Kristen M. Davidge

Predicting Complications following Expander/Implant Breast Reconstruction : An Outcomes Analysis Based on Preoperative Clinical Risk

Background: Complications following postmastectomy reconstruction can cause significant morbidity. The compound effect of individual risk factors on the development of complications following expander/implant reconstruction has not, however, been well delineated. This study evaluated the impact of clinical risk factors to predict complications following postmastectomy expander/implant reconstruction. Methods: From 2003 through 2004, 1170 expander/implant reconstructions were performed at a single center. A prospectively maintained database was reviewed. Variables including age, smoking status, body mass index, history of diabetes, hypertension, chemotherapy and/or radiation, as well as timing and laterality of reconstruction were evaluated. The primary endpoint was the development of a complication; the secondary endpoint was failure of reconstruction. Results: Over the 2 year study period, 1170 expander/implant reconstructions were performed in 884 patients. The odds of developing complications was 2.2 times greater in smokers (p < 0.001) and 2.5 times greater in women over 65 (p = 0.008). Patients who were obese were at nearly two times the odds of having complications (p = 0.02), as were patients with hypertension (p = 0.02). Similarly, the odds of reconstructive failure were five times greater in smokers (p < 0.001). Age was not a significant predictor of reconstructive failure (p = 0.09); yet, failure was nearly seven times greater in obese patients (p < 0.001), and four more times likely in those who were hypertensive (p = 0.005). Conclusions: Smoking, obesity, hypertension, and age over 65 were independent risk factors for perioperative complications following expander/implant breast reconstruction. Smoking, obesity, and hypertension were similarly associated with reconstructive failure. This information can be used to evaluate overall procedural risks and individualize reconstructive options.

Association of the serotonin transporter and 5HT1Dbeta receptor genes with extreme, persistent and pervasive aggressive behaviour in children.

There is an inverse correlation between central nervous system serotonergic activity and human aggression, and aggressive traits are at least partially heritable. The present study sought to investigate the relationship between childhood aggression and polymorphisms of two serotonin system genes: the 5HT1D&bgr; receptor gene and the serotonin transporter (5HTT) gene. Fifty children with a minimum 2-year history of aggression and scores above the 90th percentile on the Aggression subscales of both the Child Behaviour Checklist and the Teachers Report Form were included in the study. All probands and locally recruited ethnically matched controls were genotyped for the 5HT1D&bgr; G861C, 5HTTLPR (promoter) and 5HTT variable number of tandem repeats (VNTR) polymorphisms. Chi-square tests revealed a significantly reduced frequency of the 5HTT VNTR 10R allele in children displaying the high-aggression phenotype compared with normal controls (P=0.039). After correction for multiple comparisons, this association reached the level of a trend but was no longer significant. Probands also demonstrated an increased 5HT1D&bgr; 861C allele frequency, but this was not statistically significant (P=0.156). 5HTTLPR was not found to be significantly associated with aggression, but our data support previous findings of an association between this polymorphism and attention deficit hyperactivity disorder (P=0.025). While these preliminary findings should be interpreted cautiously, our data suggest that the 5HTT VNTR polymorphism is associated with measures of aggressive behaviour in a sample of children displaying extreme, persistent and pervasive aggression.

A systematic review of patient-reported outcome measures in head and neck cancer surgery.

Objective To identify, summarize, and evaluate patient-reported outcome questionnaires for use in head and neck cancer surgery with the view to making recommendations for future research. Data Sources A systematic review of the English-language literature, with the use of head-and-neck-surgery-specific keywords, was performed in the following databases: Medline, Embase, HAPI, CINAHL, Science/Social Sciences Citation Index, and PsycINFO from 1966 to March 2006. Data Extraction and Study Selection All English-language instruments identified as patient-reported outcome questionnaires that measure quality of life and/or satisfaction that had undergone development and validation in a head and neck cancer surgery population were included. Data Synthesis Twelve patient-reported outcome questionnaires fulfilled our inclusion criteria. Of these, four were developed from expert opinion alone or did not have a published development process and seven questionnaires lacked formal item reduction. Only three questionnaires (EORTC Head and Neck Module, University of Michigan Head and Neck Quality-of-life Questionnaire, and Head and Neck Cancer Inventory) fulfilled guidelines for instrument development and evaluation as outlined by the Medical Outcomes Trust. Conclusions Rigorous instrument development is important for creating valid, reliable, and responsive disease-specific questionnaires. As a direction for future instrument development, an increased focus on qualitative research to ensure patient input may help to better conceptualize and operationalize the variables most relevant to head and neck cancer surgery patients. In addition, the use of alternative methods of psychometric data analysis, such as Rasch, may improve the value of health measurement in clinical practice for individual patients.

