-up of NON-OP patients, all 10 survivors are alive at a median of 2.5 years (range 6 months to 5 years) without progression of injury or the need for operation. Five of the 10 had complete radiographic resolution of their injuries and 5 have asymptomatic and radiographically stable pseudoaneurysms.Conclusions. Selected patients with multiple severe associated injuries or high-risk premorbid conditions may have their operations for TRA delayed temporarily or even indefinitely with acceptable survival rates. The potential for rapid progression of TRA in the same patients, however, mandates serial radiographic examinations during the first week of hospitalization after injury and diagnosis. [Copyright &y& Elsevier]

An enlarging internal iliac artery aneurysm secondary to a type II endoleak after endovascular aortic repair is an uncommon entity. It carries a significant rupture risk and mortality if not addressed. The present patient had had a 6.8-cm, rapidly growing, excluded hypogastric aneurysm. The results included both a failed transarterial approach and successful percutaneous transgluteal internal iliac artery aneurysm embolization using XperCT software (Philips Healthcare, Andover, MA) for guidance. The salient points included that treatment of the “nidus” alone will not be sufficient for complete endoleak embolization, the use of direct endoleak sac angiography might better delineate the inflow and outflow dynamics than conventional transarterial angiography, and XperCT guidance (Philips Healthcare) can facilitate complex endoleak access.

Objective: Wearable activity monitors can provide detailed data on activity after cardiac surgery and discriminate a patient's risk for hospital-based outcomes. However, comparative data for different monitoring approaches, as well as predictive ability over clinical characteristics, are lacking. In addition, data on specific thresholds of activity are needed. The objective of this study was to compare 3 wearable activity monitors and 1 observational mobility scale in discriminating risk for 3 hospital-based outcomes, and to establish clinically relevant step thresholds. Methods: Cardiac surgery patients were enrolled between June 2016 and August 2017 in a cohort study. Postoperative activity was measured by 3 accelerometry monitors (StepWatch Ambulation Monitor, Fitbit Charge HR, and ActiGraph GT9X) and 1 nurse-based observation scale. Monitors represent a spectrum of characteristics, including wear location (ankle/wrist), output (activity counts/steps), consumer accessibility, and cost. Primary outcomes were duration of hospitalization >7 days, discharge to a nonhome location, and 30-day readmission. Results: Data were available from 193 patients (median age 67 years [interquartile range, 58-72]). All postoperative day 2 activity metrics (ie, from StepWatch, Fitbit, ActiGraph, and the observation scale) were independently associated with prolonged hospitalization and discharge to a nonhome location. Only steps as measured by StepWatch was independently associated with 30-day readmission. Overall, StepWatch provided the greatest discrimination (C-statistics 0.71-0.76 for all outcomes). Step thresholds between 250 and 500 steps/day identified between 74% and 96% of patients with any primary outcome. Conclusions: Data from wearable accelerometers provide additive value in early postoperative risk-stratification for hospital-based outcomes. These results both support and provide guidance for activity-monitoring programs after cardiac surgery.

Background:. Ultrasound-assisted liposuction (UAL) is a popular and minimally invasive cosmetic procedure. Third-generation devices such as the vibration amplification of sound energy at resonance (VASER)lipo system are used for body contouring with enhanced tissue specificity. Despite the widespread use of VASER UAL, published guidelines and recent expert consensus recommendations are lacking. The objective of this study is to develop an expert consensus on the recommendations for use of VASER UAL. Methods:. In a modified Delphi process, a panel of five US-based, expert plastic surgeons participated in three rounds of consensus building that spanned 4 months to align on guidance statements for the use of VASER as an adjunct to liposuction. Results:. After the experts responded to an online questionnaire that assessed device settings, postoperative instructions, side effects or complications, and best practices, 32 initial consensus statements were developed. By round 3, these consensus statements for VASER UAL had been reduced and refined to a total of 18. Conclusions:. To improve patient outcomes, clinicians must understand key factors and best practices when using VASER UAL, including device settings, provider technique, managing side effects, potential complications, and postoperative care. The consensus statements developed herein aim to provide clinicians with expert-backed recommendations for the use of VASER UAL.

