Thigh Perforator Exchange: Intraflap Perforator Augmentation of Anterolateral Thigh Free Flaps.

Peripheral perfusion in large anterolateral thigh flaps may be inadequate if perforator zones are not properly planned during flap design and harvest, and variations in vascular anatomy can contribute to operative difficulty and morbidity. Intraflap anastomosis of extrinsic perforators may allow for augmentation of perfusion while avoiding significant intramuscular dissection. Adaptation of the perforator exchange technique, previously described in autologous breast reconstruction, optimizes vascular flow in anterolateral thigh flaps.

The Vertical Profunda Artery Perforator Flap for Perineal Reconstruction.

Background: Colorectal cancer is a significant cause of cancer-related death in the United States with abdominoperineal resection (APR) remaining a necessary procedure for many patients. The resultant defects of this radical operation are complex and characterized by significant tissue voids. Pedicled vertical profunda artery perforator flaps (vPAP) can be used to obliterate these defects in patients receiving minimally invasive APR or when the abdominal donor site is unavailable.

Primary Intraosseous Granular Cell Tumor of the Sphenoid and Central Skull Base in a Pediatric Patient.

Background: Granular cell tumors occur in all ages and many anatomic sites. In the craniofacial region, they typically arise in soft tissue, not bone. We present a primary intra-osseous granular cell tumor of the sphenoid and central skull base arising in a 12- year- old girl.

New eGFR equations: Implications for cardiologists and racial inequities.

Recently, a new equation to predict estimated glomerular filtration rate (eGFR) that does not include a variable for race has been endorsed by professional organizations and increasingly adopted by clinical laboratories. We discuss the reasoning behind the development of the new equation, implications for cardiologists, and how the new eGFR equation could impact disparities in the cardiovascular care of these patients. Race, a social construct, is a poor proxy for biological variability.

Leadership for Medical Students: Lessons Learned From a Relationship-Centered Leadership Curriculum.

Despite the need for and relevance of leadership skills to the success of medical trainees and healthcare professionals, few medical schools offer formal leadership training during the preclinical years. Where such curricula exist, we have found few schools that intentionally incorporate key principles of lifestyle medicine critical to short- and long-term career development. We describe a novel relationship-centered leadership curriculum, grounded in a conceptual framework of emotional intelligence and incorporating key principles of lifestyle medicine, first piloted in 2019 and now in its fourth year of existence.

COVID-19: Lessons Learned, Lessons Unlearned, Lessons for the Future.

The COVID-19 pandemic has affected clinicians in many different ways. Clinicians have their own experiences and lessons that they have learned from their work in the pandemic. This article outlines a few lessons learned from the eyes of CHEST Critical Care Editorial Board members, namely practices which will be abandoned, novel practices to be adopted moving forward, and proposed changes to the health care system in general.

Bombesin-drug conjugates in targeted therapy for small cell lung cancer.

Small cell lung cancer (SCLC) is a aggressive form of primary lung neoplasm that often presents in elderly smokers. While stage I SCLC can be managed with surgery, extensive-stage disease is managed with chemotherapy using etoposide and cisplatin among other agents, and often complemented by radiation therapy to the chest and cranium. Recent advances in pharmacological research have yielded novel antibody and peptide-conjugated adjunctive chemotherapy, of which bombesin and bombesin receptors have played an important role due to their overexpression in SCLC and other lung cancers.

Multiple High-Risk Features for Stage II Colon Carcinoma Portends Worse Survival Than Stage III Disease.

Background: High-risk features in stage II colon cancer worsen survival and serve as an impetus for adjuvant chemotherapy. Limited data exist on the effect of multiple high-risk features on survival.

Objective: The study aimed to compare the survival of 0, 1, or multiple high-risk features in stage II to stage III colon cancer.

Dynamic transcriptome landscape in the song nucleus HVC between juvenile and adult zebra finches.

Male juvenile zebra finches learn to sing by imitating songs of adult males early in life. The development of the song control circuit and song learning and maturation are highly intertwined processes, involving gene expression, neurogenesis, circuit formation, synaptic modification, and sensory-motor learning. To better understand the genetic and genomic mechanisms underlying these events, we used RNA-Seq to examine genome-wide transcriptomes in the song control nucleus HVC of male juvenile (45 d) and adult (100 d) zebra finches.

Effect of a fluid bolus on cardiovascular collapse among critically ill adults undergoing tracheal intubation (PrePARE): a randomised controlled trial.

Background: Tracheal intubation is common in the care of critically ill adults and is frequently complicated by hypotension, cardiac arrest, or death. We aimed to evaluate administration of an intravenous fluid bolus to prevent cardiovascular collapse during intubation of critically ill adults.

Methods: We did a pragmatic, multicentre, unblinded, randomised trial in nine sites (eight ICUs and one emergency department) around the USA.

Emulating a Novel Clinical Trial Using Existing Observational Data. Predicting Results of the PreVent Study.

"Target trial emulation" has been proposed as an observational method to answer comparative effectiveness questions, but it has rarely been attempted concurrently with a randomized clinical trial (RCT). We tested the hypothesis that blinded analysts applying target trial emulation to existing observational data could predict the results of an RCT. PreVent (Preventing Hypoxemia with Manual Ventilation during Endotracheal Intubation) was a multicenter RCT examining the effects of positive-pressure ventilation during tracheal intubation on oxygen saturation and severe hypoxemia.

Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults.

