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Health campaigns often emphasise the association between excess weight and poor health. Past research suggests that whether an individual's excess weight is viewed as harmful is partially explained by the quantity of excess weight. The present research explored whether the purported cause of excess weight also influences its perceived harmfulness. Across two studies (total N = 577), participants read information about target individuals whose excess weight was caused by different factors (unhealthy lifestyle vs. medical condition). Participants rated the extent to which the target's weight was harmful and also recommended health-related behaviours to the target. For the target with overweight, when her weight was described as being caused by unhealthy behaviours as opposed to a medical condition, her weight was rated as more harmful, and she was recommended to engage in more healthy behaviours. For the target with obesity, her weight was viewed as harmful irrespective of its described cause. Compared with the target with overweight, the weight of the target with obesity was rated as more harmful and she was recommended to diet more. Perceptions of the harmfulness of 'overweight' are influenced by the purported cause of that overweight, whereas obesity itself is viewed as harmful, regardless of the cause., (© 2023 The Authors. Applied Psychology: Health and Well‐Being published by John Wiley & Sons Ltd on behalf of International Association of Applied Psychology.)

Background: The AOAC Stakeholder Panel on Infant Formula and Adult Nutritionals issued a call for methods for the determination of fluoride in infant formula. Standard Method Performance Requirement (SMPR®) 2014.016 was approved., Objective: A single-laboratory validation (SLV) of a fluoride ion-selective electrode (F-ISE) method was completed., Methods: Five powder samples were reconstituted, and hydrochloric acid was added to dissolve and release any bound fluoride. Samples included infant and adult nutritional products made from milk, whey, or soy, containing intact, partially hydrolyzed, or hydrolyzed proteins. Sodium citrate buffer was added to complex any interfering ions and adjust pH and ionic strength. Samples were analyzed in duplicate over 6 days using F-ISE., Results: Results were calculated based on one of two least-squares (log fit) standard curves (0.02 to 0.1 µg/100 g or 0.1 to 2.0 µg/100 g). The LOQ for the method was determined to be 3.3 µg/100 g, which was far below the minimum analytical value of 30 µg/100 g required in the SMPR. The fluoride concentrations ranged from approximately 3 to 14 µg/100 g reconstituted powder and the intermediate precision, RSDr, ranged from 0.7 to 12.4%. Although all of these results are out of scope for the SMPR due to their low fluoride, it should be noted that the RSDr for formulas with fluoride concentrations ranging from approximately 9 to 14 µg/100 g ranged from 0.7 to 4.3%, and the RSDr for the two formulas with fluoride concentrations at or below the theoretical detection limit of the method were only approximately10 and 12.4%. Recoveries ranged from 94 to 98% for samples spiked at three levels with NIST-traceable standard solutions, meeting the SMPR., Conclusion: The F-ISE method meets the SMPR and was adopted as a First Action Official MethodSM., Highlights: The fluoride ion-selective electrode method presented here is affordable and easy to run. The addition of acid to the samples dissolves any minerals which may bind the fluoride., (© The Author(s) 2023. Published by Oxford University Press on behalf of AOAC INTERNATIONAL. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Transcatheter aortic valve replacement (TAVR) use is gaining momentum as the mainstay for the treatment of aortic stenosis compared to surgical aortic valve replacement (SAVR). Unfortunately, TAVR-related infective endocarditis (TAVR-IE) is expected to be detected more and more as a result of the ever-expanding indications in younger patients. Given the overall poor prognosis of TAVR-IE, it is imperative that clinicians familiarize themselves with common presentations, major risk factors, diagnostic pitfalls, therapeutic approaches, and the prevention of TAVR-IE. Herein, we review all of the above in detail with the most updated available literature.

Introduction: This study examined the role of echocardiographic and cardiac histomorphology parameters in predicting mortality in patients with cardiac AL amyloidosis., Methods: Patients with endomyocardial biopsy-proven cardiac AL amyloidosis treated at MD Anderson Cancer Center between 6/2011 and 6/2020 were identified. Stored echocardiographic images and endomyocardial biopsy samples were processed for myocardial strain analysis and a detailed histomorphology characterization., Results: Of 43 patients; 44% were women and 63% white. Median age was 65 years; 51% underwent stem cell transplantation (SCT). Thirty patients (70%) died during follow up (median follow up: 4.1 years). Lower LA strain (<13.5%) and absence of SCT as a time-varying covariate were significantly associated with increased risk of death in the multivariate cox regression analysis. Higher LV mass and lower RV tricuspid annular plane systolic excursion were associated with increased odds of having ≥5% interstitial amyloid deposition on biopsy in the multivariate logistic regression analysis., Conclusion: Lower LA strain independently predicted mortality in our cohort, and its performance in the routine assessment of AL amyloidosis may be beneficial. Furthermore, SCT for cardiac AL amyloidosis was associated with improved OS. These findings need to be confirmed by larger studies in the era of contemporary systemic therapies., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Koutroumpakis, Niku, Black, Ali, Sadaf, Song, Palaskas, Iliescu, Durand, Yusuf, Lee, Buja, Deswal and Banchs.)

Background: The posterior flap is a conventional technique for closing a below-knee amputation (BKA) that uses the gastrocnemius and soleus muscle and relies on the popliteal and posterior compartment arteries. If the prior mentioned arterial blood supply is compromised, this flap likely relies on collateral flow. The purpose of this study is to identify and differentiate any significant associations between preoperative popliteal and tibial arterial flow and BKA outcomes and patient-reported function., Methods: A retrospective review identified patients from a single tertiary wound care center who received BKAs and angiogram between 2010 and 2017 by a single surgeon. BKA complications, wound healing, and amputee ambulatory status at latest follow-up were all stratified for differences according to baseline tibial vessel run-off (VRO) status, popliteal artery patency, and popliteal angioplasty outcome. Chi-square, Fisher's exact, and Wilcoxon rank sum tests were used with significance defined as p ≤ 0.05 ., Results: BKAs were performed on 313 patients, of which, 167 underwent preoperative angiography. Thirty-two were excluded due to lack of adequate follow-up leaving a total of 135 patients in the studied population. Diabetes was present in 87%, and 36% had end-stage renal disease. By the study's conclusion, 92% of BKAs had fully healed, with median time-to-healing of 79 days (range 19-1314 days). 60% of patients were ambulatory at 9.5 months. Higher VRO was associated with higher healing rates and lower complications and time-to-healing. The conversion rate of BKA to above-knee amputation (AKA) was 4%. Preoperative popliteal patency was associated with higher postoperative ambulation rates when compared to patients without popliteal flow preoperatively (patent: 71/109, 65%; occluded: 10/26, 40%; p = 0.02) and independently increased the likelihood of postoperative ambulation., Conclusions: The posterior flap design for BKA works even in the setting of popliteal occlusion. Complication rates are higher in patients with more compromised blood flow, which may ultimately lead to AKA. Given poor ambulation rates in patients who undergo AKA, the results of this study should encourage surgeons to consider a more functional BKA, even in instances when the popliteal artery is occluded.