Summary:. The field of plastic surgery, formally organized in 1931 with the founding of the American Society of Plastic and Reconstructive Surgery, was shaped in many ways by a small practice of Philadelphia physicians. At the center of the practice was Warren B. Davis, a Philadelphia otolaryngologist and plastics pioneer whose innovations in cleft palate surgery would lead to significant improvements in functional and cosmetic outcomes in his time. In addition to his own innovations, Davis was responsible for the training of John Reese, the inventor of the Reese dermatome that changed the face of burn medicine during World War II. Aside from his contributions to surgery and the founding of the American Society of Plastic and Reconstructive Surgery, Dr. Davis was also the founder and first editor of the Plastic and Reconstructive Surgery journal which to this day is the premiere, authoritative journal of plastic surgery. Lastly, Dr. Davis established a plastic surgical practice, now Jefferson Plastic Surgery. Unique in its longevity, this practice would continue to shape the field of plastic surgery and continues to improve lives today—109 years after its founding in 1913.

Class III malocclusions have been one of the major challenge to correct skeletal and dentofacial anomalies in orthodontics, some class III patients have a maxillary hypoplasia resulting in an transverse discrepancy, the golden standard for treat patients with severe class III skeletal malocclusions consists in a orthodontic therapy and orthognathic surgery, currently Mini-screw assisted rapid palatal expansion with (MARPE) is an efficient procedure for correcting maxillary transverse deficiency even in adult patients. A 25-year class III skeletal female patient with hyperdivergent growth anterior and posterior crossbite and laterognathia was treated, presurgical miniscrew assisted rapid palatal expansion was chosen to correct the patient's transverse deficiency, bimaxillary surgery was conducted to treat the mandibular hyperplasia and facial asymmetry. Surgery consisted in 1-piece Lefort to correct maxillary canting and BSSO to correct laterognathia. The treatment was complete in 18 months, CBCT images reveal the maxillary expansión, all dental and skeletal goals were achieved and the facial result was evidente. MARPE can be use before bimaxillary orthognathic surgery to correct transverse maxillary discrepancy and posterior cross-bite in adult patients, however different factors such as the severity of the deficiency, age, and the conditions of the perimaxillary sutures must be taken.

Background:. Few studies have assessed long-term complications in women undergoing implant-based breast reconstruction with use of an acellular dermal matrix (ADM). This study compared outcomes over 5 years in women undergoing breast reconstruction procedures with and without ADM. Methods:. Complications data in patients enrolled in the prospective Continued Access Reconstruction/Revision Expansion trial were segregated by use of ADM versus no ADM in patients undergoing primary breast reconstruction or revision-reconstruction. Continued Access Reconstruction/Revision Expansion trial evaluated long-term safety and effectiveness of shaped, textured, silicone implants. Results:. Of the 9502 women, 257 had primary (n = 160) or revision-reconstruction (n = 97) with ADMs; 9245 had primary (n = 6977) or revision-reconstruction (n = 2268) without ADMs. Capsular contracture rates in primary reconstruction were lower with ADM than without at year 5 (3.2% versus 7.4%); rates were similar at year 1 (≤2.4%). Capsular contracture rates in revision-reconstruction were lower with ADM than without at year 5 (1.4% versus 8.9%); rates were similar at year 1 (≤2.5%). Seroma rates were low and sustained for all cohorts throughout the 5 years (≤2.9%). Reoperation rates increased over time in all cohorts, with similar rates between groups (2.4%–47.3% from week 4 to year 5 across cohorts). Other trends over time included lower rates for asymmetry and implant malposition with ADM than without. Conclusion:. These long-term data suggest that the use of ADM in breast reconstruction procedures may provide a benefit in reducing complications, such as capsular contracture, and may sustain low rates of seroma.

A 67-year-old man presented with persistent ankle pain and instability nine months post excision of anterodistal tibial osteophytes. Radiographs confirmed anterior dislocation of the talus secondary to resection of the articular surface of the tibia. Tibiotalar arthrodesis and total ankle arthroplasty were considered, but joint preservation was desirable due to the patient's active lifestyle and the healthy condition of the remaining articular surface. The patient underwent previously unreported 10-degree posterior closing wedge osteotomy of the distal tibia effectively reducing the subluxation, stabilized the joint, and preserving tibiotalar motion. At 8 months post-op, the patient had resumed his active lifestyle.

