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Background: Cardiac surgery patients are at increased risk for venous thromboembolism (VTE). Prevention is the most critical strategy to reduce VTE-associated morbidity and death. However, there is a lack of data on the optimal approach to VTE prophylaxis in this population of high-risk patients. This study aimed to assess whether the standard dose of enoxaparin, the subcutaneous injection of 40 mg of enoxaparin daily, achieves adequate anti–factor Xa (aFXa) levels for VTE prophylaxis in patients after open heart surgery. Methods: All patients with open heart surgery with cardiopulmonary bypass from August to December 2022 who received at least 3 consecutive doses of subcutaneously administered enoxaparin were included in the study. Patients receiving therapeutic anticoagulation, patients who underwent cardiac transplantation or placement of ventricular assist device, and patients with renal insufficiency were excluded. Serum aFXa was measured 0.5 to 1 hour before the fourth dose to attain the steady-state trough levels. Results: Data were completed for 44 patients. The target aFXa level was between 0.10 and 0.20 IU/mL for the avoidance of both underanticoagulation (≤0.10 IU/mL) and overanticoagulation (>0.20 IU/mL). The mean was 0.049 IU/mL with SD of 0.026 IU/mL, which was statistically significantly lower than the lower end of the target aFXa values (0.10 IU/mL; t43 = −13; P < .001; d = −1.9; 99% CI, −0.059 to −0.043). Conclusions: The daily subcutaneous administration of 40 mg of enoxaparin leads to subprophylactic aFXa levels for most patients who undergo cardiac surgery. Further studies on the clinical relevance are warranted.

Background:. Botulinum toxin A (BTxA) has gained popularity as a nonsurgical aesthetic treatment for skin rejuvenation. However, previous studies on intradermal BTxA have shown inconsistent results. This systematic review and meta-analysis with trial sequential analysis aimed to assess the efficacy and safety of intradermal BTxA for facial rejuvenation. Methods:. Following PRISMA guidelines, a comprehensive search was conducted in various databases from January 2008 to March 2023. Outcome measures included sebum production, pore size, skin hydration, skin texture, erythema index, facial wrinkles, and facelift. Eligible studies included human-based clinical trials and prospective cohort studies published in English, focusing on healthy populations requiring facial rejuvenation. Two authors independently screened the titles and abstracts, followed by a full-text review to determine study eligibility. Data extraction and quality assessment were performed by two authors using predefined criteria. Results:. Ten studies met the inclusion criteria, including five randomized controlled trials and five prospective cohort studies with 153 participants. Studies revealed positive effects of intradermal BTxA on various outcome measures related to facial rejuvenation. These effects included improvements in sebum production, pore size, erythema index, facial wrinkles, skin texture and elasticity, and overall facelift but not skin hydration. All failed to reach the required information size in the trial sequential analysis. Conclusions:. Findings suggest positive outcomes in multiple attributes of skin quality and facial rejuvenation. However, more high-quality research is needed to establish definitive conclusions. These findings contribute to the evidence base for nonsurgical aesthetic treatments, emphasizing the importance of ongoing research in this field.

Summary:. A 26-year-old man was admitted to our hospital due to the replantation of the severed right upper arm and right thigh injury 6 days before. The patient received emergency treatment at a local hospital. He underwent amputation and replantation for the right upper arm and right thigh. After surgery, he experienced fever, limb swelling, and wound pain. At the time of admission to our hospital, the patient exhibited stable vital signs. An infection was found at the replanted wound, and the culture results showed Pseudomonas aeruginosa. After admission, the patient underwent symptomatic antiinflammatory treatment. In addition, he received fracture reduction and external fixation with a bracket, radial nerve exploration and release of the upper and lower limb external fixation with a bracket, upper femur osteotomy, and external fixation with a bracket. He also received reconstruction of elbow flexion functions with biceps femoris tendon transplantation; reconstruction of wrist joint fusion, finger extension function, and palm function; removal of the femoral external fixation with a bracket; and tibiofibular osteotomy and leg lengthening surgery. Moreover, the anterior tibial tendon was fixed to correct foot drop deformity, and the external fixation bracket was removed. Owing to these efforts, the patient achieved limb preservation with well-reconstructed functions.

