Intraoperative Techniques for the Plastic Surgeon to Improve Pain Control in Breast Surgery

Summary: In recent years, there has been a growing emphasis placed on reducing length of hospital stay and health costs associated with breast surgery. Adequate pain control is an essential component of enhanced recovery after surgery. Postoperative pain management strategies include use of narcotic analgesia, non-narcotic analgesia, and local anesthetics. However, these forms of pain control have relatively brief durations of action and multiple-associated side effects. Intraoperative regional blocks have been effectively utilized in other areas of surgery but have been understudied in breast surgery. The aim of this article was to review various intraoperative techniques for regional anesthesia and local pain control in breast surgery and to highlight areas of future technique development.

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Pemetrexed-induced painful erythematous nodules in both legs in a patient with recurrent mesothelioma

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Functional dissection of astrocyte-secreted proteins: Implications in brain health and diseases

Publication date: Available online 13 December 2017
Source:Progress in Neurobiology
Author(s): Mithilesh Kumar Jha, Jong-Heon Kim, Gyun Jee Song, Won-Ha Lee, In-Kyu Lee, Ho-Won Lee, Seong Soo A. An, SangYun Kim, Kyoungho Suk
Astrocytes, which are homeostatic cells of the central nervous system (CNS), display remarkable heterogeneity in their morphology and function. Besides their physical and metabolic support to neurons, astrocytes modulate the blood-brain barrier, regulate CNS synaptogenesis, guide axon pathfinding, maintain brain homeostasis, affect neuronal development and plasticity, and contribute to diverse neuropathologies via secreted proteins. The identification of astrocytic proteome and secretome profiles has provided new insights into the maintenance of neuronal health and survival, the pathogenesis of brain injury, and neurodegeneration. Recent advances in proteomics research have provided an excellent catalog of astrocyte-secreted proteins. This review categorizes astrocyte-secreted proteins and discusses evidence that astrocytes play a crucial role in neuronal activity and brain function. An in-depth understanding of astrocyte-secreted proteins and their pathways is pivotal for the development of novel strategies for restoring brain homeostasis, limiting brain injury/inflammation, counteracting neurodegeneration, and obtaining functional recovery.

Graphical abstract

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Considerations in Setting Up and Planning a Graft Processing Facility

Publication date: Available online 13 December 2017
Source:Hematology/Oncology and Stem Cell Therapy
Author(s): Mickey B.C. Koh




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When Clarity Is Crucial: Regulating Ocular Surface Immunity

Publication date: Available online 14 December 2017
Source:Trends in Immunology
Author(s): William Foulsham, Giulia Coco, Afsaneh Amouzegar, Sunil K. Chauhan, Reza Dana
The ocular surface is a unique mucosal immune compartment in which anatomical, physiological, and immunological features act in concert to foster a particularly tolerant microenvironment. These mechanisms are vital to the functional competence of the eye, a fact underscored by the devastating toll of excessive inflammation at the cornea – blindness. Recent data have elucidated the contributions of specific anatomical components, immune cells, and soluble immunoregulatory factors in promoting homeostasis at the ocular surface. We highlight research trends at this distinctive mucosal barrier and identify crucial gaps in our current knowledge.



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Hypoxia Inducible Factors Modify Collagen I Fibers in MDA-MB-231 Triple Negative Breast Cancer Xenografts

Publication date: February 2018
Source:Neoplasia, Volume 20, Issue 2
Author(s): Eibhlin Goggins, Samata Kakkad, Yelena Mironchik, Desmond Jacob, Flonne Wildes, Balaji Krishnamachary, Zaver M. Bhujwalla
Hypoxia inducible factors (HIFs) are transcription factors that mediate the response of cells to hypoxia. HIFs have wide-ranging effects on metabolism, the tumor microenvironment (TME) and the extracellular matrix (ECM). Here we investigated the silencing effects of two of the three known isoforms, HIF-1α and HIF-2α, on collagen 1 (Col1) fibers, which form a major component of the ECM of tumors. Using a loss-of-function approach for HIF-1α or 2α or both HIF-1α and 2α, we identified a relationship between HIFs and Col1 fibers in MDA-MB-231 tumors. Tumors derived from MDA-MB-231 cells with HIF-1α or 2α or both HIF-1α and 2α silenced contained higher percent fiber volume and lower inter-fiber distance compared to tumors derived from empty vector MDA-MB-231 cells. Depending upon the type of silencing, we observed changes in Col1 degrading enzymes, and enzymes involved in Col1 synthesis and deposition. Additionally, a reduction in lysyl oxidase protein expression in HIF-down-regulated tumors suggests that more non-cross-linked fibers were present. Collectively these results identify the role of HIFs in modifying the ECM and the TME and provide new insights into the effects of hypoxia on the tumor ECM.



