We have previously described the use of the retrograde limb of the internal mammary vein (IMV) as an additional venous outflow tract in deep inferior epigastric perforator (DIEP) flap reconstruction. In the current study, we use the Novadaq SPY ((R)) system, a novel intraoperative angiographic method, to further validate the use of the retrograde limb of the IMV. The Novadaq SPY ((R)) system laser source was used with indocyanine green angiography to evaluate the arterial, anterograde venous, and retrograde venous anastomoses of 15 patients undergoing DIEP flap breast reconstruction. The number of perforators used, patient age, exposure to radiation, coupler size, and incidence of intraoperative congestion were recorded. All flaps survived, and there were no cases of intraoperative congestion. The average time required to perform the additional retrograde anastomosis was 12 minutes. Flow of indocyanine green not only revealed patency of our anastomoses but it confirmed unobstructed flow through the retrograde limb of the IMV. Our study further validates that the retrograde limb of the IMV does in fact achieve flow away from the DIEP flap and can therefore be used as an additional or alternative outflow tract in DIEP flap breast reconstruction surgery.

Objective: During the COVID-19 pandemic, central venous access line teams were implemented at many hospitals throughout the world to provide access for critically ill patients. The objective of this study was to describe the structure, practice patterns, and outcomes of these vascular access teams during the COVID-19 pandemic. Methods: We conducted a cross-sectional, self-reported study of central venous access line teams in hospitals afflicted with the COVID-19 pandemic. To participate in the study, hospitals were required to meet one of the following criteria: development of a formal plan for a central venous access line team during the pandemic; implementation of a central venous access line team during the pandemic; placement of central venous access by a designated practice group during the pandemic as part of routine clinical practice; or management of an iatrogenic complication related to central venous access in a patient with COVID-19. Results: Participants from 60 hospitals in 13 countries contributed data to the study. Central venous line teams were most commonly composed of vascular surgery and general surgery attending physicians and trainees. Twenty sites had 2657 lines placed by their central venous access line team or designated practice group. During that time, there were 11 (0.4%) iatrogenic complications associated with central venous access procedures performed by the line team or group at those 20 sites. Triple lumen catheters, Cordis (Santa Clara, Calif) catheters, and nontunneled hemodialysis catheters were the most common types of central venous lines placed by the teams. Eight (14%) sites reported experience in placing central venous lines in prone, ventilated patients with COVID-19. A dedicated line cart was used by 35 (59%) of the hospitals. Less than 50% (24 [41%]) of the participating sites reported managing thrombosed central lines in COVID-19 patients. Twentythree of the sites managed 48 iatrogenic complications in patients with COVID-19 (including complications caused by providers outside of the line team or designated practice group). Conclusions: Implementation of a dedicated central venous access line team during a pandemic or other health care crisis is a way by which physicians trained in central venous access can contribute their expertise to a stressed health care system. A line team composed of physicians with vascular skill sets provides relief to resource-constrained intensive care unit, ward, and emergency medicine teams with a low rate of iatrogenic complications relative to historical reports. We recommend that a plan for central venous access line team implementation be in place for future health care crises.

Background: Liver transplant (LT) patients are at high risk for readmission. This study sought to identify

No abstract

The increased distance between the normal pituitary gland and the residual tumor facilitates treatment of the tumor with radiosurgery or radiotherapy and effectively reduces the incidence of radiation injury to the normal pituitary gland when compared with historical controls.

No abstract

We report the development of bilateral Salzmann's-like corneal lesions located at the site of laser in situ keratomileusis (LASIK) flap margins in 2 patients. These lesions resulted in ocular surface irritation as well as induction of irregular astigmatism and associated loss of best corrected visual acuity. Both patients had bilateral LASIK before the occurrence of the corneal lesions. A biopsy was performed on 1 nodule. The epithelium overlying this raised bluish-white corneal lesion appeared irregular in thickness, with replacement of Bowman's layer by periodic acid-Schiff positive thickened basement membrane-like material. Underlying this basement membrane was a layer of relatively regular, hypocellular, collagenlike connective tissue, which demonstrated hyalinization on trichrome staining. Based on these 2 cases, it seems possible that the hyposecretion of tears, decreased blink rate, and Dellen effect that often occur following LASIK could produce the corneal irritation needed to induce Salzmann's nodular degeneration.

In the presence of AcS, DUS alone is inadequate to accurately determine the degree of carotid stenosis with sensitivity, specificity, and negative predictive values far below that needed for clinical decision-making. MD-CTA may be necessary for improved characterization of plaque in these AcS lesions. Further studies are needed to determine DUS parameters that may identify patients who should undergo further evaluation with MD-CTA to characterize the true severity of the stenosis.