Summary:. An 80-year-old female patient was admitted to the hospital due to recurrent lymphedema, ulcers, and lymphorrhea in the right lower limb for 7 years. The physical examination revealed changes after the Charles procedure below the right knee joint plane, with a 7 × 7 cm2 lymphorrhea area in the lower one-third plane of the anterior tibia area. Continuous lymphatic exudation and scattered ulcers could be seen. The dorsal artery of the foot could not be reached due to the thickening and fibrosis of the dorsal skin of the foot. The peripheral blood circulation was favorable. The glycated hemoglobin test revealed that blood sugar was not high and could be controlled. The color Doppler ultrasound of lower limb blood vessels revealed no obvious stenosis of arteries, with normal venous return. In addition, no varicose veins or deep venous thrombosis were observed. Based on these findings, the patient was diagnosed with primary lymphedema combined with lymphorrhea after the Charles procedure, complicated with diabetes. After admission, the patient underwent lymphaticovenous anastomosis on the right lower limb under general anesthesia. During the follow-up of 2 months after surgery, it was found that the lymphorrhea was alleviated, the ulcer basically healed, and the swelling on the right lower limb decreased. At the follow-up of 6 months after surgery, the lymphorrhea was eliminated and the ulcer was healed. There were 1-cm reduction in leg and back circumference and 10% volume reduction. The lymphedema quality-of-life score of this patient was 57 points after surgery.

Summary:. An 80-year-old male patient was admitted to the hospital due to swelling in the right lower limb with local blisters caused by a forced prone position for 9 hours after syncope. The patient got up in the middle of the night and fainted beside the bed due to a transient cerebral ischemia attack. The front of the right thigh and calf contacted the bed edge, presenting a forced prone position for 9 hours. The physical examination revealed swelling of the right lower limb, accompanied by local tension blisters, and the tension of the thigh and calf was increased. The patient had a history of diabetes, and no lower limb artery or vein thrombosis was found on B-ultrasound. Based on these findings, the patient was diagnosed with well leg compartment syndrome in the right thigh and calf. When the patient was admitted, the creatine phosphokinase level was 62,300 u/L, and the creatinine level was 2.66 mg/dL. Besides, the urea level of this patient was 11 mmol/L. He developed anuria with a high creatinine level, indicating acute kidney injury. Subsequently, temporary hemodialysis was performed for treatment. The patient underwent fasciotomy of the right thigh and calf, and the vacuum-assisted closure device was adopted for wound treatment. After 2 weeks of decompression, the wound was directly sutured under tension. After renal replacement therapy, the creatine phosphokinase level of this patient was 102 u/L, and the creatinine level was 95 mol/L, which tended to be normal.

Summary:. A 50-year-old man was admitted to the hospital with a chief complaint of long-standing cold-induced numbness in the fingers for more than a year, accompanied by persistent hand pain and fingertip ulceration for 3 months. On physical examination, radial and ulnar artery pulsation was absent in both limbs, and pale skin color, low skin temperature, and limited finger range of motion were noted. Gangrene was detected in the fingertips of the left index and middle fingers, and the right middle and ring fingers. The patient was diagnosed with bilateral arterial occlusion and vibration white finger. Upon admission, the patient underwent an intervention surgery on the right side. Subsequently, transplantation of the descending branches of the left and right lateral femoral circumflex arteries was performed to restore blood flow in the bilateral radial arteries. Additionally, debridement was conducted without shortening after the surgical procedure, the patient received anticoagulation, anti-inflammatory, and symptomatic treatment. The bilateral finger skin temperature increased by 3 °C postoperatively, and the accompanying pain and numbness were alleviated. The wound healed 1 month after surgery, and no recurrence of pain or ulcer was reported during the 1-year follow-up period. Eventually, his hand function recovered, without any impact on the vascular donor site.

