Review literature on facial feminization surgery (FFS) for the transgender population and identify whether heterogeneity in reported outcomes and outcome measures exists across studies, as measured ...by a lack of consensus, and number of outcomes and outcome measures used.
A search of MEDLINE and EMBASE (database inception to January 20, 2021) was performed to retrieve FFS studies. Primary outcomes included number of reported outcomes and outcome measures; secondary outcomes included clinimetric properties of outcome measures and study characteristics.
In total, 15 articles were included. Sixty-nine outcomes and 12 outcome measures were identified. Of those outcome measures, zero were found to be valid, reliable, and responsive in patients who had undergone FFS. A variety of FFS interventions were studied, with the three most common interventions being: rhinoplasty (
= 7, 46.7%), mandibuloplasty (
= 7, 46.7%), and chondrolaryngoplasty (
= 6, 40%).
Heterogeneity was evident in reported outcomes and outcome measures in FFS literature and there is currently no outcome measure commonly used for this patient population.
Purpose
Risk of postoperative infection following breast cancer reconstruction warrants consideration of both classic and procedure-specific risk factors. We performed a retrospective chart review of ...patients with breast cancer over a 10-year period that underwent reconstructive surgery to identify factors that increase risk of postoperative infection.
Methods
Rates of postoperative infection were assessed in primary (immediate or delayed, alloplastic or autogenous) and secondary reconstructive procedures. Patient characteristics, surgical details, and cancer features were analyzed using two-sample
t
test and Fisher’s exact test for continuous and categorical data, respectively.
Results
456 procedures were performed on 264 patients with 29 cases of postoperative infection (6%). Infection was more likely to occur in earlier reconstructive procedures (
p
< 0.03). Overall, primary reconstructive procedures were associated with a higher infection rate (
p
= 0.005). Other associated risk factors included: autogenous reconstruction (
p
< 0.018), length of admission (
p
< 0.001) and immediate reconstruction (
p
= 0.01). Subgroup analysis revealed increased risk of infection with immediate autogenous reconstruction (
p
< 0.03). Furthermore, patients with greater body mass index (BMI) receiving immediate autogenous reconstruction had a greater risk of infection (
p
< 0.003). Factors unrelated to risk of infection included history of irradiation, smoking, cancer stage, tumor type and tumor size.
Conclusions
Our findings suggest that risk of infection is higher in immediate autogenous reconstructions particularly when patients are overweight (BMI > 30). Our data do not support a relationship between infection and irradiation, features of cancer, or repeated reconstructive procedures. Prospective studies may be required to further validate these findings.
Purpose:
There are limited data on coordinated breast and gynecological risk-reduction surgery for high-risk patients in Canada. Therefore, this study aims to evaluate the patient demographics, ...surgical details, and outcomes of prophylactic mastectomy (PM) with immediate reconstruction and bilateral salpingo-oophorectomy (BSO) in high-risk patients.
Methods:
We conducted a retrospective chart review at an academic center of patients who concurrently underwent PM with immediate reconstruction and laparoscopic BSO over a 7-year period (March 2010-February 2017) were identified.
Results:
A total of 16 patients underwent PM with immediate reconstruction and concurrent BSO. The mean age at the time of surgery was 46.2 ± 6.6 years. Thirteen (81%) patients were carriers of the BRCA1 or BRCA2 mutation. Two patients had prophylactic surgical therapy for BRCA1 mutation and 14 (87.5%) patients had prior oncological treatment. The most common type of procedures performed were skin-sparing, nipple-sparing mastectomy (56.2%) and reconstruction with acellular dermal matrix and implants (43.8%). All patients underwent laparoscopic BSO. The average combined case time was 282.5 ± 81.3 minutes with an average postoperative hospital stay of 1.3 ± 0.5 days. Six (37.5%) patients presented with 30-day postoperative complications, with higher rates in the alloplastic group. There were no gynecological complications.
Conclusions:
In conclusion, our results demonstrate that a combined multidisciplinary surgical approach did not increase length of stay or 30-day complication rates. Furthermore, concurrent risk-reducing strategies are an effective option for patients at high risk of breast or ovarian cancer.