Background: Hypoxemia is the most common complication during tracheal intubation of critically ill adults and may increase the risk of cardiac arrest and death. Whether positive-pressure ventilation with a bag-mask device (bag-mask ventilation) during tracheal intubation of critically ill adults prevents hypoxemia without increasing the risk of aspiration remains controversial.

Methods: In a multicenter, randomized trial conducted in seven intensive care units in the United States, we randomly assigned adults undergoing tracheal intubation to receive either ventilation with a bag-mask device or no ventilation between induction and laryngoscopy.

A Multicenter Randomized Trial of a Checklist for Endotracheal Intubation of Critically Ill Adults.

Background: Hypoxemia and hypotension are common complications during endotracheal intubation of critically ill adults. Verbal performance of a written, preintubation checklist may prevent these complications. We compared a written, verbally performed, preintubation checklist with usual care regarding lowest arterial oxygen saturation or lowest systolic BP experienced by critically ill adults undergoing endotracheal intubation.

Decreasing 30-day surgical mortality in a VA Medical Center utilizing the ACS NSQIP Surgical Risk Calculator.

Background: The Overton Brooks VA Medical Center Surgical Service had a high mortality. In an effort to reduce surgical mortality, we implemented a series of quality improvement interventions, including utilization of the ACS Surgical Risk Calculator to identify high-risk surgical patients for discussion in a multidisciplinary Pre-Operative Consultation Committee.

Methods: Retrospective study describing the implementation of a risk stratification intervention incorporating the ACS Surgical Risk Calculator Tool and a multidisciplinary Pre-Operative Consultation Committee to target high-risk patients.

Early exposure to hyperoxia and mortality in critically ill patients with severe traumatic injuries.

Background: Hyperoxia is common early in the course of resuscitation of critically ill patients. It has been associated with mortality in some, but not all, studies of cardiac arrest patients and other critically ill cohorts. Reasons for the inconsistency are unclear and may depend on unmeasured patient confounders, the timing and duration of hyperoxia, population characteristics, or the way that hyperoxia is defined and measured.

Missed Opportunities for Health Promotion Intervention in the Management of Alcohol Withdrawal Syndrome.

Objective: We aimed to characterize utilization of evidence-based health promotion practices not included in Alcohol Withdrawal Syndrome (AWS) guidelines, such as vaccinations and counseling services, hypothesizing that missed opportunities for health promotion intervention would abound.

Methods: Retrospective medical record review of 99 patients presenting to a safety-net academic medical center with AWS between August 1, 2012 and March 31, 2013.

Results: Thiamine replacement (70%), tobacco cessation counseling (28%), influenza or pneumonia vaccination (25% and 28% respectively), psychiatric counseling (70%), referral to alcohol support group or treatment center(40%), and screening for viral hepatitis and HIV (39% and 44%, respectively) were documented by healthcare providers at lower than optimal frequency.

Timing of Intubation and Clinical Outcomes in Adults With Acute Respiratory Distress Syndrome.

Objective: The prevalence, clinical characteristics, and outcomes of critically ill, nonintubated patients with evidence of the acute respiratory distress syndrome remain inadequately characterized.

Design: Secondary analysis of a prospective observational cohort study.

Setting: Vanderbilt University Medical Center.

Atrial Fibrillation Is an Independent Predictor of Mortality in Critically Ill Patients.

Objectives: Atrial fibrillation has been associated with increased mortality in critically ill patients. We sought to determine whether atrial fibrillation in the ICU is an independent risk factor for death. A secondary objective was to determine if patients with new-onset atrial fibrillation have different risk factors or outcomes compared with patients with a previous history of atrial fibrillation.

Prehospital aspirin use is associated with reduced risk of acute respiratory distress syndrome in critically ill patients: a propensity-adjusted analysis.

Objectives: Platelet activation plays an active role in the pathogenesis of acute respiratory distress syndrome. In our prior study of 575 patients at high risk for acute respiratory distress syndrome, concurrent statin and aspirin use was associated with reduced acute respiratory distress syndrome. However, the largest study (n = 3,855) to date found no significant benefit of prehospital aspirin in a lower-risk population when adjusted for the propensity for aspirin use.

Smartphones in medicine: emerging practices in an academic medical center.

Advances in mobile phone technology now provide a myriad of resources to physicians' fingertips. However, the medical profession continues to struggle with potential for misuse of these devices. There is a need for better understanding of physicians' uses of smartphones in order to establish guidelines for appropriate and professional behavior.

A split strap frame applicator for stereotactic frame placement.

Background: Symmetric and orthogonal placement of stereotactic frames is an important part of many procedures. The authors describe a split strap frame applicator for stereotactic frame placement.

Methods: A strap was developed that uses 2 pairs of straps with a common center that support the weight of the frame during screw placement.

Perioperative management of infants with the linear naevus sebaceous syndrome of Jadassohn: a report of two cases.

Neurofibromatosis and tuberous sclerosis are the most well-recognized of the congential phakomatoses, a group of six hereditary neuro-oculo-cutaneous disorders. Although easily diagnosed at birth by a parasagittal line of facial sebaceous naevi, the linear naevus sebaceous syndrome (LNSS) of Jadassohn is the rarest phakomatosis, one often characterized by airway and anaesthetic considerations that do not apply to the other phakomatoses. In addition to its obvious cutaneous manifestations, LNSS is characterized by hemifacial asymmetry, an anatomic predictor of difficult trachael intubation, and intractable seizure activity, a condition that limits selection of anaesthetics.