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Following the resurgence of the COVID-19 epidemic in the UK in late 2020 and the emergence of the alpha (also known as B117) variant of the SARS-CoV-2 virus, a third national lockdown was imposed from January 4, 2021. Following the decline of COVID-19 cases over the remainder of January 2021, the question of when and how to reopen schools became an increasingly pressing one in early 2021. This study models the impact of a partial national lockdown with social distancing measures enacted in communities and workplaces under different strategies of reopening schools from March 8, 2021 and compares it to the impact of continual full national lockdown remaining until April 19, 2021. We used our previously published agent-based model, Covasim, to model the emergence of the alpha variant over September 1, 2020 to January 31, 2021 in presence of Test, Trace and Isolate (TTI) strategies. We extended the model to incorporate the impacts of the roll-out of a two-dose vaccine against COVID-19, with 200,000 daily vaccine doses prioritised by age starting with people 75 years or older, assuming vaccination offers a 95% reduction in disease acquisition risk and a 30% reduction in transmission risk. We used the model, calibrated until January 25, 2021, to simulate the impact of a full national lockdown (FNL) with schools closed until April 19, 2021 versus four different partial national lockdown (PNL) scenarios with different elements of schooling open: 1) staggered PNL with primary schools and exam-entry years (years 11 and 13) returning on March 8, 2021 and the rest of the schools years on March 15, 2020; 2) full-return PNL with both primary and secondary schools returning on March 8, 2021; 3) primary-only PNL with primary schools and exam critical years (years 11 and 13) going back only on March 8, 2021 with the rest of the secondary schools back on April 19, 2021 and 4) part-rota PNL with both primary and secondary schools returning on March 8, 2021 with primary schools remaining open continuously but secondary schools on a two-weekly rota-system with years alternating between a fortnight of face-to-face and remote learning until April 19, 2021. Across all scenarios, we projected the number of new daily cases, cumulative deaths and effective reproduction number R until April 30, 2021. Our calibration across different scenarios is consistent with alpha variant being around 60% more transmissible than the wild type. We find that strict social distancing measures, i.e. national lockdowns, were essential in containing the spread of the virus and controlling hospitalisations and deaths during January and February 2021. We estimated that a national lockdown over January and February 2021 would reduce the number of cases by early March to levels similar to those seen in October 2020, with R also falling and remaining below 1 over this period. We estimated that infections would start to increase when schools reopened, but found that if other parts of society remain closed, this resurgence would not be sufficient to bring R above 1. Reopening primary schools and exam critical years only or having primary schools open continuously with secondary schools on rotas was estimated to lead to lower increases in cases and R than if all schools opened. Without an increase in vaccination above the levels seen in January and February, we estimate that R could have increased above 1 following the reopening of society, simulated here from April 19, 2021. Our findings suggest that stringent measures were integral in mitigating the increase in cases and bringing R below 1 over January and February 2021. We found that it was plausible that a PNL with schools partially open from March 8, 2021 and the rest of the society remaining closed until April 19, 2021 would keep R below 1, with some increase evident in infections compared to continual FNL until April 19, 2021. Reopening society in mid-April, without an increase in vaccination levels, could push R above 1 and induce a surge in infections, but the effect of vaccination may be able to control this in future depending on the transmission blocking properties of the vaccines.

