Brian H. Cho

Wide-field Retinal Imaging in the Management of Noninfectious Posterior Uveitis

PURPOSE To determine whether the use of ultra wide-field imaging changes the management or determination of disease activity in patients with noninfectious posterior uveitis. DESIGN Prospective, observational case series. METHODS setting: Divisions of Retina and Ocular Immunology at single academic medical center. patient population: Total of 43 patients with noninfectious posterior uveitis seen by 4 investigators at the Wilmer Eye Institute. procedures: Each patient underwent standard clinical examination, followed by ultra wide-field scanning laser ophthalmoscope (SLO) imaging and angiography. Investigators successively determined disease activity and management decisions based on clinical examination, examination plus simulated 30- or 60-degree fluorescein angiography (FA) (obtained by physically narrowing the field of view of the wide-field images), examination plus ultra wide-field SLO images, and examination plus wide-field FA. main outcome measures: The primary outcome was the percentage of patients whose management changed based on the availability of wide-field imaging, compared with standard examination and imaging. The secondary outcome was detection of disease activity with and without wide-angle imaging. RESULTS Management was altered in 7 of 43 patients (16%) based on examination and limited FA, whereas 21 of 43 patients (48%) had management change with the use of the ultra wide-field imaging and angiography (P < .001). Disease activity was detected in 22 of 43 patients (51%) based on examination and simulated conventional imaging, and in 27 of 43 (63%) with wide-field imaging (P = .27). CONCLUSIONS The index study, with several design limitations, has suggested that ultra wide-field imaging may alter management decisions compared to standard-of-care imaging and clinical examination. Additional studies, including longitudinal evaluations, are needed to determine whether these findings, or the subsequent management alterations, may improve patient outcomes.

Ultra-wide-field retinal imaging in the management of non-infectious retinal vasculitis.

BackgroundThe purpose of this study is to describe and quantify the benefit of ultra-wide-field imaging and fluorescein angiography (FA) in the management of non-infectious retinal vasculitis. In this prospective observational cohort series, patients with non-infectious retinal vasculitis were evaluated and enrolled by four investigators from the Divisions of Retina and Ocular Immunology at the Wilmer Eye Institute. In each patient, disease activity and the need for management changes were assessed, based on clinical examination with or without standard (60°) imaging and then with the addition of ultra-wide-field pseudo-color scanning laser ophthalmoscope (SLO) images and FA using the Optos ultra-wide-field SLO (Optos Panoramic 200MA™, Optos PLC, Dunfermline, Scotland, UK). A standardized questionnaire was completed by each investigator at the time of the clinical evaluation.The primary outcome was the percentage of patients whose management was changed by clinical examination and standard FA, compared with clinical examination plus ultra-wide-field imaging. The secondary outcome was the percentage of patients whose disease was determined to be active based on each modality.ResultsSeventy-one visits from 23 patients were reviewed and analyzed. Based on examination plus ultra-wide-field imaging and ultra-wide-field angiography, disease activity was detected in 48/71 (68%) compared with 32/71 (45%) based on examination and standard FA (P = 0.0095). Based on the clinical examination alone, the decision to alter management was made in 4 of 71 visits (6%), and an additional 3 of 71 (4%) based on simulated standard FA. The addition of ultra-wide-field SLO pseudo-color images altered management in an additional 10/71 visits (14%), and 36/71 (51%) with the addition of ultra-wide-field FA.ConclusionsUltra-wide-field fluorescein imaging and angiography can provide additional information that may be important and relevant in the management of retinal vasculitis.

Transient current suppression scheme for bi-directional DC-DC converters in 42 V automotive power systems

42 V electrical power systems are on their way to replacing the present 14 V systems in automobiles and 42 V/14 V dual voltage systems have been proposed to provide backward compatibility with the existing components for the 14 V system. The synchronous buck/boost converter is an attractive topology for 42 V/14 V dual voltage systems since it offers bi-directional operation without additional components. In this paper, transient currents generated during converter startup or changes in operation modes between buck and boost are analyzed and a cost effective solution to remove the transient currents is proposed. The validity of the proposed control strategy is investigated through simulations and experiments

The Impact of Financial Conflicts of Interest in Plastic Surgery: Are They All Created Equal?

