OBJECTIVE:ABRUPT2 was a prospective, randomized, multicenter trial to determine whether lactated Ringer's + 5% albumin (Alb) reduces resuscitation requirements compared to lactated Ringer's (LR) alone in major burns. SUMMARY BACKGROUND DATA:The prospective, observational, multicenter ABRUPT study(1) found that initiation of albumin rapidly lowered fluid input and improved urine output in patients with burns ≥ 20% TBSA. METHODS:Based on the ABRUPT trial, inclusion was increased to ≥ 25% TBSA and ≥ 20% full-thickness. Patients ≥ 18 years were randomized to receive LR or Alb (2/3 LR + 1/3 5% albumin) for initial resuscitation. The initial rate was 2-4 ml/kg/% TBSA and adjusted to urine output (0.5-1 mL/kg/hour). For safety or excessive fluid volumes (> 250 mL/kg in 24 hours), investigators could crossover between assigned study arms. RESULTS:The study was stopped at 99 subjects (Alb-48, LR-51) due to declining enrollment in 19/27 centers. Mean % TBSA burn was 46%. Twenty-six (51%) LR patients crossed over to Alb, but there were no crossovers from Alb to LR. Despite crossovers, following intention-to-treat, there were statistically significant (p 0.001) increased fluids at 24 and 48 hours for the LR group compared to Alb. The LR group averaged 1.5 (95% CI: 0.59,2.3) ml/kg/%TBSA and 2.1 (95% CI: 1.0,3.1) ml/kg/%TBSA times higher fluids compared to Alb at 24 and 48 hours, respectively. There were no differences in mortality, time to healing or acute kidney injury. CONCLUSION:The use of 5% albumin significantly reduced fluid requirements compared to LR alone in the first 48 hours after injury.

Abstract Background/Objective Human Albumin Solution (Alb) is widely used in burn shock resuscitation (BSR), even though prospective randomized studies are 20-50 years old. The observational ABRUPT1 study found that Alb lowered resuscitation volumes and improved urine output (UO). ABRUPT2 provides the only modern randomized prospective study comparing Alb to crystalloid. The purpose was to compare BSR using albumin to crystalloids alone. The hypothesis is that Alb reduces fluid volumes compared to lactated Ringer’s (LR) alone for BSR. Methods An international multicenter randomized prospective trial comparing 5% Alb to LR alone during BSR, among adults with burns >25% TBSA with >20% TBSA full thickness injury. Patients randomized to Alb received fluids consisting of one-third 5% Alb and two thirds LR, starting between 8-12 hours post burn. Resuscitation was titrated to achieve UO of 0.5-1 mL/kg/hr. For safety or excessive resuscitation volumes, investigators were allowed to crossover patients between assigned study arms in the 1st 48 hr. All analyses are based on intention-to-treat. The primary outcome was the volume of fluid administered in the 1st 24 hours. Results The study was halted at 99 subjects (Alb n = 48, LR n = 51) of a planned 400, due to slow enrollment and a 51% crossover rate from LR to Alb in the 1st 48 hr with no Alb to LR crossovers. The overall study population’s mean +/- SD age was 45.9□15.9 years, 80% were male, with 45.7□13.9% TBSA burn, 37.5□14.9% full-thickness burn, 13.3% with smoke inhalation injury, and 97.0% with flame burns. Total fluid administration in mL/kg/% TBSA burn for LR and Alb respectively were 5.21□2.53 versus 3.88□2.13 at 24 hours. Regression models which controlled for age, burn size and inhalation injury found that the LR group had received 150% more fluid in mL/kg/%TBSA burn (p=.001) and 210% more fluid (p<.001) than the albumin group at 24 and 48 hours, respectively (Figure). I:O ratios at 24 and 48 hours were lower in the Alb group (p<.001). LR patients who crossed over to Alb displayed elevated and chaotic I:O ratios characteristic of a “runaway” resuscitation, which stabilized upon initiation of Alb. Alb patients had significantly lower peak lactate and peak intra-abdominal pressure. There were no significant differences between Alb and LR in time to wound healing, Acute Kidney Injury, or mortality. Conclusions Administration of Alb at 8-12 hours post burn resulted in a statistically significant and clinically important reduction in fluid resuscitation volumes, improved UO, and lower peak lactate and IAP compared to using LR alone. Alb was also effective in rescuing uncontrolled runaway resuscitations. Applicability of Research to Practice Alb is an effective strategy to lower BSR volumes and to rescue patients receiving excessive crystalloid volumes during BSR. Funding for the study Department of Defense.

