William A. Wooden

The Cost of Intraoperative Plastic Surgery Education

PURPOSEnWithin the surgical community, it is commonly accepted that the length and cost of a surgical case increase when a resident physician participates. Many accountable care organizations, however, believe the opposite, that is, resident assistance enhances efficiency and diminishes operative time. The purpose of this study is to determine the opportunity cost to the attending surgeon for intraoperative teaching during index plastic surgery cases.nnnMETHODSnA single senior surgeons experience over a 7-year period was evaluated retrospectively for Current Procedural Terminology codes 40700 (repair of primary, unilateral cleft lip) and 42200 (palatoplasty). Variables collected include operative time, the presence or absence of a physician learner, and postgraduate year level. Statistical analysis was performed with the Kruskal-Wallis test using the S+ programming language. A cost analysis was performed to quantify the effect of longer operative times in terms of relative value units (RVUs) lost.nnnRESULTSnDuring the study period, a total of 45 patients had primary, unilateral cleft lip repair; 70 patients had cleft palate repair. Of those cases, 39 (87%) cleft lip repairs and 60 (86%) cleft palate repairs were performed with a resident or fellow present. There was a statistically significant difference in the amount of time required to perform either surgery with a physician learner than without, with operative times being 60% (p = 0.020) longer for cleft lip repair and 65% (p = 0.0016) longer for cleft palate repair. The results were further stratified based on level of training, with craniofacial fellows and plastic surgery residents (independent and integrated) compared separately. Cases where a craniofacial fellow was present required the longest operative times: 103% (p = 0.0012) longer for cleft lip repairs and 104% (p < 0.0001) longer for cleft palate repairs when compared with the senior surgeon operating alone. Using the 2011 physician work RVUs for these surgeries and the 2011 Medicare conversion factor for RVUs to dollars, the opportunity cost is over

Age at Diagnosis as a Relative Contraindication for Intervention in Facial Nonmelanoma Skin Cancer

275 per case per trainee for any physician learner. When craniofacial fellows are analyzed separately, over

Distinct Effects of Adipose-derived Stem Cells and Adipocytes on Normal and Cancer Cell Hierarchy

440 is invested in intraoperative teaching per case per fellow.nnnCONCLUSIONSnResident involvement in the operating room is crucial to the education of independent surgeons. This involvement, however, comes at a significant opportunity cost to the attending surgeon. As an incentive to retain academic surgeons and uphold a quality academic environment in the OR, compensation should be offered for intraoperative teaching.

Historical review of Dakin's solution applications

Author Affiliations: Center for Colon and Rectal Surgery, Florida Hospital, Orlando (Lee, Monson); Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio (Dietz); Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, New York (Fleming); Department of Surgery, New York University Langone Medical Center, New York (Remzi); Department of Colorectal Surgery, Cleveland Clinic Florida, Weston (Wexner); Division of Research and Optimal Patient Care (Cancer), American College of Surgeons, Chicago, Illinois (Winchester).

Abstract 20. Tourniquet vs. Epinephrine in Wide-Awake Carpal Tunnel Release

Adipose-derived stem cells (ASC) have received considerable attention in oncology because of the known direct link between obesity and cancer as well as the use of ASCs in reconstructive surgery after tumor ablation. Previous studies have documented how cancer cells commandeer ASCs to support their survival by altering extracellular matrix composition and stiffness, migration, and metastasis. This study focused on delineating the effects of ASCs and adipocytes on the self-renewal of stem/progenitor cells and hierarchy of breast epithelial cells. The immortalized breast epithelial cell line MCF10A, ductal carcinoma in situ (DCIS) cell lines MCF10DCIS.com and SUM225, and MCF10A-overexpressing SRC oncogene were examined using a mammosphere assay and flow cytometry for the effects of ASCs on their self-renewal and stem-luminal progenitor-differentiated cell surface marker profiles. Interestingly, ASCs promoted the self-renewal of all cell types except SUM225. ASC coculture or treatment with ASC conditioned media altered the number of CD49fhigh/EpCAMlow basal/stem-like and CD49fmedium/EpCAMmedium luminal progenitor cells. Among multiple factors secreted by ASCs, IFNγ and hepatocyte growth factor (HGF) displayed unique actions on epithelial cell hierarchy. IFNγ increased stem/progenitor-like cells while simultaneously reducing the size of mammospheres, whereas HGF increased the size of mammospheres with an accompanying increase in luminal progenitor cells. ASCs expressed higher levels of HGF, whereas adipocytes expressed higher levels of IFNγ. As luminal progenitor cells are believed to be prone for transformation, IFNγ and HGF expression status of ASCs may influence susceptibility for developing breast cancer as well as on outcomes of autologous fat transplantation on residual/dormant tumor cells. Implications: This study suggests that the ratio of ASCs to adipocytes influences cancer cell hierarchy, which may impact incidence and progression. Mol Cancer Res; 14(7); 660–71. ©2016 AACR.