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A Low-Toxicity DNA-Alkylating N-Mustard-Quinoline Conjugate with Preferential Sequence Specificity Exerts Potent Antitumor Activity Against Colorectal Cancer

Publication date: February 2018
Source:Neoplasia, Volume 20, Issue 2
Author(s): Tai-Lin Chen, Yi-Wen Lin, Yan-Bo Chen, Jing-Jer Lin, Tsann-Long Su, Chia-Ning Shen, Te-Chang Lee
Efficacy and safety are fundamental prerequisites for anticancer drug development. In the present study, we explored the anti–colorectal cancer (CRC) activity of SL-1, a DNA-directed N-mustard-quinoline conjugate. The N-mustard moiety in SL-1 induced DNA strand breaks, interstrand cross-links (ICLs), G2/M arrest, and apoptosis, whereas its quinoline moiety preferentially directed SL-1 to target the selective guanine sequence 5′-G-G/C-N-G-C/T-3′. Notably, SL-1 was highly cytotoxic to various CRC cell lines. Experiments using xenograft models revealed that SL-1 was more potent than 5-fluorouracil (5-FU) and oxaliplatin for suppressing the growth of RKO and RKO-E6 (oxaliplatin-resistant subline) cells as well as metastatic SW620 cells. In addition, SL-1 combined with 5-FU was more effective than oxaliplatin and 5-FU for suppressing RKO or SW620 cell growth in mice. Significantly, compared with cisplatin, oxaliplatin, or 5-FU, SL-1 alone or in combination with 5-FU did not cause obvious kidney or liver toxicity in ICR mice. In summary, SL-1, a DNA-directed alkylating agent, is established as an anti-CRC agent with high efficacy and low toxicity and thus warrants further development for the treatment of CRC patients.



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Antibiotic Prophylaxis After Immediate Breast Reconstruction: The Reality of its Efficacy

Purpose: Numerous techniques are used to prevent infection after immediate implant-based breast reconstruction. Postoperative antibiotic prophylaxis (PAP) is commonly prescribed to decrease the risk of reconstructive failure, despite conflicting evidence regarding its effectiveness. We sought to determine whether PAP decreases the risk of infection-related explantation in the setting of immediate prosthesis-based breast reconstruction. Methods: Using Truven MarketScan databases, we identified all patients who underwent immediate implant reconstruction between 1/2010-6/2014 with at least 6 months of follow-up. PAP was defined as any oral antibiotic course to be taken postoperatively based on prescriptions filled within 14 days prior to surgery through 24 hours post-discharge. Reconstructive failure defined as explantation due to infection was the primary outcome. Secondary outcomes of interest included wound complications, infection, and readmission for infection. Multivariable regression analyses controlled for demographic variables/comorbidities. Results: Of the 7,443 patients, 6,049 (81%) filled prescriptions for PAP. These patients were equally likely to develop a wound complication (OR=0.93 95%CI:0.71-1.23), infection (OR=0.89 95%CI:0.70-1.14), undergo explantation due to infection (OR=0.82 95%CI: 0.57-1.18), or require readmission for infection (OR=1.21 95%CI:0.82-1.78) compared to those who did not receive PAP. There was no significant difference in the risk of infection-related outcomes based on PAP duration. Conclusion: PAP was not associated with a reduced risk of infection or explantation following prosthesis-based breast reconstruction. Given rising rates of antibiotic resistance, focusing instead on technical considerations and the management of comorbid conditions may more effectively enhance the safety of breast reconstruction. Disclosure: This research was supported by a Mentored Clinical Investigator Award to Dr. Waljee through the Agency for Healthcare Research and Quality (1K08HS023313-01). Research reported in this publication was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under Award Number 2K24-AR053120-06 (Dr. Kevin Chung). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. This work was funded by the Chang Gung Memorial Hospital (project CORPG3G0111 and CORPG3G0161). This work was presented at the annual Plastic Surgery Research Council in 2017. Corresponding Author: Jennifer F. Waljee MD, MPH, MS, Michigan Medicine, Section of Plastic Surgery,, 2130 Taubman Center, SPC 5340, Ann Arbor, MI, 48109-5340, filip@med.umich.edu, Phone 734-998-6022, Fax 734-798-6696 ©2017American Society of Plastic Surgeons