There should be more articles in the legal journals such as Professor Gema Pérez-Sánchez's. In Franco's Spain, Queer Nation?, Professor Pérez-Sánchez has done a great service to legal scholarship in four respects. Firstly, she has written an appropriately far-ranging piece. In a discipline that has as one of its central missions the broadening of critical legal discourse, LatCrit can sometimes appear to suffer from symptoms of parochialism in its understandable emphasis on the Latina/o experience within American borders, or on the experience of its Latina/o immigrants once they have reached these shores. To be sure, this is not a problem unique to LatCrit. However, if LatCrit takes seriously its role in the legal academe of opening up all categories (such as race, gender, sexuality, and class) to critical analysis, thereby disrupting the hegemony of fixed meanings (and it does), it cannot simultaneously confine those investigations to a North or Latin American experience. While the influence of continental philosophy on American legal theory is undeniable, with a few notable exceptions, the reverse effect seems far less impressive. Even though it is unlikely that Professor Pérez-Sánchez's contribution will single-handedly correct this imbalance, it is a welcomed example of American scholarship willing and interested in non-American affairs, and it is a credit to LatCrit for including a work such as this within its movement. However, it is perhaps of no coincidence that an Article such as this was written by a non-legal scholar.

Study Design Cranial vault remodeling (CVR) for unicoronal synostosis is challenging due to the asymmetric nature of the deformity. Computer-automated surgical planning has demonstrated success in reducing the subjectivity of decision making in CVR in symmetric subtypes. This proof of concept study presents a novel method using Boolean functions and image registration to automatically suggest surgical steps in asymmetric craniosynostosis. Objective The objective of this study is to introduce automated surgical planning into a CVR virtual workflow for an asymmetric craniosynostosis subtype. Methods Virtual workflows were developed using Geomagic Freeform Plus software. Hausdorff distances and color maps were used to compare reconstruction models to the preoperative model and a control skull. Reconstruction models were rated as high or low performing based on similarity to the normal skull and the amount of advancement of the frontal bone (FB) and supra-orbital bar (SOB). Fifteen partially and fully automated workflow iterations were carried out. Results FB and SOB advancement ranged from 3.08 to 10.48 mm, and −1.75 to 7.78 mm, respectively. Regarding distance from a normal skull, models ranged from .85 to 5.49 mm at the FB and 5.40 to 10.84 mm at the SOB. An advancement of 8.43 mm at the FB and 7.73 mm at the SOB was achieved in the highest performing model, and it differed to a comparative normal skull by .02 mm at the FB and .48 mm at the SOB. Conclusions This is the first known attempt at developing an automated virtual surgical workflow for CVR in asymmetric craniosynostosis. Key regions of interest were outlined using Boolean operations, and surgical steps were suggested using image registration. These techniques improved post-operative skull morphology