Congenital ichthyosis patient with squamous cell carcinoma of the skin who received concurrent chemoradiation: A case report

Dakins solution and the Carrel-Dakin method were developed and integrated into clinical practice in the early 20th century, which were found to aid in effective wound healing and infection. This historical review briefly outlines highlights with regard to the history of infection management, wartime amputation, and wound treatment dating back to Galen through the early 20th century. This paper extensively reviews and discusses the historic use of Dakins solution, which was developed almost a century ago, in both wartime settings and in the civilian sector as well. This review further elaborates on the use of Dakins solution in the current treatment of wounds in the United States. Additionally, we discuss the history of wound care with the emphasis on the Carrel-Dakin method. Finally, this review discusses and presents contemporary application and utilization of Dakins solution in two large tertiary care centers.

Abstract 3589: Adipose stem cell-derived interferon gamma alters breast epithelial stem cell hierarchy

PURPOSE: Carpal tunnel syndrome is a common cause of upper extremity discomfort. Surgical release of the median nerve can be performed under general or local anesthetic, with or without a tourniquet. Wide-awake carpal tunnel release (CTR) (local anesthesia, no sedation) is gaining popularity. Tourniquet discomfort is a reported downside. This study reviews outcomes in wide-awake CTR and compares tourniquet versus no tourniquet use.

Melanoma Extirpation with Immediate Reconstruction: The Oncologic Safety and Cost Savings of Single-Stage Treatment

Ichthyosis is a heterogeneous cluster of keratinization disorders. Autosomal dominant ichthyosis vulgaris, the most common type, has an estimated incidence of 1 in 250 births, and X-linked recessive ichthyosis, the second most common form, has an incidence of 1 in 6000 male births. In addition, there are approximately 6.7 in 100,000 cases of moderate-to-severe ichthyosis. Congenital ichthyoses are caused by mutations in the genes responsible for keratinocyte differentiation and skin barrier function. To date, there are 36 known forms of inherited ichthyoses, with over 25 genes being implicated and multiple mutations for each gene. In ichthyosis vulgaris, mutation of the filaggrin gene leads to a paucity or absence of the granular layer of the epidermis. This results in abnormal epidermal hyperplasia with excessive formation of stratum corneum, accompanied by abnormal desquamation. The main clinical feature of this disease is dry and rough skin with marked scaling but without inflammation. The skin of the abdomen and extensor surfaces is the most commonly affected, but the skin of the face and flexor surfaces is often spared. There is limited data on how patients with ichthyosis tolerate radiation therapy. Here we describe a case of a patient with congenital ichthyosis who underwent a course of radiation therapy concurrently with chemotherapy for treatment of squamous cell cancer of the skin.

Regression Patterns in Non-Melanoma Skin Cancer

Autologous adipose stem cell transplantation is increasingly being used for soft tissue reconstruction, particularly after mastectomy. However, a recent study demonstrated recurrence of invasive ductal carcinoma in the breast within four months of autologous fat grafting. Previous studies have documented how cancer cells commandeer adipose stem cells (ASC) to support their survival by altering extracellular matrix composition and stiffness. This study focused on delineating the effects of ASCs on the self-renewal capacity of breast epithelial cells. The immortalized breast epithelial cell line MCF-10A, MCF-10A overexpressing Slug, and MCF-10A overexpressing SRC were examined using a mammosphere assay and flow cytometry for the effects of ASCs on their self-renewal and stem-luminal progenitor-differentiated cell surface marker profile. MCF-10A-Slug cells provided a unique model system to study breast epithelial cell dedifferentiation as Slug functions downstream of the breast cancer susceptibility gene BRCA1 and is a major suppressor of progenitor cell lineage commitment and differentiation. Interestingly, results with these established cell lines were reproduced in primary breast epithelial cells isolated from a high-risk patient. We show that secreted factors from ASCs promote self-renewal of all cell types examined. ASC co-culture or treatment with ASC conditioned media (CM) altered the number of CD49fhigh/EpCAMlow stem-like and CD49fmedium/EpCAMmedium luminal progenitor cells in 2D culture and mammosphere assays. ASCs secrete Interferon gamma (IFNγ), CD40 ligand, IL-23 and SERPINE1. Among these factors, only IFNγ treatment altered stem cell hierarchy; while MCF-10A-Slug cells displayed only luminal progenitor phenotype, cells treated with IFNγ contained a distinct stem-like cell population. These results suggest that paracrine activity of adipose stem cell-derived factors can either enhance dedifferentiation and promote proliferation of dormant tumor cells or predispose normal cells to transformation by blocking differentiation. Financial support: Susan G. Komen For the Cure SAC110025 and Zeta Tau Sorority (HN) Citation Format: Manjushree Anjanappa, Riesa M. Burnett, Stephanie Merfeld-Clauss, William A. Wooden, Keith L. March, Sunil Tholpady, Harikrishna Nakshatri. Adipose stem cell-derived interferon gamma alters breast epithelial stem cell hierarchy. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 3589. doi:10.1158/1538-7445.AM2014-3589