Li-Xing Man

Abdominal wall following free TRAM or DIEP flap reconstruction: a meta-analysis and critical review.

Background: Numerous studies compare techniques for free flap breast reconstruction techniques, with no consensus regarding differences in complication rates. This study compared the risk of fat necrosis, partial flap loss, total flap loss, abdominal bulge, laxity, or weakness, and abdominal hernia after deep inferior epigastric perforator (DIEP) and free transverse rectus abdominis myocutaneous (TRAM) flap surgery for breast reconstruction. Methods: A MEDLINE and manual search of English-language articles on DIEP and free TRAM flap surgery published up to April of 2007 yielded 338 citations. Two levels of screening identified 37 relevant studies. The Mantel-Haenszel fixed-effects and DerSimonian and Laird random-effects models were used to perform the meta-analysis. Results: Six studies reporting both DIEP and free TRAM flap outcomes were used to estimate pooled relative risks of complications and confidence intervals. There was a twofold increase in the risk of fat necrosis (relative risk, 1.94; 95 percent CI, 1.28 to 2.93) and flap loss (relative risk, 2.05; 95 percent CI, 1.16 to 3.61) in DIEP patients compared with free TRAM patients. There was no difference in the risk for fat necrosis when the analysis was limited to studies using muscle-sparing free TRAM flaps (relative risk, 0.91; 95 percent CI, 0.47 to 1.78). DIEP patients had one-half the risk of abdominal bulge or hernia (relative risk, 0.49; 95 percent CI, 0.28 to 0.86). Sixteen studies reporting DIEP outcomes and 23 studies reporting free TRAM outcomes were used to estimate pooled complication rates. Pooled flap-related complication rates were higher in DIEP patients, whereas donor-site morbidity was higher in free TRAM patients. Conclusion: This analysis suggests that the DIEP flap reduces abdominal morbidity but increases flap-related complications compared with the free TRAM flap in breast reconstruction.

Maternal cigarette smoking during pregnancy increases the risk of having a child with a congenital digital anomaly.

Background: The U.S. Natality database from 2001 and 2002 was used to investigate the relationship between maternal cigarette smoking during pregnancy and the risk of having a child with polydactyly, syndactyly, or adactyly. Methods: The records of 6,839,854 live births were examined to identify 5171 newborns with isolated polydactyly, syndactyly, or adactyly and 10,342 controls with no congenital anomalies. Results: Maternal cigarette use during pregnancy was associated with a significantly elevated risk of having a child with a congenital digital anomaly (unadjusted odds ratio, 1.33; 95 percent confidence interval, 1.21 to 1.47; p < 0.0001). Univariate analysis indicated that maternal marital status and medical risk factors (anemia, cardiac disease, lung disease, diabetes, hydramnios/oligohydramnios, pregnancy-associated hypertension, incompetent cervix, previous preterm or small-for-gestational-age infant, and rhesus factor sensitization) were potential confounding factors. After adjustment for these variables, the odds ratio remained significant (adjusted odds ratio, 1.31; 95 percent confidence interval, 1.18 to 1.45; p < 0.0001). Cigarette consumption per day was divided into four groups: no smoking, 1 to 10 cigarettes per day, 11 to 20 cigarettes per day, and 21 or more cigarettes per day. A statistically significant dose–response relationship was found when comparing each smoking category with the no-smoking reference group: 1.29 (95 percent confidence interval, 1.15 to 1.46), 1.38 (95 percent confidence interval, 1.12 to 1.71), and 1.78 (95 percent confidence interval, 0.97 to 3.26), respectively. Increased cigarette smoking during pregnancy resulted in an elevated risk of having a child with polydactyly, syndactyly, or adactyly. Conclusions: This is the largest study to date to investigate specifically the association between maternal cigarette smoking and the risk of having a newborn with a congenital digital anomaly. The elevated odds ratio for tobacco use and the significant trend in the dose–response relationship suggests smoking during pregnancy may be an important preventable risk factor for these common congenital differences.

Educating future leaders of medical research: analysis of student opinions and goals from the MD-PhD SAGE (Students' Attitudes, Goals, and Education) survey.

