Plastic surgery lockdown learning during coronavirus disease 2019: are adaptations in education here to stay?

The novel coronavirus disease 2019 has had a major impact on human life and livelihood. The unprecedented challenges have expanded beyond just social and work life, and have grown to impact resident education. In this article, we review the structure of plastic surgery education before the pandemic, the different online learning opportunities for self-directed learning. A summary of the range of platforms and approaches of online remote access delivery of conferences and education that emerged or expanded as a result of the crisis has been reported. This article highlighted the rapid initiatives and efforts of programs and national and international societies to support continuing medical education in conjunction with the guidelines to “shelter at home” and maintain social distancing, and possible future for expanding the reach of online academic initiatives, in addition to the role of developing virtual technologies. The coronavirus disease 2019 crisis has created an opportunity to analyze and advance online learning options to overcome the associated challenges and continue as a reliable platform even following the resolution of the social distancing requirements

Case report: Neoadjuvant systemic therapy for melanoma

We report a case of rapidly enlarging metastatic melanoma in 45-year-old White male following primary resection of thin melanoma five years ago. Location and large size of the lesion possessed significant risk of complications from surgery, therefore provided a challenge in treatment options. Neoadjuvant targeted chemotherapy was commenced and resulted in a significant reduction in size of the lesion, which allowed subsequent safe surgical resection with no residual disease on histopathology results. This case provides a good example of successful utilization of neoadjuvant systemic therapy in advanced metastatic melanoma

Adjuvant effect of biopolymeric fraction from Picrorhiza kurroa to promote both Th1 and Th2 immune responses

In this study, the plant based biopolymeric fraction RLJ-NE-205 isolated from Picrorhiza kurroa were evaluated for its potential ability as an adjuvant effect on the immune responses to Ovalbumin (specific antigen) in mice. Immunization in Balb/C mice with variable doses of RLJ-NE-205 (10 – 80 g) with optimized dose of Ovalbumin (100 g) dissolved in phosphate buffered saline or containing alum (200 g) on Days 1 and 15. After two weeks of the challenging dose, OVA specific antibodies in serum, spleen cell proliferation assay, estimation of Th1 (IL-2/IFN-gamma) and Th2 (IL-4) cytokines in serum, CD3/CD4/CD8/CD19 surface markers of T and B cell, costimulatory molecules (CD80/CD86) in spleen cells and safety studies were observed. The results suggest that OVA mediated specific antibody levels (IgG, IgG1 and IgG2a) in serum were significantly enhanced by RLJ-NE-205 (20 g) containing 100 g OVA compared with OVA control group. Moreover, RLJ-NE-205 (20 g) containing 100 g OVA on IgG, IgG1, and IgG2a antibody responses to OVA in mice were more significant than those of alum. RLJ-NE-205 (20 g) significantly enhanced the OVA induced spleen cell proliferation and estimation of Th1 and Th2 cytokines in the OVA immunized mice. However, no significant differences were observed among the OVA group and OVA/alum group. At the dose of 100 g OVA containing 20 g RLJ-NE-205, there was a significant increase in the Th1 and Th2 cytokines in serum and CD3/CD4/CD8/CD19 surface markers and costimulatory molecules (CD80/CD86) in the spleen cell by flow cytometry were observed

MicroSUCI: A microsurgical background that incorporates suction under continuous irrigation

The microsurgical anastomosis is integral to the success of autologous-free tissue transfer. Successful performance of this procedure relies strongly on operator dexterity, which can be made more challenging when blood and edematous fluids obscure the field of view. Workflow is impeded by intermittent irrigation and suctioning, necessitating presence of an assistant, with risk of arterial thrombosis, from vessels being drawn into suction drains. To negate these current disadvantages and minimize the barrier of entry to microvascular operations, we designed, manufactured, and patented a novel three-dimensional printed microsurgical background device with microfluidic capabilities that allow continuous suction and irrigation as well as provide platforms that enable multiangle retraction to facilitate operator autonomy. This was validated in an ex vivo model, with the device found to be superior to the current standard. We believe that this will have major applicability to the improvement of microsurgeon

Smile outcomes when using masseteric nerve-based nerve transfers versus direct muscle neurotization in facial palsy patients

