There are over 250,000 international treaties that aim to foster global cooperation. But are treaties actually helpful for addressing global challenges? This systematic field-wide evidence synthesis of 224 primary studies and meta-analysis of the higher-quality 82 studies finds treaties have mostly failed to produce their intended effects. The only exceptions are treaties governing international trade and finance, which consistently produced intended effects. We also found evidence that impactful treaties achieve their effects through socialization and normative processes rather than longer-term legal processes and that enforcement mechanisms are the only modifiable treaty design choice with the potential to improve the effectiveness of treaties governing environmental, human rights, humanitarian, maritime, and security policy domains. This evidence synthesis raises doubts about the value of international treaties that neither regulate trade or finance nor contain enforcement mechanisms.
Background:Despite the fact that carpal tunnel syndrome (CTS) is the most common entrapment neuropathy, the diagnostic accuracy of clinical screening examinations for CTS is controversial. The scratch collapse test (SCT) is a novel test that may be of diagnostic advantage. The purpose of our study was to determine the diagnostic accuracy of the SCT for CTS.Methods:A literature search was performed using PubMed (1966 to April 2018); Ovid MEDLINE (1966 to April 2018); EMBASE (1988 to April 2018); and Cochrane Central Register of Controlled Trials (The Cochrane Library, to April 2018). We examined the studies for the pooled sensitivity, specificity, and likelihood ratios of the SCT. This review has been registered with PROSPERO (CRD42018077115).Results:The literature search generated 13 unique articles. Seven articles were included for full text screening and 3 articles met our inclusion criteria, all of which were level II evidence with low risk of bias (165 patients). Pooled sensitivities, specificities, positive likelihood ratio, and negative likelihood ratios were 0.32 [95% CI (0.24–0.41)], 0.62 [95% CI (0.45–0.78)], 0.75 [95% CI (0.33–1.67)], and 1.03 [95% CI (0.61–1.74)], respectively. The calculated area under the summary receiver operating characteristic (AUSROC) curve was 0.25, indicating a low diagnostic accuracy.Conclusion:The SCT has poor sensitivity; however, it is moderately specific. Based on the current literature and their variable quality of the evidence, we conclude that the SCT is not an adequate screening test for detecting CTS.
Background: Although abdominally based flaps continue to be the gold standard for autologous breast reconstruction, alternative donor sites are necessary when the abdominal region is unavailable or inadequate for flap harvest. In this case, thigh-based flaps, such as the profunda artery perforator (PAP), transverse upper gracilis (TUG), or newly described TUGPAP, are thought to be reliable with low morbidity and satisfactory cosmesis. The objective of this study was to perform a systematic review of breast reconstruction with PAP, TUG, or TUGPAP, and present anatomy and surgical techniques through illustrative examples. Methods: A systematic review of the literature was conducted using PubMed, Embase, and Cochrane Library. Articles were included if they used a PAP, TUG, or TUGPAP flap for oncologic, traumatic, or congenital breast reconstruction in patients 18 years or older. Results: Forty-nine studies met inclusion criteria. Seven hundred five patients underwent 906 breast reconstructions with 1037 flaps (755 TUG, 230 PAP, and 52 TUGPAP). Mean patient age was 45.9 years. The mean flap weight for TUG, PAP, and TUGPAP flaps were 323.4, 346.9, and 437.0 g, respectively. The most common recipient vessel was the internal mammary artery in 821 flaps. The overall flap survival rate was 97.2% (1008/1037). TUG flaps had a significantly higher recipient and donor complication rate compared with both PAP (recipient: 18.1% versus 7.8%, P = 0.0001; donor: 25.8% versus 7.0%, P < 0.00001) and TUGPAP flaps (recipient: 18.1% versus 2.0%, P < 0.001; donor: 25.8% versus 7.7%, P < 0.01). Conclusion: The TUGPAP flap is a safe and effective alternative for autologous breast reconstruction when the abdominal donor site is unavailable.
