Faculty Bibliography

BACKGROUND:Corticosteroid use continues to rise nationally. Studies have evaluated the impact of chronic steroid use on surgical outcomes in smaller populations. This study investigated the impact of chronic steroid use on perioperative surgical outcomes in a surgical cohort of more than 5 million surgical patients, using a statistically rigorous methodology. METHODS:and t test analysis, and then repeated after propensity score matching. Finally, a double-adjustment logistic regression was utilized, yielding odds ratios to assess the effect of chronic steroids on perioperative outcomes within the matched population. RESULTS:Between 2008 and 2016, a total of 5,244,588 patients met inclusion criteria, of whom 181,901 (3.5%) were taking steroids for a minimum of 30 days before surgery. Patients on chronic steroids had significantly more comorbidities compared with the remaining population. After propensity score matching and double-adjusted logistic regression, chronic steroid use was found to be associated with increased surgical complications and poorer surgical outcomes. Chronic steroid use significantly increased a patient's risk of having a hospital stay longer than 30 days by 19%, risk of readmission within 30 days by 58%, risk of reoperation by 21%, and risk of death by 32%. CONCLUSION/CONCLUSIONS:After controlling for differences in comorbidities and demographics, patients on chronic steroids have significantly poorer perioperative outcomes. Chronic steroid use should be evaluated and, if possible, addressed before surgery, given their significant impact on surgical outcomes.

BACKGROUND:Posterior vault distraction (PVD) can rapidly expand calvarial volume in infancy. Limited data exist regarding its perioperative and postoperative safety profile. This study sought to investigate the patient profile, outcomes, and safety of PVD using a national pediatric database. METHODS:Posterior vault distraction patients between 2012 and 2016 were isolated from the National Surgical Quality Improvement Program Pediatric database. Patient background, perioperative outcomes, and risk factors were analyzed using chi-squared, t test analysis, and multivariate regression. RESULTS:Ninety-four patients who underwent PVD were isolated with 67 ultimately meeting inclusion criteria for the study. The majority of patients undergoing PVD had limited other documented comorbidities. No patients required reoperation or 30-day readmission. There were no incidences of stroke, surgical site infection, or death. Subdividing outcomes by specialty, plastic surgeons performed PVD on significantly older patients than neurosurgeons (188 days vs 138 days, P = 0.008). Increasing age was associated with increasing operative time (P < 0.001). Furthermore, increasing age is associated with greater absolute transfusion requirements (P = 0.018) and higher, but not significant, risk of requiring any volume of blood transfusion (P = 0.105). CONCLUSIONS:Posterior vault distraction is a safe procedure to rapidly expand calvarial volume in the setting of craniosynostosis. Increasing patient age is the strongest predictor for prolonged operative time and higher blood transfusion volumes.

BACKGROUND:Autologous bone grafts remain a standard of care for the reconstruction of large bony defects, but limitations persist. The authors explored the bone regenerative capacity of customized, three-dimensionally printed bioactive ceramic scaffolds with dipyridamole, an adenosine A2A receptor indirect agonist known to enhance bone formation. METHODS:Critical-size bony defects (10-mm height, 10-mm length, full-thickness) were created at the mandibular rami of rabbits (n = 15). Defects were replaced by a custom-to-defect, three-dimensionally printed bioactive ceramic scaffold composed of β-tricalcium phosphate. Scaffolds were uncoated (control), collagen-coated, or immersed in 100 μM dipyridamole. At 8 weeks, animals were euthanized and the rami retrieved. Bone growth was assessed exclusively within scaffold pores, and evaluated by micro-computed tomography/advanced reconstruction software. Micro-computed tomographic quantification was calculated. Nondecalcified histology was performed. A general linear mixed model was performed to compare group means and 95 percent confidence intervals. RESULTS:Qualitative analysis did not show an inflammatory response. The control and collagen groups (12.3 ± 8.3 percent and 6.9 ± 8.3 percent bone occupancy of free space, respectively) had less bone growth, whereas the most bone growth was in the dipyridamole group (26.9 ± 10.7 percent); the difference was statistically significant (dipyridamole versus control, p < 0.03; dipyridamole versus collagen, p < 0.01 ). There was significantly more residual scaffold material for the collagen group relative to the dipyridamole group (p < 0.015), whereas the control group presented intermediate values (nonsignificant relative to both collagen and dipyridamole). Highly cellular and vascularized intramembranous-like bone healing was observed in all groups. CONCLUSION:Dipyridamole significantly increased the three-dimensionally printed bioactive ceramic scaffold's ability to regenerate bone in a thin bone defect environment.