Background: When dealing with a weak smile, nerve transfer is a viable strategy. We evaluated outcomes of masseteric nerve to facial nerve transfers and compared them with direct muscle neurotization (DMN). Methods: In a retrospective cohort study of 20 patients (n = 20), we compared nerve transfer versus DMN over a 6-year period (2016–2021). Outcomes were measured using the validated Sunnybrook score, Ackerman Smile Index, and Terzis scores. Statistical analysis was performed using the Wilcoxon sign rank and Mann-Whitney U tests. Results: Comparing pre- versus postoperative scores after nerve transfers, there was a significant improvement in median overall Sunnybrook score (24 versus 47, P = 0.043), lip elevation (1 versus 2, P = 0.046), open mouth smile (1 versus 3, P = 0.003), and Terzis scores (1 versus 3, P = 0.005), with no difference in resting symmetry (−15 versus −5; P = 0.496). Compared with DMN, there was no difference in median Terzis score improvement from preoperative to postoperative state (2 versus 1, P = 0.838), median smile improvement (2 versus 2, P = 0.838), resting symmetry (10 versus 5, P = 0.144) or overall Sunnybrook score (23 versus 21, P = 1.000). Lip elevation improvement was in favor of nerve transfers (1 versus 0, P = 0.047). Conclusions: This is the first study evaluating nerve transfer neurotization of smile-mimetic muscles and comparing the outcomes with DMN, with masseteric nerve as donor. Nerve transfer leads to improved facial mimetic function, smile excursion and open mouth smiles, as does DMN, with improvement in lip elevation in favor of nerve transfer. Nerve transfer was preferred for more severe smile weakness

Protocol for a systematic review of the efficacy of fat grafting and platelet-rich plasma for wound healing

BACKGROUND: The use of fat grafting as a reconstructive surgical option is becoming much more common. Adipose-derived stem cells found in fat grafts are believed to facilitate wound healing via differentiation into fibroblasts and keratinocytes and the release of pro-healing growth factors. Several small studies have shown a positive effect of fat grafting in healing of wounds of a variety of aetiologies. When fat is combined with autologous platelet-rich plasma (PRP), there may be enhanced healing effects. This may be due to the pro-angiogenic and anti-inflammatory effects of PRP. We aim to synthesise the current evidence on combination fat grafting and PRP for wound healing to establish the efficacy of this technique. METHODS/DESIGN: We will conduct a comprehensive literature search in the MEDLINE, EMBASE, CENTRAL, Science Citation Index, and Google Scholar databases (up to July 2017) to identify studies on fat grafting and PRP for wound healing. All primary studies and systematic reviews of these studies will be included, except case reports and case series with fewer than three patients, to evaluate the outcome of fat grafting and PRP on wound healing either on its own or when compared to other studies. Primary outcome measures are expected to be the proportion of total wounds healed at 12 weeks and the average wound healing time (time for 100% re-epithelialisation). Expected secondary outcome measures are the proportion of wounds achieving 50% wound healing, the type of wound benefitting most from fat grafting, economic evaluation, health-related quality of life, and adverse events. Subgroup analysis will be performed for the proportions of wounds healed based on wound aetiology. DISCUSSION: This review will provide robust evidence of the efficacy of fat grafting and PRP for wound healing. This is an emerging technique, and this review is expected to guide clinical practice and ongoing research aimed at improving wound care. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016049881

Systematic review of the efficacy of fat grafting and platelet-rich plasma for wound healing

Adipose‐derived stem cells found in fat grafts may have significant healing properties. When fat is combined with autologous platelet‐rich plasma (PRP), there may be enhanced healing effects due to the pro‐angiogenic and anti‐inflammatory effects of PRP. This study aimed to evaluate the current evidence on fat grafting in combination with PRP for wound healing to establish the efficacy of this technique. A comprehensive search in the MEDLINE, EMBASE, CENTRAL, Science Citation Index, and Google Scholar databases (to March 2017) was conducted to identify studies on fat grafting and PRP for wound healing. Case series of less than 3 cases and studies only describing harvest technique were excluded. The database identified 571 articles, of which 3 articles that used a combination of fat and PRP for wound healing (1 RCT and 2 case series) were included in this review. A total of 69 wounds in 64 patients were treated with an average wound size of 36.32cm2. Of these, 67% of wounds achieved complete healing. When reported, the mean time to healing was 7.5 weeks for those who underwent a single treatment. There were no significant complications in any patients. The combination of fat grafting and PRP may achieve adequate wound healing with relatively quick wound healing time compared with standard wound management options. However, evidence is extremely limited, and further studies are required to evaluate its efficacy for wound healing

A comparison of outcomes between finger and pulp replantation/revascularization in a single centre