Background Free tissue transfer is the most common modality for distal third lower extremity reconstruction, yet complication rates remain high. The serratus anterior muscle free flap, which can be harvested alone or as a chimeric flap, is a robust and reliable option that remains the primary modality for distal third lower extremity defects at our institution. The objective of this study was to perform a systematic review of lower extremity reconstruction with the serratus anterior free flap and provide a retrospective review of cases at our institution. Methods A systematic review of the literature was conducted using PubMed, Embase, and Cochrane Library (PROSPERO CRD42018110692). Articles reporting reconstruction of lower extremity and foot defects using serratus anterior free flaps in adults were included. A retrospective cohort study of serratus anterior free flaps was then performed from 2012 to 2018 at our institution. Results Thirty-seven articles meeting inclusion criteria provided data on 198 flaps: 125 (63%) serratus-only flaps and 73 (37%) chimeric flaps based on the subscapular axis. Among the serratus-only flaps, defects were primarily due to chronic wounds (51%) or acute infections (33%). Flap survival rate was 97%, and the major and minor complication rates were 5 and 9%, respectively. Of the 10 cases included in the case series, flap survival rate was 100%, there were no major complications, and the minor complication rate was 44%. The average time to flap healing was 95 days and average lower extremity functional scale score was 58/80 among five patients. Conclusion Serratus anterior muscle free flaps are a versatile and reliable option for distal third lower extremity reconstruction.
Background Pelvic reconstruction with a muscle flap significantly improves postoperative outcomes following abdominoperineal resection (APR). Despite it being the gold standard, significant surgeon-selection bias remains with respect to the necessity of pelvic obliteration, flap choice, and ostomy placement. The objective of the study was to characterize management practices among colorectal surgeons (CSs) and plastic surgeons (PSs). Methods Specialty-specific surveys were distributed electronically to CSs and PSs via surgical societies. Surveys were designed to illustrate geographic and specialty-specific differences in management. Results Of 106 (54 CSs and 52 PSs) respondents (58% Canada, 21% Europe, 14% the United States, and 6% Asia/Africa), significant interdisciplinary differences in practices were observed. Most respondents indicated that multidisciplinary meetings were not performed (74% of CSs and 78% of PSs). For a nonradiated pelvic dead space with small perineal defect, 91% of CSs and 56% of PSs indicated that flap reconstruction was not required. For a radiated pelvic dead space with small perineal defect, only 54% of CSs and 6% of PSs indicated that there was no need for flap reconstruction. With respect to ostomy placement, 87% of CSs and 21% of PSs indicated that stoma placement through the rectus was superior. When two ostomies were required, most CSs preferred exteriorizing ostomies through bilateral recti and requesting thigh-based reconstruction. PSs favored the vertical rectus abdominis muscle (VRAM; 52%) over the gracilis (23%) and inferior gluteal artery perforator (IGAP; 23%) flaps. Among PSs, North Americans favor abdominally based flaps (VRAM 60%), while Europeans favor gluteal-based flaps (IGAP 78%). Conclusion A lack of standardization continues to exist with respect to the reconstruction of pelvic defects following APR and pelvic exenteration. Geographic and interdisciplinary biases with respect to ostomy placement, flap choice, and role for pelvic obliteration continues to influence reconstructive practices. These cases should continue to be approached on a case by case basis, driven by pathology, presence of radiation, comorbidities, and the size of the pelvic and perineal defect.
Background There is a paucity of research investigating the impact of patient comorbidities, such as obesity and smoking, on nerve transfer outcomes. The objective of this retrospective cohort study was to evaluate the impact of body mass index (BMI) and comorbidities on the clinical outcomes of upper extremity nerve transfers. Methods A retrospective cohort study was executed. Patients were eligible for inclusion if they had an upper extremity nerve transfer with a minimum of 12-months follow-up. Data was collected regarding demographics, comorbidities, injury etiology, nerve transfer, as well as preoperative and postoperative clinical assessments. The primary outcome measure was strength of the recipient nerve innervated musculature. Statistical analysis used the Mann-Whitney U test, Wilcoxon signed-rank test, and Spearman's rho. Results Thirty-eight patients undergoing 43 nerve transfers were eligible for inclusion. Patients had a mean age of 48.8 years and a mean BMI of 27.4 kg/m2 (range:19.7–39.0). Injuries involved the brachial plexus (32%) or its terminal branches (68%) with the most common etiologies including trauma (50%) and compression (26%). Anterior interosseous nerve to ulnar motor nerve (35%) was the most common transfer performed. With a mean follow-up of 20.1 months, increased BMI (p = 0.036) and smoking (p = 0.021) were associated with worse postoperative strength. Conclusion This retrospective cohort study demonstrated that increased BMI and smoking may be associated with worse outcomes in upper extremity nerve transfers—review of the literature yields ambiguity in both regards. To facilitate appropriate patient selection and guide expectations regarding prognosis, further experimental and clinical work is warranted.
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