Hypertrophic scars (HTS) develop from an excessive synthesis of structural proteins like collagen and a decreased expression of proteoglycans such as decorin. Previous research has demonstrated that decorin expression is significantly down-regulated in HTS, deep dermal tissue, and thermally injured tissue, reducing its ability to regulate pro-fibrotic transforming growth factor-beta 1 (TGF-β1) and normal fibrillogenesis. However, treatment of HTS fibroblasts with interferon-alpha 2b (IFN-α2b) has been shown to reduce excessive collagen synthesis and improve HTS by reducing serum TGF-β1 levels. The expression of decorin isoforms in HTS is currently unknown and the effects of TGF-β1 and IFN-α2b on decorin, decorin isoform expression and type 1 collagen are of great interest to our group. Dermal fibroblasts were treated with TGF-β1 and/or IFN-α2b, for 48 h. The expression and secretion of decorin, decorin isoforms and type 1 collagen were quantified with reverse transcription-quantitative polymerase chain reaction, immunofluorescence staining and enzyme-linked immunosorbent assays. The mRNA expression of decorin and each isoform was significantly reduced in HTS fibroblasts relative to normal skin. TGF-β1 decreased the mRNA expression of decorin and decorin isoforms, whereas IFN-α2b showed the opposite effect. IFN-α2b significantly inhibited TGF-β1's effect on the mRNA expression of type I collagen alpha 1 in papillary dermal fibroblasts and overall showed relative effects of inhibiting TGF-β1. These data support that a further investigation into the structural and functional roles of decorin isoforms in HTS pathogenesis is warranted and that IFN-α2b is an important agent in reducing fibrotic outcomes.

Background: Burn injury is a sudden and traumatic injury that affects a large part of the population worldwide, who are placed at high risk of developing hypertrophic scars (HTS). HTS are a fibrotic scar resulting in painful contracted and raised scarring, affecting mobility in joints and work life, as well as cosmetically. The aim of this research was to enhance our understanding of the systematic response of monocytes and cytokines in wound healing after burn injury, in order to develop novel approaches to prevention and treatment of HTS.Methods: Twenty-seven burn patients and thirteen healthy individuals were recruited in this study. Burn patients were stratified by burn total body surface area (TBSA). Peripheral blood samples were taken post-burn injury. Serum and peripheral blood mononuclear cells (PBMCs) were separated from the blood samples. This research investigated cytokines IL-6, IL-8, IL1RA, IL-10, and chemokine pathways SDF-1/CXCR4, MCP-1/CCR2, RANTES/ CCR5 during the wound healing process in burn patients with varying severity of injuries by using enzyme-linked immunosorbent assays. PBMCs were stained for monocytes and the chemokine receptors by flow cytometry. Statistical analysis was done by one-way ANOVA with a Tukey correction, and regression analysis was performed using Pearson's Correlation analysis.Results: The CD14+ CD16- monocyte subpopulation is larger in patients who developed HTS at 4-7 days. The CD14+ CD16+ monocyte subpopulation is smaller in the first week of injury, where it is similar after 8 days. Burn injury increased CXCR4, CCR2, and CCR5 expressions in CD14+ CD16+ monocytes. Increases in MCP-1 at 0-3 days after burn injury was positively correlated with burn severity. IL-6, IL-8, RANTES, and MCP-1 significantly increased with increasing burn severity.Conclusions: Monocytes and their chemokine receptors, as well as systemic levels of cytokines in wound healing of burn patients and scar development will require ongoing assessment to enhance our understanding of the abnormal wound healing after burn injury.

(1) Background: Exosomes (EXOs) have been considered a new target thought to be involved in and treat wound healing. More research is needed to fully understand EXO characteristics and the mechanisms of EXO-mediated wound healing, especially wound healing after burn injury. (2) Methods: All EXOs were isolated from 85 serum samples of 29 burn patients and 13 healthy individuals. We characterized the EXOs for morphology and density, serum concentration, protein level, marker expression, size distribution, and cytokine content. After a confirmation of EXO uptake by dermal fibroblasts, we also explored the functional regulation of primary human normal skin and hypertrophic scar fibroblast cell lines by the EXOs in vitro, including cell proliferation and apoptosis. (3) Results: EXOs dynamically changed their morphology, density, size, and cytokine level during wound healing in burn patients, which were correlated with burn severity and the stages of wound healing. EXOs both from burn patients and healthy individuals stimulated dermal fibroblast proliferation and apoptosis. (4) Conclusions: EXO features may be important signals that influence wound healing after burn injury; however, to understand the mechanisms by which EXOs regulates the fibroblasts in healing wounds, further studies will be required.