BackgroundFollowing the resurgence of the COVID-19 epidemic in the UK in late 2020 and the emergence of the alpha (also known as B117) variant of the SARS-CoV-2 virus, a third national lockdown was imposed from January 4, 2021. Following the decline of COVID-19 cases over the remainder of January 2021, the question of when and how to reopen schools became an increasingly pressing one in early 2021. This study models the impact of a partial national lockdown with social distancing measures enacted in communities and workplaces under different strategies of reopening schools from March 8, 2021 and compares it to the impact of continual full national lockdown remaining until April 19, 2021.MethodsWe used our previously published agent-based model, Covasim, to model the emergence of the alpha variant over September 1, 2020 to January 31, 2021 in presence of Test, Trace and Isolate (TTI) strategies. We extended the model to incorporate the impacts of the roll-out of a two-dose vaccine against COVID-19, with 200,000 daily vaccine doses prioritised by age starting with people 75 years or older, assuming vaccination offers a 95% reduction in disease acquisition risk and a 30% reduction in transmission risk. We used the model, calibrated until January 25, 2021, to simulate the impact of a full national lockdown (FNL) with schools closed until April 19, 2021 versus four different partial national lockdown (PNL) scenarios with different elements of schooling open: 1) staggered PNL with primary schools and exam-entry years (years 11 and 13) returning on March 8, 2021 and the rest of the schools years on March 15, 2020; 2) full-return PNL with both primary and secondary schools returning on March 8, 2021; 3) primary-only PNL with primary schools and exam critical years (years 11 and 13) going back only on March 8, 2021 with the rest of the secondary schools back on April 19, 2021 and 4) part-rota PNL with both primary and secondary schools returning on March 8, 2021 with primary schools remaining open continuously but secondary schools on a two-weekly rota-system with years alternating between a fortnight of face-to-face and remote learning until April 19, 2021. Across all scenarios, we projected the number of new daily cases, cumulative deaths and effective reproduction number R until April 30, 2021.ResultsOur calibration across different scenarios is consistent with alpha variant being around 60% more transmissible than the wild type. We find that strict social distancing measures, i.e. national lockdowns, were essential in containing the spread of the virus and controlling hospitalisations and deaths during January and February 2021. We estimated that a national lockdown over January and February 2021 would reduce the number of cases by early March to levels similar to those seen in October 2020, with R also falling and remaining below 1 over this period. We estimated that infections would start to increase when schools reopened, but found that if other parts of society remain closed, this resurgence would not be sufficient to bring R above 1. Reopening primary schools and exam critical years only or having primary schools open continuously with secondary schools on rotas was estimated to lead to lower increases in cases and R than if all schools opened. Without an increase in vaccination above the levels seen in January and February, we estimate that R could have increased above 1 following the reopening of society, simulated here from April 19, 2021.FindingsOur findings suggest that stringent measures were integral in mitigating the increase in cases and bringing R below 1 over January and February 2021. We found that it was plausible that a PNL with schools partially open from March 8, 2021 and the rest of the society remaining closed until April 19, 2021 would keep R below 1, with some increase evident in infections compared to continual FNL until April 19, 2021. Reopening society in mid-April, without an increase in vaccination levels, could push R above 1 and induce a surge in infections, but the effect of vaccination may be able to control this in future depending on the transmission blocking properties of the vaccines.

Abdominal contour deformities are an aesthetic challenge to the plastic surgeon. Patients present with diverse clinical histories, multiple comorbidities, and unique aesthetic demands. Weight loss, previous pregnancy, and aging are 3 principal indications for abdominoplasty. Bariatric surgery has increased demand for body contouring procedures. This heterogeneous patient cohort means a “one-size-fits-all” abdominoplasty is not appropriate. Precise evaluation, evidence-based decision-making, and artistic acumen are required while balancing patient goals with safe, realistic, and long-lasting aesthetic outcomes. This article reviews surgical options for abdominal body contouring, providing an evidence-based treatment algorithm for selecting the appropriate procedure for each patient to maximize clinical and patient reported outcomes.

Background Up to 20 percent of the general population is persistently colonized with Staphylococcus aureus, and 1 to 3 percent of the population is colonized with community-acquired methicillin-resistant S. aureus. Currently, the knowledge of methicillin-resistant Staphylococcus aureus carriage sites other than the nose, and their effect on surgical site infections in cosmetic surgery, is lacking. Methods A comprehensive literature review using the PubMed database to analyze prevalence, anatomical carrier sites, current screening and decontamination protocols and guidelines, and methicillin-resistant S. aureus in cosmetic surgery was performed. The senior author's (L.R.) methicillin-resistant S. aureus infection experience and prevention protocols were also reviewed. Results Nasal swabs detect only 50.5 percent of methicillin-resistant S. aureus colonization, and broad screening has noted the presence of methicillin-resistant S. aureus in the ear canal and umbilicus. Decolonization protocols within the orthopedic and cardiothoracic surgery literature have reduced rates of methicillin-resistant S. aureus surgical-site infections. There are no decolonization guidelines for plastic surgeons. Since instituting their decolonization protocol, the authors have had no cases of methicillin-resistant S. aureus infection in nearly 1000 cosmetic surgery procedures. Conclusions There are very limited, if any, Level I or II data regarding methicillin-resistant S. aureus screening and decolonization. As the sequelae of a surgical-site infection can be disastrous, expert opinions recommend that plastic surgeons vigorously address methicillin-resistant S. aureus colonization and infection. The authors have developed and recommend a simple decolonization protocol that includes treatment of the umbilicus, ear canal, and nares to limit surgical-site infection and improve surgical outcomes.

