Predictors of Hand Function Following Digit Replantation: Quantitative Review and Meta-Analysis

Background: Digit replantation affords the opportunity to restore hand function following amputation. To date, however, few studies have evaluated functional outcomes following replantation. Therefore, it was the objective of this study to perform a meta-analysis to better characterize the predictors of hand function. Methods: A literature search was performed using the PubMed database to identify studies that focused on digit amputation/replantation and functional outcomes. Studies were evaluated for patient- and injury-related factors and their respective effects on clinical outcomes of sensation, grip strength, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. Statistical analysis was conducted across the pooled data set to identify significant trends. Results: Twenty-eight studies representing 618 replanted digits were included in this study. We found the average grip strength was 78.7% (relative to contralateral), the average 2-point discrimination (2PD) was 7.8 mm, and the average DASH score was 12.81. After conducting statistical analysis, we found patients with more proximal injuries had lower grip strength scores (P < .05). We found 2PD scores were influenced by age, mechanism of injury, and amputation level (P < .05). Finally, we found DASH scores after replantation were predicted by mechanism of injury and level of amputation (P < .05). The following variables did not influence outcomes: gender, tobacco use, ischemia time, and digit number. Conclusions: Digit replant does not restore premorbid hand function but does result in adequate hand function. Expected functional outcomes following replant should be considered in the decision-making process. These data can help risk-stratify patients, guide postreplant expectations, and influence the decision for replantation.     

Elucidating the Preadipocyte and Its Role in Adipocyte Formation: a Comprehensive Review

Adipogenesis is a complex process whereby the multipotent adipose-derived stem cell is converted to a preadipocyte before terminal differentiation into the mature adipocyte. Preadipocytes are present throughout adult life, exhibit adipose fat depot specificity, and differentiate and proliferate from distinct progenitor cells. The mechanisms that promote preadipocyte commitment and maturation involve numerous protein factor regulators, epigenetic factors, and miRNAs. Detailed characterization of this process is currently an area of intense research and understanding the roles of preadipocytes in tissue plasticity may provide insight into novel approaches for tissue engineering, regenerative medicine and treating a host of obesity-related conditions. In the current study, we analyzed the current literature and present a review of the characteristics of transitioning adipocytes and detail how local microenvironments influence their progression towards terminal differentiation and maturation. Specifically, we detail the characterization of preadipocyte via surface markers, examine the signaling cascades and regulation behind adipogenesis and cell maturation, and survey their role in tissue plasticity and health and disease.     

Hysteroscopic sterilization in an immunosuppressed patient

Essure sterilization produces a local benign tissue response resulting in bilateral occlusion of the fallopian tubes 3 months after insertion. There is a precautionary warning about performing this procedure on immunosuppressed patients. We present a case of successful bilateral tubal occlusion with Essure in a patient with a history of kidney transplantation and receiving immunosuppressive medications.     

The candidate tumor suppressor gene Ecrg4 as a wound terminating factor in cutaneous injury

The Esophageal cancer-related gene-4 (Ecrg4) is a candidate tumor suppressor gene whose secreted protein product has been implicated in the development and progression of epithelial cancers, neuroprogenitor cell activation after central nervous system injury, cell senescence in neurodegeneration, and the survival of hematopoietic stem cells. Here, we investigated the temporal and spatial localization of Ecrg4 expression in healthy and injured mouse skin, and evaluated the biological activity of Ecrg4 using viral-mediated gene delivery in cutaneous wound healing models. Using in situ hybridization and immunohistochemistry, we found both Ecrg4 mRNA and its protein product localized to the epidermis, dermis, and hair follicles of healthy mouse skin. Upon cutaneous injury, Ecrg4 redistributed to the wound margins where gene microarray and quantitative RT-PCR showed an increased gene expression 5–10 days post-injury as a late phase injury response gene. Ecrg4 over-expression inhibited the directional migration of fibroblasts in modified Boyden chambers in vitro, but had no effect on rates of fibroblast proliferation. Ecrg4 over-expression in vivo at the wound margins delayed the rate of wound closure at 1 and 2 days after full-thickness punch injury. These findings point to the candidate tumor suppressor gene Ecrg4 as a novel, biologically active, constituent of skin and skin injury. The possibility that Ecrg4 serves as a wound termination factor during wound resolution is discussed.     