Background and Aims: Although root penetration of strong soils has been intensively studied at the scale of individual root axes, interactions between soil physical properties and soil foraging by whole plants are less clear. Here we investigate how variation in the penetration ability of distinct root classes and bulk density profiles common to real-world soils interact to affect soil foraging strategies., Methods: We utilize the functional-structural plant model 'OpenSimRoot' to simulate the growth of maize (Zea mays) root systems with variable penetration ability of axial and lateral roots in soils with (1) uniform bulk density, (2) plow pans and (3) increasing bulk density with depth. We also modify the availability and leaching of nitrate to uncover reciprocal interactions between these factors and the capture of mobile resources., Key Results: Soils with plow pans and bulk density gradients affected overall size, distribution and carbon costs of the root system. Soils with high bulk density at depth impeded rooting depth and reduced leaching of nitrate, thereby improving the coincidence of nitrogen and root length. While increasing penetration ability of either axial or lateral root classes produced root systems of comparable net length, improved penetration of axial roots increased allocation of root length in deeper soil, thereby amplifying N acquisition and shoot biomass. Although enhanced penetration ability of both root classes was associated with greater root system carbon costs, the benefit to plant fitness from improved soil exploration and resource capture offset these., Conclusions: While lateral roots comprise the bulk of root length, axial roots function as a scaffold determining the distribution of these laterals. In soils with high soil strength and leaching, root systems with enhanced penetration ability of axial roots have greater distribution of root length at depth, thereby improving capture of mobile resources., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Annals of Botany Company.)

Background: The use of biologic mesh to reinforce the abdominal wall in ventral hernia repair has been proposed as a viable alternative to synthetic mesh, particularly for high-risk patients and in contaminated settings. However, a comparison of clinical outcomes between the currently available biologic mesh types has yet to be performed., Methods: We performed a retrospective analysis of 141 patients who had undergone ventral hernia repair with biologic mesh, including noncross-linked porcine ADM (NC-PADM) (n = 51), cross-linked porcine ADM (C-PADM) (n = 17), reinforced biologic ovine rumen (RBOR) (n = 36), and bovine ADM (BADM) (n = 37) at the Stanford University Medical Center between 2002 and 2020. Postoperative donor site complications and rates of hernia recurrence were compared between patients with different biologic mesh types., Results: Abdominal complications occurred in 47.1% of patients with NC-PADM, 52.9% of patients with C-PADM, 16.7% of patients with RBOR, and 43.2% of patients with BADM ( P = 0.015). Relative risk for overall complications was higher in patients who had received NC-PADM (RR = 2.64, P = 0.0182), C-PADM (RR = 3.19, P = 0.0127), and BADM (RR = 2.11, P = 0.0773) compared with those who had received RBOR. Furthermore, relative risk for hernia recurrence was also higher in all other mesh types compared with RBOR., Conclusion: Our data indicate that RBOR decreases abdominal complications and recurrence rates after ventral hernia repair compared with NC-PADM, C-PADM, and BADM., Competing Interests: Disclosure: The authors have no financial interest to declare in relation to the content of this article. The funding of this study was solely institutional., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Functional-structural plant models are valuable modeling tools in analyzing plant development. A functional-structural plant model combines a three-dimensional representation of plant structure with models for physiological functions in order to better understand plant development. We present a guide to simulating crop root systems with OpenSimRoot, a feature-rich, highly cited, and open-source functional-structural root architecture model. We describe in detail how to create your own input files in conjunction with some examples. The aim of this guide is to highlight the potential of computational modeling in biology and to make modeling more accessible to the plant science community., (© 2022. Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Radiation therapy causes histopathologic changes in tissues, including fibrosis, loss of tissue planes, and vascular damage, which can lead to chronic wound formation. Patients with nonhealing, irradiated wounds and comorbidities that affect microvasculature suffer a "double hit", which leads to delayed wound healing. Local wound care and grafts are commonly insufficient. In this study, we evaluated limb salvage outcomes and long-term complications after free tissue transfer (FTT) in patients with chronic, irradiated leg wounds., Methods: We retrospectively reviewed patients with irradiated lower extremity wounds who underwent FTT from 2012 to 2017. Primary outcomes included limb salvage, ambulation, and overall flap success. Reconstruction involved complete excision of irradiated tissue and coverage with well-vascularized tissue., Results: Seven free flaps in six patients were identified. Average age was 68.4 years and average BMI was 27.8 kg/m 2 . Comorbid conditions included hypertension (57.1%), peripheral vascular disease (57.1%), underlying hypercoagulability (42.9%), diabetes (14.3%), and tobacco use (14.3%). Wounds were present for an average of 25.5 months prior to FTT. Donor sites included anterolateral thigh (71.4%), vastus lateralis (14.3%), and latissimus dorsi (14.3%). Overall flap success rate was 100% with one patient requiring reoperation for dehiscence. Limb salvage rate was 85.7% with one patient undergoing elective amputation due to pain. All patients could ambulate (one used a prosthesis) at a mean follow-up time of 1.4 years., Conclusions: Radiation therapy in a comorbid population often leads to the formation of chronic nonhealing wounds. We advocate for earlier consideration of FTT to provide healthy vascularized tissues, thereby avoiding prolonged wound care and patient burden. Successful limb salvage outcomes can be achieved., Competing Interests: Declaration of Competing Interest None declared, (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Reconstructive microsurgery is an effective limb-saving option for nonhealing lower extremity wounds in diabetic patients. However, the ability to predict the future need for amputation is unclear. This article seeks to identify risk factors for amputation following microsurgical free tissue transfer in the diabetic lower extremity., Methods: Diabetic patients undergoing lower extremity free flap surgery between August of 2011 and January of 2018 performed by a single surgeon were identified retrospectively. Patient comorbidities, reconstructive conditions and flap traits, microsurgical outcomes, and long-term outcomes were examined. Variables conferring risk for future amputation were examined by means of regression analysis., Results: Sixty-four patients met the criteria. The overall immediate flap success rate was 94 percent (60 of 64). Long term, 50 patients (78.1 percent) underwent successful salvage, and 14 patients (21.9 percent) required major amputation. Acute flap loss resulted in four amputations, and delayed complications (hematoma, infection, recurrent nonhealing) resulted in 10 amputations. The average time to amputation was 5.6 months. Risk factors for amputation were end-stage renal disease (OR, 30.7; p = 0.0087), hindfoot wounds (OR, 4.6; p = 0.020), elevated hemoglobin A1C level greater than 8.4 percent (OR, 1.4; p = 0.05), and positive wound cultures (OR, 6.1; p = 0.003)., Conclusions: Multiple comorbidities and poor glucose control were identified as risk factors for amputation after free flap limb salvage. However, successful limb preservation is possible., Clinical Question/level of Evidence: Risk, III., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Nipple-sparing mastectomy (NSM) offers superior esthetic outcomes without sacrificing oncologic safety for select patients requiring mastectomy. While disparities in oncologic care are well established, no study to date has investigated equitable delivery of the various mastectomy types. The objective of this study is to examine multilevel factors related to the distribution of NSM. Patients undergoing mastectomy between 2014 and 2018 across eight hospitals in a single healthcare system were retrospectively reviewed. Patients were categorized by mastectomy type-NSM or other mastectomy (OM). Patient information such as age, race, comorbidities, and median income by ZIP code was collected. Disease characteristics, such as mastectomy weight, breast cancer stage, and treatment history, were identified. Provider and system-level variables, such as specific provider, hospital of operation, and insurance status, were determined. Bivariate analysis was used to identify variables for inclusion in a backward multivariable model. A cohort of 1202 mastectomy patients was identified, with 388 receiving NSM. The average age was 55.8 years (NSM: 48.8, OM: 59.1, P < .001). 39.8% of white patients (n = 242) and 20.0% of African American patients (n = 88) received NSM (P < .001). Average mastectomy weight was 384.3 (SD 195.7) in the NSM group, compared to 839.4 (SD 521.1) in the OM group (P < .001). 41.4% (n = 359) of patients treated at academic centers, and 6.9% (n = 21) of patients treated at community centers received NSM (P < .001). In the multivariate model, the factor with the largest impact on NSM was specific provider. Odds of NSM decreased by 76%-88% for certain surgeons, while odds increased by 63 times for one surgeon. This study utilizes a large multi-institutional database to highlight disparities in NSM delivery. Expectedly, younger, relatively healthy patients, with smaller breast size were more likely to undergo NSM, in accordance with surgical guidelines. However, when all other factors were controlled, provider preferences played the most significant role in NSM delivery rates. These findings demonstrate the need for practice reexamination to ensure equitable access to NSM., (© 2020 Wiley Periodicals LLC.)