Purpose To collect national trainee-derived data about the educational process and experience of MD–PhD students. Method Eight hundred sixty-eight MD–PhD students enrolled in 15 training programs nationally were surveyed in spring 2003 via a 29-item Web-based questionnaire. Closed-ended questions assessed students’ opinions, attitudes, and goals concerning education and future careers, as well as demographic characteristics. Programs were categorized by size; students were categorized by stage of training. Statistical analyses included chi-square tests and ANOVAs. Results From 13 institutions, 492 questionnaires were received, for a 57.6% response rate. Generally, satisfaction with overall education was highest at the beginning of training, lowest during graduate school, and rebounded after the PhD. Students at smaller programs were less satisfied with information received regarding future residency/career choices and coordination between training stages. Later-stage students showed greater satisfaction in obtaining the philosophical goals of their education and a different array of clinical interests than early-stage students. A majority of students chose research as their future primary activity, academic centers as their primary practice setting, and disease oriented as their future primary research activity. Many students did not agree with the current working definition of a physician–scientist. Conclusions Findings indicate that students have clinical interests that develop over time, a variety of future career goals, and ambivalence concerning the appropriate balance of clinical and research activities. This information may provide a basis for future improvements in the education of MD–PhDs in the United States and abroad.

Antibiotic prophylaxis in uncontaminated neck dissection

To describe our institutions experience with antibiotic prophylaxis in uncontaminated neck dissection and to identify risk factors associated with postoperative wound infection.

The Future of the Orthopaedic Clinician-Scientist Part I: The Potential Role of MD-PhD Students Considering Orthopaedic Surgery

BACKGROUND There is currently a severe shortage of clinician-scientists, who fill a vital role in musculoskeletal care. One way to address this shortage is to recruit more MD-PhD students into orthopaedics. We analyzed data from a national survey of MD-PhD students to assess this potential. METHODS A total of 868 students from thirteen MD-PhD training programs were requested to fill out a multiple-choice online survey concerning their education and future goals. RESULTS We achieved a response rate of 56.7% (492 of 868). Seven (1.4%) of the 492 respondents listed orthopaedics as their primary clinical interest, and thirty (6.1%) listed it as one of their three strongest clinical interests. Among the thirty respondents, seven (23%) were senior students, five (17%) were women, and none were minorities. In comparison, 33% of the 462 respondents in the nonorthopaedic cohort were women and 12.1% were a member of a minority group (p < 0.05). Among twenty-three students who had a secondary orthopaedic interest, only one-third had a primary surgical interest. Both the thirty with a strong clinical interest in orthopaedics and the others without a strong interest in orthopaedics showed similar intent on becoming physician-scientists (a score of 2.73 and 3.30, respectively) and an interest in an academic career (90.0% and 90.3%, respectively) (p > 0.05 for both). The orthopaedic group showed significantly greater interest in clinical care as a primary activity than did the nonorthopaedic group (63.3% compared with 30.7%; p < 0.0005). Eighty-seven percent of those in the orthopaedic group reported research as their most likely primary or secondary activity. CONCLUSIONS This study suggests that there is a relatively strong interest in orthopaedic surgery (patient care and research) among MD-PhD students nationally, creating the potential to recruit approximately 100 new orthopaedic clinician-scientists every eight years (the average MD-PhD training period). Extrapolation indicates that there is the ability to double the number of orthopaedic clinician-scientists in the United States over the next fifty years. Therefore, efforts should be made to attract these students (especially women and those in underrepresented minority groups) to orthopaedic surgery. The study further suggests recruiting broadly-we should not be biased toward students late in training and just those with surgical interests.

Publication misrepresentation among otolaryngology residency applicants

OBJECTIVE: To assess the extent of research publication misrepresentation among otolaryngology residency applicants and to determine applicant attributes associated with misrepresentation. STUDY DESIGN: Prospective study. SETTING: A single otolaryngology residency program. SUBJECTS AND METHODS: Electronic Residency Application Service (ERAS) applications to the incoming 2010 class of an otolaryngology residency program were reviewed for peer-reviewed journal publications reported as “provisionally accepted,” “accepted,” or ”in print.“ Publications were verified by searching PubMed, Google Scholar, and electronic journals. Applicants with remaining unverified publications were e-mailed before announcing interviews. Erroneously reported or unverifiable publications were considered misrepresented. RESULTS: There were 432 publications reported by 173 of 325 applicants (53.2%). Twenty-two publications (5.1%) were misrepresented by 17 applicants (9.8%). Contacting applicants verified 26 publications and identified 10 errors. Seven publications were inappropriately reported as provisionally accepted, three articles were not peer-reviewed, and applicants were erroneously listed as first author on two publications. Ten publications remained unverifiable. Multivariate logistic regression models showed that being an international medical graduate (P = 0.002) and male gender (P = 0.040) were predictors of misrepresentation after adjusting for potential confounders. Among international medical graduates alone, no attributes were associated with misrepresentation. All U.S. applicants with misrepresented publications were male (P = 0.033) and were from a medical school not ranked in the top 50 by U.S. News & World Report for research (P = 0.002) or primary care (P = 0.018). CONCLUSION: Misrepresentation of research experience exists among otolaryngology residency applicants. ERAS should develop standardized definitions for publication statuses to help reduce inadvertent misrepresentation.

