John L. Semple

A 40-100 MHz B-SCAN ULTRASOUND BACKSCATTER MICROSCOPE FOR SKIN IMAGING

There is a growing interest in high resolution, subsurface imaging of cutaneous tissues using higher frequency ultrasound, and several commercial systems have been developed recently which operate at 20 MHz. Some of the possible applications of higher frequency skin imaging include tumour staging, boundary definition, and studies of the response of tumours to therapy, investigations of inflammatory skin conditions such as psoriasis and eczema, and basic studies of skin aging, sun damage and the effects of irritants. Investigation of these areas is quite new, and the role of ultrasound skin imaging is continuing to evolve. Lateral resolution in the 20 MHz imaging systems ranges from 200 to 300 microns, which limits imaging applications to cutaneous structures which are relatively large in size. In this paper, a real-time ultrasound backscatter microscope (UBM) for skin imaging is described which operates in the 40-100 MHz range, providing axial resolution between 17 and 30 microns and lateral resolution between 33 and 94 microns. This improvement in resolution over current skin ultrasound systems should prove useful in determining the margins of small skin lesions, and in obtaining more precise, in vivo skin thickness measurements to characterize nonmalignant skin disease. Example images of normal skin, seborrhoeic keratosis and malignant melanoma illustrate the imaging potential of this system.

Clinical determinants of patient satisfaction with breast reconstruction.

&NA; The main objective of this study was to examine the relationship between specific treatment variables and patient satisfaction with breast reconstruction. A questionnaire was developed that included questions on population demographics and satisfaction with the reconstruction. Of 206 women who completed the questionnaire, 23 (11.2 percent) responded that they were not satisfied, whereas 183 (88.8 percent) indicated that they were satisfied overall. A detailed retrospective chart review permitted a comparison of the treatment received by these two groups. Variables analyzed included patient age, time since surgery, reason for surgery, method and timing of reconstruction, additional surgical procedures received (mound revisions and nipple‐areola complex reconstruction), and postoperative complications. Data analysis showed that the treatment received by the two groups was similar in many respects. There was no statistical association between the method or timing of reconstruction and a patients satisfaction with the results. Furthermore, there was no difference in the number of mound revisions or nipple reconstructions performed on satisfied versus dissatisfied patients. However, the latter group experienced a substantially higher incidence of postsurgical complications (27 percent versus 61 percent, p = 0.0015). Patients were also asked to provide a written response explaining their feelings on breast reconstruction. Satisfied patients described benefits from reconstruction such as improved appearance or feelings of normalcy and wholeness. Conversely, unsatisfied patients were displeased because of poor cosmetic results, complications with the reconstructed breast, or abdominal problems. Although overall satisfaction with breast reconstruction is undoubtedly determined by multiple and complex clinical, emotional, and psychological factors, this study suggests that postoperative complications are a particularly important indicator of dissatisfaction with reconstruction. (Plast. Reconstr. Surg. 107: 46, 2001.)

Proliferation and differentiation of adipose-derived stem cells on naturally derived scaffolds

A tissue-engineered substitute that facilitates large-volume regeneration of the subcutaneous adipose tissue layer is needed for reconstructive plastic surgery. Towards this goal, we describe the in vitro culture of primary human adipose-derived stem cells (ASC) seeded into placental decellular matrix (PDM) and cross-linked hyaluronan (XLHA) scaffolds. Specifically, we evaluated cellular proliferation and adipogenic differentiation in the PDM, XLHA, and PDM combined with XLHA scaffolds. Cellular proliferation, viability, and glucose consumption were determined prior to the induction of differentiation. Adipogenesis within each of the scaffolds was investigated through gene expression analysis using end point and real time reverse transcriptase polymerase chain reaction (RT-PCR). The results indicate that the cell-adhesive PDM scaffolds facilitated proliferation and viability, while differentiation was augmented when the cells were encapsulated in the non-adhesive XLHA gels.