BackgroundRecently, several studies have demonstrated that articles that disclose conflicts of interests (COI) are associated with publication of positive results. The purpose of this study was to learn more about the different types of COI as they relate to the general topic of COI in plastic surgery. Specifically, we aimed to examine whether different types of COI are more likely than others to be associated with the presentation of positive findings. MethodsWe reviewed all original articles in Annals of Plastic Surgery, Journal of Plastic, Reconstructive, and Aesthetic Surgery, and Plastic & Reconstructive Surgery from January 1, 2012, to December 31, 2013. All scientific articles were analyzed, and several article characteristics were extracted. Disclosed COI were categorized into the following categories: consultant/employee, royalties/stock options, and research support. The findings reported in each article abstract were blindly graded as reporting a positive, negative, neutral, or not applicable result. A multivariable analysis was performed to determine whether an association existed between certain types of COI and publication of positive conclusions. ResultsA total of 3124 articles were identified of which 1185 fulfilled the inclusion criteria. Financial COI were reported in 153 studies (12.9%). The most common type of COI was “research support” (7.3%), whereas the least common was “royalties/stock options” (1.2%). Rates of different types of COI varied significantly by plastic surgery subspecialty field (P < 0.001). In the multivariable analysis, authors who disclosed COI related to research support, consultant/employee, and royalties/stock options were 1.31, 6.62, and 8.72 times more likely, respectively, to publish positive findings when compared with authors that disclosed no COI after correcting for potential confounding factors. However, consultancy/employee status was the only COI category statistically associated with publication of positive results (P < 0.001). ConclusionsSelf-reported COI are uncommon in plastic surgery research. Our results provide evidence that certain types of financial COI are more likely than others to be associated with the presentation of positive findings. This analysis suggests that certain investigators may be more biased, consciously or unconsciously, by the type of financial benefit offered by industry.

Versatility of Free Cutaneous Flaps for Upper Extremity Soft Tissue Reconstruction

The goals of upper extremity soft tissue reconstruction should go well beyond providing coverage and restoring function. As the field of reconstructive microsurgery has evolved, free cutaneous flaps (FCFs) are gaining wider application. The advantages of FCF include minimizing donor-site morbidity by preserving the muscle and fascia, improving versatility of flap design, and superior aesthetic results. This review highlights the application of anterolateral thigh, superficial circumflex iliac artery, deep inferior epigastric perforator, superficial inferior epigastric artery, and flow-through flaps for reconstruction of upper extremity defects. These flaps share several qualities in common: well-concealed donor sites, preservation of major arteries responsible of providing inflow to distal extremity, and potential for a two-team approach (donor and recipient sites). While the choice of flaps should be decided based on individual patient and defect characteristics, FCF should be considered as excellent options to achieve the goals of upper extremity reconstruction.

Abstract 10.55 BRIDGING THE GAP: EXTENDING FREE FLAP PEDICLE LENGTH WITH INTERPOSITION VEIN GRAFTS AND ARTERIOVENOUS LOOPS

PURPOSE: The purpose of this study is to assess clinical outcomes for utilization of vein grafts and arteriovenous loops in the context of free flap reconstruction. Free tissue transfer in complex oncological and traumatic defects may require extension of the vascular pedicle to reach recipient vessels and complete microvascular anastomosis. This can be accomplished by using vein grafts as a bridging medium. When interposition vein grafts (IVG) are needed for extension of both the arterial and venous conduit, a temporary arteriovenous fistula (AV loop) can be constructed as an intermediary step. These techniques have traditionally been regarded with increased risk of thrombosis and flap failure, but the body of clinically relevant published data lags behind.

