Faculty Bibliography

BACKGROUND:The Affordable Care Act sought to improve access to health care for low-income individuals. This study aimed to assess whether expansion of Medicaid coverage increased rates of post-mastectomy reconstruction (PMR) for patients who had Medicaid or no insurance. METHODS:A retrospective analysis performed through the National Cancer Database examined women who underwent PMR and were uninsured or had Medicaid, private insurance, or Medicare, and whose race/ethnicity, age, and state expansion status were known. Trends in the use of PMR after passage of Medicaid expansion in 2014 were evaluated. RESULTS:In all states and at all time periods, patients with private insurance were about twice as likely to undergo PMR as patients who had Medicaid or no insurance. In 2016, only 28.7 % of patients with Medicaid or no insurance in nonexpansion states underwent PMR (p < 0.001) compared with 38.5 % of patients in expansion states (p < 0.001). Patients in expansion states also have higher levels of education, higher income, and greater likelihood of living in metropolitan areas. Additionally, patients in all states saw an increase in early-stage disease, with a concomitant reduction in late disease, but this change was greater in expansion states than in non-expansion states. CONCLUSIONS:Expansion states have larger proportions of patients undergoing PMR than non-expansion states. This difference stems from significant differences in income, education, comorbidities, race, and location. Large metropolitan areas have the largest number of patients undergoing PMR, whereas rural areas have the least.

Background/UNASSIGNED:Despite significant advances in the management of frontal sinus fractures, there is still a paucity of large-cohort data, and a comprehensive synthesis of the current literature is warranted. The purpose of this study was to present an evidence-based overview of frontal sinus fracture management and outcomes. Methods/UNASSIGNED:A comprehensive literature search of PubMed and MEDLINE was conducted for studies published between 1992 and 2020 investigating frontal sinus fractures. Data on fracture type, intervention, and outcome measurements were reported. Results/UNASSIGNED:In total, 456 articles were identified, of which 53 met our criteria and were included in our analysis. No statistically significant difference in mechanism of injury, fracture pattern, form of management, or total complication rate was identified. We found a statistically significant increase in complication rates in patients with nasofrontal outflow tract injury compared with those without. Conclusions/UNASSIGNED:Frontal sinus fracture management is a challenging clinical situation, with no widely accepted algorithm to guide appropriate management. Thorough clinical assessment of the fracture pattern and associated injuries can facilitate clinical decision-making.

OBJECTIVE:The effectiveness of µ-opioid receptor (MOPr) agonists for treatment of visceral pain is compromised by constipation, respiratory depression, sedation and addiction. We investigated whether a fentanyl analogue, (±)-N-(3-fluoro-1-phenethylpiperidine-4-yl)-N-phenyl propionamide (NFEPP), which preferentially activates MOPr in acidified diseased tissues, would inhibit pain in a preclinical model of inflammatory bowel disease (IBD) without side effects in healthy tissues. DESIGN/METHODS:Antinociceptive actions of NFEPP and fentanyl were compared in control mice and mice with dextran sodium sulfate colitis by measuring visceromotor responses to colorectal distension. Patch clamp and extracellular recordings were used to assess nociceptor activation. Defecation, respiration and locomotion were assessed. Colonic migrating motor complexes were assessed by spatiotemporal mapping of isolated tissue. NFEPP-induced MOPr signalling and trafficking were studied in human embryonic kidney 293 cells. RESULTS:NFEPP inhibited visceromotor responses to colorectal distension in mice with colitis but not in control mice, consistent with acidification of the inflamed colon. Fentanyl inhibited responses in both groups. NFEPP inhibited the excitability of dorsal root ganglion neurons and suppressed mechanical sensitivity of colonic afferent fibres in acidified but not physiological conditions. Whereas fentanyl decreased defecation and caused respiratory depression and hyperactivity in mice with colitis, NFEPP was devoid of these effects. NFEPP did not affect colonic migrating motor complexes at physiological pH. NFEPP preferentially activated MOPr in acidified extracellular conditions to inhibit cAMP formation, recruit β-arrestins and evoke MOPr endocytosis. CONCLUSION/CONCLUSIONS:In a preclinical IBD model, NFEPP preferentially activates MOPr in acidified microenvironments of inflamed tissues to induce antinociception without causing respiratory depression, constipation and hyperactivity.

Oral cancer patients report sensitivity to spicy foods and liquids. The mechanism responsible for chemosensitivity induced by oral cancer is not known. We simulate oral cancer-induced chemosensitivity in a xenograft oral cancer mouse model using two-bottle choice drinking and conditioned place aversion assays. An anatomic basis of chemosensitivity is shown in increased expression of TRPV1 in anatomically relevant trigeminal ganglion (TG) neurons in both the xenograft and a carcinogen (4-nitroquinoline 1-oxide)-induced oral cancer mouse models. The percent of retrograde labeled TG neurons that respond to TRPV1 agonist, capsaicin, is increased along with the magnitude of response as measured by calcium influx, in neurons from the cancer models. To address the possible mechanism of TRPV1 sensitivity in tongue afferents, we study the role of PAR₂, which can sensitize the TRPV1 channel. We show co-expression of TRPV1 and PAR₂ on tongue afferents and using a conditioned place aversion assay, demonstrate that PAR₂ mediates oral cancer-induced, TRPV1-evoked sensitivity in an oral cancer mouse model. The findings provide insight into oral cancer-mediated chemosensitivity.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Interactive surgical simulation using the finite element method to model human skin mechanics has been an elusive goal. Mass-spring networks, while fast, do not provide the required accuracy. METHODS:This paper presents an interactive, cognitive, facial flaps simulator based on a projective dynamics computational framework. Projective dynamics is able to generate rapid, stable results following changes to the facial soft tissues created by the surgeon, even in the face of sudden increases in skin resistance as its stretch limit is reached or collision between tissues occurs. Our prior work with the finite element method had been hampered by these considerations. Surgical tools are provided for; skin incision, undermining, deep tissue cutting, and excision. A spring-like "skin hook" is used for retraction. Spring-based sutures can be placed individually or automatically placed as a row between cardinal sutures. RESULTS:Examples of an Abbe/Estlander lip reconstruction, a paramedian forehead flap to the nose, a retroauricular flap reconstruction of the external ear, and a cervico-facial flap reconstruction of a cheek defect are presented. CONCLUSIONS:Projective dynamics has significant advantages over mass-spring and finite element methods as the physics backbone for interactive soft tissue surgical simulation.

ABSTRACT/UNASSIGNED:Nutrition plays a vital role in promoting skin integrity and supporting tissue repair in the presence of chronic wounds such as pressure injuries (PIs). Individuals who are malnourished are at greater risk of polymorbid conditions, adverse clinical outcomes, longer hospital lengths of stay, PI development, and mortality, and incur increased healthcare costs compared with patients who are adequately nourished. In addition, some patient populations tend to be more vulnerable to PI formation, such as neonates, patients with obesity, older adults, and individuals who are critically ill. Accordingly, this article aims to review the latest nutrition care recommendations for the prevention and treatment of PIs, including those recommendations tailored to special populations. A secondary objective is to translate nutrition recommendations into actionable steps for the healthcare professional to implement as part of a patient plan of care.Implementing an evidence-based plan of care built around individualized nutrition interventions is an essential step supporting skin integrity for these populations. The 2019 Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline (CPG) affirms that meeting nutrient requirements is essential for growth, development, maintenance, and repair of body tissues. Many macronutrients and micronutrients work synergistically to heal PIs. Registered dietitian nutritionists play an important role in helping patients identify the most nutrient dense foods, protein supplements, and oral nutrition supplements to meet their unique requirements.