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Absorbable Antibiotic Beads Prophylaxis in Immediate Breast Reconstruction

Background: Breast reconstruction with tissue expander is the most common mode of reconstruction following mastectomy. Infection necessitating tissue expander removal is a significant complication leading to patient distress as well as increased health care costs. Methods: Over 3 years, 127 breast reconstructions with tissue expanders were performed by a single surgeon. Fifty-nine of these reconstructions were performed using a standardized protocol in which patients washed with chlorhexidine several days prior to surgery and received intravenous antibiotics preoperatively. Intraoperatively, the submuscular pocket was irrigated with triple antibiotic solution and the skin was re-prepped with povidone iodine prior to expander placement. This group was referred to as the preintervention group. Sixty-eight of the reconstructions were performed using the standardized protocol with the addition of biodegradable antibiotic beads (Stimulan ® with vancomycin and gentamicin) in the submuscular pocket. This group made up the post intervention group. The primary outcome was the rate of infection necessitating tissue expander removal. Results: Tissue expander loss due to infection was 11.9% in preintervention group and 1.5% in the post intervention group, (p=0.024). Higher body mass index was associated with a statistically significant increase in infections necessitating implant removal. Conclusions: The use of absorbable antibiotic beads in the submuscular pocket reduced the risk of periprosthetic implant infection necessitating implant removal by 8-fold. Financial Disclosure Statement: The authors have the following to disclose: Nothing Presented at (if applicable): Robert Ivy Plastic Surgery Meeting, Philadelphia, PA on April 22 2017 Absorbable Antibiotic Beads Prophylaxis in Immediate Breast Reconstruction Corresponding Author: Kenna M. Denise M.D F.A.C.S , 2350 Freedom Way Ste 107, York, PA. USA. e-mail address: dmkenna@comcast.net ©2017American Society of Plastic Surgeons

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Indocyanine Green Angiography Use in Breast Reconstruction: A National Analysis of Outcomes and Cost in 110,320 Patients

Background: Indocyanine Green (ICG) angiography has gained popularity in breast reconstruction due to its ability to assess the viability of both mastectomy skin and tissue flaps. We aim to analyze trends and outcomes associated with the use of ICG angiography in breast reconstruction. Methods: Using 2012-2014 data from the Healthcare Cost and Utilization Project National Inpatient Sample, Agency for Healthcare Research and Quality, we identified breast reconstructions that were performed with or without the use of ICG angiography. Trends over time were assessed using the Cochran-Armitage test. Outcomes were assessed using logistic regression and generalized linear modeling. Results: Over the study period, 110,320 patients underwent breast reconstruction: 107,005 (97.0%) without the use of ICG and 3,315 (3.0%) with the use of ICG angiography. Indocyanine green angiography use increased over time: 750 patients (1.9%) in 2012, increasing to 1,275 patients (3.7%) in 2013 (p

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Low Dose Insulin as an Anti-Scarring Therapy in Breast Surgery: A Randomised Controlled Trial

