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A woman with history of bilateral breast augmentation 15 years prior presented with right breast swelling, peri-implant effusion and a palpable inferomedial mass. Effusion aspiration demonstrated pleiomorphic cells consistent with breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Further diagnostic studies confirmed stage III disease with a 4.7 cm right breast mass and fluorodeoxyglucose uptake in an internal mammary chain lymph node. The patient underwent surgery with incomplete resection due to invasion of the chest wall followed by chemotherapy and radiation therapy. BIA-ALCL typically presents as an indolent effusion, however advanced disease carries a worse prognosis. This case highlights successful treatment without recurrence past the one-year mark as well as the need for multidisciplinary management when dealing with advanced disease.

Prepectoral prosthetic breast reconstruction continues to gain popularity, largely due to its decreased postoperative pain, animation deformity, and operative time as compared to subpectoral reconstruction. Widespread use has led to opportunities for surgical revisions. While some techniques for submuscular reconstruction revisions, such as implant exchange and fat grafting, also apply to prepectoral revisions, others require modification for the prepectoral space. The prosthesis' unique reliance on the mastectomy flaps and acellular dermal matrix for support leads to a progressive alteration of the breast footprint, conus, envelope, and nipple-areola complex position. To date, revisions of prepectoral reconstructions have not been addressed in the literature. This article presents the senior author's (N.P.B.) techniques for (1) revising prepectoral breast reconstructions, including staged and direct-to-implant reconstructions, with a special focus on nipple-sparing reconstruction, and (2) minimizing undesirable outcomes of prepectoral reconstruction.

BACKGROUND In heart failure (HF) patients with renal insufficiency (RI), we hypothesize that mechanical circulatory support (MCS) with the left ventricular assist device (LVAD) will promote renal function recovery (RR). We sought to quantify RR with LVAD support over 6 months of follow-up. METHODS RR data at 30, 90, and 180 days were analyzed for all LVAD patients with RI at the time of surgery. RI was defined as either the use of hemodialysis (HD) or a glomerular filtration rate (GFR) less than 60 mL/min/1.73 m2 . RESULTS Between January 2008 and December 2013, 47 of 127 (37%) LVAD recipients had RI at the time of surgery. The mean preoperative GFR was 48 ± 7. We observed RR at each follow-up, with 30-, 90-, and 180-day mean GFRs of 79 ± 33, 71 ± 31, and 63 ± 21, respectively. The absolute increase in GFR at 30, 90, and 180 days was 34 ± 31, 26 ± 29, and 19 ± 20, respectively (All with P

Heart failure patients requiring total artificial heart (TAH) support often have concomitant renal insufficiency (RI). We sought to quantify renal function recovery in patients supported with TAH at our institution. Renal function data at 30, 90, and 180 days after TAH implantation were analyzed for patients with RI, defined as hemodialysis supported or an estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 m. Between January 2008 and December 2013, 20 of the 46 (43.5%) TAH recipients (age 51 ± 9 years, 85% men) had RI, mean preoperative eGFR of 48 ± 7 ml/min/1.73 m. Renal function recovery was noted at each follow-up interval: increment in eGFR (ml/min/1.73 m) at 30, 90, and 180 days was 21 ± 35 (p = 0.1), 16.5 ± 18 (p = 0.05), and 10 ± 9 (p = 0.1), respectively. Six patients (30%) required preoperative dialysis. Of these, four recovered renal function, one remained on dialysis, and one died. Six patients (30%) required new-onset dialysis. Of these, three recovered renal function and three died. Overall, 75% (15 of 20) of patients' renal function improved with TAH support. Total artificial heart support improved renal function in 75% of patients with pre-existing significant RI, including those who required preoperative dialysis.

We studied preBötzinger Complex (preBötC) inspiratory interneurons to determine the cellular mechanisms that influence burst termination in a mammalian central pattern generator. Neonatal mouse slice preparations that retain preBötC neurons generate respiratory motor rhythms in vitro. Inspiratory-related bursts rely on inward currents that flux Na(+), thus outward currents coupled to Na(+) accumulation are logical candidates for assisting in, or causing, burst termination. We examined Na(+)/K(+) ATPase electrogenic pump current (I(pump)), Na(+)-dependent K(+) current (I(K-Na)), and ATP-dependent K(+) current (I(K-ATP)). The pharmacological blockade of I(pump), I(K-Na), or I(K-ATP) caused pathological depolarization akin to a burst that cannot terminate, which impeded respiratory rhythm generation and reversibly stopped motor output. By simulating inspiratory bursts with current-step commands in synaptically isolated preBötC neurons, we determined that each current generates approximately 3-8 mV of transient post-burst hyperpolarization that decays in 50-1600 ms. I(pump), I(K-Na), and - to a lesser extent - I(K-ATP) contribute to terminating inspiratory bursts in the context of respiratory rhythm generation by responding to activity dependent cues such as Na(+) accumulation.

Purpose: In heart failure patients with renal insufficiency (RI), we hypothesize that mechanical circulatory support with the left ventricular assist device (LVAD) will promote renal function recovery (RR). We sought to quantify RR with LVAD support over six months of follow-up. Methods: RR data at 30, 90 and 180 days were analyzed for all LVAD patients with RI at the time of surgery. RI was defined as either the use of hemodialysis (HD) or a glomerular filtration rate (GFR) less than 60 ml/min/ 1.73m2. Mean GFR calculations exclude those patients on HD. Results: Between January, 2008 and December, 2013, 47 of 127 (37%) LVAD recipients (age 57±12yrs, 72% men) had RI at the time of surgery. Of these 47 patients, 8.5% of LVAD implantations were elective, 91% were urgent, 1.5% were emergent and 21% were redo operations. The mean preoperative creatinine level was 1.84± 0.6 mg/dL with a MELD score of 16.5± 6. Most patients (74.5%) were on inotrope support at the time of implantation. Among the study group, the overall 30-day mortality was 15%. The mean pre-operative GFR was 48± 7. We observed renal function recovery at each follow-up, with 30, 90 and 180-day mean GFRs of 79±33, 71± 31 and 63± 21, respectively (Fig). Mean improvement in GFR for 30, 90 and 180 days was 34± 31, 26± 29 and 19± 20, respectively (All with p < 0.001). Four of the 47 patients (8.5%) with RI required HD pre-operatively. Of these, 3 recovered renal function; 2 by 30 days and 1 by 90 days. An additional four patients (8.5%) that were previously non-HD-dependent required HD post-operatively. Two of these 4 patients recovered renal function during the study period. Conclusion: Renal insufficiency improves significantly with LVAD support. While improvements in GFR are marked in the first 30 days, they remain above pre-operative levels during 6-month follow-up. Additionally, among those patients requiring either preor post-operative HD, a majority (62.5%) recovered renal function.