High-dose-rate Interstitial Brachytherapy Boost with a Pedicled Latissimus Dorsi Myocutaneous Flap for Myxofibrosarcoma of the Arm

Summary: A 71-year-old man was found to have a 7.4 × 2.9 × 7.0 cm myxofibrosarcoma of the right medial arm close to neurovascular structures. He received 50 Gray (Gy) of preoperative external beam radiation. Radical resection resulted in a 15 × 10 cm defect. Nine brachytherapy catheters were placed, and a pedicled latissimus dorsi myocutaneous flap was used in reconstruction. Final pathology confirmed myxofibrosarcoma, high grade. The tumor was <1 mm from 2 margins. A total of 17.5 Gy of brachytherapy was delivered to the surgical bed from postoperative days 7 to 9. The flap developed fat necrosis distally which eventually required surgical debridement on postoperative day 58. It subsequently healed well and maintained good function of the limb. The patient remains under surveillance without evidence of recurrence

Face Time: Educating Face Transplant Candidates

Objective: Face transplantation is the innovative application of microsurgery and immunology to restore appearance and function to those with severe facial disfigurements. Our group aims to establish a multidisciplinary education program that can facilitate informed consent and build a strong knowledge base in patients to enhance adherence to medication regimes, recovery, and quality of life. Methods: We analyzed handbooks from our institution's solid organ transplant programs to identify topics applicable to face transplant patients. The team identified unique features of face transplantation that warrant comprehensive patient education. Results: We created a 181-page handbook to provide subjects interested in pursuing transplantation with a written source of information on the process and team members and to address concerns they may have. While the handbook covers a wide range of topics, it is easy to understand and visually appealing. Conclusions: Face transplantation has many unique aspects that must be relayed to the patients pursuing this novel therapy. Since candidates lack third-party support groups and programs, the transplant team must provide an extensive educational component to enhance this complex process. Practice Implications: As face transplantation continues to develop, programs must create sound education programs that address patients’ needs and concerns to facilitate optimal care

Teacher extra work : a local perspective

ix, 109 leaves ; 29 cm. --In this study, 78% (305) teachers of the Alberta Teachers Association Local #41 and Lethbridge Public School District #51, were asked to provide information concerning their present working conditions. In addition, 106 of those respondents took part in a week- long logbook providing more detailed data on the working life of teachers. Three subsets of teachers (elementary school-junior high/middle school-high school) tabulated their extra time spent devoted to (1) professional duties and (2) out of school commitment to instruction. Respondents included: 153 elementary, 57 junior high/middle school and 95 high school teachers. Of the 106 (100%) responding to logbooks, 58 were elementary, 25 were junior high/middle and 23 were high school teachers. On average, teachers in the district as a whole devoted 162.4 hours yearly to professional activities over assigned contractual workload hours (elementary-178.4 hours, junior high/middle school-191.5 hours, high school-119.3 hours). Their extra out-of-school commitment to instruction provided an average of 209.2 hours yearly over assigned contractual workload hours (elementary-123.4 hours, junior high/middle school-243.2 hours, high school-327.0 hours). When total average hours of extra work of professional and school expected time were adjusted to account for preparation time, the figures were 323, 316, and 290 respectively for elementary, junior high, and high school. These data show that there is little discernable difference in the amount of extra work done. Logbooks documented respondents averaging 9.25 hours engaged in school and professional activities during a typical work day. On the weekend respondents recorded an average 6.25 hours further devoted to school and professional related activities. Broken down by subset, school related/professional hours on the weekend included: elementary- 7.41/0.24, junior high/middle school-3.82/0.86, high school-4.0/2.3 respectively. The study provided ATA Local #41 with important information that would expand the baseline data with regard to collective contract agreements and present working conditions. First, it gave future committee members and researchers a basis for comparison. Secondly, the study determined how much time teachers in the district spent on specific teaching and school related activities, and how this differed between elementary, junior/middle and high school levels. Thirdly, the study provided data for comparison in regard to provincial wide studies on teacher workload. Finally, the study provided the Local with data useful in informing the public and other education stakeholders about the nature of teacher workloads

Reduced Radiation Exposure for Face Transplant Surgical Planning Computed Tomography Angiography

