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[This corrects the article DOI: 10.7759/cureus.22513.].

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Burns to the breast are a rare complication after breast reconstruction. Decreased sensation and radiation therapy may contribute to the development of burns. Solar burns may also be related to wearing dark-colored clothing. This literature review aims to analyze the incidence of solar burns on alloplastic and autologous breast reconstruction following mastectomy. Also included is the first published report of a delayed breast burn years after alloplastic reconstruction. Methods: A PubMed literature search of articles was performed using the search formula "burns" AND "breast reconstruction." Abstracts were evaluated for relevance based on inclusion and exclusion criteria. Pertinent reference bibliographies were then screened for additional relevant resources. Results: The PubMed search resulted in 598 articles, of which 12 met inclusion criteria with 22 cases of solar burns to reconstructed breasts (23 including the addition of our case report). Five occurred following alloplastic reconstruction with 80% of these patients radiated and 100% wearing dark clothing. The remaining 18 patients had autologous reconstruction with 50% wearing dark clothing. Twenty-two percent of patients in the autologous group required surgical debridement as compared to 40% of the alloplastic group. Conclusions: Solar burns in autologous and alloplastic breast reconstruction, while rare, pose significant complications in the reconstructed breast and appear to be exacerbated by radiation and dark-colored clothing. Patients should be counseled accordingly with discussion of this potential risk in a comprehensive informed consent, and precautions should be recommended to avoid this type of injury.

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Regeneration of peripheral nerves after repair is incomplete. Painful microneuromas may form at the site of an appropriately performed primary microsurgical nerve repair leading to a persistent Tinel's sign and hypersensitivity in that location. Here, we describe an autologous option using a free muscle-derived nerve wrap with the intent to capture axonal escape at the site of primary nerve coaptation. We demonstrate this technique on a patient undergoing primary nerve repair of a laceration to the superficial branch of the radial nerve using extensor digitorum communis muscle as a donor graft. This has become our preferred technique over commercially available nerve wraps as the muscle wrap is autologous, not limited by cost, and has the potential to limit microneuroma formation at the coaptation site.

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BACKGROUND: The recovery for patients after tendon repair is frequently limited by development of tendon adhesions. This scar tissue formation is dependent on immune system activation. Tacrolimus has unique properties that may contribute to the prevention of overactive scarring by inhibition of inflammatory cytokines. METHODS: Herein, we present a case using systemic immunosuppression to prevent recurrent adhesion accumulation in a patient with a prior spaghetti wrist injury. Tacrolimus began 1 week before repeat-secondary tenolysis surgery, and it continued for 3 months postoperative. Dosing was tapered to a serum level between 5 and 8 µg/L. RESULTS: The 27-year-old male patient suffered a volar wrist laceration transecting all flexor tendons and volar wrist nerves. He underwent immediate repair but had a poor outcome despite early range of motion therapy. A primary tenolysis only improved his average arc of finger motion from 72 to 95 degrees. Secondary tenolysis augmented with systemic tacrolimus improved his arc of finger motion from 95 to 202 degrees. Mechanistically, tacrolimus prevents proper function of activated T and B cells. This results in decreased proliferation, angiogenesis, and cytoskeletal organization of fibroblasts on inflammation and integrin adhesions, and it potentially explains the reduced tendon molecule adhesions seen in this patient. CONCLUSIONS: Tacrolimus may be effective in reducing motion, limiting tendon adhesions. The novel use of this medication resulted in the return of near-normal hand function in a patient placed on low-dose tacrolimus after primary tenolysis had failed.

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Adjuvant therapy plays an integral role in the treatment algorithm for stage III and stage IV cutaneous melanoma. Current ongoing clinical trials are exploring the effects of neoadjuvant therapeutics, specifically for the presurgical treatment of high-risk, borderline resectable disease. In both the adjuvant and neoadjuvant settings, the early chemotherapeutic and biochemical antitumor agents are making way to newer immune therapies, mutation-specific targeted therapies, and oncolytic vaccines that are transforming the treatment of malignant melanoma. The use of these systemic therapies in addition to surgical resection has been shown to increase both overall and progression-free survival.

