Austin Y. Ha

BACKGROUND: Postoperative pain control after abdominally based autologous microvascular breast reconstruction is critical to functional recovery, patient satisfaction, and early discharge. The transversus abdominis plane block using 0.25% bupivacaine hydrochloride has been shown to be effective, but it is limited by a short duration of effect. Liposomal bupivacaine is a recently U.S. Food and Drug Administration-approved preparation of bupivacaine that can provide up to 72 hours of pain relief. The purpose of this randomized, controlled trial was to compare the analgesic efficacy of liposomal bupivacaine and conventional bupivacaine. METHODS: This study was a prospective, single-blind, randomized, controlled trial of 44 patients undergoing abdominally based autologous breast reconstruction between June of 2016 and February of 2018 performed by a single surgeon. Each patient was randomized to receive either 266 mg of liposomal bupivacaine or 75 mg of conventional bupivacaine to the transversus abdominis plane at the conclusion of the reconstruction procedure. All patients were managed postoperatively according to an enhanced recovery protocol. RESULTS: In our study of 44 patients, 22 patients received a transversus abdominis plane block with conventional bupivacaine and 22 patients received liposomal bupivacaine. There were no significant differences with regard to any outcome measure. No differences were found in total opioid consumption (p = 0.98), Quality of Recovery-15 scores (p = 0.72), pain scores (p = 0.39), or length of stay (p = 0.20). CONCLUSION: In the setting of a robust enhanced recovery after surgery protocol, liposomal bupivacaine does not confer advantages over conventional bupivacaine when used as single injections in transversus abdominis plane blocks after abdominally based microvascular breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Mammalian target of rapamycin complex 1 (mTORC1), a nutrient sensor and central controller of cell growth and proliferation, is altered in various models of Alzheimer's disease (AD). Even less studied or understood in AD is mammalian target of rapamycin complex 2 (mTORC2) that influences cellular metabolism, in part through the regulations of Akt/PKB and SGK. Dysregulation of insulin/PI3K/Akt signaling is another important feature of AD pathogenesis. We found that both total mTORC1 and C2 protein levels and individual C1 and C2 enzymatic activities were decreased in human AD brain samples. In two rodent AD models, mTORC1 and C2 activities were also decreased. In a neuronal culture model of AD characterized by accumulation of cellular amyloid-β (Aβ)42, mTORC1 activity was reduced. Autophagic vesicles and markers were correspondingly increased and new protein synthesis was inhibited, consistent with mTORC1 hypofunction. Interestingly, mTORC2 activity in neural culture seemed resistant to the effects of intracellular amyloid. In various cell lines, Aβ expression provoked insulin resistance, characterized by inhibition of stimulated Akt phosphorylation, and an increase in negative mTORC1 regular, p-AMPK, itself a nutrient sensor. Rapamycin decreased phospho-mTOR and to lesser degree p-Rictor. This further suppression of mTORC1 activity protected cells from Aβ-induced toxicity and insulin resistance. More striking, Rictor over-expression fully reversed the Aβ-effects on primary neuronal cultures. Finally, using in vitro assay, Rictor protein addition completely overcame oligomeric Aβ-induced inhibition of the PDK-Akt activation step. We conclude that striking a new balance by restoring mTORC2 abundance and/or inhibition of mTORC1 has therapeutic potential in AD.

BACKGROUND: Plastic surgeons are frequently consulted for hand and facial injuries, and patients are often transferred to trauma centers for evaluation of these problems. The authors sought to identify the frequency and impact of "unnecessary" transfers for emergency evaluation by a plastic surgeon at a Level I trauma center. METHODS: The authors reviewed more than 32,000 consecutive emergency department encounters at their institution between April of 2009 and April of 2013 and found 1181 patients transferred for evaluation by plastic surgery. Using a retrospective chart review, necessity of transfer was determined based on the intervention performed at the authors' institution and the availability of resources at the transferring site. RESULTS: Of all the patients referred for "emergency" evaluation, 860 (74.1 percent) were unnecessary. Transfers for hand-related issues were more likely to be coded as unnecessary compared with referrals for facial trauma and infection (76 percent versus 66 percent; p < 0.001). The average time from referral to discharge from the emergency department was 412 minutes. The expense for these unnecessary transfers exceeded $4.6 million. CONCLUSIONS: This is the first intervention-based study evaluating the impact of unnecessary transfer for evaluation of hand and facial emergencies. Using a framework based on objective outcomes, the authors found that fewer than one-third of patients required emergent transfer for evaluation by a plastic surgeon, and almost half did not receive an intervention following transfer. Based on patient time and financial expenses for these unnecessary evaluations, improvements could be made in both quality and cost of care by limiting inappropriate emergency department referrals.

BACKGROUND: En bloc capsulectomy has recently increased in prominence as a potential surgical therapy for patients with breast implant illness (BII). However, this procedure has chiefly been recommended for treating breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). OBJECTIVES: This study aimed to review the current literature and evaluate the public understanding of treatment options for BII via social media to characterize any potential communication disconnect between clinicians and patients. METHODS: An electronic literature review was performed to identify all available publications mentioning evidence-based support for en bloc capsulectomy as treatment for BII and BIA-ALCL. Twitter social media posts referencing BII or BIA-ALCL were analyzed from 2010 to 2019. Author identity and any mention of surgical treatment were assessed. RESULTS: A total of 115 publications on the subject of BII and 315 articles on BIA-ALCL were identified. En bloc resection was recommended only for patients with a diagnosis of BIA-ALCL. A total of 6419 tweets referencing BII and 6431 tweets referencing BIA-ALCL were identified. Tweets referencing BIA-ALCL were significantly more likely to be authored by physicians (25.9% vs 5.3%, P < 0.001), and tweets referencing BII were significantly more likely to mention any surgical treatment (7.8% vs 1.9%, P < 0.001) and en bloc capsulectomy (1.4% vs 0.3%, P < 0.001). CONCLUSIONS: This study demonstrates that a communication disconnect exists between the scientific literature and social media regarding treatment options for BII and BIA-ALCL. Physicians should be aware of these potential misconceptions to empathetically address patient concerns in a patient-centered manner.