Topical negative pressure (TNP) therapy has emerged as a high‐technology, microprocessor‐controlled physical wound‐healing modality. Complex effects at the wound–dressing interface following ...application of a controlled vacuum force have been documented. These include changes on a microscopic, molecular level and on a macroscopic, tissue level: interstitial fluid flow and exudate management, oedema reduction, effects on wound perfusion, protease profiles, growth factor and cytokine expression and cellular activity, all leading to enhanced granulation tissue formation and improved wound‐healing parameters. Primary indications for clinical use have been documented and include traumatic wounds, open abdominal wounds, infected sternotomy wounds, wound bed preparation, complex diabetic wounds and skin‐graft fixation. Whilst this therapy now forms an essential part of the wound healing armamentarium, extensive clinical trials are recommended to confirm efficacy and delineate its optimum use.
Necrotizing fasciitis (NF) is a life-threatening infection and a surgical emergency. Not all clinicians have the experience or resources to detect NF in its early stages.
To develop a diagnostic ...algorithm for primary care and emergency physicians to identify patients with possible NF, including an initial approach to triaging such individuals.
Medline was searched to identify studies of validated algorithms for NF diagnosis and/or cohort or case series providing clinical and diagnostic features of NF. Candidate algorithms were validated via application to 3 published cases of initially misdiagnosed NF. We retrospectively reviewed NF cases between 2011 and 2022 at our center to validate our algorithm.
The search yielded 540 articles; 109 were included following a review of abstracts. No published validated diagnostic algorithm was identified. Using the reported clinical and diagnostic features of NF, we generated an algorithm of the “3Ds” of NF: Disproportionate pain, Dermatological findings, and Disorganized physiology. A larger number of Ds indicated a greater level of suspicion for NF and prioritization for urgent surgical consultation. In 3 published cases of missed NF, the 3Ds algorithm successfully identified all as having possible NF. On reviewing our cases, we identified 56 patients with NF during an 11 year period. 66% of whom had the 3Ds at their initial presentation.
The 3Ds algorithm, a simple and easy-to-remember tool can be easily applied in a primary or emergency care setting, and may improve the early diagnosis of NF. Retrospective analysis of NF cases allows for validation of this algorithm. However, this algorithm requires prospective validation.
Median sternotomy infection and bony nonunion are two commonly described complications which occur in 0.4-5.1% of cardiac procedures. Although relatively infrequent, these complications can lead to ...significant morbidity and mortality. The aim of this retrospective study is to evaluate the initial experience of a transverse plate fixation system following wound complications associated with sternal dehiscence with or without infection following cardiac surgery.
A retrospective chart review of 40 consecutive patients who required sternal wound reconstruction post sternotomy was performed. Soft tissue debridement with removal of all compromised tissue was performed. Sternal debridement was carried using ronguers to healthy bleeding bone. All patients underwent sternal fixation using three rib plates combined with a single manubrial plate (Titanium Sternal Fixation System®, Synthes). Incisions were closed in a layered fashion with the pectoral muscles being advanced to the midline. Data were expressed as mean±SD, Median (range) or number (%). Statistical analyses were made by using Excel 2003 for Windows (Microsoft, Redmond, WA, USA).
There were 40 consecutive patients, 31 males and 9 females. Twenty two patients (55%) were diagnosed with sternal dehiscence alone and 18 patients (45%) with associated wound discharge. Thirty eight patients went on to heal their wounds. Two patients developed recurrent wound infection and required VAC therapy. Both were immunocompromised. Median post-op ICU stay was one day with the median hospital stay of 18 days after plating.
Sternal plating appears to be an effective option for the treatment of sternal wound dehiscence associated with sternal instability. Long-term follow-up and further larger studies are needed to address the indications, benefits and complications of sternal plating.