Background: Recent advances in burn care have significantly improved the survival rate of patients with extensive burn injuries, placing greater emphasis on reconstruction to improve the long-term outcomes of scar deformities. Anterior and lateral neck contractures are common after burn injuries; they limit range of motion, complicate airway management and create significant cosmetic deformities. Traditional methods have been used to release contractures and improve function. However, they are subject to variable results, residual neck tightness, recurrence and suboptimal cosmetic appearance. Microvascular free tissue transfer is a more technically challenging and time-consuming method, but it offers the potential to overcome the long-term limitations of simpler options. In this paper, we present our experience with microvascular free flaps for the release of burn scar contractures of the neck as a potential high-quality permanent solution. Methods: Over a 10-year period, nine free flaps were performed on burn patients with total body surface area (TBSA) burns between 20 and 70%, who developed moderate to severe neck contractures. Four anterolateral thigh (ALT) flaps, four radial forearm free flaps (RFFFs) and one ulnar forearm flap were used to release neck contractures. Results: All nine flaps were completed successfully with significant improvement in the neck's range of motion. Good aesthetic results were achieved with smooth contour and thin coverage. Overall, the patients were satisfied. However, five out of nine cases required at least one secondary procedure for flap defatting to reach optimal results. Conclusion: Post-burn scar contractures of the cervical region compromise the cosmetic appearance and airway security of recovering burn patients, imposing a significant impact on their psychological and functional quality of life. Consequently, cervical contractures can be prioritized when planning reconstruction for burn patients. Free flaps can be considered an important and reliable method of reconstruction for neck contracture deformity following burn injuries.

Guidelines and protocols for orthoses in burn scar contracture rehabilitation are limited. The current study aims to determine the optimal frequency of casting, potentially facilitating the development of a serial casting protocol. Previous literature supporting casting has low generalizability due to methodology limitations. Seven patients with burn scar contracted joints, who did not respond to traditional therapy, were recruited in this study. Patients were serially casted once, three times, or five times a week. Joint range of motion was maximized with stretching and exercise techniques before every new cast application. Across all patients, active range of motion increased from 65.8 ± 27.8° to 108.1 ± 23.3° with casting; or from 57.8 ± 16.2% to 96.7 ± 2.9% of normal. Similarly, scars improved from 9.5 ± 1.5 to 4.9 ± 1.4 on the Modified Vancouver Scar Scale score. This therapeutic effect was achieved within an average of 8.5 ± 3.7 d and 4.0 ± 2.2 new cast applications. Given the study findings, the procedures outlined could be used to develop a standardized serial casting protocol for burn scar contracture rehabilitation.

Significance: Hypertrophic scars (HTS) are a fibroproliferative disorder that occur following deep dermal injury and affect up to 72% of burn patients. These scars result in discomfort, impaired mobility, disruption of normal function and cosmesis, and significant psychological distress. Currently, there are no satisfactory methods to treat or prevent HTS, as the cellular and molecular mechanisms are complex and incompletely understood. This review summarizes the biology of proteins in the dermal extracellular matrix (ECM), which are involved in wound healing and hypertrophic scarring. Recent Advances: New basic research continues toward understanding the diversity of cellular and molecular mechanisms of normal wound healing and hypertrophic scarring. Broadening the understanding of these mechanisms creates insight into novel methods for preventing and treating HTS. Critical Issues: Although there is an abundance of research conducted on collagen in the ECM and its relationship to HTS, there is a significant gap in understanding the role of proteoglycans and their specific isoforms in dermal fibrosis. Future Directions: Exploring the biological roles of ECM proteins and their unique isoforms in HTS, mature scars, and normal skin will further the understanding of abnormal wound healing and create a more robust understanding of what constitutes dermal fibrosis. Research into the biological roles of ECM protein isoforms and their regulation during wound healing warrants a more extensive investigation to identify their distinct biological functions in cellular processes and outcomes.