Background:. As long-term, regular aesthetic botulinum neurotoxin A (BoNT-A) use becomes more commonplace, it is vital to understand real-world risk factors and impact of BoNT-A immunoresistance. The first Aesthetic Council on Ethical Use of Neurotoxin Delivery panel discussed issues relating to BoNT-A immunoresistance from the health care professionals’ (HCPs’) perspective. Understanding the implications of BoNT-A immunoresistance from the aesthetic patient’s viewpoint allows HCPs to better support patients throughout their aesthetic treatment journey. Methods:. A real-world consumer study surveyed 363 experienced aesthetic BoNT-A recipients across six Asia-Pacific territories. The survey mapped participants’ BoNT-A aesthetic treatment journey and characterized awareness and attitudes relating to BoNT-A immunoresistance and treatment implications. At the second Aesthetic Council on Ethical use of Neurotoxin Delivery meeting, panelists discussed survey findings and developed consensus statements relating to the impact of BoNT-A immunoresistance on the aesthetic treatment journey. Results:. Aesthetic BoNT-A patients’ depth of knowledge about BoNT-A immunoresistance remains low, and risk/benefit communications need to be more lay-friendly. The initial consultation is the most important touchpoint for HCPs to raise awareness of BoNT-A immunoresistance as a potential side effect considering increased risk with repeated high-dose treatments. HCPs should be cognizant of differences across BoNT-A formulations due to the presence of certain excipients and pharmacologically unnecessary components that can increase immunogenicity. Standardized screening for clinical signs of secondary nonresponse and a framework for diagnosing and managing immunoresistance-related secondary nonresponse were proposed. Conclusion:. These insights can help patients and HCPs make informed treatment decisions to achieve desired aesthetic outcomes while preserving future treatment options with BoNT-A.

Summary:. Leg muscle hypertrophy is a unique physical symptom in East Asian women. Compared with traditional surgical treatment for calf muscle hypertrophy, botulinum toxin is widely favored by East Asian women because of its minimal trauma and significant effects. We describe the case of a 22-year-old woman with pulmonary embolism because of deep vein thrombosis, who presented with hypertrophy of bilateral calf muscles, and was administered 300 U of botulinum toxin A injection in July 2022. On the third day after the injection, she experienced swelling and pain in her left leg, which gradually worsened and made walking difficult. She underwent an ultrasound examination of lower limbs, which revealed several deep and shallow vein thrombi in the left lower limb. Computed tomography arterial imaging indicated multiple embolisms in pulmonary arteries. This study aimed to explore and analyze the causes of pulmonary embolism after botulinum toxin treatment for calf muscle hypertrophy by reviewing and analyzing the patient’s symptoms, diagnosis, and treatment process to provide management strategies for treatment and prevention of this disease.

Background:. Different landmarks on the abdomen have been used to evaluate abdominal aesthetics. However, because researchers use different methods for landmark measurements, there is no consensus as to which landmarks to use for either assessing abdominal aesthetics or guiding surgical planning. Methods:. Female model photographs were analyzed for abdominal aesthetics with the umbilicus as the key dividing point. Because of the limitation on the number of landmarks that could be shown with model photographs, abdominal landmarks on actual female patients were studied. The variations of landmark metrics due to positional changes and before/after our polydioxanone (PDO)–assisted high-definition liposuctions were recorded. Results:. For model photographs, the abdominal apex to mid-umbilicus distance (AU) versus midumbilicus to lower abdominal skin crease (UC) ratio was 1.626. Almost all bony landmarks demonstrated significant caudal shift when switched from standing to supine positions. Meanwhile, other landmarks also underwent substantial changes. This provides evidence that metrics taken in different positions cannot be compared with one another. As expected, after umbilici were elevated with our special technique, the relevant metrics improved postoperatively, with results close to being ideal. However, marked deviations from the mean measured values do exist. Conclusions:. Abdominal landmarks change with positional adjustment. In standing position, many landmarks can be used for assessment of abdominal aesthetics. Ideally, efforts should be made such that the final AU/UC is close to 1.618, and XU/UP and UIC close to ideal, for satisfactory surgical results. Nevertheless, in actual practice, umbilicus positions can be varied to accomplish desired goals.