Objective: Protaction of maxilla is usually the more commonly and less invasive treatment approach for skeletal Class III with a hypoplastic maxilla. The aim of this study was the comparison of the skeletal and dental effects of two treatment protocols for maxillary protaction: a)MARPE in combination with facemask (FM) b)MARPE and mandibular miniplates (MM). Patients: Thirteen patients (6 facemask, 7 mandibular miniplates) were investigated by means of pre- and posttreatment cephalograms and Conebeam Computer Tomographies (CBCTs). The two groups matched with regard to initial cephalometric and CBCTs values. The treatment objectives were to correct the transversal and antero-posterior maxillay deficiency. Results: Both groups showed a significant movement of A-point (FM group:+2.86 ± 0.94—p = 0.028; MM: 4.08 ± 0.64—p = 0.018). Also Both groups showed a significant change in ANB°, Wits appraisal and UL-ELine (mm). Upper and lower incisor inclination did not change significantly during treatment in both groups. Conclusions: Both treatments achieve comparable rates of maxillary protaction and expansion, without dentoalveolar side effects. However, it is important to consider age, the type of growth of the patient (high angle vs low angle) and the cooperation of patients and parents to one or another treatment. Consequently, the timing of treatment seems to be more important.

Background. The predictors of recurrent autoimmune hepatitis (R-AIH) after liver transplantation (LT) are heterogeneous with limited data to guide immunosuppression, with little data on impact of race. Aims. To describe the incidence, predictors, and outcomes of R-AIH. Methods. We studied patients undergoing LT for AIH during 2000–2017 at our center. Liver biopsies were performed for clinical indications. R-AIH was defined using clinical and histologic criteria. Results. Among 75 patients undergoing LT for AIH (mean age 45 ± 16, 65% female individuals, 19% Black), 71 (95%) received antithymocyte globulin induction with tacrolimus-based immunosuppression. R-AIH developed in 20 (27%) patients at a median interval of 313 d (interquartile range, 155–1205). R-AIH was associated with level 2 HLA-DR mismatch (hazard ratio, 3.6; (95% confidence interval, 1.3-9.9; P = 0.01) and Black race (hazard ratio, 4.5; 95% confidence interval, 1.8-11.8; P = 0.002)] in the multivariable analysis. R-AIH developed in 62% of patients with level 2 HLA-DR mismatch on single-agent immunosuppression but in

Purpose: Acute carpal tunnel syndrome (CTS) can develop after distal radius fractures (DRFx), necessitating urgent carpal tunnel release (CTR). This complication has not been specifically investigated after open reduction internal fixation (ORIF) of DRFx (DRFx-ORIF). Identifying risk factors would allow for better definition of the indications for prophylactic CTR at the time of DRFx-ORIF. Methods: We reviewed the records of 1,750 patients who underwent DRFx-ORIF at 2 level I trauma centers over 90 months. Of these patients, 10.7% underwent simultaneous CTR with DRFx-ORIF. Twenty patients who developed acute CTS within 3 weeks after DRFx-ORIF were identified. A case-controlled methodology was used; each patient was matched with 4 control patients who were treated with DRFx-ORIF but did not develop acute CTS on the operative limb. Differences between cases and controls were evaluated via univariable logistic regression modeling. Multivariate analysis was not performed because of the relatively small size of the cohort. Results: The development of acute CTS after DRFx surgical treatment resulted in 1.1% of patients returning to the operating room for an urgent second surgery. Three statistically significant risk factors for the development of acute CTS after DRFx-ORIF were identified via univariable analysis. Open fractures, AO C-type DRFx, and any intervening surgical procedure between injury and DRFx-ORIF were associated with greater relative odds of developing acute CTS. Conclusions: Patients with open fractures, AO C-type DRFx, and any intervening surgical procedure are at increased risk for developing acute CTS after DRFx-ORIF and warrant consideration for prophylactic release at the time of DRFx-ORIF. Type of study/level of evidence: Therapeutic III. Key words: acute carpal tunnel syndrome, carpal tunnel release, complications, distal radius fracture