Background:  There are many factors to consider when choosing between amputations versus salvage in lower extremity reconstructive surgery. Postoperative functionality and survival benefit are critical factors when deciding between limb salvage and amputation., Methods:  In this review, we present the evidence and the risks and benefits between these two options in the setting of the acute, trauma population and the chronic, diabetes population., Results:  The trauma population is on average young without significant comorbidities and with robust vasculature and core strength for recovery. Therefore, these patients can often recover significant function with anamputation and prosthesis. Amputation can therefore be the more desirable in this patient population, especially in the case of complete traumatic disruption, unstable patients, high risk of extensive infection, and significant nerve injury. However, traumatic lower extremity reconstruction is also a viable option, especially in the case of young patients and those with intact plantar sensation and sufficient available tissue coverage. The diabetic population with lower extremity insult has on average a higher comorbidity profile and often lower core strength. These patients therefore often benefit most from reconstruction to preserve limb length and improve survival. However, amputation may be favored for diabetics that have no blood flow to the lower extremity, recalcitrant infection, high-risk comorbidities that preclude multiple operations, and those with end stage renal disease., Conclusion:  Many patient-specific factors should be considered when deciding between amputation vs. salvage in the lower extremity reconstruction population., Competing Interests: None declared., (Thieme. All rights reserved.)

The American Society of Breast Surgeons (ASBrS) outlined definitive guidelines for contralateral prophylactic mastectomy (CPM) in 2016. Despite this, rates of CPM have remained steady. The objective of this study was to identify factors contributing to persistent over-delivery of CPM. Breast cancer patients across 8 hospitals in a single healthcare system from 2014 to 2018 were retrospectively reviewed. The patients were divided according to whether they received nonindicated CPMs versus other mastectomy types. Nonindicated CPM were those procedures not meeting ASBrS consensus guidelines for recommended patients. CPM rate was calculated for each year in the study period. Patient, disease, provider, and system level factors were obtained. Bivariate analysis was used to identify variables for inclusion in a backward multivariable model. A total of 1,051 patients were analyzed. Nonindicated CPM rates by year remained steady throughout the time period (P = .391). In multivariable regression, patient, disease, and provider level factors were associated with odds of undergoing CPM. Every unit increase in age was associated with a 4% reduction in odds of undergoing CPM (CI 0.941-0.986). Stage 3 breast cancer compared to stage 1 had 53% lower odds of CPM (CI 0.288-0.757). Implant-based breast reconstruction had 2.9-fold higher odds of CPM compared to no reconstruction (CI 1.476-5.551). No system level factors were statistically significant. CPM rates have not notably decreased since the ASBrS consensus statement with certain patient and provider factors impacting persistent overuse of CPM. These results inform oncologic and reconstructive providers of factors contributing to continued use of a nonindicated procedure., (© 2020 Wiley Periodicals LLC.)

A soil coring protocol was developed to cooptimize the estimation of root length distribution (RLD) by depth and detection of functionally important variation in root system architecture (RSA) of maize and bean. The functional-structural model OpenSimRoot was used to perform in silico soil coring at six locations on three different maize and bean RSA phenotypes. Results were compared to two seasons of field soil coring and one trench. Two one-sided T -test (TOST) analysis of in silico data suggests a between-row location 5 cm from plant base (location 3), best estimates whole-plot RLD/D of deep, intermediate, and shallow RSA phenotypes, for both maize and bean. Quadratic discriminant analysis indicates location 3 has ~70% categorization accuracy for bean, while an in-row location next to the plant base (location 6) has ~85% categorization accuracy in maize. Analysis of field data suggests the more representative sampling locations vary by year and species. In silico and field studies suggest location 3 is most robust, although variation is significant among seasons, among replications within a field season, and among field soil coring, trench, and simulations. We propose that the characterization of the RLD profile as a dynamic rhizo canopy effectively describes how the RLD profile arises from interactions among an individual plant, its neighbors, and the pedosphere., Competing Interests: The authors declare that there is no conflict of interest regarding the publication of this article., (Copyright © 2020 James D. Burridge et al.)

Equinus contracture carries 3- and 4-fold associations with diabetes and plantar foot ulceration, respectively. Percutaneous tendo-Achilles lengthening is a useful method to alleviate peak plantar pressure resulting from equinus. We aimed to evaluate the effectiveness of percutaneous tendo-Achilles lengthening and estimate the relative longevity of the approach in reducing ulcer recurrence. The medical records of patients with equinus contracture who underwent percutaneous tendo-Achilles lengthening from 2010 to 2017 were reviewed. Included patients presented with plantar ulcers and a gastroc-soleus equinus of any angle <10° of ankle dorsiflexion with the affected knee extended and flexed. Patients who received concomitant tendon lengthening procedures (including anterior tibial tendon or flexor digitorum longus) were excluded. Outcome measures included time to wound healing, time to ulcer recurrence, and development of transfer lesion. Ninety-one patients underwent percutaneous tendo-Achilles lengthening with subsequent pedal ulceration without concomitant procedures. A total of 69 (75.8%) patients had a plantar forefoot ulcer, 7 (7.7%) had midfoot ulcers, 5 (5.5%) had hindfoot ulcers, and 3 (3.3%) had ulcers in multiple locations. Seven patients received prophylactic tendo-Achilles lengthening. At a mean follow-up of 31.6 months (±26), 66 (78.6%) wounds healed at a median 12.9 weeks. A total of 29 patients (43.9%) experienced ulcer recurrence at a mean of 12 months. Twelve patients (13%) experienced a transfer lesion at a mean of 16.6 months. Tendo-Achilles lengthening can be an effective adjunctive approach to achieve wound healing and reduce long-term ulcer recurrence in patients with equinus contracture and neuropathic plantar foot ulcers. A relengthening procedure may be needed within approximately 12 months from index surgery., (Copyright © 2020 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Increased time to mastectomy (TTM) has significant implications for mortality, well-being, and satisfaction. However, certain populations are subject to disparities that increase TTM. This study examines vulnerable populations and the patient-, disease-, provider-, and system-level factors related to treatment delays. Patients undergoing mastectomy for breast cancer from 2014 to 2018 across 8 hospitals in a single health care system were retrospectively reviewed. Demographics, disease characteristics, and provider- and system-level information were collected. Time from biopsy-proven diagnosis to mastectomy was calculated. Univariate analysis identified variables for inclusion in the multivariable model. One thousand, three hundred thirty patients met inclusion. Median TTM was 55.0 days. Factors from all levels-patient, disease, provider, and systemic-were significantly related to disparities. African-American patients had 11.6% longer TTM compared to white patients (69.0 vs 56.0 days, P < .0001). TTM was 15.5% longer for low-income patients when compared to high-income patients (65.0 vs 49.0 days, P = .0014). Preoperative plastic surgery visits led to 19.3% longer TTM (P = .0012); oncologic appointments for neo-adjuvant chemotherapy led to a 231.0% increase (P < .0001). Average time from last neo-adjuvant treatment to mastectomy was 44.4 days (SD 26.5); average TTM from diagnosis for patients not receiving neo-adjuvant chemotherapy was 58.5 days (SD 13.3). Patients with Medicaid waited 14.5% longer compared to patients with commercial insurance (94.0 vs 62.0 days, P = .0005). In our review of care across a large health care system, we identified multiple levels contributing to disparities in TTM. Identification of these disparities offers valuable insight into process improvement and intervention., (© 2020 Wiley Periodicals LLC.)