To the authors’ knowledge, this is the first report of an allergy to onabotulinumtoxinA. The 43-year-old woman experienced severe itching after injection of Botox and Juvederm. Results of prick and patch testing confirmed a T-cell–mediated allergy to Botox. This case can aid in the evaluation of suspected allergies to Botox. Level of Evidence: 5 ![Graphic][1] [1]: /embed/inline-graphic-1.gif

Cybernetic attacks have been wrongly perceived as weapons of physical destruction rather than of disruption. Because modern, post‐industrial societies have become critically dependent on computer networks to function on a day‐to‐day basis, disruption of those networks could have serious social and economic consequences. In order to better protect society, policymakers will have to re‐orient their approach toward cyber security so as to emphasize the genuine cybernetic threat, which is network disruption rather than physical destruction.

The type of reconstruction performed following skin tumor surgery is directly related to the type, extent, and site of the skin tumor. The skin tumors with which the plastic surgeon is most often confronted are the basal and squamous cell cancers and melanoma. It is well documented that the incidence of these tumors are increasing at an alarming rate. This is believed to be primarily due to excessive sun exposure and the thinning of the protective ozone layer. Under these circumstances, the plastic surgeon today must be well equipped to not only treat these tumors, as well as other rarer diseases, but also to reconstruct the sometimes challenging resulting defects. The guiding reconstructive principle is as Ralph Millard admonished: Replace lost tissue with like tissue. A skin graft at the tip of the nose can be very distracting due to its patch-like, depressed appearance. In contrast, a full-thickness skin flap would allow the reconstructive "material" to blend in with its surroundings for a more impressive result. The plastic surgeon has several items in his armamentarium to assist in the execution of this principle. Some of the techniques are based on age-old ideas, while others represent very recent, almost revolutionary advances. These advances include: 1. The introduction of the tissue expander: This concept has allowed the plastic surgeon to reconstruct defects that would would have normally required disfiguring skin grafts or free tissue transfers. 2. The elucidation of the vascular supply to the skin and underlying muscles and fascia: This knowledge has endowed the plastic surgeon with a tremendous pallet of reliable flaps to reconstruct a particular defect.

The authors of this paper,1 who so enviably sit upon a veritable Sierra Madre treasure of complication data, have delivered yet another rare and unusual practice “biopsy” of our aesthetic surgery corpus. With an exhaustive analysis of almost 130,000 patient encounters, their subject of interest this time was surgical site infections (SSI). And as the authors rightfully caution, this biopsy per force, only included patients who had had infections severe enough to invoke the insurance coverage of a medical and/or surgical intervention. This explains the paper's calculation of the otherwise deceivingly low overall infection incidence of 0.46% with a range of from 0.2% to 1.9%. Whereas, as is also pointed out, the veritable incidence of SSIs as reported in our literature for these same aesthetic procedures, ranges from 0.001% to 32.6%. More importantly, and with few …

Google Glass has the potential to become a ubiquitous and translational technological tool within clinical plastic surgery. Google Glass allows clinicians to remotely view patient notes, laboratory results, and imaging; training can be augmented via streamed expert master classes; and patient safety can be improved by remote advice from a senior colleague. This systematic review identified and appraised every Google Glass publication relevant to plastic surgery and describes the first plastic surgical procedures recorded using Google Glass.A systematic review was performed using PubMed National Center for Biotechnology Information, Ovid MEDLINE, and the Cochrane Central Register of Controlled Trials, following modified Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Key search terms "Google" and "Glass" identified mutually inclusive publications that were screened for inclusion.Eighty-two publications were identified, with 21 included for review. Google Glass publications were formal articles (n = 3), editorial/commentary articles (n = 7), conference proceedings (n = 1), news reports (n = 3), and online articles (n = 7). Data support Google Glass' positive impact on health care delivery, clinical training, medical documentation, and patient safety. Concerns exist regarding patient confidentiality, technical issues, and limited software. The first plastic surgical procedure performed using Google Glass was a blepharoplasty on October 29, 2013.Google Glass is an exciting translational technology with the potential to positively impact health care delivery, medical documentation, surgical training, and patient safety. Further high-quality scientific research is required to formally appraise Google Glass in the clinical setting.