Background:. Within the past decade, poly-4-hydroxybutyrate (P4HB) biosynthetic mesh has been introduced as a potential alternative to traditional biologic and synthetic mesh in ventral hernia repair (VHR). The aim of this study was to systematically assess clinical outcomes with the P4HB in VHR. Methods:. A literature search identified all articles published in 2000 involving the use of P4HB in VHR. Descriptive statistics were used to synthesize collective data points, including postoperative outcomes. A pooled analysis of postoperative outcomes was performed using chi-square test and Fisher exact test. Results:. Across 7 studies, the P4HB was used in 453 patients. The mean rate of surgical site infection (SSI) was 6.8% (31/453), reoperation 10.7% (30/281), and recurrence 9.1% (41/453). At an average follow-up of 26.8 months, the incidence of recurrence was 10.4% (28/270). Onlay was significantly associated with increased recurrence (14.2% versus 4.4%, P = 0.001). Among sublay placements, there was no difference in recurrence in clean (Center for Disease Control [CDC] 1) or contaminated (CDC >1) wounds (2.7% versus 6.1%, P = 0.585), but contaminated wounds were associated with increased SSI (2.7% versus 15.2%, P = 0.028). Ventral Hernia Working Group grade 2 and 3 did not have different incidences of recurrence (8.0% versus 5.1%, P = 0.526) nor SSI (5.1% versus 14.6%, P = 0.265). Conclusions:. Overall, clinical outcomes of the P4HB mesh in VHR are acceptable. The P4HB mesh serves as a reliable alternative to traditional synthetic and biologic mesh across a range of defect characteristics and patient health conditions. Further research is needed to better understand the conditions in which it may provide a clinical benefit over traditional mesh types.

Background:. Mesh reinforcement is a cornerstone of modern ventral hernia repair (VHR); yet, complications with synthetic mesh and cost of biologic have created a need for alternative options. Biosynthetic mesh is a resorbable scaffold that theoretically leverages the benefits and minimizes deficiencies of existing mesh types. This study evaluates 2-year outcomes following poly-4-hydroxybutyrate (P4HB) mesh reinforcement for complex VHR. Methods:. A retrospective review of all consecutive VHR with P4HB (n = 70) was conducted from 2015 to 2018 by a single surgeon. Clinical outcomes, quality of life (QoL; and cost were assessed. Results:. Seventy patients were included with an average age and body mass index of 58.6 years and 33 kg/m2, respectively. High-risk comorbidities included hypertension (59%), and smoking history (50%). Cases were primarily modified Ventral Hernia Working Group class 2 (50%), or 3 (36%), with average defect size of 323 cm2 (25–972 cm2). P4HB was placed in the retromuscular (80%) or onlay (20%) plane. Mean follow-up was 24 months (12.2–41 months). Hernia recurrence rate was 5.7% (n = 4) and occurred an average of 285 days (209–368 days) post-repair. Of the 21 surgical site occurrences (SSO), 5 (7%) required surgical intervention. A significant improvement in overall QoL (P = 0.001) was noted following repair. Defect size and SSOPI were independently associated with increased direct cost. Conclusions:. P4HB mesh for complex VHR is associated with favorable 2-year clinical outcomes, acceptable hernia recurrence rate, and a significant improvement in QoL. This study supports the use of biosynthetic mesh as an effective biomaterial for complex VHR.

Cowden disease is a rare autosomal dominant disorder first described by Rachel Cowden in 1963 as one of the phosphatase and tensin homolog (PTEN) gene hamartoma tumor syndromes. Commonly affecting multiple systems, patients typically have an increased risk of breast and thyroid cancers as well as macrocephaly and benign hamartomatous growths. Due to the benign nature of many of the symptoms, true prevalence is likely higher than reported rates. Malformations associated with PTEN gene lead to dysregulation of cell proliferation yielding increased risk of neoplasm and frequently benign growths. Associated dysregulation of angiogenesis may result in arteriovenous malformations (AVMs). Intracranial AVMs may be asymptomatic. These AVMs present a risk of rupture and subsequent morbidity and mortality. Those with Cowden disease must be monitored for development of intracranial AVMs. Patients should be made aware that treatment for intracranial AVMs may be invasive and include serial embolization.