Objective: To test the hypothesis that wide area detector face transplant surgical planning CT angiograms with simulated lower radiation dose and iterative reconstruction (AIDR3D) are comparable in image quality to those with standard tube current and filtered back projection (FBP) reconstruction. Materials and Methods The sinograms from 320-detector row CT angiography of four clinical candidates for face transplantation were processed utilizing standard FBP, FBP with simulated 75, 62, and 50% tube current, and AIDR3D with corresponding dose reduction. Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were measured at muscle, fat, artery, and vein. Image quality for each reconstruction strategy was assessed by two independent readers using a 4-point scale. Results: Compared to FBP, the median SNR and CNR for AIDR3D images were higher at all sites for all 4 different tube currents. The AIDR3D with simulated 50% tube current achieved comparable SNR and CNR to FBP with standard dose (median muscle SNR: 5.77 vs. 6.23; fat SNR: 6.40 vs. 5.75; artery SNR: 43.8 vs. 45.0; vein SNR: 54.9 vs. 55.7; artery CNR: 38.1 vs. 38.6; vein CNR: 49.0 vs. 48.7; all p-values >0.19). The interobserver agreement in the image quality score was good (weighted κ = 0.7). The overall score and the scores for smaller arteries were significantly lower when FBP with 50% dose reduction was used. The AIDR3D reconstruction images with 4 different simulated doses achieved a mean score ranging from 3.68 to 3.82 that were comparable to the scores from images reconstructed using FBP with original dose (3.68–3.77). Conclusions: Simulated radiation dose reduction applied to clinical CT angiography for face transplant planning suggests that AIDR3D allows for a 50% reduction in radiation dose, as compared to FBP, while preserving image quality

Perioperative management of face transplantation: A survey

Background: Since the first facial allograft transplantation was reported in France in 2005, 18 cases have been performed in 4 countries and the rate is increasing. Methods: We have devised a survey to assess anesthesia-related management and rationale of facial allograft transplantation. It was sent to the lead anesthesiologists of the first 14 face transplants performed worldwide. Results: Responses were received corresponding to 13 face transplants. The median duration of surgery and anesthesia was 19 hours (95% confidence interval 15-23 hours). The surgical preparation and dissection of multiple small anatomical structures of the recipient was time-consuming for 11 cases. Blood loss was considerable. All patients received packed red blood cells (median 20 U, 95% confidence interval 5-28 U). A median of 13 L of crystalloid was administered (95% confidence interval 10-18 L). Conclusions: During facial allograft transplantation, the anesthesiologist must be prepared for a long anesthetic with rapid blood loss after reperfusion of the graft. Comment in Out on a limb with composite tissue allografts: expanding the immunology toolbox. [Anesth Analg. 2012

A Bio-Inspired Swellable Microneedle Adhesive for Mechanical Interlocking with Tissue

Achieving significant adhesion to soft tissues while minimizing tissue damage poses a considerable clinical challenge. Chemical-based adhesives require tissue-specific reactive chemistry, typically inducing a significant inflammatory response. Staples are fraught with limitations including high-localized tissue stress and increased risk of infection, and nerve and blood vessel damage. Here, inspired by the endoparasite Pomphorhynchus laevis which swells its proboscis to attach to its host’s intestinal wall, we have developed a biphasic microneedle array that mechanically interlocks with tissue through swellable microneedle tips, achieving ~ 3.5 fold increase in adhesion strength compared to staples in skin graft fixation, and removal force of ~ 4.5 N/cm2 from intestinal mucosal tissue. Comprising a poly(styrene)-block-poly(acrylic acid) swellable tip and non-swellable polystyrene core, conical microneedles penetrate tissue with minimal insertion force and depth, yet high adhesion strength in their swollen state. Uniquely, this design provides universal soft tissue adhesion with minimal damage, less traumatic removal, reduced risk of infection and delivery of bioactive therapeutics

The surgical patient of yesterday, today, and tomorrow — a time-trend analysis based on a cohort of 8.7 million surgical patients

Background: Global healthcare delivery is challenged by the aging population and the increase in obesity and type 2 diabetes. The extent to which such trends affect the cohort of patients the authors surgically operate on remains to be elucidated. Comprising of 8.7 million surgical patients, the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database can be analyzed to investigate the echo of general population dynamics and forecast future trends. Material and methods: The authors reviewed the ACS-NSQIP database (2008–2020) in its entirety, extracting patient age, BMI, and diabetes prevalence. Based on these data, the authors forecasted future trends up to 2030 using a drift model. Results: During the review period, median age increased by 3 years, and median BMI by 0.9 kg/m2. The proportion of patients with overweight, obesity class I, and class II rates increased. The prevalence of diabetes rose between 2008 (14.9%) and 2020 (15.3%). The authors forecast the median age in 2030 to reach 61.5 years and median BMI to climb to 29.8 kg/m2. Concerningly, in 2030, eight of ten surgical patients are projected to have a BMI above normal. Diabetes prevalence is projected to rise to 15.6% over the next decade. Conclusion: General population trends echo in the field of surgery, with the surgical cohort aging at an alarmingly rapid rate and increasingly suffering from obesity and diabetes. These trends show no sign of abating without dedicated efforts and call for urgent measures and fundamental re-structuring for improved future surgical care