The changing paradigm of ethics in uterus transplantation: a systematic review

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/154399/1/tri13548_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/154399/2/tri13548.pd

Increased flap weight and decreased perforator number predict fat necrosis in DIEP breast reconstruction

PMID: 25289212BACKGROUND: Compromised perfusion in autologous breast reconstruction results in fat necrosis and flap loss. Increased flap weight with fewer perforator vessels may exacerbate imbalances in flap perfusion. We studied deep inferior epigastric perforator (DIEP) and muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps to assess this concept. METHODS: Data from patients who underwent reconstruction with DIEP and/or MS-TRAM flaps between January 1, 2010 and December 31, 2011 (n = 123) were retrospectively reviewed. Patient demographics, comorbidities, intraoperative parameters, and postoperative outcomes were collected, including flap fat necrosis and donor/recipient site complications. Logistic regression analysis was used to examine effects of flap weight and perforator number on breast flap fat necrosis. RESULTS: One hundred twenty-three patients who underwent 179 total flap reconstructions (166 DIEP, 13 MS-TRAM) were included. Mean flap weight was 658 ± 289 g; 132 (73.7%) were single perforator flaps. Thirteen flaps (7.5%) developed fat necrosis. African American patients had increased odds of fat necrosis (odds ratio, 11.58; P < 0.001). Odds of developing fat necrosis significantly increased with flap weight (odds ratio, 1.5 per 100 g increase; P < 0.001). In single perforator flaps weighing more than 1000 g, six (42.9%) developed fat necrosis, compared to 14.3% of large multiple perforator flaps. CONCLUSIONS: Flaps with increasing weight have increased risk of fat necrosis. These data suggest that inclusion of more than 1 perforator may decrease odds of fat necrosis in large flaps. Perforator flap breast reconstruction can be performed safely; however, considerations concerning race, body mass index, staging with tissue expanders, perforator number, and flap weight may optimize outcomes.JH Libraries Open Access Fun

Preoperative anemia and postoperative outcomes in immediate breast reconstructive surgery : a critical analysis of 10,958 patients from the ACS-NSQIP database

PMID: 25289224Background: Preoperative anemia is independently associated with adverse outcomes after general and cardiac surgery. Outcomes after breast reconstruction are not established. We assessed the effect of preoperative anemia on 30-day postoperative morbidity and length of hospital stay (LOS) in patients undergoing immediate breast reconstruction. Methods: We identified patients undergoing immediate breast reconstruction from 2008 to 2010 from the American College of Surgeons’ National Surgical Quality Improvement Program database (a prospective outcomesbased registry from hospitals worldwide). De-identified data were obtained for demographics, preoperative risk factors, 30-day morbidity, and LOS. Morbidity variables included flap/graft/prosthesis, cardiac, respiratory, neurological, urinary, wound, and venous thromboembolism outcomes. Logistic regression assessed the crude and adjusted effect of anemia (hematocrit <36%) on postoperative 30-day morbidity. Measures of central tendency of LOS were compared across increasing severities of anemia in patients developing adverse events versus controls. Results: The study population included 10,958 patients; 1556 (16.74%) had preoperative anemia. Crude odds ratio for 30-day morbidity was significantly higher in anemic patients, unadjusted odds ratio = 1.33 (P < 0.008). This prevailed after extensive adjustment for confounding, yielding an adjusted odds ratio = 1.38 (P < 0.03). Patients who experienced adverse effects had protracted LOS, and the presence of anemia significantly amplified this effect. Conclusions: These data provide new insight into the effect of anemia in immediate breast reconstruction, demonstrating an independent association between preoperative anemia and 30-day morbidity. These findings suggest treating anemia when possible; however, prospective studies should explore the efficacy, safety, and cost-effectiveness of such treatments.JH Libraries Open Access Fun

Use of vascular clips to approximate skin grafts on the burned hand

Background: Burns of the hands are common and can lead to significant functional and aesthetic impairment. Traditionally, sutures or staples are used to approximate adjacent skin grafts on the hand; however, we have found that vascular clips are a suitable alternative. We report a series of three patients in which vascular clips were used to approximate adjacent skin grafts autografted to treat full-thickness burns. Methods: Three patients presented with full-thickness burns involving their hands. Vascular clips were used to adhere adjacent skin grafts to the dorsal surfaces of the hands. Two patients sustained bilateral burns to the hands; vascular clips were used on one hand while sutures or staples were used on the other hand. In another patient, vascular clips were used. Results: Satisfactory functional and aesthetic outcomes were observed in all three patients 1–2 months post-reconstruction. One patient had hypertrophic scarring at multiple graft sites including his hands. Similar functional and aesthetic outcomes were achieved in both hands of the patients who had skin grafts approximated with vascular clips and traditional methods. Conclusion: Use of vascular clips to approximate skin grafts on the hands is a simple and effective method resulting in satisfactory functional and aesthetic outcomes. Keywords: Skin graft, Vascular cli