Background: Abdominally based free tissue transfer (FTT) and latissimus dorsi and immediate fat transfer (LIFT) procedures are both fully autologous options for breast reconstruction. The former is specialized and requires comfort with microsurgical technique, whereas LIFT combines a common set of techniques familiar to all plastic surgeons. Comparing the two methods for clinical effectiveness and complications for equivalency in outcomes may help elucidate and enhance patient decision-making., Methods: A retrospective review of a prospectively maintained database between March of 2017 and July of 2018 was performed to compare the LIFTs and FTTs performed by the senior surgeon. Outcomes of interest included postoperative complications, flap success, and follow-up revision and fat-grafting procedures., Results: Sixty-five breasts were reconstructed by FTT; and 31 breasts were reconstructed with LIFT. Demographics were similar (p > 0.05). LIFT had a shorter length of operation time (343 ± 128 minutes versus 49 ± 137 minutes) (p < 0.0001) and a shorter length of stay (1.65 ± 0.85 days versus 3.83 ± 1.65 days) (p < 0.001). FTTs had a shorter time until drain removal (13.3 ± 4.3 days versus 24.0 ± 11.2 days) (p < 0.0001). The number of major (requiring operation) and minor complications were not statistically different (i.e., FTTs, 20.0 percent major and 27.7 percent minor; LIFT, 12.9 percent major and 19.35 percent minor) (p > 0.05). The need for revisions (FTTs, 0.80 ± 0.71; LIFT, 0.87 ± 0.71) and fat grafting (FTTs, 41.54 percent; LIFT, 58.8 percent) was not statistically different (p > 0.05)., Conclusions: Both the LIFT and abdominally based FTT have similar outcomes and complication rates. However, LIFT may be preferred in patients who require shorter operation times. The LIFT may be the fully autologous breast reconstruction of choice for nonmicrosurgeons., Clinical Question/level of Evidence: Therapeutic, III.

Introduction: The thigh has been called the reconstructive warehouse. The anterolateral thigh (ALT) and vastus lateralis (VL) flaps are popular options for free tissue transfer in lower extremity reconstruction. We sought to review the largest experience of these flaps in the chronic wound population., Methods: We retrospectively reviewed patients who underwent lower extremity reconstruction using ALT or VL flaps by a single surgeon between 2012 and 2018., Results: Fifty ALT and 34 VL flaps were identified. Comorbidities were similar between groups with the exception of body mass index (ALT, 26.8; VL, 30.1; P = 0.0121). There was also a significant difference rate of independent ambulation preoperatively (ALT, 98.0%; VL, 85.3%; P = 0.0375). An adjunct was needed for recipient site coverage in 31.5% (19/50) of ALT patients and 100% (34/34) of VL patients. Of the patients who received skin grafts, delayed placement was more frequent in the ALT (53.3%) versus VL cohort (18.2%) (P = 0.0192). Median graft take and the rate of skin graft revision were not statistically different. Flap success rates were similar: ALT, 92.0%; and VL, 94.1%. Overall complication rates were not significantly different: ALT, 26.0%; and VL, 38.2%. Infectious complications were also comparable. Subsequent debulking procedures were performed on 8.0% of ALT flaps and 11.8% VL flaps (P = 0.7092). Limb salvage rates were similar between both cohorts (ALT, 82.0%; VL, 88.2%). Ambulation rate was significantly higher for the ALT cohort at 92.0% compared with 73.5% for the VL cohort (P = 0.0216). Median follow-up was similar for both groups., Conclusions: We present the largest comparison study of ALT and VL flaps in lower extremity salvage. Complication rates, flap success, and limb salvage were similar between the 2 cohorts. Despite a high prevalence of osteomyelitis in both cohorts, there was no difference in infectious complications. Although the need for skin grafting remains an inherent disadvantage of the VL flap, a significant proportion of ALT recipients also needed an adjunct for recipient site coverage. Ambulation rate was significantly greater in the ALT group. However, flap type was no longer significant for ambulation when controlling for preoperative ambulatory status.

Purpose: The aim of this study is to critically examine the multidisciplinary approach to abdominal wall reconstruction (AWR) in the solid organ transplant (SOT) population at our institution, MedStar Georgetown University Hospital, using a modified component separation technique (CST)., Methods: A retrospective review of AWR utilizing modified open CST with biologic mesh in SOT patients was performed from January 2010 to June 2018. Patient demographics, comorbidities, operative details, complications, and outcomes were recorded. Descriptive statistics, logistic and linear regression analyses were performed to appraise outcomes., Results: Thirty-five patients were included; mean age was 53 years. Patient demographics and comorbidities were: 82.9% male, 45.7% history of tobacco use, and 28.6% diabetes. Fifty-one percent had undergone prior hernia repair. Transplant types were: kidney (9), liver (16), liver/kidney (1), small bowel (7), multivisceral (2). All were on an immunosuppressive regimen at time of surgery; 22.9% included steroids. Average defect size was 361 cm 2 . Additional soft tissue procedures were performed in 65.7% (n = 23) of patients. Median time to healing was 29.0 days. Complication rate was 31.4% (n = 11); six patients required reoperation within 90 days. Recurrence rate was 5.7% (n = 2) at mean of follow up of 3.0 years. Additional soft tissue procedures were statistically significant for healing time (p = 0.037). Steroid use was statistically significant for reoperation within 90 days (OR = 12.500; 95% CI 1.694-92.250); however, steroid use was not significant after correction for confounders., Conclusion: Modified open CST with biologic mesh is a safe, efficacious approach to complex AWR in the SOT population with recurrence rates comparable to the general population.

