Christina R. Vargas

Pancreas-Targeted NIR Fluorophores for Dual-Channel Image-Guided Abdominal Surgery

Objective: Pancreas-related complications are some of the most serious ones in abdominal surgery. The goal of this study was to develop and validate novel near-infrared (NIR) fluorophores that would enable real-time pancreas imaging to avoid the intraoperative pancreatic injury. Design: After initial screening of a large NIR fluorophore library, the performance of 3 selected pancreas-targeted 700 nm NIR fluorophores, T700-H, T700-F, and MB, were quantified in mice, rats, and pigs. Dose ranging using 25 and 100 nmol, and 2.5 µmol of T700-F, and its imaging kinetics over a 4 h period were tested in each species. Three different 800 nm NIR fluorophores were employed for dual-channel FLARE™ imaging in pigs: 2 μmol of ZW800-1 for vessels and kidney, 1 μmol of ZW800-3C for lymph nodes, and 2 μmol of ESNF31 for adrenal glands. Results: T700-F demonstrated the highest signal to background ratio (SBR), with peak SBR at 4 h postinjection in mice. In pigs, T700-F produced an SBR ≥ 2 against muscle, spleen, and lymph nodes for up to 8 h after a single intravenous injection. The combination of T700-F with each 800 nm NIR fluorophore provided simultaneous dual-channel intraoperative imaging of pancreas with surrounding organs in real time. Conclusion: Pancreas-targeted NIR fluorophores combined with the FLARE dual-channel imaging system enable the real-time intraoperative pancreas imaging which helps surgeons perform safer and more curative abdominal surgeries.

Online patient resources for breast reconstruction: an analysis of readability.

Background: Online resources for health information are commonly used by many patients. The discrepancy between functional health literacy and available patient information is recognized as an important contributor to health disparities. To provide understandable patient information, the National Institutes of Health and the American Medical Association have advised that health literature for patients be written at a sixth-grade reading level. This study identifies the most popular, online, patient-targeted resources for breast reconstruction information, and evaluates readability of these sites in the context of literacy in the United States. Methods: A Web search for “breast reconstruction” was performed using the two largest Internet search engines, and the top 10 websites common to both were identified. Patient-targeted content was downloaded from all relevant articles immediately available from the main sites. A total of 114 articles were assessed for readability using 10 established analyses. Readability scores were also calculated for the groups of articles arranged by website for comparison. Results: The average reading level was 11.5 across all evaluated sites (Coleman-Liau, 11.8; Flesch-Kincaid, 10.9; FORCAST, 10.7; Fry, 12; Gunning Fog, 12.7; New Dale-Chall, 10.6; New Fog Count, 9.7; Raygor Estimate, 12; and Simple Measure of Gobbledygook, 13). Readability comparison by individual website demonstrated disparity in average reading level from 9.7 to 14.9. Conclusions: Online patient resources for breast reconstruction exceed recommended reading levels and are too difficult to be understood by a large portion of the population. Significant variability between sites provides an opportunity to direct patients to appropriate websites for their level of health literacy.

Assessing the Accuracy and Readability of Online Health Information for Patients With Pancreatic Cancer