Dog bites have been well described and characterized in the pediatric population. Comparatively, dog-bite injuries in adults and the settings in which surgeons become involved are less studied. An electronic hospital database identified all patients 18 years or older who were treated for dog bites from 2010 to 2014. Demographics, injury information, intervention type, and payer source were collected. Socioeconomic analysis was performed using Geographic Information Systems mapping. A total of 189 adults presented to the emergency department with dog-bite-related injuries. The most common injury location was the hand (n = 62, 32.8%), followed by the head and neck (n = 36, 19.1%). Of the 189 patients, 33 adults (17.5%) were forwarded to a surgical subspecialist for repair. A head and neck injury was significantly more likely to be repaired by a surgical specialist (P = 0.011). The most common breed of dog identified was pit bull (n = 29, 47.5%). The majority of pit bull attacks involved the extremities (65.5%) compared to other breeds of dogs. Pit bull victims were noted to have a lower average annual income compared to other breed victims ($64,708 versus $75,004; P = 0.16). Annual income between intervention group and no intervention group was not significantly different (P = 0.26). This study is the 1st to perform a socioeconomic analysis in the adult dog-bite population and encourages the use of a surgical specialist in the setting of a head and neck bite.

G protein-coupled receptors (GPCRs) are the largest family of transmembrane signaling proteins. Within the gastrointestinal tract, GPCRs expressed by epithelial cells sense contents of the lumen, and GPCRs expressed by epithelial cells, myocytes, neurons, and immune cells participate in communication amongst cells. GPCRs control digestion, mediate digestive diseases, and coordinate repair and growth. GPCRs are the target of over one third of therapeutic drugs, including many drugs used to treat digestive diseases. Recent advances in structural, chemical, and cell biology research have revealed that GPCRs are not static binary switches that operate from the plasma membrane to control a defined set of intracellular signals. Rather, GPCRs are dynamic signaling proteins that adopt distinct conformations and subcellular distributions when associated with different ligands and intracellular effectors. An understanding of the dynamic nature of GPCRs has provided insights into the mechanism of activation and signaling of GPCRs, and has revealed opportunities for drug discovery. We review the allosteric modulation, biased agonism, oligomerization, and compartmentalized signaling of GPCRs that control digestion and digestive diseases. We highlight the implications of these concepts for the development of selective and effective drugs to treat diseases of the gastrointestinal tract.

BACKGROUND:The Gustilo classification serves as a proxy for injury severity, but recent data suggest rising complications with decreasing arterial runoff. This study aims to compare different microsurgical anastomosis options based on the number of patent vessels in the lower extremity. METHODS:A single-center retrospective review of 806 lower extremity free flaps performed from 1976 to 2016 was performed. Patients with Gustilo type IIIB injuries were grouped based on the number of patent vessels in the leg (three, two, or one). Patients were compared based on the type of anastomosis performed, evaluating for perioperative complications and flap failures. RESULTS:Perioperative complications occurred in 111 flaps (27 percent): 71 take-backs (17 percent), 45 partial losses (11 percent), and 37 complete losses (9 percent). Among patients with three-vessel runoff (61.8 percent), there was no difference in take-backs or flap loss between those with end-to-end versus end-to-side anastomoses. In 68 patients (18.7 percent) with two-vessel runoff, no difference between take-backs or flap loss was noted when comparing any anastomosis (i.e., end-to-end into an injured vessel, end-to-end into an uninjured vessel, or end-to-side into an uninjured vessel), although vein grafts were required more often in the end-to-side groups (p < 0.01). Finally, in 39 patients (10.7 percent) with single-vessel runoff, no difference was seen between end-to-end anastomosis into an injured vessel or end-to-side anastomosis into an uninjured vessel in terms of take-backs or flap loss. CONCLUSION:Higher rates of flap failure correlated with decreasing numbers of patent vessels in the leg, but neither type of microvascular anastomosis nor vessel selection demonstrated any impact on reconstructive outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, III.