Asunto(s)

Melanoma , Neoplasias Cutáneas , Quimioterapia Adyuvante , Terapia Combinada , Humanos , Melanoma/tratamiento farmacológico , Terapia Neoadyuvante , Neoplasias Cutáneas/terapia

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Rare variants of melanoma include melanoma in pregnancy and pediatric melanoma. Because of their low incidence, treatment recommendations are based on standards of treatment for cutaneous melanoma; however, each of these forms requires specific considerations during diagnosis, staging, and treatment.

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Melanoma , Pediatría , Neoplasias Cutáneas , Niño , Femenino , Humanos , Incidencia , Melanoma/diagnóstico , Melanoma/epidemiología , Melanoma/terapia , Estadificación de Neoplasias , Embarazo , Neoplasias Cutáneas/diagnóstico , Neoplasias Cutáneas/epidemiología , Neoplasias Cutáneas/cirugía

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Plastic surgeons report the highest prevalence of chronic musculoskeletal pain and fatigue among surgical subspecialties. Musculoskeletal pain impacts daily life, career longevity, and economic burden secondary to occupational injury. Poor postural awareness and ergonomic set up in the operating room represent the most common etiology. METHODS: A literature review was performed to highlight the ergonomic set-up, postural pitfalls, occupational injuries, and musculoskeletal pain in the operating room. An institutional survey was administered among resident and attending surgeons regarding musculoskeletal pain, posture, ergonomic education, and future improvements. Literature results, survey data, and intraoperative photographs were analyzed in collaboration with physical therapists and personal trainers. RESULTS: Survey results demonstrated that 97% of resident and attending respondents experienced musculoskeletal pain and 83% reported a lack of education in posture and ergonomics. The main postural pitfalls included head forward and flexed positioning, abduction and internal arm rotation, and kyphosis of the thoracic spine. The collaborators developed instructional videos to assess posture and biomechanics and demonstrate targeted stretching and strength exercises to address specific neck, back, and shoulder pain. CONCLUSIONS: Poor posture is unavoidable in the operating room at times. These educational videos should be utilized for self-motivated and prophylactic conditioning outside of the operating room to maintain physical well-being throughout a career in plastic surgery. Future focus should be aimed at implementing dedicated ergonomic education and physical wellness programs early in surgical resident training.

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This article discusses the pathophysiology, presentation, cause, and treatment of ischemic pain in the surgical patient. Causes of ischemic pain vary but all fundamentally cause local acidosis in the peripheral tissues, which causes signals to be passed through ascending pain pathways to the thalamus and eventual cerebral cortex where it is interpreted as ischemic pain. Ischemic pain is classically associated with an insidious onset but can present in the acute or chronic setting. Treatments are aimed at improving perfusion to the affected tissue. Surgical options include repairing damaged vessels, bypassing diseased vessels, performing thrombectomy, or embolectomy. Numerous conservative therapies exist.

Asunto(s)

Embolectomía/métodos , Isquemia/complicaciones , Manejo del Dolor/métodos , Dolor/etiología , Tromboembolia/complicaciones , Terapia Trombolítica/métodos , Humanos , Isquemia/terapia , Tromboembolia/terapia

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Complex regional pain syndrome (CRPS) has been described as pain a patient feels that is disproportionate to the inciting event. CRPS is also associated with autonomic dysfunction, swelling, dystrophic skin changes, stiffness, functional impairment, and eventual atrophy. This hyperalgesic disease affects musculoskeletal, neural, and vascular structures more commonly in the upper extremity than the lower extremity. Although the etiology behind the pathophysiology of CRPS is unknown, the pain pathway extending from peripheral nociception to central nervous system modulation of stimuli is highly sensitized and overactive, disrupting the surrounding autonomic response. The diagnosis and treatment of CRPS are reviewed.