IMPORTANCE The degree to which patients are empowered by written educational materials depends on the texts readability level and the accuracy of the information provided. The association of a websites affiliation or focus on treatment modality with its readability and accuracy has yet to be thoroughly elucidated. OBJECTIVE To compare the readability and accuracy of patient-oriented online resources for pancreatic cancer by treatment modality and website affiliation. DESIGN An online search of 50 websites discussing 5 pancreatic cancer treatment modalities (alternative therapy, chemotherapy, clinical trials, radiation therapy, and surgery) was conducted. The websites affiliation was identified. Readability was measured by 9 standardized tests, and accuracy was assessed by an expert panel. MAIN OUTCOMES AND MEASURES Nine standardized tests were used to compute the median readability level of each website. The median readability scores were compared among treatment modality and affiliation categories. Accuracy was determined by an expert panel consisting of 2 medical specialists and 2 surgical specialists. The 4 raters independently evaluated all websites belonging to the 5 treatment modalities (a score of 1 indicates that <25% of the information is accurate, a score of 2 indicates that 26%-50% of the information is accurate, a score of 3 indicates that 51%-75% of the information is accurate, a score of 4 indicates that 76%-99% of the information is accurate, and a score of 5 indicates that 100% of the information is accurate). RESULTS The 50 evaluated websites differed in readability and accuracy based on the focus of the treatment modality and the websites affiliation. Websites discussing surgery (with a median readability level of 13.7 and an interquartile range [IQR] of 11.9-15.6) were easier to read than those discussing radiotherapy (median readability level, 15.2 [IQR, 13.0-17.0]) (P = .003) and clinical trials (median readability level, 15.2 [IQR, 12.8-17.0]) (P = .002). Websites of nonprofit organizations (median readability level, 12.9 [IQR, 11.2-15.0]) were easier to read than media (median readability level, 16.0 [IQR, 13.4-17.0]) (P < .001) and academic (median readability level, 14.8 [IQR, 12.9-17.0]) (P < .001) websites. Privately owned websites (median readability level, 14.0 [IQR, 12.1-16.1]) were easier to read than media websites (P = .001). Among treatment modalities, alternative therapy websites exhibited the lowest accuracy scores (median accuracy score, 2 [IQR, 1-4]) (P < .001). Nonprofit (median accuracy score, 4 [IQR, 4-5]), government (median accuracy score, 5 [IQR, 4-5]), and academic (median accuracy score, 4 [IQR, 3.5-5]) websites were more accurate than privately owned (median accuracy score, 3.5 [IQR, 1.5-4]) and media (median accuracy score, 4 [IQR, 2-4]) websites (P < .004). Websites with higher accuracy were more difficult to read than websites with lower accuracy. CONCLUSIONS AND RELEVANCE Online information on pancreatic cancer overestimates the reading ability of the overall population and lacks accurate information about alternative therapy. In the absence of quality control on the Internet, physicians should provide guidance to patients in the selection of online resources with readable and accurate information.

Does Increased Experience with Tissue Oximetry Monitoring in Microsurgical Breast Reconstruction Lead to Decreased Flap Loss? The Learning Effect.

Background: Early studies have shown that near-infrared monitoring with tissue oximetry shows promise in providing earlier detection of free flap vascular compromise. However, large-scale clinical evaluation of this technology on flap outcome has not previously been established. This study examines the effect of tissue oximetry on flap reexploration rates and salvage over a 10-year period. The learning curve for this new technology is also assessed. Methods: A retrospective review was performed of prospectively maintained data on all microsurgical breast reconstructions performed at an academic institution from 2004 to 2014. Patients were divided into two separate cohorts—standard clinical monitoring and standard clinical monitoring plus tissue oximetry—and rates of reexploration and flap salvage were compared. Subgroup analysis (tertiles) was performed to assess outcomes with increasing experience. Results: A total of 380 flaps (36.2 percent) received standard clinical monitoring, and 670 flaps (63.8 percent) received additional tissue oximetry monitoring. The rate of flap salvage before implementation of tissue oximetry monitoring was 57.7 percent and increased to 96.6 percent (p < 0.001). The number of complete flap losses decreased from 11 (2.9 percent) to one (0.1 percent) with the use of tissue oximetry (p < 0.001). Subgroup analysis demonstrated significantly fewer reexplorations in the third tertile. Conclusions: Inclusion of continuous tissue oximetry in the postoperative monitoring protocol of microsurgical breast reconstruction is associated with significantly improved salvage rates and fewer flap losses. Furthermore, learning curve assessment demonstrates that use of tissue oximetry can decrease the rate of reexploration over time.

A Systematic Review of Topical Vasodilators for the Treatment of Intraoperative Vasospasm in Reconstructive Microsurgery.

