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Peripheral nerve allograft: how innovation has changed surgical practice
No full textThe landscape of available technology and surgical technique has changed over the last several decades, thus leading to changes in the peripheral nerve repair surgical algorithm. Neurorrhaphy is a common procedure; however, it is well recognized that nerve repair should be performed tensionless, thus preventing the ability to perform direct repair with a nerve gap. Historically, nerve gaps were repaired with autograft. However, autograft surgery has been associated with complications such as numbness and chronic pain, which left surgeons searching for alternatives. Nerve allografts were first utilized in the 1800s but failed due to the immune response. In the modern era, they were again utilized in the 1980s, but did not gain popularity because of the need for the use of immunosuppressants. It was evident through the 1990s that continued innovation in peripheral nerve repair was needed, as studies showed that only approximately 50% of patients with nerve gap repair achieved good or excellent outcomes. In the 2000s, the advent of an engineered nerve allograft (Avance® Nerve Graft) changed the landscape of peripheral nerve repair. Early clinical evaluation of Avance showed that adequate sensation was able to be achieved in nerve gaps up to 30 mm, providing an alternative to autografts. As engineered nerve allograft use became more conventional, studies showed 87.3% meaningful recovery in nerve gaps up to 50 mm. Furthermore, recent studies have shown that gaps between 50-70 mm have shown 69% meaningful recovery. While technology and surgical technique continue to improve, these results are promising for large nerve gap repair
Review of cost and surgical time implications using virtual patient specific planning and patient specific implants in midface reconstruction
No full textAim: Summarize the available data on midfacial virtual patient specific planning and patient specific implants, highlighting the financial costs and savings, and additionally emphasize the potential cost implications of transitioning to “in-house” virtual 3D modeling and printing.Methods: Review of current literature.Results: Current literature suggests cost benefits of virtual patient specific planning and patient specific implants in the form of improved ischemia time, better boney apposition between flaps, and reduced patient complications. This reduction of complications includes a reduction in blood loss and time spent in the intensive care unit from flap failure. Improved boney apposition results in a higher likelihood of boney union and a further reduction in failure and complications. Subjective benefits of virtual patient specific planning and patient specific implants are shown in the form of improved reconstructive surgeon mental energy. In-house production of 3D models and presurgical planning provides additional cost benefits for providers as they can produce viable models at a fraction of the price of that which is produced by industrial companies. Providers can also construct and use models in an expedient manner compared to industrial models, allowing for the opportunity to be utilized in more acute settings. The foundation of developing an in-house workflow is adequate funding, resources, and clinical volume. Facilities also must focus on appropriate quality and safety measures, as well as appropriate workflow development for adequate production of models.Conclusion: Virtual patient specific planning and patient specific implants show benefits in midfacial reconstructive outcomes, resulting in realized financial and temporal gains for both patient and provider. These gains may be enhanced by moving to in-house planning and printing
Free tissue transfer for lower extremity trauma in the pediatric patient
No full textAim: The utilization of free-tissue transfer secondary to traumatic lower extremity defects in the pediatric population is scarcely described. Factors include microsurgeon inexperience, inadequate center resources, and fear of historically described poor surgical outcomes. The aim of this study is to investigate more recent articles describing free-flap microsurgical reconstruction for these defects. Methods: A systematic review of the literature was conducted through the online databases PubMed, Embase, and Web of Science, examining for articles with at least 20 subjects utilizing free-tissue transfer for soft-tissue defects of the pediatric (aged 18 and younger) lower extremity following traumatic etiology since 2005. Outcomes included flap failure, return to the operating room, and functional status, where available.Results: Seven studies were deemed appropriate for inclusion, with a total of 243 flaps included. Motor vehicle and motorcycle accidents were greater than 75% of total etiology. Most defects involved the foot or ankle (65.1%). In total, perforator flaps compromised the majority of flaps (54%), with the most common being the anterolateral thigh, the scapular/parascapular, and deep inferior epigastric flaps. Less common perforators included the groin flap, tensor fascia lata, radial forearm, lateral arm, and thoracodorsal perforator flap. Muscle-based flaps were less common (46%), with the latissimus dorsi and rectus muscle flaps composing the majority. The most commonly used recipient vessel was the anterior tibialis (49.5%) and posterior tibialis vessels (45.3%). Most studies performed reconstruction within 7-10 days of presentation. There was a cumulative 6.5% flap failure rate.Conclusion: Free tissue transfer for pediatric lower extremity trauma is an important tool that likely leads to powerful outcomes. Recent trends indicate increasing usage of perforator flaps. This study shows that based on existing data, free flap utilization for pediatric patients is an adequate modality for repair, and may warrant greater consideration moving forward
Anti-angiogenic drugs in cancer therapeutics: a review of the latest preclinical and clinical studies of anti-angiogenic agents with anticancer potential
No full textCancer is a group of diseases with significant morbidity and mortality. In cancer cells, where energy requirements are exceptionally high, angiogenesis, which is the sprouting of new blood vessels from pre-existing ones, is an important process for tumour survival and progression. Hence, extensive research in recent years focuses on the discovery of new anticancer drugs that target angiogenesis. Several methodologies have been developed preclinically, including the inhibition of pro-angiogenic factors and their receptors via micromolecular agents or monoclonal antibodies and the inhibition of other compensatory pathways beyond the traditional angiogenic ones. The purpose of the literature review is to present new anticancer drugs that target the process of angiogenesis and have been under preclinical or clinical investigation during the last five years. Many new anticancer drugs targeting angiogenesis are identified in the literature. The results of the in vitro and in vivo evaluation of these drugs show that, apart from inhibiting angiogenesis, they also affect cancer cell proliferation and tumour growth. Recent clinical studies show that these drugs increase the overall or disease-free survival of patients, even those with persistent, chemotherapy-resistant and metastatic types of cancer, although treatment-related side effects are not uncommon. Drugs that target the process of angiogenesis are likely to be the future of anticancer therapy, especially in cases where more traditional treatments do not produce the desired results and where combination regimens of anti-angiogenic agents with standard chemotherapeutics increase patient survival