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Síndromes de Dolor Regional Complejo/terapia , Manejo del Dolor/métodos , Dimensión del Dolor/métodos , Síndromes de Dolor Regional Complejo/diagnóstico , Humanos , Extremidad Superior

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BACKGROUND: Liposomal bupivacaine (Exparel) is a long-acting local anesthetic preparation with demonstrated efficacy over placebo in reducing postoperative pain and opioid requirement. Limited comparative efficacy and cost-effectiveness data exist for its use in total knee arthroplasty (TKA) when used in a multimodal, opioid-sparing analgesic and anesthetic approach. We hypothesized that liposomal bupivacaine offers no clinical advantage over our standard of care but carries significant economic impact. METHODS: This is a prospective, randomized, single-blinded, controlled trial comparing liposomal bupivacaine periarticular injection (PAI) to our current approach including conventional bupivacaine PAI, in the setting of regional anesthesia. All adult unilateral TKA patients of the collaborating surgeon were eligible to participate in the study. Patients were randomized 1:1 to either the liposomal bupivacaine protocol or the standard-of-care protocol. All patients received regional anesthesia and standard postoperative analgesia protocols. Patients and all postoperative healthcare providers were blinded to study arm assignment. RESULTS: A total of 59 patients were enrolled per our a priori power calculation after 1 exclusion for randomization error. No significant demographic differences between the study arms were found. There was no statistically significant difference in the primary outcome of number of physical therapy (PT) sessions required to achieve home-going discharge goals (3.0 ± 1.2 vs 3.6 ± 1.3, P = .137), nor in the clinical secondary outcomes. A significant difference in medication charges was found. CONCLUSION: Our study supports earlier literature suggesting no significant clinical benefit of using liposomal bupivacaine over standard of care in TKA and underscores cost-of-care concerns with this agent.

Asunto(s)

Anestésicos Locales/administración & dosificación , Artroplastia de Reemplazo de Rodilla/efectos adversos , Bupivacaína/administración & dosificación , Dolor Postoperatorio/prevención & control , Anciano , Analgésicos Opioides/administración & dosificación , Anestesia de Conducción , Anestesia Local , Quimioterapia Combinada , Femenino , Humanos , Inyecciones Intraarticulares , Liposomas , Masculino , Persona de Mediana Edad , Manejo del Dolor/métodos , Dimensión del Dolor , Dolor Postoperatorio/etiología , Estudios Prospectivos

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BACKGROUND: Inguinal lymphadenectomy (LND) is influential in reducing the mortality of squamous cell carcinoma of the penis (SCCP). We investigated the impact of urologic workforce density (UD) and rural residence (RR) on the practice of LND and mortality of SCCP (SCCP-RM). MATERIALS AND METHODS: UD was determined from the 2014 to 2015 Area Health Resource File data, while RR was determined using the 2003 rural-urban continuum codes. All cases of SCCP within the surveillance, epidemiology, and end results 18 registry with known county codes were used for analysis (n = 2863). RESULTS: Overall, 48.69% of cases lived in a county with less than the mean UD, 8.38% lived in counties with no urologists, 14.60% lived in a rural county, and 19.2% (n = 550) had LND performed. UD and RR had no impact on the prevalence of LND, number of lymph nodes examined, or the mean number of lymph nodes positive for SCCP (all p > 0.05). Adjusted analysis indicated that older patients and patients with regional stage of cancer were at a greater risk for post-LND SCCP-RM (hazard ratio [HR] 1.68, 95% confidence interval [CI] 1.28-2.21, and HR 4.32, 95% CI 3.09-6.06, respectively). There was no difference in the HR of SCCP-RM dependent on race, marital status, education, RR, UD, or LND. CONCLUSION: While demand on the urologist workforce has increased in rural demographics, no impact of limited access to urologists on the practice of LND in SCCP could be identified in this study. In addition, there was no significant difference in the risk of SCCP-specific mortality related to lower UD or RR.