Background: The role of insulin in expediting wound healing is firmly established within the context of major trauma and burns however only limited clinical evidence exists as to its effects upon scar formation. This study aims to build upon previous laboratory work to examine the potential anti-scarring properties of insulin in a clinical environment. Methods: 91 patients undergoing bilateral aesthetic breast surgeries were recruited to receive low-dose insulin and placebo injections to the medial 3cm of their sub-mammary incisions within the context of a randomised, intra-patient, placebo controlled trial and scar quality was assessed at 3, 6, and 12-month reviews using the Manchester Scar Scale. Results: Across the cohort at 12-month review the insulin-treated scars had lower scar scores (p=0.055) compared to placebo. Sub-group analysis of individuals with heavier scars showed median scar scores were significantly lower for the insulin-treated scars in regards to both scar contour (p=0.048) and scar distortion (p=0.045). Conclusions: Sub-cutaneous insulin injections reduced the appearance of scarring in this study when compared to placebo. The greatest effect was seen in those participants who showed heavier scars and as such insulin has a role as an antiscarring therapy in individuals likely to be affected by heavier scarring. Further research is required to more precisely delineate what subjects may benefit most from this treatment. Acknowledgments: Jon Pleat. Director at Restore Burn & Research Foundation Di Lawrence-Watt. Emeritus Professor Brighton & Sussex Medical School Financial Disclosure Statement: None of the authors have anything to disclose and no funding was received for this article. Presented at: 2016 Winter BAPRAS meeting, London Trial Identification: South East Research Ethics Committee (REC reference 10/H1102/67). Corresponding Author:MJ Hallam, M.D, MRCS, BM, Department of Plastic Surgery, St John's Hospital, Livingston, Edinburgh, EH54 6PP, UK. mj_hallam@hotmail.co.uk ©2017American Society of Plastic Surgeons

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The “Boomerang Lift”: A 3-Step Compartment Based Approach to the Youthful Cheek

Background: Autologous fat grafting (AFG) is an important tool for plastic surgeons treating the aging face. Malar augmentation with fat is often targeted to restore the youthful facial contour and provides support to the lower eyelid. The existence of distinct facial fat compartments suggests a step-wise approach may be appropriate in this regard [1]. Here we describe a three-step approach to malar augmentation using targeted deep malar fat compartmental augmentation, termed the "Boomerang Lift". Methods: Clinical patients undergoing AFG for malar augmentation were injected in three distinct deep malar fat compartments: 1. the lateral sub-orbicularis oculi fat (LSOOF), medial sub-orbicularis oculi fat (MSOOF), and lastly to the deep medial cheek (DMC) (n=9). Intra-operative 3D images were taken at baseline and following compartmental injections(Canfield® VECTRA H1). Images were overlaid between the augmented and baseline captures, and the 3D surface changes were analyzed, which represented the resulting "augmentation zone" (AZ). Results: 3D analysis of patients (n=9) demonstrated a unique pattern for AZ consistent across patients. The AZ resembled a boomerang, with the short tail supporting the medial lower lid, and the long tail extending laterally along the zygomatic arch. The upper border was restricted by the level of the naso-jugal interface, and the lower border was defined medially by the nasolabial fold and laterally by the level of the zygomatico-cutaneous ligament. Injections to the lateral and medial SOOF defined the boundaries of the boomerang shape, while the injection to the deep medial cheek provided maximum projection. Conclusions: This is the first description of deep malar augmentation zones described in clinical patients. 3D surface imaging was an ideal method for analyzing the surface change in response to targeted facial fat grafting. Our technique resulted in a reproducible surface shape, which we term the "Boomerang Lift". The authors of this study have no financial disclosures. Corresponding Author: Oren M. Tepper, MD, Assistant Professor, Division of Plastic and Reconstructive Surgery, Director of Aesthetic Surgery, Director of Craniofacial Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, 875 Park Avenue, New York, NY 10075, orenteppermd@yahoo.com ©2017American Society of Plastic Surgeons

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Scholar : Obstructive sleep apnea - νέα αποτελέσματα

Serum ferritin and obstructive sleep apnea—epidemiological study

EH Thorarinsdottir, ES Arnardottir, B Benediktsdottir… - Sleep and Breathing, 2017

Purpose Ferritin is an intracellular iron storage protein and a marker of inflammation. Studies
have shown that subjects with obstructive sleep apnea (OSA) have higher levels of
circulating pro-inflammatory cytokines, but little is known about the association between

[HTML] Improvement in obstructive sleep apnea after a tailored behavioural sleep medicine intervention targeting healthy eating and physical activity: a randomised controlled …

H Igelström, P Åsenlöf, M Emtner, E Lindberg - Sleep and Breathing, 2017

Purpose The aim of the present single-centre randomised controlled trial was to assess the
effect of a behavioural sleep medicine (BSM) intervention on obstructive sleep apnea (OSA)
severity in patients who have been referred for new treatment with continuous positive

Does increased serum d-lactate mean subclinical hyperpermeability of intestinal barrier in middle-aged nonobese males with Osa?