Preamble: The present document is an Expert Consensus Document that includes evidence about the standards for the acquisition, measurement, and reporting of intravascular ultrasound studies (IVUS). This document is intended to inform practitioners, payers, and other interested parties of the opinion of the American College of Cardiology (ACC) concerning evolving areas of clinical practice and/or technologies that are widely available or new to the practice community. Topics chosen for coverage by Expert Consensus Documents are so designed because the evidence base and experience with technology or clinical practice are not considered sufficiently well developed to be evaluated by the formal ACC/American Heart Association (AHA) Practice Guidelines process. Often, the topic is the subject of considerable ongoing investigation. Thus, the reader should view the Expert Consensus Document as the best attempt of the ACC to inform and guide clinical practice in those areas where rigorous evidence may not yet be available or the evidence to date is not widely accepted. When feasible, Expert Consensus Documents include indications or contraindications. Some topics covered by Expert Consensus Documents will be addressed subsequently by the ACC/AHA Practice Guidelines Committee. The Task Force on Clinical Expert Consensus Documents makes every effort to avoid any actual or potential conflicts of interest that might arise as a result of an outside relationship or personal interest of a member of the writing panel. Specifically, all members of the writing panel are asked to provide disclosure statements to inform the writing effort of all such relationships that might be perceived as real or potential conflicts of interest.

Ligand activation of the nuclear receptor PPARgamma induces adipogenesis and increases insulin sensitivity, while activation of other PPAR isoforms (-alpha and -delta) induces little or no fat cell differentiation. Expression and activation of chimeras formed between PPARgamma and PPARdelta in fibroblasts has allowed us to localize a major domain of PPARgamma responsible for adipogenesis to the N-terminal 138 amino acids, a region with AF-1 transcriptional activity. Using this region of PPARgamma as bait, we have used a yeast two-hybrid screen to clone a novel protein, termed PGC-2, containing a partial SCAN domain. PGC-2 binds to and increases the transcriptional activity of PPARgamma but does not interact with other PPARs or most other nuclear receptors. Ectopic expression of PGC-2 in preadipocytes containing endogenous PPARgamma causes a dramatic increase in fat cell differentiation at both the morphological and molecular levels. These results suggest that interactions between PGC-2, a receptor isoform-selective cofactor and PPARgamma contribute to the adipogenic action of this receptor.

Background: The competitive efficacy of the superficial musculoaponeurotic system (SMAS) rhytidectomy (SMASectomy) facelift has been well established. However, the outcomes after an associated open necklift have not been as reliable; the persistent incidence of recurrent bands and iatrogenic deformities has prompted a change in technique. Objectives: The author conducted a long-term retrospective review to evaluate a variation on the SMASectomy facelift technique. A solely lateral, “low SMAS” approach was substituted for direct necklift in all patients. Methods: Patients who were candidates for a facelift underwent this laterally based, SMASectomy technique. Those who underwent concomitant full-face CO2 laser resurfacing were excluded from the review. A total of 198 patients treated consecutively during a 7-year period (2006-2012) were included in the study. Results: Postoperative follow-up ranged from 1 to 7 years. All patients’ neck deformities were fully corrected by the solely lateral SMASectomy technique. In addition, the patients recovered more rapidly than with traditional direct necklift, with no nerve injuries, skin compromise, or hypertrophic scarring. Conclusions: Results indicate that midline open necklift can be replaced by the low SMASectomy. Level of Evidence: 4 ![Graphic][1] [1]: /embed/inline-graphic-1.gif

This paper examines whether the United States should sell powerful offensive weapons to the Gulf Cooperation Council (GCC) states. A number of analysts and U.S. Congressmen have either opposed or expressed concern over the nature of U.S. arms sales to the Gulf region. Some of these individuals make the case that major offensive conventional weapons are poorly suited to countering a nuclear-armed Iran. Others are concerned by the potential of such weapons to increase the likelihood or consequences of war in the region. By contrast, this paper argues that major offensive weapons are likely to be essential in maintaining a favorable balance of power in the Gulf if Iran develops and deploys nuclear weapons. Moreover, the sale of such weapons to the GCC states could help to dissuade Iran from developing nuclear weapons and convince it to accept strong international controls on its nuclear program.

Traditionally, the primary goal of any abdominoplasty has always been to excise the central lower abdominal excess skin or pannus and plicate the abdominal fascia through a suprapubic incision. Unfortunately, this traditional abdominoplasty may often fall short of this goal: a scar that may ride too high; persistent skin and lipodystrophy at the pubis, thighs, flanks, and hips; and unfortunately a consistent incidence of midline skin necrosis or wound dehiscence. High lateral tension abdominoplasty addresses these shortfalls. It may be defined as a more complete treatment of the lower trunk aesthetic unit from the abdomen to the pubis, hips, and thighs, with a greater overall aesthetic result and margin of vascular safety. This article outlines the techniques and tools to accomplish these superior results safely and consistently.