Background: Technical advances have been made in reconstructive diabetic limb salvage modalities. It is unknown whether these techniques are widely used. This study seeks to determine the role of patient- and hospital-level characteristics that affect use., Methods: Admissions for diabetic lower extremity complications were identified in the 2012 to 2014 National Inpatient Sample using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. The study cohort consisted of admitted patients receiving amputations, limb salvage without flap techniques, or advanced limb salvage with flap techniques. Multinomial regression analysis accounting for the complex survey design of the National Inpatient Sample was used to determine the independent contributions of factors expressed as marginal effects., Results: The authors' study cohort represented 155,025 admissions nationally. White non-Hispanic patients had the highest proportion of reconstruction without and with flaps, whereas black patients had the lowest. Multinomial regression models revealed that controlling for nongas gangrene and critical limb ischemia, both of which have a much greater incidence in minorities, the effect of race against receipt of reconstructive modalities was attenuated. Access to urban teaching hospitals was the strongest protective factor against amputation (9 percent reduction; p < 0.01) and predictor of receiving limb salvage without flaps (5 percent increase; p < 0.01) and with flaps (3 percent increase; p < 0.01)., Conclusions: This study identified multiple patient- and hospital-level factors associated with decreased access to the gamut of reconstructive limb salvage techniques. Disparity reduction will likely require a multifaceted strategy that addresses the severity of disease presentation seen in minorities and delivery system capabilities affecting access and use of reconstructive limb salvage procedures., Clinical Question/level of Evidence: Risk, III.

Background: Simultaneous ventral hernia repair and panniculectomy (SVHRP) is a procedure that is more commonly being offered to patients with excess skin and subcutaneous tissue in need of a ventral hernia repair; however, there are concerns about surgical-site complications and uncertainty regarding the durability of repair. SVHRP outcomes vary within the literature. This study assessed the durability, complication profile, and safety of SVHRP through a large data-driven repository of SVHRP cases.360 METHODS:: The current SVHRP literature was queried using the MEDLINE, PubMed, and Cochrane databases. Predefined selection criteria resulted in 76 relevant titles yielding 16 articles for analysis. Meta-analysis was used to analyze primary outcomes, identified as surgical-site occurrence and hernia recurrence. Secondary outcomes included review of techniques used and systemic complications, which were analyzed with pooled weighted mean analysis from the collected data., Results: There were 917 patients who underwent an SVHRP (mean age, 52.2 ± 7.0 years; mean body mass index, 36.1 ± 5.8 kg/m; mean pannus weight, 3.2 kg). The mean surgical-site occurrence rate was 27.9 percent (95 percent CI, 15.6 to 40.2 percent; I = 70.9 percent) and the mean hernia recurrence rate was 4.9 percent (95 percent CI, 2.4 to 7.3 percent; I = 70.1 percent). Mean follow-up was 17.8 ± 7.7 months. The most common complications were superficial surgical-site infection (15.8 percent) and seroma formation (11.2 percent). Systemic complications were less common (7.8 percent), with a thromboembolic event rate of 1.2 percent. The overall mortality rate was 0.4 percent., Conclusions: SVHRP is associated with a high rate of surgical-site occurrence, but surgical-site infection seems to be less prominent than previously anticipated. The low hernia recurrence rate and the safety of this procedure support its current implementation in abdominal wall reconstruction.

Three-dimensional models of root growth, architecture and function are becoming important tools that aid the design of agricultural management schemes and the selection of beneficial root traits. However, while benchmarking is common in many disciplines that use numerical models, such as natural and engineering sciences, functional-structural root architecture models have never been systematically compared. The following reasons might induce disagreement between the simulation results of different models: different representation of root growth, sink term of root water and solute uptake and representation of the rhizosphere. Presently, the extent of discrepancies is unknown, and a framework for quantitatively comparing functional-structural root architecture models is required. We propose, in a first step, to define benchmarking scenarios that test individual components of complex models: root architecture, water flow in soil and water flow in roots. While the latter two will focus mainly on comparing numerical aspects, the root architectural models have to be compared at a conceptual level as they generally differ in process representation. Therefore, defining common inputs that allow recreating reference root systems in all models will be a key challenge. In a second step, benchmarking scenarios for the coupled problems are defined. We expect that the results of step 1 will enable us to better interpret differences found in step 2. This benchmarking will result in a better understanding of the different models and contribute toward improving them. Improved models will allow us to simulate various scenarios with greater confidence and avoid bugs, numerical errors or conceptual misunderstandings. This work will set a standard for future model development., (Copyright © 2020 Schnepf, Black, Couvreur, Delory, Doussan, Koch, Koch, Javaux, Landl, Leitner, Lobet, Mai, Meunier, Petrich, Postma, Priesack, Schmidt, Vanderborght, Vereecken and Weber.)

Surgeons often seek to perfect their technical dexterity, and hand dominance of the surgeon is an important factor given the constraints of operative field laterality. However, experience often dictates how surgeons are able to compensate. While surgeons have experienced preference for the ipsilateral breast, the impact of surgeon handedness, experience, and volume has not been directly examined in a single study. A retrospective chart review of five breast surgeons (2 LHD) at a single institution identified 365 mastectomy patients, totaling 594 breasts, between January 2015 and June 2018. The breasts were identified as ipsilateral or contralateral based on the surgeons' handedness. Surgeons were grouped based on length of surgical experience, three with ≥15 years and two with <15 years. Surgeons with greater experience were the highest volume surgeons in this series. Data included patient demographics, breast and oncologic history, surgical techniques, and surgical outcomes including complications. A total of 270 nonprophylactic and 324 prophylactic mastectomies were identified, of which 529 were performed by surgeons with greater than 15 years of experience and 65 by surgeons with less than 15 years. The overall complication rate was 33.5% (n = 199), of which 18.0% (n = 107) were on the ipsilateral breast and 15.5% (n = 92) were on the contralateral breast. 9.1% of complications required re-operation (n = 54). The odds of any complication on the ipsilateral breast were 2.9 times higher than complications on the contralateral breast when looking exclusively at surgeons with <15 years of experience (P = .0353, OR = 2.92, 1.06-8.03). Surgeons with <15 years of experience have a 2.71 (P = .05, OR 2.71, 1.361-5.373) increase in any ischemic complication and a 16 times (P < .0001, OR = 16.01, 5.038-50.933) increase in major operative ischemic complications. Our study finds that surgeons with less than 15 years of surgical experience have a 2.9 times higher rate of overall complication when operating on the ipsilateral breast. However, years of experience and surgeon volume have a much greater impact on any and ischemic complications after mastectomy., (© 2019 Wiley Periodicals, Inc.)

