Although dystonias are a common group of movement disorders the mechanisms by which brain dysfunction results in dystonia are not understood. Rapid-onset Dystonia-Parkinsonism is a hereditary dystonia caused by mutations in the ATP1A3 gene. Affected subjects can be symptom free for years but rapidly develop persistent dystonia and parkinsonism-like symptoms after a stressful experience. Using a mouse model here we show that an adverse interaction between the cerebellum and basal ganglia can account for the symptoms of the patients. The primary instigator of dystonia is the cerebellum whose aberrant activity alters basal ganglia function which in turn causes dystonia. This adverse interaction between the cerebellum and basal ganglia is mediated through a di-synaptic thalamic pathway which when severed is effective in alleviating dystonia. Our results provide a unifying hypothesis for the involvement of cerebellum and basal ganglia in generation of dystonia and suggest therapeutic strategies for the treatment of RDP.

Venous thromboembolism is associated with substantial morbidity and mortality and is largely preventable. Despite this fact, appropriate prophylaxis is vastly underutilized. To improve compliance with best practice prophylaxis for VTE in hospitalized trauma patients, we implemented a mandatory computerized provider order entry-based clinical decision support tool. The system required completion of checklists of VTE risk factors and contraindications to pharmacologic prophylaxis. With this tool, we were able to determine a patient's risk stratification level and recommend appropriate prophylaxis. To evaluate the effect of our mandatory computerized provider order entry-based clinical decision support tool on compliance with prophylaxis guidelines for venous thromboembolism (VTE) and VTE outcomes among admitted adult trauma patients.

Background All hospitalized patients should be assessed for VTE risk factors and prescribed appropriate prophylaxis. To improve best-practice VTE prophylaxis prescription for all hospitalized patients, we implemented a mandatory computerized clinical decision support (CCDS) tool. The tool requires completion of checklists to evaluate VTE risk factors and contraindications to pharmacologic prophylaxis, and then recommends the risk-appropriate VTE prophylaxis regimen. Objectives To examine the effect of a quality improvement intervention on race- and gender-based healthcare disparities across two distinct clinical services. Research Design Retrospective cohort study of a quality improvement intervention Subjects 1942 hospitalized medical patients and 1599 hospitalized adult trauma patients Measures Proportion of patients prescribed risk-appropriate, best-practice VTE prophylaxis Results Racial disparities existed in prescription of best-practice VTE prophylaxis in the pre-implementation period between black and white patients on both the trauma (70.1% vs. 56.6%, p=0.025) and medicine (69.5% vs. 61.7%, p=0.015) services. After implementation of the CCDS tool, compliance improved for all patients and disparities in best-practice prophylaxis prescription between black and white patients were eliminated on both services: trauma (84.5% vs. 85.5%, p=0.99) and medicine (91.8% vs. 88.0%, p=0.082). Similar findings were noted for gender disparities in the trauma cohort. Conclusions Despite the fact that risk-appropriate prophylaxis should be prescribed equally to all hospitalized patients regardless of race and gender, practice varied widely prior to our quality improvement intervention. Our CCDS tool eliminated racial disparities in VTE prophylaxis prescription across two distinct clinical services. Health information technology approaches to care standardization are effective to eliminate healthcare disparities.

Background Mastectomy flap necrosis is the source of considerable morbidity and cost following breast reconstruction. A great deal of effort has been put forth to predicting and even preventing its incidence intraoperatively. Methods A review of the literature was performed evaluating the evidence of mastectomy skin flap perfusion technologies. Results Multiple technologies have leveraged spectroscopy and/or angiography to provide real-time assessment of flap perfusion, including indocyanine green, fluorescein, and light-based devices. Conclusion This manuscript endeavors to review the evidence on mastectomy skin flap perfusion analysis, highlighting the benefits, and downsides of the current technologies and identifying exciting areas of future research and development.