M Heizati, N Li, L Shao, X Yao, Y Wang, J Hong… - Medicine, 2017

… Checking for direct PDF access through Ovid. View on Journal Site. Abstract. Few attention has
been directed to the potential effects of intermittent hypoxia experienced in obstructive sleep
apnea on the integrity and permeability of intestinal barrier, particularly in adults …

Cardiopulmonary coupling spectrogram as an ambulatory clinical biomarker of sleep stability and quality in health, sleep apnea and insomnia

RJ Thomas, C Wood, MT Bianchi - Sleep, 2017

… coupled cardiopulmonary oscillations, periods of which correlated significantly with periods of
manually scored apneas and hypopneas in the PhysioNet Sleep Apnea Database … obstructive
sleep apnea). The amounts of broad and narrow spectral band coupling in e-LFC …

Complex sleep apnea after full-night and split-night polysomnography: the Greek experience

K Baou, C Mermigkis, A Minaritzoglou, E Vagiakis - Sleep and Breathing, 2017

… positive airway pressure devices for titrating pressures and treating adult patients with obstructive
sleep apnea syndrome: an … Szollosi I, Roebuck T, Thompson B, Naughton MT (2006) Lateral
sleeping position reduces severity of central sleep apnea/Cheyne- Stokes …

Evidence of Osteoclastic Activity in the Human Temporal Bone

T Kamakura, JB Nadol Jr - Audiology and Neurotology, 2017

… [2015] indicated that patients with SSCD demonstrated higher BMI and higher rates of obstructive
sleep apnea, consistent with increased intracranial pressure as causative of SSCD. In the current
study, sleep apnea was described in the medical history of case 3. Yu et al …

PACAP (6-38) or kynurenate microinjections into the RVLM prevent development of sympathetic long-term facilitation following acute intermittent hypoxia

ZM Kakall, PM Pilowsky, MMJ Farnham - American Journal of Physiology-Heart and …, 2017

… NMDA: n-methyl-d-aspartate 67 NTS: nucleus of the solitary tract 68 OSA: obstructive sleep apnea
69 PACAP: pituitary adenylate cyclase activating polypeptide 70 PKA: protein kinase A 71 …
sympathetic activity, obstructive sleep apnea, cardiovascular 117 118 119 120 121 122 …

[PDF] Mediastinal Hemangiopericytoma/Solitary Fibrous Tumor: A rare case

M Halkar, R Kartan, S Kallus - 2017

… His other medical problems were non- insulin dependent diabetes mellitus, hypertension,
obstructive sleep apnea, arthritis. His father had lung cancer and there was history of breast
and colon cancer on the mother's side of family. Introduction …

Evaluation of Edema of the Extremity

JH Fish, F Lurie - Current Management of Venous Diseases, 2018

… Vena cava obstruction, vena cava … venous insufficiency, KTS Klippel-Trenaunay syndrome, OM
osteomyelitis, CRPS chronic regional pain syndrome, CVH central venous hypertension, CHF
congestive heart failure, RV right ventricle, OSA obstructive sleep apnea, PH pulmonary …

[PDF] Benefits and Drawbacks of NVivo QSR Application

S Dollah, A Abduh, R Rosmaladewi - Advances in Social Science, Education and …, 2017

… [9] FR Almeida, N. Henrich, C. Marra, LD Lynd, AA Lowe, H. Tsuda, JA Fleetham, B. Pliska, and
N. Ayas, "Patient preferences and experiences of CPAP and oral appliances for the treatment
of obstructive sleep apnea: a qualitative analysis," Sleep Breath., vol. 17, no. 2, pp …

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Scholar : CPAP - νέα αποτελέσματα

Increased Urinary Erythropoietin Excretion in Severe Sleep Apnea-Hipoapnea Syndrome: The Effect of CPAP.