Mortality on Mount Everest, 1921-2006: descriptive study

Objective To examine patterns of mortality among climbers on Mount Everest over an 86 year period. Design Descriptive study. Setting Climbing expeditions to Mount Everest, 1921-2006. Participants 14 138 mountaineers; 8030 climbers and 6108 sherpas. Main outcome measure Circumstances of deaths. Results The mortality rate among mountaineers above base camp was 1.3%. Deaths could be classified as involving trauma (objective hazards or falls, n=113), as non-traumatic (high altitude illness, hypothermia, or sudden death, n=52), or as a disappearance (body never found, n=27). During the spring climbing seasons from 1982 to 2006, 82.3% of deaths of climbers occurred during an attempt at reaching the summit. The death rate during all descents via standard routes was higher for climbers than for sherpas (2.7% (43/1585) v 0.4% (5/1231), P<0.001; all mountaineers 1.9%). Of 94 mountaineers who died after climbing above 8000 m, 53 (56%) died during descent from the summit, 16 (17%) after turning back, 9 (10%) during the ascent, 4 (5%) before leaving the final camp, and for 12 (13%) the stage of the summit bid was unknown. The median time to reach the summit via standard routes was earlier for survivors than for non-survivors (0900-0959 v 1300-1359, P<0.001). Profound fatigue (n=34), cognitive changes (n=21), and ataxia (n=12) were the commonest symptoms reported in non-survivors, whereas respiratory distress (n=5), headache (n=0), and nausea or vomiting (n=3) were rarely described. Conclusions Debilitating symptoms consistent with high altitude cerebral oedema commonly present during descent from the summit of Mount Everest. Profound fatigue and late times in reaching the summit are early features associated with subsequent death.

Retrograde Microvascular Augmentation (turbocharging) of a Single-pedicle Tram Flap Through a Deep Inferior Epigastric Arterial and Venous Loop

Modern trends in breast reconstruction with the TRAM flap have promoted adequate blood supply to the flap while minimizing the donor-site defect in the anterior abdominal wall. Preservation of the rectus abdominis muscle (both unipedicled and bipedicled), supercharging, delayed, and free-flap techniques all have promoted these principles.A new technique is presented utilizing the single pedicle with a transmidline retrograde microvascular loop anastomosis of the deep inferior epigastric artery and vein. The turbocharging allows increased blood flow to the remote areas of the flap as well as augmented venous outflow. In addition, the abdominal-wall donor site is similar to that of a single pedicle. This technique is ideal for reconstruction where the entire flap is required, a lower abdominal scar is present, or the recipient vessels for the free flap are absent or damaged. (Plast. Reconstr. Surg. 93: 109, 1994.)

Using a Mobile App for Monitoring Post-Operative Quality of Recovery of Patients at Home: A Feasibility Study

Background Mobile apps are being viewed as a new solution for post-operative monitoring of surgical patients. Mobile phone monitoring of patients in the post-operative period can allow expedited discharge and may allow early detection of complications. Objective The objective of the current study was to assess the feasibility of using a mobile app for the monitoring of post-operative quality of recovery at home following surgery in an ambulatory setting. Methods We enrolled 65 consecutive patients (n=33, breast reconstruction surgery; n=32, orthopedic surgery) and asked them to use a mobile phone daily to complete a validated quality of recovery scale (QoR-9) and take photographs of the surgical site for the first 30 days post-op. Surgeons were asked to review patient-entered data on each patient in their roster daily. A semistructured questionnaire was administered to patients and surgeons to assess satisfaction and feasibility of the mobile device. Results All 65 patients completed the study. The mean number of logins was 23.9 (range 7-30) for the breast patients and 19.3 (range 5-30) for the orthopedic patients. The mean number of logins was higher in the first 14 days compared to the 15-30 days post-op for both breast patients (13.4 vs 10.5; P<.001) and for the orthopedic patients (13.4 vs 6.0; P<.001). The mean score for overall satisfaction with using the mobile device was 3.9 for breast patients and 3.7 for orthopedic patients (scored from 1 (poor) to 4 (excellent)). Surgeons reported on the easy-to-navigate design, the portability to monitor patients outside of hospital, and the ability of the technology to improve time efficiency. Conclusions The use of mobile apps for monitoring the quality of recovery in post-operative patients at home was feasible and acceptable to patients and surgeons in the current study. Future large scale studies in varying patient populations are required.

Adipose tissue engineering in vivo with adipose-derived stem cells on naturally derived scaffolds.

Placental decellular matrix (PDM) and PDM combined with cross-linked hyaluronan (XLHA) scaffolds, seeded with primary human adipose-derived stem cells (ASC), were investigated in a subcutaneous athymic mouse model. The in vivo response at 3 and 8 weeks was characterized using histological and immunohistochemical staining. Fibrous capsule formation was assessed and the relative number of adipocytes in each scaffold was quantified. Undifferentiated ASC were localized using immunostaining for human vimentin. Unilocular and multilocular adipocytes were identified by intracellular lipid accumulation. Staining for murine CD31 assessed implant vascularization. Both scaffolds macroscopically maintained their three-dimensional volume and supported mature adipocyte populations in vivo. There was evidence of implant integration and a host contribution to the adipogenic response. The results suggested that incorporating the XLHA had a positive effect in terms of angiogenesis and adipogenesis. Overall, the PDM and PDM with XLHA scaffolds showed great promise for adipose tissue regeneration.