Background: The authors refine their anatomical patient selection criteria with a novel midclavicular-to-inframammary fold measurement for nipple-sparing mastectomy performed through an inframammary approach., Methods: Retrospective review was performed of all nipple-sparing mastectomies performed through an inframammary approach. Exclusion criteria included other mastectomy incisions, staged mastectomy, previous breast operation, and autologous reconstruction. Preoperative anatomical measurements for each breast, clinical course, and specimen weight were obtained., Results: One hundred forty breasts in 79 patients were analyzed. Mastectomy weight, but not sternal notch-to-nipple distance, was strongly correlated with midclavicular-to-inframammary fold measurement on linear regression (R = 0.651; p < 0.001). Mastectomy weight was not correlated with ptosis. Twenty-five breasts (17.8 percent) had ischemic complications: 16 (11.4 percent) were nonoperative and nine (6.4 percent) were operative. Those with mastectomy weights of 500 g or greater were nine times more likely to have operative ischemic complications than those with mastectomy weights less than 500 g (p = 0.0048). Those with a midclavicular-to-inframammary fold measurement of 30 cm or greater had a 3.8 times increased incidence of any ischemic complication (p = 0.00547) and a 9.2 times increased incidence of operative ischemic complications (p = 0.00376) compared with those whose midclavicular-to-inframammary fold measurement was less than 30 cm., Conclusions: Breasts undergoing nipple-sparing mastectomy by means of an inframammary approach with midclavicular-to-inframammary fold measurement greater than or equal to 30 cm are at higher risk for having ischemic complications, warranting consideration for a staged approach or other incision. The midclavicular-to-inframammary fold measurement is useful for assessing the entire breast and predicting the likelihood of ischemic complications in inframammary nipple-sparing mastectomies., Clinical Question/level of Evidence: Risk, III.

Satisfaction rates are reported as high after subcutaneous mastectomy for chest masculinization. We examined patient satisfaction based on linguistic analysis of social media posts showing postoperative results and compared them to aesthetic quality ratings from plastic surgeons., Methods: Fifty publicly available images of subcutaneous mastectomy postoperative results of female-to-male gender transition patients were selected from Instagram. The photograph's corresponding post and comments were then analyzed for sentiment through the IBM Watson tone analyzer, which rated the presence of joy on a continuous scale from 0 to 1. Three plastic surgeons rated aesthetic quality on an ordinal scale of 1 to 10. Results of both analyses were then compared., Results: Joy was rated as a mean value of 0.74 (±0.13) in posts and 0.81 (±0.13) in comments. The mean ratings of results were found to be chest contour 6.1 of 10 (±1.7), scar position 5.3 of 10 (±1.8), scar quality 4.8 of 10 (±1.9), nipple position 5.2 of 10 (±1.9), and nipple quality 5.1 of 10 (±2.0). A positive relationship was found between post joy and nipple quality ( r = 0.33, P = 0.0169). There were no other associations detected between level of joy and the ratings of results by plastic surgeons ( P > 0.05)., Conclusions: Despite wide variety in surgical appearance, there is a high level of satisfaction and community support. This is in contrast to the low-quality ratings by plastic surgeons. The results demonstrate the strong psychological and functional underpinnings chest masculinization has for patients. However, surgical results can be improved through a variety of techniques such that patients have both excellent surgical results and high satisfaction., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: Although venous thrombosis is a leading cause of flap failure, the majority of lower extremity free flap planning is centered on arterial system evaluation. Preoperative identification of relevant abnormality in lower extremity venous systems by means of duplex ultrasound may aid in the diagnosis of clinically important abnormality that could affect lower extremity flap outcomes., Methods: Between November of 2014 and August of 2017, 57 patients underwent preoperative lower extremity venous duplex imaging and free tissue transfer for lower extremity wounds. A retrospective review was performed to describe lower extremity venous pathologic findings, relevant patient demographic data, comorbid conditions, and outcomes. Discovery of venous abnormality helped guide recipient vein selection., Results: Fifty-seven consecutive patients underwent 59 free flap operations to treat chronic lower extremity wounds. Venous duplex ultrasonography detected venous insufficiency (defined as >0.5 second of reflux) in 23 patients (39.0 percent), including 16 (27.2 percent) with deep thigh reflux, six (10.2 percent) with superficial calf reflux, and four (6.78 percent) with deep calf reflux. Deep venous thrombosis was found in four patients (6.78 percent) and treated with anticoagulation. The flap success rate was 98.3 percent. Five patients (8.47 percent) progressed to amputation. At a mean follow-up time of 15.1 ± 9.51 months (range, 1.67 to 35.2 months), 53 patients (89.8 percent) were able to continue community ambulation., Conclusions: Lower extremity venous duplex testing before free tissue transfer may be useful for optimizing flap recipient vessel selection and for detecting potentially unknown venous abnormality. Development of free flap planning protocols incorporating preoperative vascular imaging is important to achieving good functional outcomes in this comorbid patient population., Clinical Question/level of Evidence: Diagnostic, IV.

Background: Poor health literacy is an epidemic in the United States, associated with higher mortality rates and poor postoperative care. Autologous breast reconstruction is highly complex, and the identification of complications is difficult even for non-plastic surgeon practitioners. The authors sought to explore the problem of health literacy in this context and identify the ideal postoperative patient education materials., Methods: Available online postoperative patient education materials for autologous breast reconstruction and corresponding readability scores were assessed. To derive the ideal formula for materials, the authors crowd-sourced quizzes with A/B testing, a method to examine the outcome of two versions of a single variable. The authors implemented their findings and compared performance on postoperative quizzes with and without oral reinforcement., Results: Of the 12 postoperative flap complication patient education materials found through an Internet search, the average grade level readability level was 9.9. Only one of 12 (8.3 percent) mentioned symptoms and signs of flap compromise. The A/B tests result revealed that text approximately 400 to 800 words written on a sixth-grade level led to the highest quiz scores. Patients scored significantly higher on the postoperative day-2 quiz when patient education materials, modeled after these findings, were reinforced with oral presentation (p = 0.0059). Retention of high quiz scores remained at postoperative day 10., Conclusions: Currently available patient education materials are at a high reading level and lack specific information on the identification of flap compromise. The authors propose the most effective postoperative instructions to be approximately 400 to 800 words written on a grade-six level with images and oral reinforcement.

The application of venous thromboembolism (VTE) prophylaxis has been the topic of intense debate in plastic surgery. The overall incidence of VTE is low in plastic surgery patients as compared to other surgical subspecialties but may be higher in the inpatient rather than outpatient plastic surgery populations. The Caprini Risk Assessment Model is the most highly studied and validated tool to assess VTE risk in plastic surgery patients. However, the Caprini model lacks procedure-specific risk assessment and patient-specific risk factor calculations. Due to these limitations, such as the low incidence and the heterogeneous nature of the specialty, trials lacked the power to capture proof of benefit, except in the highest-risk inpatient population. The emerging use of aspirin and novel oral anticoagulants may provide an alternative, as noninferiority in terms of efficacy and safety has been demonstrated in other fields. In this review, the authors intend to summarize the current state of evidence for prevention and explore the modalities available for prophylaxis, including novel oral anticoagulants.