Objective: Acute type A aortic dissection (ATAAD) is a surgical emergency with significant morbidity and mortality, as well as significant center-level variation in outcomes. Our study aims to leverage a nationally representative database to assess contemporary in-hospital outcomes in surgical repair of ATAAD, as well as the association of age and sex with outcomes. Methods: The National Inpatient Sample was queried to identify hospital discharge records of patients aged ≥18 years who underwent urgent surgical repair of ATAAD between 2017 and 2018. Patients with a diagnosis of thoracic aortic dissection, who underwent surgical intervention of the ascending aorta, were identified. Patient demographics were assessed, and predictors of in-hospital mortality were identified. Results: We identified 7805 weighted cases of surgically repaired ATAAD nationally, with an overall mortality of 15.3%. Mean age was 60.0 ± 13.6 years. There was a male predominance, although female subjects made up a larger proportion of older age groups—female subjects up 18.4% of patients younger than 40 years with ATAAD but 53.6% of patients older than 80 years. In multivariable analysis controlling for sex, race, comorbidities, and malperfusion, age was a significant predictor of mortality. Patients aged 71 to 80 years had a 5.3-fold increased risk of mortality compared with patients ≤40 years old (P 80 years had a 6.8-fold increased risk of mortality (P

Summary:. Necrotizing soft tissue infection (NSTI) is a complex infection known for its rapid progression of necrosis within the subcutaneous tissue and fascia. Time is of essence for the management of NSTI. In this report, we present a case of NSTI after infection of poorly managed diabetic foot ulcer in the ankle. The limb salvage approach involves sequential staged procedures. Multiple surgical debridements and “washout” were performed for source control. At the same time, the patient also received a systemic antibiotic regimen. In the second stage, a perforator free flap taken from the anterolateral thigh was used to repair the extensive soft tissue defect and reconstruct a functional foot to achieve maximal limb salvage. The kickstand technique of external fixation was used to reduce soft tissue compression and enhance the surgical offloading of the skin flap. At the 2-year follow-up, the skin integrity of the flap was well-preserved, and the patient returned to his premorbid quality of life.

Summary:. Injectable poly-L-lactic acid (PLLA) has been widely used for skin texture improvement, volume augmentations of the face or body, and other cosmetic or reconstructive treatment. Despite its significant efficacy, many side effects have also been reported. Here, we describe a case of rosacea aggravated by intracutaneous injection of PLLA using a mesogun injector with stamp-type microneedle. After the treatment, the patient exhibited aggravated rosacea symptoms, such as flushing and erythema. A possible mechanism for the exacerbations might be that PLLA stimulated subclinical inflammatory reaction in the skin. We suggest that PLLA injection should be administered more cautiously in patients with rosacea or other inflammatory skin lesions.

Background. ABO type B and O kidney transplant candidates have increased difficulty identifying a compatible donor for living donor kidney transplantation (LDKT) and are harder to match in kidney paired donation registries. A2-incompatible (A2i) LDKT increases access to LDKT for these patients. To better inform living donor selection, we evaluated the association between A2i LDKT and patient and graft survival. Methods. We used weighted Cox regression to compare mortality, death-censored graft failure, and all-cause graft loss in A2i versus ABO-compatible (ABOc) recipients. Results. Using Scientific Registry of Transplant Recipients data 2000–2019, we identified 345 A2i LDKT recipients. Mortality was comparable among A2i and ABOc recipients; weighted 1-/5-/10-y mortality was 0.9%/6.5%/24.2%, respectively, among A2i LDKT recipients versus 1.4%/7.7%/22.2%, respectively, among ABOc LDKT recipients (weighted hazard ratio [wHR], 0.811.041.33; P = 0.8). However, A2i recipients faced higher risk of death-censored graft failure; weighted 1-/5-/10-y graft failure was 5.7%/11.6%/22.4% for A2i versus 1.7%/7.5%/17.2% for ABOc recipients (wHR in year 1 = 2.243.565.66; through year 5 = 1.251.782.53; through year 10 = 1.151.552.07). By comparison, 1-/5-/10-y wHRs for A1-incompatible recipients were 0.631.966.08/0.390.942.27/0.390.831.74. Conclusions. A2i LDKT is generally safe, but A2i donor/recipient pairs should be counseled about the increased risk of graft failure and be monitored as closely as their A1-incompatible counterparts posttransplant.