Background: Supermicrosurgery has allowed the replantation/revascularization of the pulp, but how does this currently compare with more proximal digit replantation/revascularization? Methods: In a retrospective case study over a 5-year period at our institute, a total of 21 patients (n = 21) had either finger or pulp replantation-revascularization posttrauma. All pulp replants had a single-vessel anastomosis viz., “artery-to-artery” or “artery-to-vein” only, with venous outflow dependent on the skin-shave technique, while more proximal replants had both arterial and venous anastomoses. Age, sex, ischemic time, handedness, smoker status, and injury-replant interval were compared between the two groups, with all procedures performed by a single surgeon. The outcome parameters studied were length of hospital stay, timeline for wound healing, viability, and functional outcomes. Results: Our patients consisted of 18 men and three women, of which 14.3% were smokers and 85.7% were right-handed. There were 11 finger replantation/revascularizations (n = 11) versus 10 pulp replantation/revascularizations (n = 10). The average age of digit replantation/revascularization patients was 44.8 years compared with 26.4 years in pulp replantation/revascularization patients (Student t test, P = 0.04). Mean ischemia time in digital replants was 67 minutes versus 32.3 minutes in pulp replantation/revascularization (Student t test, P = 0.056). Digital replantation/revascularization was viable in 72% of cases versus a 90% viability in the pulp subcohort. Conclusions: In our patient cohort, pulp replantation/revascularizations produced better postoperative viability. Where supermicrosurgery expertise is available, pulp replantation/revascularization should be considered a worthwhile option when compared with digital replantation/revascularization

Workplace factors associated with mental health of healthcare workers during the COVID-19 pandemic: an international cross-sectional study

BACKGROUND: The association of workplace factors on mental health of healthcare workers (HCWs) during the COVID-19 pandemic needs to be urgently established. This will enable governments and policy-makers to make evidence-based decisions. This international study reports the association between workplace factors and the mental health of HCWs during the pandemic. METHODS: An international, cross-sectional study was conducted in 41 countries. The primary outcome was depressive symptoms, derived from the validated Patient Health Questionnaire-2 (PHQ-2). Multivariable logistic regression identified factors associated with mental health outcomes. Inter-country differences were also evaluated. RESULTS: A total of 2,527 responses were received, from 41 countries, including China (n=1,213; 48.0%), UK (n=891; 35.3%), and USA (n=252; 10.0%). Of all participants, 1343 (57.1%) were aged 26 to 40 years, and 2021 (80.0%) were female; 874 (34.6%) were doctors, and 1367 (54.1%) were nurses. Factors associated with an increased likelihood of depressive symptoms were: working in the UK (OR=3.63; CI=[2.90-4.54]; p<0.001) and USA (OR=4.10; CI=[3.03-5.54]), p<0.001); being female (OR=1.74; CI=[1.42-2.13]; p<0.001); being a nurse (OR=1.64; CI=[1.34-2.01]; p<0.001); and caring for a COVID-19 positive patient who subsequently died (OR=1.20; CI=[1.01-1.43]; p=0.040). Workplace factors associated with depressive symptoms were: redeployment to Intensive Care Unit (ICU) (OR=1.67; CI=[1.14-2.46]; p=0.009); redeployment with perceived unsatisfactory training (OR=1.67; CI=[1.32-2.11]; p<0.001); not being issued with appropriate personal protective equipment (PPE) (OR=2.49; CI=[2.03-3.04]; p<0.001); perceived poor workplace support within area/specialty (OR=2.49; CI=[2.03-3.04]; p<0.001); and perceived poor mental health support (OR=1.63; CI=[1.38-1.92]; p<0.001). CONCLUSION: This is the first international study, demonstrating that workplace factors, including PPE availability, staff training pre-redeployment, and provision of mental health support, are significantly associated with mental health during COVID-19. Governments, policy-makers and other stakeholders need to ensure provision of these to safeguard HCWs’ mental health, for future waves and other pandemics

Illustrating a new global-scale approach to estimating potential reduction in fish species richness due to flow alteration

Changes in river discharge due to human activities and climate change would affect the sustainability of freshwater ecosystems. To globally assess how changes in river discharge will affect the future status of freshwater ecosystems, global-scale hydrological simulations need to be connected with a model to estimate the durability of freshwater ecosystems. However, the development of this specific modelling combination for the global scale is still in its infancy. In this study, two statistical methods are introduced to link flow regimes to fish species richness (FSR): one is based on a linear relationship between FSR and mean river discharge (hereafter, FSR-MAD method), and the other is based on a multi-linear relationship between FSR and ecologically relevant flow indices involving several other flow characteristics and mean river discharge (FSR-FLVAR method). The FSR-MAD method has been used previously in global simulation studies. The FSR-FLVAR method is newly introduced here. These statistical methods for estimating FSR were combined with a set of global river discharge simulations to evaluate the potential impact of climate-change-induced flow alterations on FSR changes. Generally, future reductions in FSR with the FSR-FLVAR method are greater and much more scattered than with the FSR-MAD method. In arid regions, both methods indicate reductions in FSR because mean discharge is projected to decrease from past to future, although the magnitude of reductions in FSR is different between the two methods. In contrast, in heavy-snow regions a large reduction in FSR is shown by the FSR-FLVAR method due to increases in the frequency of low and high flows. Although further research is clearly needed to conclude which method is more appropriate, this study demonstrates that the FSR-FLVAR method could produce considerably different results when assessing the global role of flow alterations in changing freshwater ecosystems