Lentiviral gene therapy with platelet-derived growth factor B sustains accelerated healing of diabetic wounds over time.

The treatment of diabetic wounds is a formidable clinical challenge. In this study, lentiviral vectors carrying the human platelet-derived growth factor B (PDGF-B) gene were used to treated diabetic mouse wounds. Full-thickness 2.0-cm × 2.0-cm excisional wounds were created on the dorsa of genetically diabetic C57BL/KsJ-m+/+Leprdb mice. Lentiviral vectors containing the PDGF-B gene were injected into the wound margins and base. Mice were killed at 14-, 21-, and 35-day intervals. Measurement of the residual epithelial gap showed a trend towards increased healing in lentiviral PDGF-treated wounds compared with untreated and saline-treated wounds at all time points. At 21 days, there was significantly increased healing in lentiviral PDGF-treated wounds (0.98 ± 0.17 cm) compared with saline-treated wounds (1.22 ± 0.30 cm; P < 0.05). Immunohistochemistry for CD31 revealed significantly increased neovascularization in lentiviral PDGF-treated wounds compared with untreated and saline-treated wounds at 14 and 21 days (P < 0.01). Picrosirius red staining demonstrated thicker and more highly organized collagen fibers in treated wounds compared with untreated and saline-treated wounds. Quantitative analysis of collagen content showed a 3.5-fold and 2.3-fold increase in lentiviral PDGF-treated wounds versus untreated and saline-treated wounds, respectively (P < 0.01). Lentiviral gene therapy with PDGF-B can sustain diabetic wound healing over time and may possess promising potential in the clinical setting.

Complementary and alternative medicine for allergic rhinitis

Purpose of reviewOtolaryngologists and other physicians who diagnose and treat allergic rhinitis encounter patients who use complementary medicine and alternative remedies. This article reviews the recent literature regarding complementary and alternative therapies for the treatment of allergic rhinitis. Recent findingsThere are a myriad of modalities for treating allergic rhinitis. Few are studied with rigorous randomized, double-blind, placebo-controlled trials for clinical efficacy. Often, the biological mechanisms and adverse effects are even less well understood. A few therapies, including spirulina, butterbur, and phototherapy hold some promise. Thus far, complementary and alternative therapies have not been integrated into the general treatment armamentarium of allergic rhinitis. SummarySeveral studies report beneficial effects of certain alternative treatments for allergic rhinitis. Additional insight into the mechanisms of action, short-term and long-term effects, and adverse events is needed.

The effect of antibiotics on the microbiome in acute exacerbations of chronic rhinosinusitis

Current treatment of acute exacerbations of chronic rhinosinusitis (CRS) is driven by identification of predominant bacteria using culture‐based methods and determination of antibiotic sensitivities. The objective of this study was to evaluate the response of the sinonasal microbiome to antibiotic therapy in the setting of an acute exacerbation of CRS.

The effect of intranasal fluticasone propionate irrigations on salivary cortisol, intraocular pressure, and posterior subcapsular cataracts in postsurgical chronic rhinosinusitis patients.

Intranasal corticosteroid irrigations, especially budesonide, are used increasingly in the management of chronic rhinosinusitis. In post–endoscopic sinus surgery patients, irrigations may offer improved delivery at higher doses to the paranasal sinuses than intranasal spray preparations. Fluticasone propionate may have higher potency and lower systemic bioavailability than budesonide, but there is little data on its effects as an intranasal irrigation on the hypothalamic‐pituitary‐adrenal axis or on ocular findings.