Ultrasound-guided Multilevel Paravertebral Blocks and Total Intravenous Anesthesia Improve the Quality of Recovery after Ambulatory Breast Tumor Resection

Background:Regional anesthesia improves postoperative analgesia and enhances quality of recovery (QoR) after ambulatory surgery. This randomized, double-blinded, parallel-group, placebo-controlled trial examines the effects of multilevel ultrasound-guided paravertebral blocks (PVBs) and total intravenous anesthesia on QoR after ambulatory breast tumor resection. Methods:Sixty-six women were randomized to standardized general anesthesia (control group) or PVBs and propofol-based total intravenous anesthesia (PVB group). The PVB group received T1–T5 PVBs with 5 ml of 0.5% ropivacaine per level, whereas the control group received sham subcutaneous injections. Postoperative QoR was designated as the primary outcome. The 29-item ambulatory QoR tool was administered in the preadmission clinic, before discharge, and on postoperative days 2, 4, and 7. Secondary outcomes included block success, pain scores, intra- and postoperative morphine consumption, time to rescue analgesia, incidence of nausea and vomiting, and hospital discharge time. Results:Data from sixty-four patients were analyzed. The PVB group had higher QoR scores than control group upon discharge (146 vs. 131; P < 0.0001) and on postoperative day 2 (145 vs. 135; P = 0.013); improvements beyond postoperative day 2 lacked statistical significance. None of the PVB group patients required conversion to inhalation gas–based general anesthesia or experienced block-related complications. PVB group patients had improved pain scores on postanesthesia care unit admission and discharge, hospital discharge, and postoperative day 2; their intraoperative morphine consumption, incidence of nausea and vomiting, and discharge time were also reduced. Conclusion:Combining multilevel PVBs with total intravenous anesthesia provides reliable anesthesia, improves postoperative analgesia, enhances QoR, and expedites discharge compared with inhalational gas- and opioid-based general anesthesia for ambulatory breast tumor resection.

Time to reconsider subcutaneous mastectomy for breast- cancer prevention?

Genetic testing for women at increased risk of developing breast cancer has moved from the research setting to become part of established clinical practice. By testing for inherited mutations in BRCA1 and BRCA2, we are identifying more and more women who have an 80% or more lifetime risk of developing breast cancer. Since the discovery of BRCA1 in 1994, several clinical studies have led to strategies for reducing the risk of developing breast cancer, including prophylactic mastectomy, prophylactic oophorectomy, and preventive tamoxifen. We believe that in 2005, all prophylactic options, including subcutaneous and total mastectomy should be discussed and made available to women who find themselves unfortunate enough to have inherited a BRCA mutation.

Replacing Ambulatory Surgical Follow-Up Visits With Mobile App Home Monitoring: Modeling Cost-Effective Scenarios

Background Women’s College Hospital (WCH) offers specialized surgical procedures, including ambulatory breast reconstruction in post-mastectomy breast cancer patients. Most patients receiving ambulatory surgery have low rates of postoperative events necessitating clinic visits. Increasingly, mobile monitoring and follow-up care is used to overcome the distance patients must travel to receive specialized care at a reduced cost to society. WCH has completed a feasibility study using a mobile app (QoC Health Inc, Toronto) that suggests high patient satisfaction and adequate detection of postoperative complications. Objective The proposed cost-effectiveness study models the replacement of conventional, in-person postoperative follow-up care with mobile app follow-up care following ambulatory breast reconstruction in post-mastectomy breast cancer patients. Methods This is a societal perspective cost-effectiveness analysis, wherein all costs are assessed irrespective of the payer. The patient/caregiver, health care system, and externally borne costs are calculated within the first postoperative month based on cost information provided by WCH and QoC Health Inc. The effectiveness of telemedicine and conventional follow-up care is measured as successful surgical outcomes at 30-days postoperative, and is modeled based on previous clinical trials containing similar patient populations and surgical risks. Results This costing assumes that 1000 patients are enrolled in bring-your-own-device (BYOD) mobile app follow-up per year and that 1.64 in-person follow-ups are attended in the conventional arm within the first month postoperatively. The total cost difference between mobile app and in-person follow-up care is