M Félez, N Grau, A Ruiz, E Guardiola, C Sanjuas… - Archivos de …, 2017

Abstract Tissue hypoxia stimulates the production of erythropoietin (EPO), the main effect of
which is, in turn, to stimulate erythropoiesis. Sleep apnea-hypopnea syndrome (SAHS) is an
entity characterized by repeated episodes of hypoxemia during sleep. To analyze whether

[HTML] Improvement in obstructive sleep apnea after a tailored behavioural sleep medicine intervention targeting healthy eating and physical activity: a randomised controlled …

H Igelström, P Åsenlöf, M Emtner, E Lindberg - Sleep and Breathing, 2017

… of the present single-centre randomised controlled trial was to assess the effect of a behavioural
sleep medicine (BSM) intervention on obstructive sleep apnea (OSA) severity in patients who
have been referred for new treatment with continuous positive airway pressure (CPAP …

Complex sleep apnea after full-night and split-night polysomnography: the Greek experience

K Baou, C Mermigkis, A Minaritzoglou, E Vagiakis - Sleep and Breathing, 2017

… A split-night polysomnography (PSG), or two formal overnight PSGs (diagnostic and
continuous PAP (CPAP) titration study), were performed … Keywords Complex sleep apnea .
Central apneas . Obstructive sleep apnea . CPAP apparatus Introduction …

CPAP-MAD Combination Therapy For CPAP Intolerant Patients With Moderate to Severe OSA

J Stadiem - 2017

Abstract The treatment of obstructive sleep apnea (OSA) allows for a multidisciplinary
approach between dentistry and medicine. Continuous positive airway pressure (CPAP) is
the gold standard for OSA treatment, but the non-adherence rates are high. The mandibular

Serum ferritin and obstructive sleep apnea—epidemiological study

EH Thorarinsdottir, ES Arnardottir, B Benediktsdottir… - Sleep and Breathing, 2017

… All patients were treated with autoPAP or continuous PAP (CPAP) units (ResMed Corp., San
Diego, California, USA) and treatment was only changed to bilevel PAP (BiPAP) or adaptive
servoventilation if treatment efficacy on autoPAP or CPAP was inadequate (defined by AHI …

不同通气策略对截石位腹腔镜手术老年患者肺内分流的影响

高蕾， 方铮， 徐彦， 杨旅军， 顾卫东 - 老年医学与保健, 2017

… C组. 在预给氧期和诱导期, A1组和A2组给予100% FiO2＋8cmH2O持续正压通气（
continuous positive airway pressure,CPAP）,C 组给予100%FiO2＋0cmH2O
CPAP.麻醉维持期3 组均给予40%FiO2＋8cmH2O PEEP. 气管拔管前 …

OSAHS 患者甲状腺激素水平对临床症状及代谢的影响

李树奇， 方桂桔， 邓新宇， 甘玉燕， 薛青， 张灿辉 - 收藏, 2017

… 228例。测定并比较各组间甲状腺激素水平(FT_3、FT_4、TSH),依据检验结果进一步对甲状腺激
素水平与嗜睡评分、血脂(TC、TG、LDL-C)进行相关性分析。临床干预阶段,选取重度OSAHS
伴重度缺氧患者50例进行持续经鼻持续正压通气(n-CPAP)治疗,比较治疗前后主要睡眠参数 …

Epilepsie en slaperigheid overdag

AW de Weerd - Epilepsie, 2018

… Er werd derhalve besloten tot instellen van 'continuous positive air pressure' (cpap)-therapie
met als doel de bovenste luchtweg in de slaap open te houden en zo goede respiratie te
verzekeren … In ieder geval heeft hij de cpap en het aed gecontinueerd …

Cardiopulmonary coupling spectrogram as an ambulatory clinical biomarker of sleep stability and quality in health, sleep apnea and insomnia

RJ Thomas, C Wood, MT Bianchi - Sleep, 2017

… periods. The reason for the recording was to assess sleep quality in the context of persistent
fatigue despite highly compliant CPAP use. Insomnia patients No study-specific constraints
were placed on the subjects, who maintained a sleep log in addition …

[PDF] Benefits and Drawbacks of NVivo QSR Application

S Dollah, A Abduh, R Rosmaladewi - Advances in Social Science, Education and …, 2017

… 36–43, 2008. [9] FR Almeida, N. Henrich, C. Marra, LD Lynd, AA Lowe, H. Tsuda, JA Fleetham,
B. Pliska, and N. Ayas, "Patient preferences and experiences of CPAP and oral appliances for
the treatment of obstructive sleep apnea: a qualitative analysis," Sleep Breath., vol …

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