Background:. Split-thickness skin grafting (STSG) is a commonly used tool in the plastic surgeon’s reconstructive armamentarium. Fibrin glue (FG) consists of a combination of clotting factors and thrombin whose key properties include adherence and hemostasis. This preliminary study aimed to assess clinical outcomes and cost of FG for STSG fixation in a general wound reconstruction. Methods:. A retrospective review was conducted in all patients undergoing STSG placement by a single surgeon (JPF) from January 2016 to March 2018. Twenty patients were identified and matched by wound location and wound size. Patients were then divided into 2 groups based on the method of STSG fixation: FG (n = 10) or suture only (SO) (n = 10). Results:. In patients with FG fixation, we observed trends of decreased adjusted operative times (34.9 versus 49.4 minutes, P = 0.612), a similar length of stay (2.8 versus 3.5 days, P = 0.306), and liberation from the use of negative pressure wound therapy (0 versus 10 wounds, P < 0.0001). There were no observed differences between the 2 groups in terms of graft-related complications at 180 days (1 complication FG versus 0 complications SO). Time to 100% graft take was also not different (20.2 versus 29.4 days, P = 0.405). Additionally, total direct cost ($16,542 FG versus $24,266 SO; P = 0.545) and total charges ($120,336 FG versus $183,750 SO; P = 0.496) were not statistically different between the FG and SO groups. Conclusions:. In this preliminary comparative assessment, FG for STSG fixation has shown no difference in clinical outcomes to SO fixation, trends of decreased operative time, and afforded complete liberation from negative pressure wound therapy dressings.

Background:. Retromuscular hernia repairs (RHRs) decrease hernia recurrence and surgical site infections but can cause significant pain. We aimed to determine if pain and postoperative outcomes differed when comparing suture fixation (SF) of mesh to fibrin glue fixation (FGF). Methods:. Patients undergoing RHR (n = 87) between December 1, 2015 and December 31, 2017 were retrospectively identified. Patients received SF of mesh (n = 59, 67.8%) before the senior author changing his technique to FGF (n = 28, 32.2%). These 2 cohorts were matched (age, body mass index, number of prior repairs, mesh type, defect size, and wound class). Outcomes were analyzed using a matched pairs design with multivariable linear regression. Results:. Two matched groups (21 FGF and 21 SF) were analyzed (45.2% female, average age 56 years, average body mass index 34.7 kg/m2, and average defect size 330 cm2). Statistical significance was observed for FGF compared with SF: length of stay (3.7 versus 7.1 days, P = 0.032), time with a drain (17.2 versus 27.5 days, P = 0.012), 30-day postoperative visits (2 versus 3, P = 0.003), pain scores (5.2 versus 3.1, P = 0.019) and activity within the first 24 hours (walking versus sitting, P = 0.002). Operative time decreased by 23.1 minutes (P = 0.352) and postoperative narcotic represcription (3 versus. 8 patients, p=0.147) also decreased. Average cost for patients receiving SF was $36,152 compared to $21,782 for FGF (P = 0.035). Conclusions:. Sutureless RHR using FGF may result in decreased pain when compared with a matched cohort receiving SF, translating to enhanced recovery time, shortened hospital stay, and decreased costs.

Summary:. A 46-year-old female presented after 3 years of steadily increasing numbness in her hands bilaterally with worse symptoms in her right hand. She reported nighttime paresthesia and exacerbation of her symptoms while writing, typing, and driving. Tinel’s and carpal tunnel compression test were positive bilaterally. During the right hand carpal tunnel release, a layer of synovium was present deep to the carpal ligament with a tendinous portion running midline longitudinally along the median nerve. This layer was an anomalous palmaris profundus (PP) tendon within the carpal tunnel, which inserted distally in the palmar fascia. The PP tendon was freed and released. The PP is a rare muscle variation of the forearm and wrist, and although it has no function, it has been reported as a cause of median nerve compression at the wrist. More commonly, it is an incidental finding during carpal tunnel surgery. Because of its close association with the median nerve, it can cause confusion when encountered during carpal tunnel surgery. Clinicians should be aware of this rare finding, which may be present during carpal tunnel surgery. We present a case, with intraoperative photographs, of a PP tendon that was encountered during a carpal tunnel release.

Abstract Prolactinomas are the most common form of endocrinologically active pituitary adenoma; they account for ∼ 45% of pituitary adenomas encountered in clinical practice. Giant adenomas are those > 4 cm in diameter. Less than 0.5% of pituitary adenomas encountered in neurosurgical practice are giant prolactinomas. Patients with giant prolactinomas typically present with highly elevated prolactin levels, endocrinologic disturbances, and neurologic symptoms from mass-induced pressure. Described here is an unusual case of a giant prolactinoma presenting with neck pain and structural compromise of the occipital condyles. Transnasal biopsy of the nasopharyngeal portion of the mass obtained tissue consistent with an atypical prolactinoma with p53 reactivity and a high Ki-67 index of 5%. Despite the size and invasiveness of the tumor, the patient had resolution of his clinical symptoms, dramatic reduction of his hyperprolactinemia, and near-complete disappearance of his tumor following medical treatment.