The male upper lip has a distinctly longer cutaneous height from the nasal base to the upper vermilion border than its female counterpart. The subnasal indirect lip lift using the bullhorn technique or its modifications allows for shortening of this height to feminize the lower face, creating a more aesthetically pleasing upper lip secondary to increased vermilion height and lip pout. Patient selection is critical, taking into account lip height, vermilion height, alar base width, skin type, upper incisal show, and maxillary height. Precise measurements, controlled excision of the planned resection, and meticulous reapproximation of skin provide an aesthetic result, while minimizing visible scarring.

The effect of diabetes on postoperative outcomes following surgical management of pressure ulcers is poorly defined despite evidence showing that patients with diabetes are at increased risk for developing pressure ulcers, as well as postoperative wound complications including delayed healing and infection. This study aimed to examine the impact of diabetes on postoperative outcomes following surgical management of pressure ulcers using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. In this retrospective analysis all CPT codes with ICD-9 diagnoses of pressure ulcers were reviewed. A total of 3,274 patients who underwent surgical management of pressure ulcers were identified, of which 1,040 (31.8%) had diabetes. Overall primary outcomes showed rates of superficial and deep incisional SSI were 2.0% and 4.2%, respectively, while the rate of wound dehiscence was 2.1%. Univariate analysis of primary outcomes stratified by diabetes status showed that patients with diabetes had significantly higher rates of superficial incisional SSI (3.9% vs. 2.3%; p=0.01), deep incisional SSI (7.0% vs. 4.3%; p=0.001), wound dehiscence (5.2% vs. 2.7%; p<0.001), as well as significantly higher rates of readmission (12.8% vs. 8.9%; p=0.001). Multivariate analysis for significant outcomes between groups on univariate analysis demonstrated that diabetes was an independent risk factor for superficial incisional SSI (OR = 2.7; 95% CI: 1.59 - 4.62; p<0.001), deep incisional SSI (OR = 1.85; 95% CI: 1.26 - 2.70; p=0.002), wound dehiscence (OR = 4.09; 95% CI: 2.49 - 6.74; p<0.001), and readmission within 30 days (OR = 1.38; 95% CI: 1.05 - 1.82; p=0.02). These findings emphasize the importance of preoperative prevention, and vigilant postoperative wound care and monitoring in patients with diabetes to minimize morbidity and optimize outcomes. Future prospective studies are needed to establish causality between diabetes and these outcomes.

In this study, we evaluated the effect of local injection of osteoblastic cells differentiated from bone marrow or adipose tissue-mesenchymal stromal cells (BM-OB and AT-OB, respectively) on bone repair. For that, the cells were harvested from male Wistar rats (200 g), under the rules of the Committee of Ethics in Animal Research of the University of Sao Paulo. The BM-OB were obtained by osteoblastic differentiation of bone marrow-mesenchymal stromal cells for 10 days. The AT-OB were obtained by osteoblastic differentiation of adipose tissue-mesenchymal stromal cells for 10 days. Under general anesthesia, unilateral 5-mm defect was created in the calvaria of rats and in order to simulate preexisting defects only after 2 weeks the defects were treated. Each defect was locally injected with BM-OB or AT-OB (5 9 10⁶ cells/defect in 50 ll PBS). PBS without cells was injected as Control. Four weeks after cell injection, the animals were euthanized, and the bone formation was analyzed by microtomography (micro-CT) and nanoindentation assay. The data were evaluated using the ANOVA test followed by the Tukey's test when appropriated (p B 0.05). The morphometric parameters generated from micro-CT images showed that bone volume, percentage of bone volume, bone surface and trabecular number were higher in defects injected with BM-OB or AT-OB compared with Control (p = 0.001 for all). Trabecular separation was lower in defects injected with BM-OB or AT-OB compared with Control (p = 0.001). The qualitative parameters generated from nanoindentation indicated that elastic modulus and hardness of bone formed in defects injected with BM-OB or AT-OB were higher compared with Control (p = 0.05 for both). In conclusion, the use of local injection of osteoblastic cells differentiated from bone marrow or adipose tissue-mesenchymal stromal cells induced the same amount of bone formation opening new therapeutic possibilities for the treatment of bone defects