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Carcinoma de Células Escamosas/mortalidad , Escisión del Ganglio Linfático/estadística & datos numéricos , Neoplasias del Pene/mortalidad , Características de la Residencia/estadística & datos numéricos , Urólogos/provisión & distribución , Anciano , Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/cirugía , Humanos , Conducto Inguinal , Masculino , Persona de Mediana Edad , Neoplasias del Pene/patología , Neoplasias del Pene/cirugía , Población Rural/estadística & datos numéricos , Programa de VERF , Estados Unidos/epidemiología , Población Urbana/estadística & datos numéricos

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Phosphor-converted light emitting diodes (pcLEDs) produce white light through the use of phosphors that convert blue light emitted from the LED chip into green and red wavelengths. Understanding the mechanisms of degradation of the emission spectra and quantum yields of the phosphors used in pcLEDs is of critical importance to fully realize the potential of solid-state lighting as an energy efficient technology. Toward this end, time-resolved photoluminescence spectroscopy was used to identify the mechanistic origins of enhanced stability and luminescence efficiency that can be obtained from a series of carbidonitride red phosphors with varying degrees of substitutional carbon. The increasing substitution of carbon and oxygen in nitrogen positions of the carbidonitride phosphor (Sr2Si5N8-[(4x/3)+z]CxO3z/2:Eu2+) systematically changed the dimensions of the crystalline lattice. These structural changes caused a red shift and broadening of the emission spectra of the phosphors due to faster energy transfer from higher to lower energy emission sites. Surprisingly, in spite of broadening of the emission spectra, the quantum yield was maintained or increased with carbon substitution. Aging phosphors with lowered carbon content under conditions that accurately reflected thermal and optical stresses found in functioning pcLED packages led to spectral changes that were dependent on substitutional carbon content. Importantly, phosphors that contained optimal amounts of carbon and oxygen possessed luminescence spectra and quantum yields that did not undergo changes associated with aging and therefore provided a more stable color point for superior control of the emission properties of pcLED packages. These findings provide insights to guide continued development of phosphors for efficient and stable solid-state lighting materials and devices.

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OBJECTIVE: Cocaine users display deficits in inhibitory control and make impulsive choices that may increase risky behavior. Buspirone is an anxiolytic that activates dopaminergic and serotonergic systems and improves impulsive choice (i.e., reduces sexual risk-taking intent) in cocaine users when administered chronically. We evaluated the effects of acutely administered buspirone on inhibitory control and impulsive choice. METHODS: Eleven subjects with a recent history of cocaine use completed this within-subject, placebo-controlled study. Subjects performed two cued go/no-go and a sexual risk delay-discounting task following oral administration of buspirone (10 and 30 mg), triazolam (0.375 mg; positive control), and placebo (negative control). Physiological and psychomotor performance and subject-rated data were also collected. RESULTS: Buspirone failed to change inhibitory control or impulsive choice; however, slower reaction times were observed at the highest dose tested. Buspirone did not produce subject-rated drug effects but dose-dependently decreased diastolic blood pressure. Triazolam impaired psychomotor performance and increased ratings of positive subject-rated effects (e.g., Like Drug). CONCLUSIONS: These findings indicate that acutely administered buspirone has little impact on behavioral measures of inhibitory control and impulsive sexual decision-making. Considering previous findings with chronic dosing, these findings highlight that the behavioral effects of buspirone differ as a function of dosing conditions.