Background: Intraoperative vasospasm during reconstructive microsurgery is common, often unpredictable, and potentially devastating with regard to flap survival. Current methods of pharmacologic management vary, and may be shifting as a result of changes in the availability of individual medications. This review aims to provide a concise examination of the published literature regarding use, efficacy, and adverse effects of the agents described for local management of vascular spasm during microsurgery. Methods: A systematic review of the literature was performed to identify articles relevant to pharmacologic treatment of intraoperative vasospasm in vivo. An additional review of the literature was performed with regard to each agent identified in order to provide clinical background information. Results: Systematic review identified 20 articles, in which 14 vasodilator agents were evaluated. Drugs were classified into five pharmacologic categories: phosphodiesterase inhibitors (papaverine, pentoxifylline, and amrinone), local anesthetics (lidocaine), calcium channel blockers (nicardipine, verapamil, nifedipine, and magnesium sulfate), direct vasodilators (sodium nitroprusside, prostaglandin E1, nitroglycerin, and hydralazine), and alpha antagonists (phentolamine and chlorpromazine). Despite a variety of methods, these studies indicate some degree of experimental evidence of efficacy for each of these agents. Conclusions: Available literature regarding use of topical vasodilating agents for intraoperative management of vasospasm during microsurgery is limited and largely based on animal models, which may not reliably generalize to the reconstructive patient population. Well-controlled translational study in clinically applicable and reproducible models is needed to guide evidence-based clinical management of this important phenomenon.

Properties of meshes used in hernia repair: a comprehensive review of synthetic and biologic meshes.

BACKGROUND Data on the mechanical properties of the adult human abdominal wall have been difficult to obtain rendering manufacture of the ideal mesh for ventral hernia repair a challenge. An ideal mesh would need to exhibit greater biomechanical strength and elasticity than that of the abdominal wall. The aim of this study is to quantitatively compare the biomechanical properties of the most commonly used synthetic and biologic meshes in ventral hernia repair and presents a comprehensive literature review. METHODS A narrative review of the literature was performed using the PubMed database spanning articles from 1982 to 2012 including a review of company Web sites to identify all available information relating to the biomechanical properties of various synthetic and biologic meshes used in ventral hernia repair. RESULTS There exist differences in the mechanical properties and the chemical nature of different meshes. In general, most synthetic materials have greater stiffness and elasticity than what is required for abdominal wall reconstruction; however, each exhibits unique properties that may be beneficial for clinical use. On the contrary, biologic meshes are more elastic but less stiff and with a lower tensile strength than their synthetic counterparts. CONCLUSIONS The current standard of practice for the treatment of ventral hernias is the use of permanent synthetic mesh material. Recently, biologic meshes have become more frequently used. Most meshes exhibit biomechanical properties over the known abdominal wall thresholds. Augmenting strength requires increasing amounts of material contributing to more stiffness and foreign body reaction, which is not necessarily an advantage.

Readability of online patient resources for melanoma.

Medical information is often difficult for patients to understand. With specialized vocabulary and complex pathophysiology, even well-educated adults have trouble interpreting information about their healthcare. The average American adult reads at a seventh-grade level. In light of the inherent complexity of health information, the American Medical Association and National Institutes of Health have recommended that information for patients should be written at a sixth-grade level. The goal of this study was to evaluate the most commonly used online patient resources about melanoma in the context of these recommendations. A web search for ‘melanoma’ identified the 10 most-accessed websites. Location filters were disabled and sponsored results were excluded to avoid inadvertent search bias. All relevant, patient-directed articles were downloaded and formatted into plain text. Pictures, videos, links, advertisements, and references were removed. Readability analysis was carried out using 10 established tests, both overall and arranged by parent website for comparison. A total of 130 articles for melanoma information were identified. The overall mean reading grade level was 12.6. All sites exceeded the recommended sixth-grade level. Secondary analysis of articles grouped by website indicated a range of readability across sites from 9.9 (high school freshman) to 14.9 (university sophomore). Online patient resources for melanoma uniformly exceed the recommended reading level and may be too difficult for many Americans to understand. The range of readability among websites may indicate an opportunity for physicians to direct patients to more appropriate resources for their level of health literacy.

A Novel Free Flap Monitoring System Using Tissue Oximetry with Text Message Alerts.