Background As deep inferior epigastric artery perforator (DIEP) flaps have gained popularity in breast reconstruction, the postoperative care of these patients, including the appropriate hospital length-of-stay and the need for intensive care unit (ICU) admission, has become a topic of debate. At our institution, we have adopted a pathway that aims for discharge on postoperative day 3, utilizing continuous tissue oximetry without ICU admission. This study aims to evaluate outcomes with this pathway to assess its safety and feasibility in clinical practice. Methods A retrospective review was performed of patients undergoing DIEP flap breast reconstruction between January 2013 and August 2014. Data of interest included patient demographics and medical history as well as complication rates and date of hospital discharge. Results In total, 153 patients were identified undergoing 239 DIEP flaps. The mean age was 50 years (standard deviation [SD] = 10.2) and body mass index (BMI) 29.4 kg/m2 (SD = 5.2). Over the study period, the flap failure rate was 1.3% and reoperation rate 3.9%. Seventy-one percent of patients were discharged on postoperative day 3. Nine patients required hospitalization beyond 5 days. Theoretical cost savings from avoiding ICU admissions were $1,053 per patient. Conclusion A pathway aiming for hospital discharge on postoperative day 3 without ICU admission following DIEP flap breast reconstruction can be feasibly implemented with an acceptable reoperation and flap failure rate.

Background Breast reconstruction is becoming an increasingly important and accessible component of breast cancer care. We hypothesize that prepectoral patients benefit from lower short-term complications and shorter periods to second-stage reconstruction compared with individuals receiving reconstruction in the subpectoral plane. Methods An institutional review board–approved retrospective review of all adult postmastectomy patients receiving tissue expanders (TEs) was completed for a 21-month period (n = 286). Results A total of 286 patients underwent mastectomy followed by TE placement, with 59.1% receiving prepectoral TEs and 40.9% receiving subpectoral TEs. Participants receiving prepectoral TEs required fewer clinic visits before definitive reconstruction (6.4 vs 8.8, P <0.01) and underwent definitive reconstruction 71.6 days earlier than individuals with subpectoral TE placement (170.8 vs 242.4 days, P < 0.01). Anesthesia time was significantly less for prepectoral TE placement, whether bilateral (68.0 less minutes, P < 0.01) or unilateral (20.7 minutes less, P < 0.01). Operating room charges were higher in the prepectoral subgroup ($31,276.8 vs $22,231.8, P < 0.01). Partial necrosis rates were higher in the prepectoral group (21.7% vs 10.9%, P < 0.01). Conclusions Patients undergoing breast reconstruction using prepectoral TE-based reconstruction benefit from less anesthesia time, fewer postoprative clinic visits, and shorter time to definitive reconstruction, at the compromise of higher operating room charges.

Background In 2018, the Northeastern Society of Plastic Surgeons first Women in Plastic Surgery was established, reflecting the national trend to address the gender gap between men and women in surgery. Conferences, such as the annual NESPS, are important opportunities to increase visibility of female role models and resources to address deterrents to surgical careers. We thus sought to examine the participation and visibility of women in the NESPS over the last decade. Methods Abstracts and programs from the NESPS regional conferences between 2013 and 2019 were accessed via the publicly available past meetings archives, and registration lists were provided by the NESPS. Registrants, panelists, speakers, moderators, and first author and senior author listed for each poster presentation, podium presentation was listed, sex was determined (male or female), and sex were aggregated by category of participation. Significance was set at a P value of less than 0.05. Results Registration of women for the NESPS annual conferences was constant for 5 years (2013–2017), followed by an increase in female registrants from 27.1% in 2017 to 42.3% in 2019. Female representation among poster and podium presentations also increased from 2017 to 2019 (7.7%–23.3% poster presentations and 11.1%–23.4% podium presentations). Invited positions (speakers, panelists, and moderators) had a peak of 32.2% in 2017, but otherwise, there is no clear evidence of improved representation of women. Conclusions We found an increase in the proportion of female registrants at the annual NESPS conferences from 2013 to 2019. However, visibility of female participants fluctuated over the same period; addressing this represents one opportunity for closing the gender gap at the NESPS. As the percentage of female trainees continues to rise, we look to female faculty to continue to participate in educational events, such as the NESPS meeting, and to be present as role models for the growing new generation of female plastic surgeons.

Prepectoral breast reconstruction has reemerged as a promising alternative to submuscular implants, as they place the patient at lower risk for pain, muscular impairment, and animation deformity. However, the thinner amount of overlying tissue in prepectoral reconstruction presents its own unique set of challenges. A "rippling" deformity is seen in some prepectoral patients, which is typically corrected with fat grafting. This report details our recommended technique for fat grafting in the prepectorally implanted patient.