Dopaminergic system genes in childhood aggression: Possible role for DRD2

Abstract Excessive or deficient levels of extracellular dopamine have been hypothesized to contribute to a broad spectrum of mood, motor, and thought abnormalities, and dopaminergic system genes have been implicated in aggressive behaviour from animal and human studies. Objective. We examined selected members of the dopaminergic system genes for association with child aggression. Method. We analyzed polymorphisms in the dopamine transporter DAT1/SLC6A3, dopamine receptor DRD2, and DRD4 genes in our sample of pervasive childhood aggression consisting of 144 cases paired with 144 healthy controls, matched for sex and ethnicity. Results. Aggressive children were significantly more likely to have the at least one copy of the G allele for the DRD2 A-241G polymorphism (genotypic P=0.02; allelic P=0.01). The DRD2 rs1079598 CC genotype was overrepresented in aggressive children compared to controls (genotype P=0.04). The DRD2 TaqIA T allele (P=0.01) and the TT genotype (P=0.01) were also significantly overrepresented in aggressive children. Conclusions. Our preliminary results suggest that three polymorphisms in DRD2 are associated with childhood aggression. Future studies are required to replicate the current results and to further explore the relationship between the dopamine system and aggressive behaviour in children.

Naming the soft tissue layers of the temporoparietal region: unifying anatomic terminology across surgical disciplines.

BACKGROUND The complexity of temporoparietal anatomy is compounded by inconsistent nomenclature. OBJECTIVE To provide a comprehensive review of the variations in terminology and anatomic descriptions of the temporoparietal soft tissue layers, with the aim of improving learning and communication across surgical disciplines. METHODS MEDLINE (1950–2009) searches were conducted for anatomic studies of the temporoparietal region, and for studies describing temporoparietal anatomy in the context of surgical techniques. RESULTS Sixty-nine articles were included in the review. Naming of the soft tissue layers of the temporoparietal region was inconsistent both within and across surgical disciplines, with several terms utilized for the same layer and occasionally the same term applied to different layers. Studies also varied in their description of the vascular, neural, and soft tissue architecture of the temporoparietal region. CONCLUSION A uniform, descriptive nomenclature is paramount to facilitating surgical education and interpreting future studies. A naming system based on the Terminologica Anatomica is proposed in this review. From superficial to deep, the proposed terms for the soft tissue layers of the temporoparietal region include: temporoparietal fascia, loose areolar tissue plane, superficial leaflet of temporal fascia, fat pad of temporal fascia, deep leaflet of temporal fascia, fat pad deep to temporal fascia, temporalis or temporal muscle, and pericranium.

Qualitative assessment of patient experiences following sacrectomy.

The primary objective was to investigate patient experiences following sacral resection as a component of curative surgery for advanced rectal cancers, soft tissue and bone sarcomas.

Median to Radial Nerve Transfers for Restoration of Wrist, Finger, and Thumb Extension

Radial nerve injury results in loss of wrist, finger, and thumb extension. Traditionally, radial nerve palsies that fail to recover spontaneously have been reconstructed with tendon transfers or nerve grafts. Nerve transfers are a novel approach to the surgical management of Sunderland grade IV and V radial nerve injuries. We describe our technique for median to radial nerve transfers. In this procedure, the flexor digitorum superficialis nerve is transferred to the extensor carpi radialis brevis nerve for wrist extension, and the flexor carpi radialis nerve is transferred to the posterior interosseous nerve for finger and thumb extension. Our experience with these nerve transfers has demonstrated excellent outcomes up to 10 months after injury. Indeed, unlike tendon transfers, median to radial nerve transfers have the potential to restore normal radial nerve function, including independent finger motion. Tension-free nerve coaptation and postoperative motor re-education are critical factors to achieving these successful outcomes.

Processes of care in autogenous breast reconstruction with pedicled TRAM flaps: expediting postoperative discharge in an ambulatory setting.