The role of MT1-MMP in the progression and metastasis of osteosarcoma
No full textThe dysregulation of Membrane - type 1 matrix metalloproteinase (MT1-MMP) has been extensively studied in numerous cancer types, and plays key roles in angiogenesis, cancer progression, and metastasis. MT1-MMP is a predictor of poor prognosis in osteosarcoma (OS), yet the molecular mechanisms of disease progression are unclear. This review provides a summary of the literature relating to the gene and protein expression of MT1-MMP (MMP-14) in OS clinical samples, evaluates the expression in cell lines and experimental models, and analyses its potential role in the progression and metastasis of OS. In addition, the therapeutic potential of MT1-MMP as a drug target has been assessed. Due to the biological complexity of MMPs, inhibition has proven to be challenging. However, exploiting the expression and proteolytic capacity of MT1-MMP could open new avenues in the search for novel, safer and selective drugs for use in OS
Postoperative atrial fibrillation is associated with increased resource utilization after cardiac surgery: a regional analysis of the Southeastern United States
No full textAim: Postoperative atrial fibrillation (POAF) is a known risk factor for morbidity and mortality following cardiac surgery though contemporary resource utilization data is limited. We hypothesize that POAF increases the length of stay, hospital cost, and discharges to facilities, though this trend may be tempering over time.Methods: Records were extracted for all patients in a regional database who underwent coronary artery bypass grafting, aortic valve replacement, or both (2012-2020). Patients without a history of atrial fibrillation were stratified by POAF for univariate analysis. Patients were propensity-score matched to account for baseline, operative, and postoperative differences.Results: Of the 27,307 cardiac surgery patients, 23% developed POAF. Matching resulted in 5926 well-balanced pairs of patients with and without POAF. Every metric of resource utilization was higher for patients with POAF, including ICU length of stay (58 h vs. 49 h, P < 0.0001), postoperative length of stay (7 days vs. 5 days, P < 0.0001), discharge to a facility (27% vs. 23%, P < 0.0001), and readmission (11% vs. 8%). The mean additional total hospital cost attributable to POAF was 6705 is associated with POAF. These conservative estimates demonstrate the broad impact of POAF on in and out of hospital resource utilization that warrants future efforts at containment and quality improvement
Grey zones in the supportive treatments of cardiac amyloidosis
No full textRecent advances in the diagnosis and treatment of cardiac amyloidosis (CA) have translated into a longer life expectancy of patients and more challenging clinical scenarios. Compared to the past, patients with CA and heart failure (HF) currently encountered in clinical practice are a more heterogeneous population and require tailored strategies. The perception of CA as a treatable disease has opened new possibilities for the management of these patients, but many grey areas remain to be explored. The aim of this review is to provide practical suggestions for daily clinical activity in the management of challenging scenarios in CA, including the effectiveness and tolerability of evidence-based HF medication; rate vs. rhythm control in atrial fibrillation, thromboembolic risk, and anticoagulation therapies; replacement of severe aortic valve stenosis; the impact of implantable cardioverter defibrillator on survival; and the usefulness of cardiac resynchronization therapy
Experimental assessment of regenerative properties of platelet rich plasma on the human skin - a review
No full textSeveral studies demonstrated the favorable effects of platelet rich plasma (PRP) on the skin and promoted its wide use in clinical practice. The growth factors stored in platelet alfa-granules allow for the tissue regeneration and the main fields of application of PRP in current clinical practice are the cartilage and musculoskeletal defects, osteoarthritis and other bone disorders, chronic and difficult to heal wounds, and aesthetic procedures. The relevant number of different PRP preparation protocols may explain the inconsistency of the different clinical outcomes reported in the literature. Despite the technological advances in PRP preparation, the objective assessment of the clinical efficacy of PRP from the literature reports still is difficult due to the low homogeneity of the samples in terms of both inclusion criteria and size. Therefore, it might be useful to establish standardized and reproducible experimental models to confirm and objectively measure the effectiveness of the available clinical results. Many experimental investigations have been carried out to objectively assess the effectiveness of PRP and platelet gel on several tissues. As far as the skin is concerned, the studies carried out to date are limited to fibroblasts in in-vitro culture models or to collagen, vascular supply, epithelium, and hair follicle in in-vivo models. The skin, however, is a very complex organ, where different cell lines coexist and feature complex mutual interaction. A model that combines the advantages of both in-vitro and in-vivo cultures is the ex-vivo model. The demonstration of the platelet derived growth factors effects through the ex-vivo human full-thickness skin culture model is a keystone to support the evidence of the PRP effectiveness, as it represents an objective, fast, reproducible, and ethical investigational method
Soft-tissue management and reconstruction of lower-extremity trauma
No full textSoft-tissue management and subsequent salvage of the lower extremity following trauma has long presented difficult challenges to the plastic surgeon. Trauma to the lower extremity can produce long-term sequelae consisting of psychological trauma, functional deficits, and increased costs to the healthcare system. Avoiding incorrect management is important, and is compounded by the fact that few guidelines exist on appropriate treatment and patient counseling. This study aims to describe the authors’ experience at a large limb salvage center in order to further delineate management strategies
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