Over the past few years, I have certainly been a zealot when it comes to promoting the perioperative checklist. As with religion, once you “see the light,” all you want to do is bask in it and encourage others to do the same. Paradoxically, this mission has been a labor of love. The majority of my colleagues, of every surgical persuasion, have not adopted checklists as earnestly as I have delivered the message. Looking back, I have heard “everything”: from understandable hindrances caused by institutional barriers, to apathetic excuses immunized by the sanctum of private practice. Perhaps the only way to become a believer is to create your own operative checklist, conduct your own “controlled” experiment, and experience your own revelation: seeing is truly believing.1 Clearly, there can never be a level I study to otherwise prove this outcome. No one would allow for random logistical errors and chart their consequences. As I reflect on my own 15-year checklist experience, my team would be quick to point out the innumerable instances in which the checklist has prevented “near-miss” events: errors that I have called errors of omission. Decidedly, my checklist has become part of a larger personal philosophy; a singular expression of an overarching goal: put simply, to get better. This should come as no surprise to plastic surgeons. It is in our DNA to strive to get better, all the time. This is what simultaneously drives us, haunts us, inspires us and, together, pushes our field forward. Our everyday practices are simply honing stones on which our skills should be sharpened. The key word is “should,” because it is insidiously easy to establish a standard of care that is too comfortable. In fact, we have only ourselves to move the target a little farther away every time we rashly think we have reached it. Otherwise, a practice ceases to be a true “practice” and instead evolves into a mill. To this end, the surgeon must embed multiple prophylactic modalities, beyond my original “operating room checklist.” For this purpose I now propose a more encompassing mandate: a “practice checklist.” This checklist extends the narrow scope of procedural mandates to encompass the holistic elements of managing the entire patient experience, from the design of the incision to the longevity of the outcome. This broader effort goes beyond reducing errors of omission to include those of commission. Notably, these errors should not only encompass the usual litany of “physical” complications. As aesthetic surgeons, we must be willing to consider our “aesthetic” complications as well. To this end, the following list of surgical criteria and goals fittingly reads like entries within the Guinness Book of World Records

The age-adjusted prevalence of peripheral arterial disease (PAD) in the U.S. population has been estimated to approach 12%. The clinical consequences of occlusive peripheral arterial disease (PAD) include pain on walking (claudication), pain at rest, and loss of tissue integrity in the distal limbs; the latter may ultimately lead to amputation of a portion of the lower extremity. Surgical bypass techniques and percutaneous catheter-based interventions may be used to successfully revascularize the limbs of certain patients with PAD. In many patients, however, the anatomic extent and distribution of arterial occlusion is too severe to permit relief of pain and/or healing of ischemic ulcers. No effective medical therapy is available for the treatment of such patients. The purpose of this clinical protocol is to document the safety of therapeutic angiogenesis achieved in this case by percutaneous catheter-based delivery of the gene encoding vascular endothelial growth factor (VEGF) in patients with PAD; and, as secondary objectives, investigate the bioactivity of this strategy to relieve rest pain and heal ischemic ulcers of the lower extremities. The rationale for this human protocol is based upon preclinical studies performed in a rabbit model of hindlimb ischemia. These studies are described in detail below and in the manuscripts enclosed in the Appendix to this proposal. In brief, a single intra-arterial bolus of VEGF recombinant human protein, delivered percutaneously to the ischemic limb via an intravascular catheter, resulted in angiographic, hemodynamic, physiologic, and histologic evidence of augmented collateral artery development. Subsequently, similar results were achieved using an angioplasty catheter with a hydrogel-coated balloon to deliver 400 micrograms of a plasmid containing the cDNA for VEGF to the internal iliac artery in the same animal model. Accordingly, we propose to administer arterial gene (VEGF) therapy to patients with rest pain and/or ischemic leg ulcers considered not to be candidates for conventional revascularization techniques. The dose of plasmid to be administered will be progressively escalated beginning with 500 micrograms for the first four patients, 1000 micrograms for the following six patients, 2000 micrograms for the third group of six patients, and 400 micrograms for the fourth group of six patients.