The noninvasive,quantitative, in vivo assessment of adenoviral-mediated gene delivery in skin wound biomaterials

Because there are few reports using gene delivery in clinically-approved synthetic matrices, we examined the feasibility of using a noninvasive imaging system to study the kinetics of luciferase gene expression when delivered in an adenoviral vector. Using a mouse model of full thickness injury, we quantified the kinetics of gene expression, determined the optimal dose of particle delivery, and established the temporal importance of drug delivery in obtaining optimal gene expression. Specifically, we found that the ideal time to deliver adenovirus to a graft is during the early phase of graft wound closure (days 0–3 post-operatively) for a peak of gene expression to occur 7 days after delivery. Under these conditions, there is a saturating dose of 6 × 10⁸ adenoviral particles per graft. In light of these findings, we examined whether the efficacy of delivery could be increased by modulating the composition of the grafts. When a collagen gene-activated matrix (GAM) containing basic fibroblast growth factor (FGF2) was compared to matrix alone, a significant increase in gene expression is observed when identical amounts of vector are delivered (p < 0.05). Taken together, these results show how a noninvasive and quantitative assessment of gene expression can be used to optimize gene delivery and that the composition of matrices can dramatically influence gene expression in the wound bed.     

A Linear Variant of Segmental Schwannomatosis Localized to the Upper Extremity

Introduction  Schwannomas represent benign peripheral nerve sheath tumors. Their phenotypic presentations in schwannomatosis and segmental schwannomatosis have been well described. To date, however, cases of schwannomatosis or multiple schwannomas localized to a single nerve fascicle have been limited in the literature. Case Presentation  In this study, we identify a case of a 48 year-old non-neurofibromatosis male who presented with symptomatic schwannomas localized to a single nerve fascicle of the upper extremity. Intraoperative exploration revealed four schwannomas arising from a 15-cm segment of ulnar nerve fascicle. Surgical excision was successful, without neurological deficit or recurrence. Conclusion  This study identifies a case of schwannomatosis localized to a single nerve fascicle that may represent a linear variant of segmental schwannomatosis. The presentation may represent a temporary linear appearance in progression to “nonlinear” segmental variant; however, a molecularly distinct subset of schwannomas cannot be excluded.     

The pedicled myocutaneous flap as a choice reconstructive technique for immediate adjuvant brachytherapy in sarcoma treatment

Successful treatment of soft-tissue sarcomas is highly dependent on total tumour resection coupled with adjuvant radiation therapy to achieve local control and decrease recurrence. Reconstruction of soft-tissue defects after resection aims to cover vital structures, while providing enough stable tissue to withstand adjuvant brachytherapy treatment. In the present study, pedicled myocutaneous flaps were used as a vital adjunct in the treatment of soft-tissue sarcoma, and our experience with 2 such patients is described. The flaps served to reconstruct large three-dimensional defects while providing stable coverage over brachytherapy hardware to allow for delivery of radiation in the immediate postoperative period. Pedicled locoregional myocutaneous flaps provide a safe, easy, and reliable reconstructive technique in the treatment of soft-tissue sarcoma.     

Single Dual-Trained Surgeon for Breast Care Leads to Higher Reconstruction Rates After Mastectomy

Background

Breast reconstruction improves the quality of life for mastectomy patients but is underutilized in the United States. This study investigated reconstruction rates for a dual-trained oncologic plastic surgeon to explore how provider-based factors influence reconstruction.

Methods

We evaluated consecutive mastectomy patients treated at the University of California, San Diego Medical Center between 2009 and 2012. We identified mastectomy patients based on Current Procedural Terminology codes and evaluated them for patient- and disease-specific variables. We evaluated reconstruction rates for the traditional team model of collaborating plastic and oncologic surgeons versus a single surgeon, dual trained in surgical breast oncology and plastic surgery. A multivariate regression analysis was then used to identify the significant predictors of reconstruction.

Results

Mastectomy was performed in 344 patients. The surgeon group was a significant predictor of postmastectomy reconstruction (p < 0.05). The traditional team of oncologic and plastic surgeons reconstructed 93 (63.3 %) of 147 mastectomy patients, whereas the single dual-trained surgeon reconstructed 140 (71.1 %) of 197 mastectomy patients. Race and insurance status did not influence the receipt of reconstruction in our single-surgeon model, however, patients of older age [odds ratio (OR) 0.93, confidence interval (CI) 0.89–0.98, p < 0.01], higher body mass index (OR 0.89, CI 0.82–0.97, p < 0.01), or more advanced disease (p < 0.01) were less likely to undergo reconstruction.

Conclusions

A single dual-trained surgeon for breast care influences reconstruction rates. A dual-trained surgeon increases the likelihood of reconstruction and obtains rates higher than previously reported. This may reflect the comprehensive care provided by a multidisciplinary-trained professional. A single surgeon providing care in oncology and reconstruction represents a comprehensive approach to breast care and demonstrates a relationship between provider practice and breast reconstruction.