Objective:. We sought to confirm and extend the understanding of clinical outcomes following creation of a common distal autogenous access, the radiocephalic arteriovenous fistula (RCAVF). Background:. Interdisciplinary guidelines recommend distal autogenous arteriovenous fistulae as the preferred hemodialysis (HD) access, yet uncertainty about durability and function present barriers to adoption. Methods:. Pooled data from the 2014-2019 multicenter randomized-controlled PATENCY-1 and PATENCY-2 trials were analyzed. New RC-AVFs were created in 914 patients, and outcomes were tracked prospectively for 3-years. Cox proportional hazards and Fine-Gray regression models were constructed to explore patient, anatomic, and procedural associations with access patency and use. Results:. Mean (SD) age was 57 (13) years; 45% were on dialysis at baseline. Kaplan-Meier estimates of 3-year primary, primary-assisted, and secondary patency were 27.6%, 56.4%, and 66.6%, respectively. Cause-specific 1-year cumulative incidence estimates of unassisted and overall RC-AVF use were 46.8% and 66.9%, respectively. Patients with larger baseline cephalic vein diameters had improved primary (per mm, hazard ratio [HR] 0.89, 95% confidence intervals 0.81–0.99), primary-assisted (HR 0.75, 0.64–0.87), and secondary (HR 0.67, 0.57–0.80) patency; and higher rates of unassisted (subdistribution hazard ratio 1.21, 95% confidence intervals 1.02–1.44) and overall RCAVF use (subdistribution hazard ratio 1.26, 1.11–1.45). Similarly, patients not requiring HD at the time of RCAVF creation had better primary, primary-assisted, and secondary patency. Successful RCAVF use occurred at increased rates when accesses were created using regional anesthesia and at higher volume centers. Conclusions:. These insights can inform patient counseling and guide shared decision-making regarding HD access options when developing an individualized end-stage kidney disease life-plan.

ABSTRACT: Objectives: Infantile hemangioma (IH) is defined as a benign vascular tumor composed of immature vascular endothelial cells, with the unique characteristics of rich vascularization and self-regression into fibro-fatty tissue. CD133-positive hemangioma stem cells (HemSCs), present in the proliferating IH tissue, can be used to establish the IH animal model, which has highlighted the pathogenesis of IH in recent years. This study focused on the biological characteristics and differentiation capacity of HemSCs and aimed to provide a theoretical possibility for its application in tissue engineering. Methods: To further confirm our hypothesis, we used fluorescence-activated cell sorting (FACS), in vitro multipotent induced differentiation, angiogenesis assay, and antibody array to identify the surface markers, multipotent differential potential, angiogenesis potential, and secreted factors of HemSCs, respectively, utilizing human adipose stem cells(hADSCs) as the control. Results: We successfully isolated and cultured HemSCs. FACS indicated that, on average, more than 80% of HemSCs matched the criteria of mesenchymal stem cell (MSC) surface markers. Our results confirmed that HemSCs could differentiate into adipocytes, osteocytes, and chondrocytes. Additionally, compared with fibroblasts or hADSCs, HemSCs could promote angiogenesis through para-secretion. Conclusions: HemSCs may originate from normal MSCs, and owing to their powerful proliferative and angiogenic abilities, they could be considered an IH pathogenic factor. These characteristics demonstratet heir potential as a candidate seed cell in tissue engineering.