Background/purpose: The primary objective of this study is to describe the authors' experience at the Children's National Health System with the coordination of the Fetal Medicine Institute and the Cleft and Craniofacial Center. This collaboration highlights the accuracy and completeness of prenatal diagnosis of cleft abnormalities with expedient postnatal management., Methods: With Institutional Review Board approval, the authors retrospectively reviewed 74 patients referred for potential orofacial cleft and 44 met the inclusion criteria. Follow-up fetal ultrasonography is typically performed and three-dimensional imaging was performed when feasible. If questionable anomalies or facial findings are present on these studies, the authors proceed with fetal magnetic resonance imaging. A thorough consultation is held with the cleft team, resulting in a comprehensive plan of care. Postnatal examination confirmed the correct prenatal diagnosis in nearly all patients., Results: Sensitivity and specificity for isolated unilateral cleft lip were 89% and 100%, respectively; for unilateral cleft lip and palate, sensitivity and specificity were 82% and 90%, respectively; for bilateral cleft lip and palate, sensitivity and specificity were 97% and 90%, respectively. Initial postnatal evaluation by the cleft surgeon occurred at an average age of 21 days after birth. All patients who were candidates for presurgical orthodontia were treated at an appropriate young age (mean: 66.5 days)., Conclusions: Coordinated prenatal evaluation of patients with cleft lip/palate by multidisciplinary centers plays an important role in the care of these complex patients. The results of the authors' study demonstrated high sensitivity and specificity for the prenatal diagnosis of cleft lip/palate, leading to timely postnatal evaluation and treatment.

Background: Incisional hernia is a common complication following visceral organ transplantation. Transplant patients are at increased risk of primary and recurrent hernias due to chronic immune suppression and large incisions. We conducted a retrospective review of patients with a history of liver or kidney transplantation who underwent hernia repair to analyze outcomes and hernia recurrence., Methods: This is a single center, retrospective review of 19 patients who received kidney and/or liver transplantation prior to presenting with an incisional hernia from 2011 to 2017. All hernias were repaired with open component separation technique (CST) with biologic mesh underlay., Results: The mean age of patients was 61.0±8.3 years old, with a mean body mass index of 28.4±4.8 kg/m2, 15 males (78.9%), and four females (21.1%). There were seven kidney, 11 liver, and one combined liver and kidney transplant patients. The most common comorbidities were hypertension (16 patients, 84.2%), diabetes (9 patients, 47.4%), and tobacco use (8 patients, 42.1%). Complications occurred in six patients (31.6%) including hematoma (1/19), abscess (1/19), seroma (2/19), and hernia recurrence (3/19) at mean follow-up of 28.7±22.8 months. With the exception of two patients with incomplete follow-up, all patients healed at a median time of 27 days., Conclusions: This small, retrospective series of complex open CST in transplant patients shows acceptable rates of long-term hernia recurrence and healing. By using a multidisciplinary approach for abdominal wall reconstruction, we believe that modified open CST with biologic mesh is a safe and effective technique in the transplant population with complex abdominal hernias.

The opioid crisis is public health emergency, in part due to physician prescribing practices. As a result, there is an increased interest in reducing narcotic use in the postsurgical setting., Methods: From January 1, 2018, to October 31, 2018, we employed a multidisciplinary, multimodal Enhanced Recovery After Surgery (ERAS) pathway abdominally based free tissue transfer involving the rectus. Preoperative, intraoperative, and postoperative nonnarcotic modalities were emphasized. Factors in reducing narcotic consumption, pain scores, and antiemetic use were identified., Results: Forty-two patients were included for a total of 66 free flaps, with a 98.4%(65/66) success rate. Average postoperative in-hospital milligram morphine equivalent (MME) use was 37.5, but decreased 85% from 80.9 MME per day to 12.9 MME per day during the study period. Average pain scores and antiemetic doses also decreased. Postoperative gabapentin was associated with a significant 59.8 mg decrease in postoperative MME use, 21% in self-reported pain, and a 2.5 fewer doses of antiemetics administered but increased time to ambulation by 0.89 days. Postoperative acetaminophen was associated with a significant 3.0 point decrease in self-reported pain., Conclusions: This study represents our early experience. A shift in the institutional mindset of pain control was necessary for adoption of the ERAS protocol. While the ERAS pathway functions to reduce stress and return patients to homeostasis following surgery, postoperative gabapentin resulted in the greatest reduction in postoperative opioid use, self-reported pain, and postoperative nausea vomiting compared to any other modality., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Tissue defects that result from diabetic foot infections are often complex and necessitate reconstructive soft-tissue surgery to achieve closure. Intrinsic muscle flaps of the foot require attention to major vascular pedicles and are useful for closing smaller ulcerations. Microvascular free flaps are beneficial for large defects and provide long-term survivability. Perioperative planning is an important aspect of caring for diabetic patients requiring reconstructive surgery. These techniques are valuable tools for use in efforts to preserve a functional limb in this patient population., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Implants offer a method for augmenting abdominal flaps in the setting of deficient volume in breast reconstruction. They may be placed immediately at the time of reconstruction or on a delayed basis. The authors seek to compare outcomes from a single surgeon and previously published studies., Methods: A systematic review was performed, querying multiple databases. A retrospective review was conducted for patients who underwent abdominally based flap breast reconstruction and implant placement between July of 2005 and August of 2015 performed by the senior author (M.Y.N.)., Results: A systematic review of the literature yielded four articles, for a total of 96 patients (142 breasts) included for systematic review. Eighty-seven breasts (61 percent) were reconstructed with immediate implant at the time of flap reconstruction and 55 breasts (39 percent) had a staged approach to implant placement. Complications were noted in 28 breasts (32 percent) following immediate placement and in 10 breasts (18 percent) following staged placement. A total of 53 patients (79 breasts) were retrospectively reviewed, all of whom underwent reconstruction in a staged manner. Twelve breasts (15 percent) were found to have a flap- or implant-related complication; 97.5 percent of implants/flap reconstructions were successful, with a 54 percent revision rate. When pooling systematic and retrospective data, there was a significant difference in complication rates between the staged and immediate reconstruction cohorts (p < 0.001) in favor of the staged approach., Conclusions: The literature supports a higher rate of implant-related complications following immediate implantation at the time of flap reconstruction. The authors' experience with implant placement highlights the safety and effectiveness of the staged approach., Clinical Question/level of Evidence: Therapeutic, IV.

Background: Social media discussions are alive among plastic surgeons. This article represents a primer on beginning to understand how the public would seek out plastic surgeons and how demographics shape their preferences., Methods: An anonymous 31-question survey was crowdsourced by means of MTurk., Results: There were a total of 527 respondents. Of these respondents, 33 percent follow plastic surgeons on social media, with those aged younger than 35 years 3.9 times more likely to do so. Google was the first place people would look for a plastic surgeon (46 percent). When asked what was the most influential of all online methods for selecting a surgeon, practice website ranked first (25 percent), but social media platforms ranked higher as a whole (35 percent). Those considering surgical or noninvasive procedures are thee times more likely to select social media platforms as the most influential online method in selecting a surgeon and five times more likely to follow a plastic surgeon on social media. The majority would prefer not seeing the surgeon's private life displayed on social media (39 percent). Respondents were evenly split regarding whether graphic surgical images would lead them to unfollow accounts. Ninety-six percent of the general public were unclear of the type of board certification a plastic surgeon should hold., Conclusions: Clear differences in engagement and perception exist in the public based on age, sex, parental status, and reported country of origin. Social media will soon become a critical strategy in outreach and engagement and a valuable tool in clearing misconceptions within plastic surgery.