The Ethics of Penis Transplantation: A Systematic Review

Purpose: We conducted this systematic review to document ethical concerns regarding human penis allotransplantation and how these concerns have changed over time. Methods: We searched six databases (MEDLINE via PubMed, Embase, CINAHL, Scopus, Web of Science, and Google Scholar) from inception to November 9, 2018 to find articles addressing ethical concerns related to penis allotransplantation. Inclusion criteria were articles written in English on the topic of penis allotransplantation that discussed at least one bioethical principle. Data was extracted and categorized into the four bioethical pillars: autonomy, beneficence, nonmaleficence, and justice. We assessed theme frequency by publication year and temporal trends. A sub-analysis of the Bioethical pillars and themes specifically addressing the first penis transplantation case performed in 2006 were extracted and evaluated separately. Results:Search results yielded 142 citations. Thirty-nine articles were eligible and included in the final data extraction and analysis. Publication years were 2006 through 2018 with an average of 3 publications per year (range: 0 to 12). The most frequently addressed bioethical pillar was nonmaleficence with themes included in 37 of 39 articles (95%), followed by beneficence (36 of 39, 92%), justice (32 of 39, 82%), and autonomy (29 of 39, 74%). Top concerns pertaining to nonmaleficence included the risk-benefit ratio (n=30, 81%) and risks of long-term immunosuppression (n=29, 78%). Top concerns regarding beneficence included restoration of bodily function, integrity, or aesthetics (n=33, 92) and improved QOL (n=25, 69%). Top concerns pertaining to justice included patient selection (n=25, 78%), burden to donor family, and impact on deceased donor solid organ donation (n=13, 41%). Top concerns regarding autonomy included patient informed consent (n=18, 62%), and donor or donor family informed consent (n=16, 55%). Bioethical issues in reference to the 2006 case were mentioned in 29 of 39 articles (74%); nonmaleficence was most often addressed, mentioned in 27 of 29 articles (93%). Conclusions: Penis transplantation has been a topic of much ethical debate. During the 12-year study period, nonmaleficence was the most common recurring ethical pillar with the two most common themes being risks and benefits for undergoing the procedure and the need for life-long immunosuppression. The first attempt in 2006 that resulted in the graft being removed greatly influenced the field of penis transplantation

The Effects of Depression and Anti-depressants on Patient Satisfaction after Breast Reconstruction

Background: A personal history of depression prior to a breast cancer diagnosis and its effect on post-diagnosis quality of life (QOL) in women undergoing breast reconstruction is relatively unknown. We performed the current study to determine if depression alters QOL for patients who undergo breast reconstruction by assessing the pre-to-post-operative change in patient-reported BREAST-Q scores. Methods: This study is a single-center, post-hoc analysis of 300 patients with completed BREAST-Q data who underwent breast reconstruction following a diagnosis of breast cancer from November 2013 to 2016. Patients completed the BREAST-Q at four time points: pre-operatively, 6-weeks following tissue expander insertion for patients undergoing staged reconstruction, 6-months following final reconstruction, and 12-months following final reconstruction. Medical records of breast reconstruction patients were reviewed to identify patients who had a pre-cancer diagnosis of clinical depression and/or anti-depressant medication use. BREAST-Q scores were compared between the depression (n=50) and no depression (n=250) patients, along with anti-depressant (n=36) and no anti-depressant (n=14) use in the depression group. Results: The Sexual Well-being scores at the 6-week tissue expander follow up for patients in the depression group (median = 37, IQR = 25-47) were significantly lower (p\u3c0.01) than the scores for patients in the no depression group (median = 47, IQR = 39-60) following adjusted analysis. There were no statistically significant differences in BREAST-Q scores in other domains. Conclusion: Patients with a diagnosis of depression prior to breast cancer had lower BREAST-Q Sexual Well-being scores in the 6-week tissue expander group with or without anti-depressant medication. No differences in BREAST-Q scores were observed among the remaining domains, although Satisfaction of Breasts: 6-months post-op, Psychosocial Well-being: 6-weeks post TE, Sexual Well-being: 6-weeks post TE and 6-months post-op were clinically significant

Women Continue to Be Underrepresented in Surgery: A Study of AMA and ACGME Data from 2000-2016

Objective: In the past decade women have comprised nearly half of U.S. medical school graduates. However, women remain underrepresented among surgical residents and practicing surgeons. We conducted the current study to assess recent trends in the female-to-male (F:M) ratios among residents and physicians pursuing careers in surgery. Design: We used retrospective population statistics published by the American Medical Association (AMA) and the Accreditation Council for Graduate Medical Education (ACGME) from 2000-2016. We compared trends of female-to-male ratios among residents and surgeons in surgical subspecialties to evaluate for potential differences over time. Setting: Published online population statistics Participants: We stratified both board-certified surgeons and surgical residents by sex and specialty. Results: From 2000-2013, the proportion of female surgeons among all female physicians remained constant (12-13%). The proportion of board-certified female surgeons to all surgeons increased (from 15% in 2000 to 25% in 2013). The F:M ratios of board-certified surgeons in neurosurgery and orthopedic surgery were 1:10.6 and 1:13.9, with resident ratios 1:4.8 and 1:5.9, respectively. One specialty with increasingly equivalent ratios is plastic surgery with integrated resident F:M ratios of 1:3.1 in 2008 to 1:1.4 in 2015, and board-certified plastic surgeons of 1:9.2 in 2008 to 1:5.3 in 2013. Conclusion: Although the gender gap is narrowing, women continue to be underrepresented in surgical specialties. It is important for fields with disproportionate representation to be aware of these differences and take steps towards creating and supporting a more diverse workforce