Virtual interviews are planned for the upcoming 2020-2021 residency cycle. This presents a unique challenge for medical students. Due to the importance of the interaction of applicants and interviewers during the interview, medical students should thoroughly prepare for the upcoming virtual interview season. We offer practical and realistic concepts and techniques to optimize their interview experience. Technology and audiovisual equipment should be adjusted and enhanced to minimize video conferencing application errors and interview downtime. The applicant’s interview environment should focus on proper lighting, background, camera angles, and minimizing unwanted distractions. Mock interview sessions are invaluable to applicants and provide the opportunity to simulate the interview, refine their technology, adjust their environment, and become more comfortable in a virtual interview setting. These actions will prevent unnecessary disruptions and increase the focus of the interview toward the communication between the applicant and the interviewer.

Summary:. Field sterility is commonly used for skin and minor hand surgery performed in the ambulatory setting. Surgical site infection (SSI) rates are similar for these same procedures when performed in the main operating room (OR). In this paper, we aim to look at both current evidence and common sense logic supporting the use of some of the techniques and apparel designed to prevent SSI. This is a literature review of the evidence behind the ability of gloves, masks, gowns, drapes, head covers, footwear, and ventilation systems to prevent SSIs. We used MEDLINE, EMBASE, and PubMed and included literature from the inception of each database up to March 2019. We could not find substantial evidence to support the use of main OR sterility practices such as head covers, gowns, full patient draping, laminar airflow, and footwear to reduce SSIs in skin and minor hand surgery. Field sterility in ambulatory minor procedure rooms outside the main OR is appropriate for most skin and minor hand surgery procedures. SSIs in these procedures are easily treatable with minimal patient morbidity and do not justify the cost and waste associated with the use of main OR sterility.

Background. Clinicians may be reluctant to transplant small pediatric kidneys that have prolonged cold ischemia time (CIT) for fear of an additional deleterious effect because pediatric grafts are thought to be more sensitive to ischemia. We aimed to assess the risks associated with transplantation of small pediatric kidneys with prolonged CIT. Methods. We performed a retrospective cohort study examining US registry data between 1998 and 2013 of adult first-time kidney-only recipients of small pediatric kidneys from donors weighing 10 to 20 kg, stratified by CIT levels of 0 to 18 (n = 1413), 19 to 30 (n = 1116), and longer than 30 (n = 338) hours. Results. All-cause graft survival by CIT groups at 1-year was 92%, 88%, and 89%, respectively. 1-year risk-adjusted graft survival hazard ratios were significantly higher with CIT of 19 to 30 hours (adjusted hazard ratios, 1.37; 95% confidence interval, 1.04-1.81) and somewhat higher with CIT greater than 30 hours (adjusted hazard ratios, 1.24; 95% confidence interval, 0.82-1.88) relative to recipients with CIT 0 to 18 hours. There was little variation in the effect of CIT on graft survival when restricted to single kidney transplants only and no significant interaction of CIT category and single kidney transplantation (P = 0.93). Conclusions. Although prolonged CIT is associated with lower early graft survival in small pediatric donor kidney transplants, absolute decreases in 1-year graft survival rates were 3% to 4%.