Insufflation of epinephrine-containing solutions (clysis) has shown to decrease blood loss in burn surgery. Current delivery methods are associated with significant cost and may predispose burn patients to hypothermia. This was a proof-of-concept study to evaluate a novel surgeon-operated clysis delivery system. Our initial experience with a novel fluid management system is presented. Temperature, pressure, and volume of clysis was recorded. Patient and burn factors were evaluated and complications collected. Finally, a cost-effectiveness analysis was conducted. Thirty-seven consecutive cases comprising 22 adult patients (15/22, 68% male), with a mean age of 49 years (+/−19) were reviewed. The mean % total body surface area of all patients was 39 (+/−21.7). The mean temperature, pressure, and volume of administered clysis was 32.2 degrees Celsius (+/−4.4), 265.04 mmHg (+/−56.17), and 5805.8 mL (+/−4844.4), respectively. The mean dose of epinephrine administered was 14.5 mg (+/−12.1). The mean temperature variability was 1.1 °C (+/−1.2). The total mean of packed red blood cells (PRBC) transfused was 507.6 mL (+/−624.4). There were no recorded complications. We identified a cost savings of CAD 20,766 over the cases examined, compared to our conventional clysis delivery technique. This novel technique provides rapid and safe infiltration of warmed clysis in burn surgery. We were able to maintain intra-operative euthermia. In addition, this technique may be transfusion-sparing. The introduction of this method of clysis administration was associated with significant cost-savings. Future randomized study is necessary.

Significance: Hypertrophic scars (HTS) and keloids are common after thermal injuries and other trauma to deep regions of dermis of the skin. These abnormal scars can cause contractures and the thick masses of scar tissue that result in functional and cosmetic impairment. Management of these dermal fibrotic conditions includes a wide range of medical and surgical treatments, which can be time consuming, only partially effective, and often uncomfortable for patients.Recent Advances: The molecular pathophysiology of HTS has become more understood over the past two decades, where thermal injury to the reticular dermis results in an inflammatory response, fibrogenic growth factor release, and the formation of a dermal scar with increased collagen and proteoglycan composition in an abnormal morphology. Lasers are becoming a widely used form of treatment for these types of scars; however, the evidence for the beneficial effects of laser treatments and the understanding of their mechanism of action are still evolving.Critical Issues: Paradoxically, laser delivery of thermal energy to the skin is suggested to improve scar remodeling and wound healing, yet HTS is a well-recognized complication of excessive thermal energy delivered by laser treatments. This review aims to examine the current evidence for the use of lasers for HTS, and to investigate the molecular mechanisms where re-injury of a burn scar from laser treatment could result in overall improvements in scar quality.Future Directions: Improved design of clinical trials for the treatment of scarring in the future will evolve from new methodology and models of HTS in animals and humans.

Skin grafting is often the only treatment for skin trauma when large areas of tissue are affected. This surgical intervention damages the deeper dermal layers of the skin with implications for wound healing and a risk of scar development. Photobiomodulation (PBM) therapy modulates biological processes in different tissues, with a positive effect on many cell types and pathways essential for wound healing. This study investigated the effect of fluorescent light energy (FLE) therapy, a novel type of PBM, on healing after skin grafting in a dermal fibrotic mouse model. Split-thickness human skin grafts were transplanted onto full-thickness excisional wounds on nude mice. Treated wounds were monitored, and excised xenografts were examined to assess healing and pathophysiological processes essential for developing chronic wounds or scarring. Results demonstrated that FLE treatment initially accelerated re-epithelialization and rete ridge formation, while later reduced neovascularization, collagen deposition, myofibroblast and mast cell accumulation, and connective tissue growth factor expression. While there was no visible difference in gross morphology, we found that FLE treatment promoted a balanced collagen remodeling. Collectively, these findings suggest that FLE has a conceivable effect at balancing healing after skin grafting, which reduces the risk of infections, chronic wound development, and fibrotic scarring.