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Buspirona/administración & dosificación , Trastornos Relacionados con Cocaína/psicología , Descuento por Demora/efectos de los fármacos , Inhibición Psicológica , Conducta Sexual/efectos de los fármacos , Conducta Sexual/psicología , Adulto , Ansiolíticos/administración & dosificación , Descuento por Demora/fisiología , Método Doble Ciego , Femenino , Humanos , Masculino , Persona de Mediana Edad , Desempeño Psicomotor/efectos de los fármacos , Desempeño Psicomotor/fisiología , Tiempo de Reacción/efectos de los fármacos , Tiempo de Reacción/fisiología , Conducta Sexual/fisiología

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BACKGROUND: A variety of patient factors are known to adversely impact outcomes after carotid endarterectomy (CEA) or carotid artery stenting (CAS). However, their specific impact on complications and mortality and how they differ between CEA and CAS is unknown. The purpose of this study is to identify patient and hospital factors that adversely impact outcomes. METHODS: Patients who underwent CEA or CAS between 1998 and 2012 (N = 1,756,445) were identified using the Agency for Healthcare Research and Quality National Inpatient Sample and State Ambulatory Services Databases. A multivariate analysis was completed to evaluate the impact of demographics, patient factors, type of symptoms (transient ischemic attack or cerebrovascular accident), volume of cases (3 per year vs 1-2 interventions), and interventions upon outcomes, perioperative complications (stroke, myocardial infarction, and bleeding), duration of stay, inpatient mortality, and cost. Significant factors were then used as part of a multivariate regression analysis to determine odds ratios. A subgroup analysis using propensity matching evaluating 1:1 risk-matched asymptomatic and symptomatic patients was completed. Patient cohorts were matched on the basis of Charlson scores. RESULTS: Over the study period a total of 1,583,614 asymptomatic CEA, 7317 asymptomatic CAS, 162,362 symptomatic CEA, and 3149 symptomatic CAS patients were included. Symptomatic disease portends a worse outlook after either CEA or CAS. Costs of the procedure increased with complications with stroke adding the most significant cost burden. For risk-matched asymptomatic and symptomatic patients, female gender (P < .001) and performing one or two cases per year (P < .05) were associated with higher cerebrovascular accident risk. In asymptomatic and symptomatic patients, predictors of myocardial infarction included congestive heart failure (P < .001) and peripheral artery disease (P < .05) and predictors of bleeding included peripheral artery disease (P < .05) and chronic obstructive pulmonary disease (P < .01) for symptomatic patients only. For both asymptomatic and symptomatic patients, predictors of mortality included female gender (P < .001) and performing one or two cases per year (P < .01). Female gender was one of the strongest overall predictors of adverse outcome after CAS (odds ratio, 21.39 for death; P < .001). Low volume (<3 cases per year per practitioner) is a predictor of adverse outcome after CAS only. CONCLUSIONS: Higher rates of postoperative stroke and inpatient mortality for women undergoing CAS is an unexpected finding, and may indicate that this population is vulnerable to complications after endovascular management. Low volume is a predictor of complications and subsequent mortality primarily for CAS. Patients who undergo CEA continue to have superior outcomes compared with matched cohorts who undergo CAS.

Asunto(s)

Angioplastia/efectos adversos , Enfermedades de las Arterias Carótidas/terapia , Endarterectomía Carotidea/efectos adversos , Angioplastia/economía , Angioplastia/instrumentación , Angioplastia/mortalidad , Enfermedades Asintomáticas , Enfermedades de las Arterias Carótidas/complicaciones , Enfermedades de las Arterias Carótidas/economía , Enfermedades de las Arterias Carótidas/mortalidad , Distribución de Chi-Cuadrado , Análisis Costo-Beneficio , Bases de Datos Factuales , Endarterectomía Carotidea/economía , Endarterectomía Carotidea/mortalidad , Costos de la Atención en Salud , Mortalidad Hospitalaria , Hospitales de Bajo Volumen , Humanos , Ataque Isquémico Transitorio/etiología , Modelos Logísticos , Análisis Multivariante , Oportunidad Relativa , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Puntaje de Propensión , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores Sexuales , Stents , Accidente Cerebrovascular/etiología , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos

RESUMEN

Although the mechanism is unknown, Btx-A injection may be an effective, localized, nonsurgical treatment option without addictive properties or systemic side effects for the treatment of ischemic digits. Clinical research supports the safety and efficacy of injection of Btx-A for the treatment of Raynaud phenomenon.