Objective: The safety and feasibility of preoperative pembrolizumab combined with chemoradiotherapy (PPCT) for resectable esophageal squamous cell carcinoma have been confirmed by the prior Preoperative Anti-PD-1 Antibody combined with Chemoradiotherapy for Locally Advanced Squmous Cell Carcinoma of Esophageus (PALACE)-1 trial. Potential therapeutic benefit was also observed with a pathologic complete response rate of 55.6% after PPCT. We will conduct the multicenter single-arm PALACE-2 study to investigate the efficacy and to further confirm the safety of PPCT (ClinicalTrials.gov ID: NCT04435197). Methods: A total of 143 patients with previously untreated, locally advanced, and surgically resectable esophageal squamous cell carcinoma (T2 through T4a, N0 through N+, M0) will be enrolled in PALACE-2. Main exclusion criteria are autoimmune disease, interstitial lung disease, ongoing immunosuppressive therapy, and having received chemotherapy, radiotherapy, target therapy, or immune therapy for this or any other malignancies. Positive programmed cell death ligand 1 expression is not mandatory for enrollment. Patients will receive PPCT, which includes concurrent pembrolizumab (200 mg on day 1 and day 22), carboplatin (area under the curve = 2, once a week for 5 weeks), nab-paclitaxel (50 mg/m2, once a week for 5 weeks), and radiotherapy (23 fractions of 1.8 Gy, 5 fractions a week). Esophagectomy will be performed within 4 to 6 weeks after the completion of PPCT. Results: The primary end point is the rate of pathologic complete response. Secondary outcome measures are 3-year disease-free survival rate, 3-year overall survival rate, R0 resection rate, and adverse events during neoadjuvant and perioperative periods. Conclusions: PPCT was preliminarily demonstrated to be safe, feasible, and to provide potential therapeutic benefits by the PALACE-1 trial. The subsequent multicenter PALACE-2 study will investigate the efficacy and further confirm the safety of PPCT for locally advanced, resectable esophageal squamous cell carcinoma.

Summary:. We present the case of a 13-year-old girl who developed numerous gingival masses that recurred after two prior resections. Following the initial resection as a child, she reported that there was a period of resolution for several years before recurrence as a teenager. After the second resection, the masses recurred after 4 months. The lesions obscured the majority of her dentition and interfered with speech, eating, and oral hygiene. The patient underwent staged resection of the masses, and the wounds were allowed to heal by secondary intention. The histopathologic findings of the specimens were consistent with a diagnosis of peripheral ossifying fibroma, which is unusual as these are generally solitary lesions. We believe that this case brings attention to an underrecognized and atypical presentation of peripheral ossifying fibroma, and it should be considered in the differential diagnosis of multicentric gingival masses.

Background:. Botulinum neurotoxin A (BoNT-A) injection is the most widely performed aesthetic procedure and a first-line therapeutic option for various medical conditions. The potential for BoNT-A immunoresistance and secondary nonresponse related to neutralizing antibody (NAb) formation warrants attention as the range of BoNT-A aesthetic applications continues to expand. Methods:. An international multidisciplinary panel reviewed published evidence on BoNT-A immunoresistance in aesthetic and therapeutic applications and discussed best practices integrating clinical, ethical, and aesthetic considerations. Consensus statements relating to awareness, assessment, and management of the risk of NAb-related secondary nonresponse in aesthetic practice were developed. Results:. There was a consensus that, as doses used in aesthetic practice become like those in therapeutics, rates of NAb formation may be expected to increase. However, the true extent of NAb formation in aesthetics is likely underestimated due to limitations of published evidence and variability in treatment patterns of aesthetic patients. Since BoNT-A therapy is often lifelong, practitioners need to recognize immunogenicity as a potential complication that might affect future therapeutic use and strive to minimize modifiable risk factors. The selection and use of a BoNT-A product with the least immunogenic potential from the beginning may thus be advantageous, especially when treatment with high doses is planned. Conclusions:. In view of current trends in BoNT-A aesthetic use, it is essential for practitioners to conduct thorough clinical assessments, inform patients of treatment risks, and develop BoNT-A treatment plans to minimize immunogenicity. This can help preserve the option of continued or future BoNT-A treatment with satisfactory outcomes.