Background The time to detection of vascular compromise is a significant predictor of free flap salvage outcomes as early reexploration improves salvage rates. Continuous transcutaneous near-infrared tissue oximetry is an objective, quantitative method of detecting flap vascular compromise and has been shown to allow earlier reexploration and higher salvage rates than clinical assessment alone. We designed a novel text messaging system to improve communication using tissue oximetry monitoring. Methods A retrospective review was performed of a prospectively collected database of all microsurgical breast reconstructions from 2008 to 2015. A novel text messaging system was introduced in 2013 and programmed to send text messages alert when the tissue oximetry readings suggested potential flap compromise based on established thresholds. Patient demographics and complications, including rate of reexploration and flap loss were assessed. Results There were 900 autologous microsurgical breast free flaps during the study period: 614 were monitored with standard clinical monitoring and tissue oximetry compared with 286 flaps with the additional text messaging system. There were 27 unplanned returns to the operating room in the tissue oximetry group and 5 in the text messaging group with 1 complete flap loss in each group. Reexploration occurred sooner as a result of these text message alerts (17.5 vs. 26.6 hours postoperatively), however, it did not achieve statistical significance. Conclusions We were able to demonstrate the use of a novel text messaging system for tissue oximetry. This alert system shows promise in identifying impending flap loss with rapid notification of the surgical team.

Assessment of patient health literacy: a national survey of plastic surgeons.

Background: Health literacy affects patient participation, compliance, and outcomes. Nearly half of American adults have inadequate functional health literacy. Identification and accommodation of patients with low literacy is an important goal of the American Medical Association, U.S. Department of Health and Human Services, and the Healthy People 2020 initiative. This study aims to assess plastic surgeons’ perception of patient literacy. Methods: A survey was distributed to American Society of Plastic Surgeons members about time devoted to patient counseling, use of techniques for evaluating and enhancing patient understanding, perception of level of education, and estimated literacy. Participation was voluntary and data were collected anonymously using an online survey tool. Results: There were 235 participants in the survey (9.9 percent response rate). Patient literacy was most frequently assessed using their general impression (62.2 percent) and by asking patients about their employment (37.3 percent); 26.2 percent did not assess literacy. The majority of surgeons (62 percent) reported spending at least 20 minutes counseling new patients, and 37 percent reported spending more than 30 minutes. Lay terminology (94 percent) and pictures/diagrams (84.6 percent) were common patient education aids, whereas only 8.1 percent use teach-back methods. Plastic surgeons overestimated the level of education and reading level of their patients compared with national data. Conclusions: Formal assessment of health literacy is rarely performed, as most plastic surgeons use a general impression. Although plastic surgeons devote significant time to patient counseling, evidence-based communication methods, such as the teach-back method, are underused. Simple, directed questions can identify patients with low literacy skills, to accommodate their communication needs.

Readability Assessment of Patient Information about Lymphedema and Its Treatment.

Background: Patient use of online resources for health information is increasing, and access to appropriately written information has been associated with improved patient satisfaction and overall outcomes. The American Medical Association and the National Institutes of Health recommend that patient materials be written at a sixth-grade reading level. In this study, the authors simulated a patient search of online educational content for lymphedema and evaluated readability. Methods: An online search for the term “lymphedema” was performed, and the first 12 hits were identified. User and location filters were disabled and sponsored results were excluded. Patient information from each site was downloaded and formatted into plain text. Readability was assessed using established tests: Coleman-Liau, Flesch-Kincaid, Flesch Reading Ease Index, FORCAST Readability Formula, Fry Graph, Gunning Fog Index, New Dale-Chall Formula, New Fog Count, Raygor Readability Estimate, and Simple Measure of Gobbledygook Readability Formula. Results: There were 152 patient articles downloaded; the overall mean reading level was 12.6. Individual website reading levels ranged from 9.4 (cancer.org) to 16.7 (wikipedia.org). There were 36 articles dedicated to conservative treatments for lymphedema; surgical treatment was mentioned in nine articles across four sites. The average reading level for conservative management was 12.7, compared with 15.6 for surgery (p < 0.001). Conclusions: Patient information found through an Internet search for lymphedema is too difficult for many American adults to read. Websites queried had a range of readability, and surgeons should direct patients to sites appropriate for their level. There is limited information about surgical treatment available on the most popular sites; this information is significantly harder to read than sections on conservative measures.