Summary: Wide-awake local anesthesia no tourniquet surgery has been shown to decrease cost and hospital length of stay. The authors studied the use of virtual reality during wide-awake local anesthesia no tourniquet outpatient upper extremity surgery to assess its effect on patient pain, anxiety and fun. Patients undergoing wide-awake local anesthesia no tourniquet surgery were randomized to use (virtual reality) or not use (non–virtual reality) virtual reality during their procedures. Pain, fun, and anxiety were measured with a Likert scale at several time points, as were blood pressure and heart rate. A postoperative questionnaire was used to assess overall satisfaction. Virtual reality patients exhibited lower anxiety scores during injection, during the procedure, and at the end of the procedure. There were no differences in blood pressure, heart rate, or pain scores. Compared with non–virtual reality patients, virtual reality patients’ fun scores were higher. Virtual reality patients felt the experience helped them to relax, and they would recommend virtual reality–assisted wide-awake local anesthesia no tourniquet surgery. Among patients with self-reported preexisting anxiety, virtual reality patients had lower pain and anxiety scores during injection of local anesthesia compared with non–virtual reality patients. This study demonstrates that readily available virtual reality hardware and software can provide a virtual reality experience that reduces patient anxiety both during the injection of local anesthesia and during the surgical procedure. (Plast. Reconstr. Surg. 144: 408, 2019.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Objectives: To investigate the effect of prenatal exposure to polychlorinated biphenyls (PCBs) and dichlorodiphenyl-dichloroethylene (DDE) on weight, height and body mass index (BMI) in adult female offspring of the Michigan fisheater cohort examined between 1973 and 1991. Methods: 259 mothers from the Michigan fisheater cohort were studied. Prenatal exposure to PCBs and DDE was estimated by extrapolating maternal measurements to the time that the women gave birth. 213 daughters aged 20-50 years in 2000 were identified and 83% of them participated in at least one of two repeated investigations in 2001/02 (n = 151) and 2006/07 (n = 129). To assess the effect of prenatal PCB and DDE exposure on anthropometric measurements, generalised estimating equations nested for repeated measurements (2001/02 and 2006/07) and for sharing the same mother were used. We controlled for maternal height and BMI and for daughters' age, birth weight, having been breastfed and number of pregnancies. Results: Maternal height and BMI were significant predictors of the daughters' height, weight and BMI. Low birth weight (,2500 g) was significantly associated with reduced adult offspring weight and BMI. The weight and BMI of adult offspring were statistically significantly associated with the extrapolated prenatal DDE levels of their mothers. Controlling for confounders and compared to maternal DDE levels of ,1.503 mg/l, offspring BMI was increased by 1.65 when prenatal DDE levels were 1.503-2.9 mg/l and by 2.88 if levels were .2.9 mg/l. Prenatal PCB levels showed no effect. Conclusion: Prenatal exposure to the oestrogenic endocrine-disrupting chemical DDE may contribute to the obesity epidemic in women.

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IntroductionThe management and removal of thoracostomy tubes for trauma-related hemothorax and pneumothorax is controversial. General recommendations exist; however, institutional data related to an algorithmic approach has not been well described. The difficulty in establishing an algorithm centers about individualized patients’ needs for subsequent management after thoracostomy tube placement. In our institution, we use the same protocol for all trauma patients who receive a thoracostomy tube with minimal complications.PurposeTo present the clinical outcomes of patients who required a tube thoracostomy for traumatic injury and were managed by an institutional protocol.MethodsA retrospective chart review of 313 trauma patients at a single level I trauma institution from January 2008 through June 2012 was conducted. Inclusion criteria were patient age ≥ 18 years, involvement in a trauma, and requirement of a thoracostomy tube. The patients’ charts were reviewed for demographic data, injury severity score (ISS), length of stay (LOS), and chest-tube specific data. Thoracostomy tube complications were defined as persistent air leak, persistent pneumothorax, recurrent pneumothorax, and clotting of thoracostomy tube. The patients were managed per our institutional algorithm. Descriptive statistics were performed.ResultsMost of the patients who required a thoracostomy tube had blunt-related traumas (271/313; 86.6%), while 42 patients (13.4%) sustained penetrating injuries. There were 215 (68.7%) male patients. The average age at time of injury was 45.7 ± 21.1 years and the mean ISS was 24.9 ± 15.9 (mean ± SD). Elevated alcohol levels were found in 65 of the 247 patients who were tested upon admission (26.3%). Overall, 15 patients (4.8%) developed a thoracostomy tube related complication: persistent air leak in six patients, persistent pneumothorax in six patients, recurrent pneumothorax in two patients, and clotted thoracostomy tube in one patient. The average LOS was 10.4 ± 8.4 days, and the mean length of thoracostomy tube placement was 5.9 ± 4.3 days.ConclusionsOur algorithmic thoracostomy tube management protocol resulted in a complication rate of 4.8%. By managing thoracostomy tubes in a systematic manner, our patients have improved outcomes following placement and removal compared to other studies.

Using grounded theory, a multidisciplinary study team compared the narratives of 30 women who had recently experienced a breast cancer scare. Even though 10 women received a benign diagnosis, all women reported a difficult time prediagnosis, characterized by an array of emotions and contemplation of the meaning of life. Diagnosis separated the two groups with emotional relief dominant for the benign group and intensification of emotions for the cancer group. For those diagnosed with cancer, three factors contributed to arriving at a point of acceptance about the diagnosis and treatment: (a) sustained coping mechanisms; (b) a belief system that shifted the meaning of the cancer experience; and (c) the ability to manage non-cancer-related stressful events. Implications include the need for tailored biopsychosocial treatments that focus on reducing stress, enhancing support systems, reframing beliefs about the illness, and providing the opportunity for the women to talk about their experiences.

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Given the height-breast cancer risk association, the emerging evidence linking breast cell proliferation to hormones associated with growth, and the finding in this study that the relationship between age at menarche and adult height no longer exists for women born in 1966 or later, it is possible that the long-established relationship between age at menarche and breast cancer risk may also no longer exist.

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