Objectives: Heparin-induced thrombocytopenia (HIT) is an immune-mediated complication that occurs in a small percentage of patients exposed to heparin. Concerns of HIT are particularly high in patients undergoing cardiac procedures requiring cardiopulmonary bypass, as they are exposed to high doses of heparin intraoperatively. Our aim was to identify and assess the hospital courses of patients who were diagnosed with HIT during readmission following cardiac surgery. Methods: A retrospective review of patients who underwent open cardiac surgical procedures from June 2017 through October 2019 was performed. Of these, we identified patients who were newly diagnosed with HIT upon readmission. HIT positivity was defined as a positive anti-PF4 antibody screening test, plus a positive serotonin release assay. Results: Of the 2496 patients identified, 13 patients were HIT positive on index admission and were excluded. Of the remaining 2483 patients, 351 were readmitted within 30 days. Six were newly diagnosed with HIT during readmission, 5 of whom presented with thrombotic complications. One patient was readmitted with thrombocytopenia and was started on argatroban; the remaining 5 did not have a significantly lower platelet count on readmission. Of the 12 patients readmitted for venous thromboembolism, 4 tested positive for HIT. Conclusions: HIT can have a delayed appearance following open heart surgery. Venous thromboembolism appears to be a significant indicator for HIT during readmission, even in the absence of thrombocytopenia. This may support the use of non-heparin anticoagulation for cardiac surgery patients readmitted with thromboembolism until HIT status is determined.

Background: Prolonged survival of patients after pancreaticoduodenectomy can be associated with late complications due to altered gastrointestinal anatomy. The incidence of gastric cancer is increasingly reported. We set out to examine our experience with gastric cancer as a late complication after pancreaticoduodenectomy with a focus on incidence, risk factors, and outcomes. Methods: We queried our prospectively collected institutional database for patients that developed gastric cancer after pancreaticoduodenectomy and conducted a systematic review of the literature. Results: Our database revealed 6 patients who developed gastric cancer following pancreaticoduodenectomy, presenting with a mean age of 62.2 years and an even sex distribution. All of those patients underwent pancreaticoduodenectomy for malignant indications with an average time to development of metachronous gastric cancer of 8.3 years. Four patients complained of gastrointestinal discomfort prior to diagnosis of secondary malignancy. All of these cancers were poorly differentiated and were discovered at an advanced T stage (≥3). Only half developed at the gastrointestinal anastomosis. Four underwent surgery with a curative intent, and 2 patients are currently alive (mean postgastrectomy survival = 25.5 months). In accordance with previous literature, biliopancreatic reflux from pancreaticoduodenectomy reconstruction, underlying genetic susceptibility, and adjuvant therapy may play a causative role in later development of gastric cancer. Conclusion: Long-term survivors after pancreaticoduodenectomy who develop nonspecific gastrointestinal complaints should be evaluated carefully for complications including gastric malignancy. This may serve as an opportunity to intervene on tumors that typically present at an advanced stage and with aggressive histology.

Due to the ongoing coronavirus disease 2019 pandemic, virtual interviews are planned for the 2021-2022 residency application cycle. The virtual interview will remain novel to applicants for each match cycle until the graduating medical student class has experience from virtual interviews during their medical school admissions. The virtual interview poses unique challenges that are unique from in-person formats. Given the lack of experience of applicants in the 2022 match, practicing interviewing skills prior to the actual date is vital to success. We describe a postgraduate year 1 (PGY1)–run mock interview session for applicants preparing for the 2021-2022 otolaryngology interview cycle and discuss the methodology. Deliberate practice with PGY1 residents who have just recently undergone the virtual interview process can better prepare applicants for their virtual interviews, improve on-camera behaviors, and ameliorate mental health challenges unique to the virtual format.

Primary aortic sarcoma is a rare diagnosis that carries a poor prognosis. This case report features a 68-year-old man, treated 4 years earlier with an endovascular aortic aneurysm repair, who presented with fever, low back discomfort, and abdominal pain. Given the concern for an infected endograft, the patient underwent explantation and replacement with a cadaveric aortoiliac cryograft. Ultimately, the pathology returned as an angiosarcoma. Although endovascular aortic aneurysm repair is the gold standard for abdominal aortic aneurysm repair in patients with suitable anatomy, there are trade-offs associated with less invasive approaches compared with open approaches. Keywords: Angiosarcoma, EVAR, Aortic sarcoma