Renal Mass Ablation in the Octogenarian and Nonagenarian Population

Introduction: The gold standard for the management of T1a and T1b renal tumors is partial nephrectomy. This study aims to analyze the outcomes of renal mass thermal ablations as an alternative therapy in the octogenarian and nonagenarian patient population, specifically. Methods: Departmental database of all percutaneous renal ablations performed between February 2008 and August 2019 was reviewed. 34 tumors were ablated in 19 males and 15 females with a mean age of 84.1 ± 3.1 years (range 80-92 years). Patient demographics, procedural and postprocedural data were evaluated. Results: Ten microwave and 24 cryoablations were performed, all ablations were performed under CT guidance for 27 T1a and 7 T1b renal tumors (1.4-5.9cm). The mean Charlson comorbidity index was 6.7. Thirty-one ablations were performed as the primary management, 3 were performed for tumor recurrence following partial nephrectomy (2) or prior ablation (1). The average number of probes used in cryoablation was 3.3 compared to 2.7 probes used in microwave ablation. Overall complication rate in cases in the 31 cases in which there was sufficient follow up was 23% and major complication rate was 13%, including two episodes of bleeding requiring red blood cell transfusion. Additionally there was one incidentally detected pseudoaneurysm in the ablation cavity of an asymptomatic patient which was subsequently embolized more than one year following the ablation. The mean pre procedure creatinine was 1.20 and mean creatinine at least 3 months post procedure was 1.23. Of the 25 patients with at least 3 months of CT or MR follow up, there was no local recurrence and median follow-up was 23.7 months (range 1.1-94.9 months). Concurrent biopsies were performed in 31 of the 34 cases. The pathology showed a majority of clear cell renal cell carcinoma (15), followed by oncocytic neoplasm (7), nondiagnostic specimen (4) and papillary renal cell carcinoma (3). Discussion: Thermal ablation of renal masses in the elderly population is an effective treatment option with a low recurrence rate. Complications are higher than previously reported in the literature which may be related the advanced age and comorbidities of these patients

Repair of Nasal Septal Perforation with Porcine Small Intestinal Submucosa Xenograft

Background: Numerous techniques have been described for nasal septal perforation repair, with various degrees of success in achieving closure. Evidence supports the use of bilateral mucoperichondrial advancement flaps with interpositional grafting for greatest success. Many surgeons use autografts such as fascia, cartilage, bone, and pericranium, however, extracellular matrices have also become popular. Objective: We analyze factors determining the success of nasal septal perforations repaired using using an acellular, freeze-dried interpositional xenograft derived from Porcine Small Intestinal Submucosa (PSIS). Methods: Patients with septal perforation repaired by the senior author from 1998 to 2006 were examined in a retrospective chart review with regard to perforation size, etiology, pre- and postoperative symptoms, follow-up, outcomes and complications. Results: Forty-seven PSIS repairs were performed on 46 patients. Two procedures were planned staged procedures. Of the total 47 procedures, 41 (87.2%) continued to be closed at the site of repair during the follow up period. Follow up ranged from 6 months to 4.9 years with a mean of 18.3 months. Two patients (4.3%) were found to have perforations at the site of closure in the immediate post-operative period. One patient (2.1%) perforated at the site of closure after the immediate post-operative period. Subjective symptom scores demonstrated improvement in crusting, epistaxis and obstruction postoperatively. Larger perforations correlated with poorer outcomes. Conclusions: The authors conclude that closure of nasal septal perforation with an interpositional xenograft derived from PSIS compares favorably to published results for autografts with advantages including absence of donor site morbidity, easy graft modification and manipulation, and shorter operative time

The Subscapular System of Flaps in Head and Neck Reconstruction

Presentation: 35:41 Note: PowerPoint slides are at bottom of page

Creating metamaterial building blocks with directed photochemical metallization of silver onto DNA origami templates

DNA origami can be used to create a variety of complex and geometrically unique nanostructures that can be further modified to produce building blocks for applications such as in optical metamaterials. We describe a method for creating metal-coated nanostructures using DNA origami templates and a photochemical metallization technique. Triangular DNA origami forms were fabricated and coated with a thin metal layer by photochemical silver reduction while in solution or supported on a surface. The DNA origami template serves as a localized photosensitizer to facilitate reduction of silver ions directly from solution onto the DNA surface. The metallizing process is shown to result in a conformal metal coating, which grows in height to a self-limiting value with increasing photoreduction steps. Although this coating process results in a slight decrease in the triangle dimensions, the overall template shape is retained. Notably, this coating method exhibits characteristics of self-limiting and defect-filling growth, which results in a metal nanostructure that maps the shape of the original DNA template with a continuous and uniform metal layer and stops growing once all available DNA sites are exhausted