Abstract 8.40 A POST-OPERATIVE PROTOCOL FOR AUTOLOGOUS FREE FLAP BREAST RECONSTRUCTION OPTIMIZING RESOURCES AND PATIENT SAFETY

METHODS: A Markov model was used to simulate the effects of standard prevention compared to tibial neurolysis on the long-term costs associated with foot ulcers and amputations. This model included eight health states. A baseline analysis was built on a five-year model to determine the cumulative incidence of foot ulcers and amputations with each strategy. Subsequently, a cost-effectiveness analysis and cohort-level Markov simulations were conducted with a model composed of 20 six-month cycles. The outcomes explored were quality adjusted life years (QALYs); the incremental cost-effectiveness of tibial neurolysis in comparison with standard treatment and the net monetary benefits of tibial neurolysis. A sensitivity analysis was also performed.

Abstract P28: Nanofiber-Hydrogel Composite with Human Adipose-Derived Stem Cells to Enable Soft Tissue Regeneration

PSRC Abstract Supplement P oter P rofs transection without repair. First, we evaluated the extensor digitorum longus (EDL) muscles of 15 adult wildtype C57BL/6 mice (n=3 per time point) at days 1, 3, 5, 7, and 14 after sciatic nerve injury. The uninjured EDL muscles served as the experimental controls. These muscles were harvested for immunostaining with CD68 (monocytes/ macrophages) and DAPI (nuclear) staining. Next, using the same injury and mouse model, flow cytometry was utilized to evaluate total cells present in EDL muscle after sciatic nerve injury. Animals were sacrificed at days 1 and 5 after nerve injury, and all muscles of the hindlimb innervated by the sciatic nerve were harvested from the right injured and left uninjured legs. Cells were analyzed following muscle digestion.

Proximal femur reconstruction using a vascularized fibular epiphysis within a cadaveric femoral allograft in a child with Ewing sarcoma: a case report

Periarticular reconstruction of appendicular bones in skeletally immature patients after tumor resection is a surgical challenge that requires a multidisciplinary approach. The authors present a case of Ewing sarcoma of the proximal femur in an 8-year old girl treated with wide resection of the primary tumor and reconstruction using a vascularized fibula epiphyseal autograft within a cadaveric femoral allograft. The native femoral head was preserved to restore articular anatomy. Postoperative course was without complications. This report demonstrates the use of a vascularized fibula autograft within a cadaveric femoral allograft to optimize growth potential and joint durability in a pediatric patient. ABSTRACT

Use of a Multivector Mandibular Distractor for Treatment of Pediatric Proximal Interphalangeal Joint Pilon Fractures: A Case-Based Review

Background The difficulties in surgical treatment of pilon fractures of the finger include fragment reconstitution and posthealing stiffness. In adults, external fixation with traction and early active range of motion (AROM)/passive range of motion (PROM) during healing is considered necessary for avoiding joint stiffness and attaining realignment. The authors present a unique approach to pediatric pilon fractures that uses open reduction and multivector external fixation with delayed AROM/PROM. Initial immobilization and significant traction allowed for joint realignment and prevented noncompliance with staged distraction. The authors believe this immobilization leads to a superior outcome because, unlike adults, children tend to avoid stiffness and a larger distraction force allowed for sufficient joint realignment to regain range of motion (ROM). Methods A right-handed 13-year-old boy sustained a right ring finger fracture and presented 12 days later. Radiographs revealed a comminuted Salter-Harris 4 fracture of the middle phalanx. The patient underwent open reduction and placement of multivector external fixation using a pediatric mandibular distractor/fixator. Significant traction was applied to distract the finger to length. Results Hardware was removed 6 weeks postoperatively and AROM was initiated after splinting. The patient started PROM 8 weeks postoperatively. Strengthening was initiated 2 weeks later. ROM improved and rehabilitation was continued. The patient exhibited nearly equal grip strength 12 weeks postoperatively. At 14 months follow-up, radiographs showed complete healing and joint realignment. There was no deformity or pain and finger length was restored. Conclusion Management of pediatric pilon fractures is rarely described and presents unique considerations. Early-stage traction and immobilization using a multivector mandibular fixator/distractor is suitable in a child because noncompliance is avoided and there is a decreased risk for stiffness. Combining early immobilization with subsequent-staged AROM, PROM, and strengthening resulted in no loss of ROM and maintained articular symmetry.