Background: A multidisciplinary patient care plan was developed to facilitate early discharge following autogenous breast reconstruction and included (1) preadmission patient education, (2) perioperative multimodal pain management, (3) intraoperative nerve blocks, and (4) postdischarge telephone advice. This study evaluated the success of this care plan in the first 18 months after its implementation. Methods: A retrospective cohort study of all consecutive women undergoing pedicled transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction (November of 2009 to May of 2011) was performed. The primary outcome was time to discharge; secondary outcomes included complications, readmission, and self-report pain at discharge. Predictors of discharge time were analyzed using stepwise multivariable regression modeling. Results: Ninety-one women (mean age, 50.0 ± 8.5 years) underwent pedicled TRAM flap reconstruction (76 percent unilateral and 81 percent delayed), with 77 percent receiving the intended multimodal analgesia protocol. Mean time to discharge was 38.7 ± 27.6 hours. Overall, 40 percent of patients were discharged within 24 hours, but successful early discharge increased significantly over the study period. Key predictors of shorter time to discharge were use of multimodal analgesia, lower American Society of Anesthesiologists class, and surgery more than 6 months after implementation of the care plan. Conclusions: The authors’ initial experience has supported the safety and feasibility of expedited discharge following pedicled TRAM flap breast reconstruction, with adherence to the authors’ care plan improving steadily over the study period. Multimodal pain management proved a key modifiable factor in facilitating early discharge. A prospective study is currently underway to evaluate patient-reported quality of recovery following ambulatory surgery in this population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Supercharge End-to-Side Anterior Interosseous-to-Ulnar Motor Nerve Transfer for Restoring Intrinsic Function: Clinical Experience.

Background: The authors reviewed their initial clinical experience with the supercharge end-to-side anterior interosseous–to–ulnar motor nerve transfer and refined their indications for this technique. Methods: A retrospective cohort study was performed of all patients undergoing the supercharge end-to-side procedure from 2009 to 2012. Preoperative and intraoperative data were reviewed. Function was evaluated using manual muscle testing; pinch/grip strength; and Disabilities of the Arm, Shoulder and Hand questionnaire scores. Differences in preoperative and postoperative function were evaluated using paired t tests and Wilcoxon signed rank tests. Predictors of poor outcome and changes in outcome over time were also analyzed. Results: Fifty-five patients (69 percent men; mean age, 50.0 ± 15.5 years) were included. Diagnoses were varied, but all patients demonstrated clinically significant ulnar intrinsic weakness and electrodiagnostic evidence of denervation of the first dorsal interosseous muscle. Postoperative first dorsal interosseous strength; key pinch strength; grip strength; and Disabilities of the Arm, Shoulder and Hand questionnaire scores improved significantly from baseline at a mean follow-up of 8.0 ± 5.7 months. No patients demonstrated weakness of pronation postoperatively. Absent preoperative compound muscle action potentials in the ulnar nerve significantly predicted poor intrinsic muscle recovery. The degree of intrinsic recovery attributable to the supercharge end-to-side transfer was difficult to determine. Conclusions: The supercharge end-to-side anterior interosseous–to–ulnar nerve transfer may be a useful technique for augmenting intrinsic muscle function for severe, in-continuity lesions of the ulnar nerve where limited surgical options exist. Future research is required to determine the proportion of intrinsic recovery attributable to this transfer. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Nerve Transfers to Restore Upper Extremity Function in Cervical Spinal Cord Injury: Update and Preliminary Outcomes.

Background: Cervical spinal cord injury can result in profound loss of upper extremity function. Recent interest in the use of nerve transfers to restore volitional control is an exciting development in the care of these complex patients. In this article, the authors review preliminary results of nerve transfers in spinal cord injury. Methods: Review of the literature and the authors’ cases series of 13 operations in nine spinal cord injury nerve transfer recipients was performed. Representative cases were reviewed to explore critical concepts and preliminary outcomes. Results: The nerve transfers used expendable donors (e.g., teres minor, deltoid, supinator, and brachialis) innervated above the level of the spinal cord injury to restore volitional control of missing function such as elbow extension, wrist extension, and/or hand function (posterior interosseous nerve or anterior interosseous nerve/finger flexors reinnervated). Results from the literature and the authors’ patients (after a mean postsurgical follow-up of 12 months) indicate gains in function as assessed by both manual muscle testing and patients’ self-reported outcomes measures. Conclusions: Nerve transfers can provide an alternative and consistent means of reestablishing volitional control of upper extremity function in people with cervical level spinal cord injury. Early outcomes provide evidence of substantial improvements in self-reported function despite relatively subtle objective gains in isolated muscle strength. Further work to investigate the optimal timing and combination of nerve transfer operations, the combination of these with traditional treatments (tendon transfer and functional electrical stimulation), and measurement of outcomes is imperative for determining the precise role of these operations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.