Risk Factors of Not Reaching MCID after Elective Lumbar Spine Surgery: A Case Control Study

Background The therapeutic effect of spine surgery has been traditionally evaluated by physical examination, radiographic findings, and general perception of patient’s health status. However, these assessments are often insufficient to represent surgical outcomes.Patient-reported outcomes (PROs) are tools developed to measures quality outcomes following spinal surgery. Examples include the Patient-Reported Outcomes Measurement Information System Function 4-item Short Form (PROMIS-PF), Visual Analogue Scale (VAS), ODI (Oswestry Disability Index), SF-36 (Short Form Health Survey), and EQ-5D (EuroQuol-5D). The minimum clinically important difference (MCID) is an assessment tool to note the smallest clinical difference in PROs and provides the threshold where patients experience clinical benefit that justifies treatment plans or procedures despite the cost and side effects. MCID results reflect patient-perceived functional improvement, which can be a core metric in lumbar surgery for degenerative disease. Clinical and sociodemographic risk factors may serve to identify high-risk patients via MCID assessment. This study aims to identify risk factors associated with failure of reaching MCID based on PROMIS PF after elective lumbar spine surgery and the data registry from Michigan Spine Surgery Spine Surgery Improvement Collaborative (MSSIC). The results of this study can provide opportunities to optimize medical conditions of patients in prior to any elective lumbar surgery. METHODS MSSIC is a state-wide quality-improvement initiative database including 29 hospitals and 200 orthopedic- and neurosurgeons from various settings. Member hospitals are required to perform an annual minimum of 200 spine surgeries. MSSIC reviews elective spine surgeries for degenerative disease but excludes non-degenerative and/or complex pathology (i.e., spinal cord injury, traumatic fractures, pre-existing infection, grade 3 or 4 spondylolisthesis, scoliosis greater than 25◦, congenital anomalies, or ≥ 4-level fusion). Utilizing MSSIC, 10,922 patients who had undergone elective lumbar spine surgery were selected with 90 day follow up, and 7,200 patients with 1-year follow up. Patients with missing data were excluded from the study. Patient demographics, clinical presentation, medical history, surgical procedure, details of hospital stay, postsurgical adverse events within 90 days of surgery, and patient-reported outcome after surgery were reviewed. A patient was considered to have achieved MCID if there was an increase in ≥4.5 points. RESULTS Of 10,922 patients with 90-day follow-up, 4,453 patients (40.8%) did not reach MCID. Of 7,200 patients with 1-year follow up, 2,361 patients (23.8%) did not achieve MCID. There were significant baseline differences in demographic profiles and operative characteristics for those who had follow-up at 90 days and 1 year after their surgery. At 90 days after surgery, significant factors of not reaching MCID and their relative risk included symptom duration more than 1 year (1.34), previous spine surgery (1.25), African American descent (1.25), chronic opiate use (1.23), less than high school education (1.20), morbid obesity (1.15), ASA class \u3e2 (1.15), current smoking (1.14), chronic obstructive pulmonary disease (COPD) (1.13), depression (1.09), history of DVT (1.08), scoliosis (1.06), anxiety (1.06), baseline PROMIS (1.06), and surgery invasiveness (1.02). At 1 year after surgery, significant factors of not reaching MCID and their relative risk included symptom duration more than 1 year (1.41), less than high school education (1.34), previous spine surgery (1.30), morbid obesity (1.30), chronic opiate use (1.25), age (1.21), current smoking (1.21), African American descent (1.20), ASA class \u3e2 (1.18), history of DVT (1.12), depression (1.10), chronic obstructive pulmonary disease (COPD) (1.09), and baseline PROMIS (1.06). Independent ambulatory status (0.83 and 0.88 for 90-day and 1-year follow-up, respectively) and private insurance (0.83 and 0.85 for 90-day and 1-year follow-up, respectively) were associated with higher likelihood of reaching MCID. CONCLUSION This case control study identifies relevant risk factors of not reaching MCID after elective lumbar spine surgery. The results may assist clinicians in identifying high risk patients and optimizing patients’ medical conditions prior to spinal surgery