Peptide based therapeutics are desirable owing to their high biological specificity. However, a number of these fail in clinical testing due to an adverse inflammatory response. Mast cells play a key role in directing the host response to drugs and related products. Although the role of Fc epsilon RI receptor is well known, Mas-related G-protein coupled receptor X2 (MRGPRX2) binding of endogenous peptides, and drugs will activate mast cells independent of Fc epsilon RI. Identifying peptides that activate mast cells through MRGPRX2, and their respective activation potency, can be used to reduce the failure rate of peptide therapeutics at clinical trial. Moreover, it will allow for peptide design where mast cell activation is actually desired. It was found that FRKKW and WNKWAL are two motifs that activate human LAD2 cells similar to PAMP-12 controls. Peptide activators of MRGPRX2 could be reduced to X-a-(Y) ((n >= 3))-X-b where: X-a is an aromatic residue; X-b is a hydrophobic residue; and Y is a minimum 3 residue long sequence, containing a minimum of one positively charged residue with the remainder being uncharged residues. Artificial peptides WKKKW and FKKKF were constructed to test this structural functionality and were similar to PAMP-12 controls. Peptides with different activation potentials were found where FRKKW = WKKKW = FKKKF > PAMP-12 = WNKWAL > YKKKY > FRKKANKWALSR = FRKKVVNKAALSR > KVVKWK > FRKK = WNKWA > KYKYK > NKWALSR = YKKY = WNK. These sequences should be considered when designing peptide-based therapeutics. Statement of significance Mast cells release immune regulating molecules upon activation that direct host's immune response. MRGPRX2 receptor provides an alternate pathway for mast cell activation that is independent of Fc epsilon RI receptor. It is thought that mast cell activation through MRGPRX2 plays a critical role in high failure rates of drugs in clinical trials. Identifying peptide sequences that activate mast cells through MRGPRX2 can serve two important purposes, namely, sequences to avoid when designing peptide therapeutics, and artificial peptides with different activation potentials for mast cells. Herein, we have identified a general amino acid sequence that induces mast cell activation through MRGPRX2. Furthermore, by modulating the identified sequence, artificial peptides have been designed which activate mast cells by varying degrees for therapeutic applications. (C) 2021 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.

Hypertrophic scars are a dermal form of fibroproliferative diseases that develop after skin trauma to the deep dermis.Dysfunction of the chemokine network can result in prolonged inflammation, abnormal blood vessel development, and a fibrotic wound-healing environment.To understand the role of the chemokine signaling in pathological scar formation, the inhibitory effects of scar formation by chemokine inhibitors of AMD3100, Maraviroc, and CAS445479-97-0 were investigated using a mouse model of dermal fibrosis, in which human split-thickness skin grafts were transplanted into full-thickness excision wounds in the dorsal of athymic nude mice, and the human skin grafts developed scars morphologically and histologically similar to human hypertrophic scars.The mice were treated with one of chemokine inhibitors from 5 days after grafting daily for 1 week and thereafter once a week.Mouse wounds were monitored, and scar tissues were collected at 2, 6, and 12 weeks after grafting for further histological and biochemical analysis.AMD3100 and Maraviroc reduced wound contraction.AMD3100 improved collagen orientation and up-regulated mRNA level of decorin in the early phase of wound healing.AMD3100, CAS445479-97-0 and Maraviroc reduced scar thickness, macrophage recruitment and myofibroblast formation, and down-regulated gene expressions of type I collagen in the early phase, heat shock protein 47 in the late phase, alpha-smooth muscle actin, and connective tissue growth factor throughout the whole phase of wound healing.Blocking chemokine pathways significantly improved scars in this dermal fibrotic model, which can be potential therapeutic targets for hypertrophic scars.