Solid organ transplantation (SOT) has emerged from an experimental approach in the 20 th century to now being an established and practical definitive treatment option for patients with end-organ dysfunction. The evolution of SOT has seen the field progress rapidly over the past few decades with incorporation of a variety of solid organs-liver, kidney, pancreas, heart, and lung-into the donor pool. New advancements in surgical technique have allowed for more efficient and refined multi-organ procurements with minimal complications and decreased ischemic injury events. Additionally, immunosuppression therapy has also seen advancements with the expansion of immunosuppressive protocols to dampen the host immune response and improve short and long-term graft survival. However, the field of SOT faces new barriers, most importantly the expanding demand for SOT that is outpacing the current supply. Allocation protocols have been developed in an attempt to address these concerns. Other avenues for SOT are also being explored to increase the donor pool, including split-liver donor transplants, islet cell implantation for pancreas transplants, and xenotransplantation. The future of SOT is bright with exciting new research being explored to overcome current obstacles., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Warming temperatures and increasing CO 2 are likely to have large effects on the amount of carbon stored in soil, but predictions of these effects are poorly constrained. We elevated temperature (canopy: +2.8 °C; soil growing season: +1.8 °C; soil fallow: +2.3 °C) for 3 years within the 9th-11th years of an elevated CO 2 (+200 ppm) experiment on a maize-soybean agroecosystem, measured respiration by roots and soil microbes, and then used a process-based ecosystem model (DayCent) to simulate the decadal effects of warming and CO 2 enrichment on soil C. Both heating and elevated CO 2 increased respiration from soil microbes by ~20%, but heating reduced respiration from roots and rhizosphere by ~25%. The effects were additive, with no heat × CO 2 interactions. Particulate organic matter and total soil C declined over time in all treatments and were lower in elevated CO 2 plots than in ambient plots, but did not differ between heat treatments. We speculate that these declines indicate a priming effect, with increased C inputs under elevated CO 2 fueling a loss of old soil carbon. Model simulations of heated plots agreed with our observations and predicted loss of ~15% of soil organic C after 100 years of heating, but simulations of elevated CO 2 failed to predict the observed C losses and instead predicted a ~4% gain in soil organic C under any heating conditions. Despite model uncertainty, our empirical results suggest that combined, elevated CO 2 and temperature will lead to long-term declines in the amount of carbon stored in agricultural soils., (© 2016 John Wiley & Sons Ltd.)

To construct an intracellular machine, we sought a symbiotic relationship between a photosynthetic green alga and human cells. Human cells selectively take up the minimal eukaryote Nannochloris eukaryotum and the resulting symbionts are able to survive and proliferate. Host cells can utilize N. eukaryotum's photosynthetic apparatus for survival, and expression of cellular vascular endothelial growth factor can be controlled with input of photonic energy. This seemingly rare spontaneous association provides an opportunity to fabricate light-controlled, intracellular machines.

A method was developed for the analysis of vitamins D2 and D3 in a variety of nutritional products. To extract vitamins D2 and D3 from products containing substantial amounts of fat, a saponification with alcoholic potassium hydroxide is required to release the vitamin D. Trideuterium-labeled vitamin D is added to the sample prior to saponification, and quantitation is achieved using linear regression of the ratio of peak response for 2H3-D and vitamin D. Acceptable linearity was achieved between 0.6 and 27 microg/100 g with a correlation requirement of >0.999. The method detection limit of 0.02 microg/100 g was verified by spiking placebo products carried through the saponification and extraction steps of the method. At the quantitation limit (0.12 microg/100 g), the signal was easily distinguished from the background. Vitamin D3 spike recoveries ranged from 107 to 119% at the low level and 104 to 116% at the high-level spike. Vitamin D2 recoveries were 105 to 116% and 91 to 110% for the low- and high-level spikes, respectively. SRM 1849a has a certified concentration of 11.1 +/- 1.7 microg/100 g; using this standard reference material, the range of 9.4 to 12.8 microg/100 g was met on each of the 6 days. Method repeatability, determined in 12 vitamin D3 product matrixes over 6 days, ranged from 3.9 to 48%. The adult nutrition-milk protein sample was the most notable; it failed within-day, as well as day-to-day, precision requirements. There was no attempt to optimize the sample preparation to accommodate any problem matrix.

During the "Standards Development and International Harmonization: AOAC INTERNATIONAL Mid-Year Meeting" held on June 29, 2011, an Expert Review Panel (ERP) on behalf of AOAC INTERNATIONAL adopted the method "Simultaneous Determination of Vitamins D2 and D3 by LC-MS/MS in Infant Formula and Adult Nutritionals" as an AOAC Official First Action method. Vitamins D2 and D3 are extracted from the sample using pentane-ether; the extract is collected and dried under nitrogen. Vitamin D is separated from interfering compounds using UPLC, and quantitated using tandem mass spectrometry (MS/MS). Preliminary data showed the intermediate precision ranged from 3.34-8.05% and an accuracy range of 98.5-111% over the samples tested for vitamin D3. For vitamin D2, the intermediate precision ranged from 2.37-5.45% and accuracy ranged from 96.4-104% over the four matrixes evaluated. The analytical range for the method is bounded by the concentrations of the working standards, 21-270 ng/mL, and is equivalent to 0.168-2.16 mcg/100 g in ready-to-feed product. The practical method quantitation limit is 0.168 mcg/100 g product with method detection limit of 60 ng/100 g product. The ERP reviewed the data and determined that the performance characteristics of the method met the standard method performance requirements, and therefore the method was granted First Action status.

Rats found food in a rectangular enclosure in three experiments testing how learning about a distinctive feature near a goal interacts with learning based on the geometry of an enclosure. Rats trained to follow a feature in square and triangular enclosures and to use geometry in the rectangle followed the feature when it was in the rectangle (Experiment 1). Rats trained with the feature in a geometrically consistent corner of the rectangle learned about both geometry and the feature (Experiment 2). Training with the feature in the square did not block learning of geometry when both predicted the location of food in the rectangle (Experiment 3). The "geometric module" (Cheng, 1986) may have a special status in spatial learning.

The selective 5-HT2 receptor antagonist MDL 28,133A dose dependently-blocked the long-term deficits in rat brain 5-HT concentrations produced by the substituted amphetamine analogue 3,4-methylenedioxymethamphetamine (MDMA). This protective effect of MDL 28,133A could be abolished by coadministration of the dopamine precursor, L-dihydroxyphenylalanine (L-DOPA). Electrophysiological experiments demonstrated that the ability of MDL 28,133A to block the MDMA-induced slowing of A9 dopaminergic neurons was also sensitive to L-DOPA administration. Both sets of experiments suggest an interaction of MDL 28,133A at the level of dopamine synthesis. Consistent with this explanation, MDL 28,133A antagonized the MDMA-induced stimulation of dopamine synthesis in vivo. MDMA-induced 5-HT release did not reduce the firing rate of dopaminergic neurons as assessed by dopamine depletion following synthesis inhibition with alpha-methyl-p-tyrosine (alpha-MPT). This indicates that the effect of 5-HT2 receptor antagonists on MDMA-induced dopamine synthesis is not due simply to the removal of an inhibitory serotonergic input followed by an increase in dopamine cell firing and autoreceptor activation. MDL 28,133A was also shown to be without effect on the sensitivity of terminal dopamine autoreceptors. The results are consistent with the hypothesis that 5-HT2 receptors are permissive for the stimulation of dopamine synthesis necessary to support MDMA-induced transmitter efflux.