Oxidative stress plays an important role in cancer development and treatment. Recent data implicate the tumor suppressor BRCA1 in regulating oxidative stress, but the molecular mechanism and the ...impact in BRCA1-associated tumorigenesis remain unclear. Here, we show that BRCA1 regulates Nrf2-dependent antioxidant signaling by physically interacting with Nrf2 and promoting its stability and activation. BRCA1-deficient mouse primary mammary epithelial cells show low expression of Nrf2-regulated antioxidant enzymes and accumulate reactive oxygen species (ROS) that impair survival in vivo. Increased Nrf2 activation rescues survival and ROS levels in BRCA1-null cells. Interestingly, 53BP1 inactivation, which has been shown to alleviate several defects associated with BRCA1 loss, rescues survival of BRCA1-null cells without restoring ROS levels. We demonstrate that estrogen treatment partially restores Nrf2 levels in the absence of BRCA1. Our data suggest that Nrf2-regulated antioxidant response plays a crucial role in controlling survival downstream of BRCA1 loss. The ability of estrogen to induce Nrf2 posits an involvement of an estrogen-Nrf2 connection in BRCA1 tumor suppression. Lastly, BRCA1-mutated tumors retain a defective antioxidant response that increases the sensitivity to oxidative stress. In conclusion, the role of BRCA1 in regulating Nrf2 activity suggests important implications for both the etiology and treatment of BRCA1-related cancers.
We had anecdotally observed that fluid resuscitation volumes often exceed those estimated by the Parkland Formula in adults with isolated cutaneous burns. The purpose of this study was to compare ...estimated and actual fluid resuscitation volumes using the Parkland Formula. We performed a retrospective study of fluid resuscitation in patients with burns > or = 15% TBSA. Patients with inhalation injury, high voltage electrical injury, delayed resuscitation, or associated trauma were excluded. We studied 31 patients (mean age 51 +/- 20 years, mean TBSA burn 27 +/- 10%). The 24 hour resuscitation volume of 13 354 +/- 7386 ml (6.7 +/- 2.8 ml/kg/%TBSA) was significantly greater than predicted (P = 0.001) and exceeded estimated volume in 84% of the patients. The mean urine output in the first 24 hrs was 1.2 +/- 0.6 ml/kg/hr. After the first 8 hours of resuscitation, the infusion rate decreased by 34% in 16 patients (DCR group), while in 15 patients the rate increased by 47% (INCR group). Both the DCR and INCR groups received significantly more fluid than predicted, (5.6 +/- 2.1 ml/kg/%TBSA and 7.7 +/- 3.1 ml/kg/%TBSA respectively). The INCR patients had significantly larger full thickness burns (14 +/- 11% vs 3 +/- 6%, P < 0.001). Our findings reveal that despite its effectiveness, the Parkland Formula underestimated the volume requirements in most adults with isolated cutaneous burns, and especially in those with large full thickness burns.
Background: During the COVID-19 pandemic, challenges involving variable lockdowns, physical distancing, and reduced patient volumes necessitated modifications in the surgical clerkship curriculum ...(SCC) for medical students. As a result, a period of rapid adaptation in the realm of surgical education ensued at the University of Toronto's faculty of medicine, which represents 19% of all newly trained Canadian physicians each year. Methods: We offer a qualitative analysis of pandemic-related changes to the SCC, focusing on the impact on learners and educators at Canada's largest faculty of medicine. Our diverse team of faculty and trainee authors were directly involved in the surgical clerkship experience over the last year and a half. Results: Adaptation to pandemic restrictions involved a significant increase in digital curriculum delivery and a flipped-classroom approach, while maintaining an emphasis on core competencies defined by the CanMEDS framework. Virtual delivery was a welcome change, and virtual rounds and handovers improved convenience for attendees, often across different sites. For medical students briefly assigned to a service, these changes may have diminished an immersive team experience and reduced opportunities for physical exam, surgical skill development, and career exploration. Nearly all students at our institution were able to complete required components of the SCC. Conclusion: An increase in virtual delivery of the SCC was well-tolerated by learners, but a reduction of in-person experiences carried a negative impact on skill development and career exploration. Future studies to evaluate and refine these changes using a CanMEDS framework will be crucial to engender lasting improvements to surgical education.
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