Asunto(s)

Toxinas Botulínicas Tipo A/uso terapéutico , Fármacos Neuromusculares/uso terapéutico , Enfermedad de Raynaud/tratamiento farmacológico , Toxinas Botulínicas Tipo A/farmacología , Contraindicaciones , Humanos , Inyecciones Intralesiones , Fármacos Neuromusculares/farmacología , Enfermedad de Raynaud/fisiopatología , Resultado del Tratamiento , Vasoconstricción/efectos de los fármacos , Vasoconstricción/fisiología

RESUMEN

Reductive cleavage of C(6)F(5)SeSeC(6)F(5) with elemental M (M = Zn, Cd, and Hg) in pyridine results in the formation of (py)(2)Zn(SeC(6)F(5))(2), (py)(2)Cd(SeC(6)F(5))(2), and Hg(SeC(6)F(5))(2). Structural characterization of the Zn and Cd compounds reveals tetrahedral coordination environments, while the Hg compound shows a complicated series of linear structures with two short, nearly linear Hg-Se bonds, up to two longer and perpendicular Hg...Se interactions, and no coordinated pyridine ligands. All three compounds exhibit well-defined intermolecular pi-pi-stacking interactions in the solid state. They are volatile and decompose at elevated temperatures to give MSe and either (SeC(6)F(5))(2) or Se(C(6)F(5))(2).

RESUMEN

A pair of mer-octahedral lanthanide chalcogenolate coordination complexes [(THF)(3)Ln(EC(6)F(5))(3) (Ln = Er, E = Se; Ln = Yb, E = S)] have been isolated and structurally characterized. Both compounds show geometry-dependent bond lengths, with the Ln-E bonds trans to the neutral donor tetrahydrofuran (THF) significantly shorter than the Ln-E bonds that are trans to negatively charged EC(6)F(5) ligands. Density functional theory calculations indicate that the structural trans influence evidenced by the differences in these bond lengths results from a covalent Ln-E interaction involving ligand p and Ln 5d orbitals.

RESUMEN

The title salt, [Yb(C(4)H(10)O(2))(4)][Hg(2)(C(6)H(5)Se)(6)], consists of eight-coordinate homoleptic [Yb(DME)(4)](2+) dications (DME is 1,2-dimethoxy-ethane) countered with [Hg(2)(SePh)(6)](2-) di-anions. The cations and anions have twofold rotation and inversion symmetry, respectively. The Yb centre displays a square-anti-prismatic coordination geometry and the Hg centre has a distorted tetra-hedral coordination environment. One phenyl-selenolate anion and one methyl group of a DME ligand are disordered over two positions with equal occupancies. This structure is unique in that it represents a less common mol-ecular lanthanide species in which the lanthanide ion is not directly bonded to an anionic ligand. There are no occurrences of the [Hg(2)(SePh)(6)](2-) dianion in the Cambridge Structural Database (Version of November 2007), but there are similar oligomeric and polymeric Hg(x)(SePh)(y) species. The crystal structure is characterized by alternating layers of cations and anions stacked along the c axis.

RESUMEN

Reactions of Ln(SePh)3 with SeO2 in THF give octanuclear oxoselenido clusters with the general formula (THF)8Ln8O2Se2(SePh)16 (Ln = Ce, Pr, Nd, Sm). In this isomorphous series, the eight Ln(III) ions are connected in the center by a pair of mu3-O2- ligands and mu5-Se2- ligands, with 14 bridging and two terminal selenolate ligands capping the cluster surface. Thermal decomposition at 700 degrees C of the Nd compound in vacuo led to the formation of a phase mixture of NdSe2, Nd2Se3, and Nd2O3. Near-IR emission experiments on the (THF)8Nd8O2Se2(SePh)16 and the fluorinated thiolate compound (DME)2Nd(SC6F5)3 demonstrate that clusters with oxo ligands are not only highly emissive, but also they emit at wavelengths not found in conventional oxides.