Hypertrophic scars (HTS) are a common complication following burn injuries with prolonged inflammation. They do not respond well to current treatment options including mechanical, biomolecular and surgical therapies. Toll-like receptor (TLR) 2 and 4 respond to microbes and damaged endogenous ligands to trigger pro-inflammatory pathways, and they are expressed more in HTS fibroblasts compared to normal skin fibroblasts. TLR2 responds to microbial lipoteichoic acid (LTA) while TLR4 responds to microbial lipopolysaccharide (LPS) and endogenous ligands. We investigated the role of burn tissue and small leucine-rich proteoglycans (decorin and biglycan) in the stimulation of TLR2 and TLR4 pathways using cells stably transfected with TLR2 or TLR4 linked to a reporter system. Normal skin (n = 5) was collected post-abdominoplasty, and burn eschar samples (n = 18) were collected from 18 patients between 0 and 14 days post-burn. We found that burn tissue stimulates TLR2 activity significantly more than normal tissue and contains significantly higher levels of LTA. Burn tissue was a stronger stimulator of TLR4 than was normal skin. Burn tissue samples' stimulation of TLR4 and TLR2 correlated. The time post-burn (0-14 days) of wound tissue sampling correlated positively but moderately with TLR2 and TLR4 simulation. In comparison to the dose-dependent effects of natural decorin or biglycan on TLR4 activation, their denatured forms exhibited stronger or weaker stimulation, respectively. They were not potent stimulators of TLR2. TLR2 and TLR4 stimulation is not limited to bacteria in wounds and likely involves multiple endogenous damage-associated molecular patterns. Insight into mechanisms of HTS will facilitate the development of future targeted therapies to modify wound progression and provide benefits to patients suffering with HTS and other fibroproliferative disorders.

Background: Hepatic artery thrombosis represents a potentially fatal complication following liver transplantation. Rates of hepatic artery thrombosis are significantly higher in children, with mortality reported up to 80 percent. Microsurgical anastomosis has been shown to decrease the rate of hepatic artery thrombosis and now represents the standard of care at the authors’ institution. In this article, the authors present the largest study of its type directly comparing rates of hepatic artery thrombosis with and without microsurgical reconstruction of the hepatic artery. Methods: All pediatric patients who underwent primary orthotopic liver transplantation between 1989 and 2018 were included. Patients were divided into two cohorts: standard anastomosis with loupes, and microsurgical anastomosis under the operating microscope. The authors’ primary outcome was the rate of hepatic artery thrombosis. Secondary outcomes were graft survival, patient survival, retransplantation rate, requirement for intraoperative blood products, and length of stay. Results: Two hundred thirty-one children met criteria for inclusion. One hundred eighty cases were performed with loupe magnification and 51 cases were performed under the microscope. The hepatic artery thrombosis rate was lower, but not significantly so (p = 0.114), in the microsurgical group [n = 1 (2.0 percent)] compared with the standard cohort [n = 15 (8.3 percent)]. Survival analysis revealed a significant increase in graft survival with microsurgical anastomosis (p = 0.020), but not patient survival (p = 0.196). The retransplantation rate was significantly lower with microsurgical anastomosis (p = 0.021). Conclusions: Microsurgical anastomosis was associated with a clinically important decrease in hepatic artery thrombosis compared with standard loupe anastomosis. The graft survival rate was significantly higher in the microsurgical cohort, with a reduced retransplantation rate at 1 year. On this basis, the authors recommend microsurgical hepatic artery anastomosis in cases of pediatric liver transplantation.  CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Unilateral coronal craniosynostosis (UCS) affects many infants resulting in abnormalities affecting the forehead and orbits. As a result, the deformity caused by UCS is very noticeable and there are several surgical treatment options available to normalize the head shape. However, there is a lack of consistently used outcome measures, resulting in difficulty assessing surgical outcomes and on-going debate over optimal treatments. Current techniques to quantify deformity in UCS are cumbersome, provide limited information, or are based on subjective assessments. In this study, a cranial deformity index was developed to quantify abnormality at the frontal bones for UCS that is accessible, user-friendly, and generates objective surface distance measurements. The cranial deformity index is defined as the Euclidean distance at the point of the largest deviation between the deformed skull compared to a reference skull. In addition, the index was successfully used to quantify post-operative changes in a single case of UCS that underwent corrective surgery. The reproducibility of the index was assessed using test-retest reliability and was demonstrated to be highly reproducible (ICC = 0.93). A user-friendly measurement index that is based on open-source software may be a valuable tool for surgical teams. In addition, this information can augment the consultation experience for patients and their families.

Minimally invasive techniques for myxoma resection are rapidly becoming standard of care for such lesions. Inframammary incisions are commonly used in breast reconstruction. The use of this previous incision for myxoma resection is safe and serves as a cosmetically superior site for female patients. We describe a patient who underwent successful atrial myxoma resection through a previous breast augmentation inframammary incision.