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Background The last decade has seen an increasing prevalence of prophylactic mastectomies with decreasing age of patients treated for breast cancer. Data are limited on the prevalence of histopathologic abnormalities in this population. This study aimed to measure the prevalence of histopathologic findings in contralateral prophylactic mastectomy (CPM) and bilateral prophylactic mastectomy (BPM) patients and identify predictors of findings. Methods Our institution’s prophylactic mastectomies from 2004 to 2011 were reviewed. Breast specimens with prior malignancies were excluded. Patient factors and pathology reports were collected. Independent predictive factors were identified with univariate and multivariate logistic analysis. Results A total of 524 specimens in 454 patients were identified. Malignancy was found in 7.0 % of CPM and 5.7 % of BPM specimens. In CPM patients, ipsilateral lobular carcinoma-in situ [odds ratio (OR) 4.0] and mammogram risk group (OR 2.0) were predictive of malignancy. Age group (OR 1.5), ipsilateral lobular carcinoma-in situ (OR 2.3), and prior bilateral salpingo-oophorectomy (OR 0.3) were predictive of moderate- to high-risk histopathology. Only increasing age group was predictive of increased moderate- to high-risk histopathology in BPM patients (OR 2.3). There were no independent predictors of malignancy in BPM. BRCA status was not predictive in either CPM or BPM. Conclusions Patients with lobular carcinoma-in situ in the index breast or high-risk mammograms have a higher prevalence of malignancies. Although BRCA patients may benefit from prophylactic mastectomy, the genetic diagnosis does not increase the prevalence of detecting occult pathology. BPM patients can be counseled about relative risk, where occult pathology increases with age.

Background To determine if a modified ovarian sensitivity index (MOSI), based on initial follicular measurements and the initial follicle-stimulating hormone (FSH) dose, can predict the production of high-quality embryos for successful implantation during in vitro fertilization (IVF). Methods This study consisted of two phases: 1) a retrospective study and 2) a prospective observational study. For the first phase, 363 patients charts were reviewed, of which 283 had embryos transferred. All women underwent a standardized antagonist-based IVF protocol. At the first follow-up (Day 3/4), the number and size of the follicles were determined. MOSI was calculated as ln (number follicles (≥6 mm) × 1000 / FSH initial dose). Afterward, the number and quality of the ova, embryo development, and the number and quality of the blastocysts were determined. Embryo implantation was confirmed by β-hCG. For the second phase, 337 IVF cycles were followed to determine MOSI’s accuracy. Results MOSI could predict the production of ≥4 high-quality embryos by Day 2 (AUC = 0.69, 95%CI:0.63–0.75), ≥2 blastocysts (AUC = 0.74, 95%CI:0.68–0.79), and ≥ 35% rate of blastocyst formation (AUC = 0.65, 95%CI:0.58–0.72). Using linear regression, MOSI was highly associated with the number of ova captured (β = 5.15), MII oocytes (β = 4.31), embryos produced (β = 2.90), high-quality embryos (β = 0.98), and the blastocyst formation rate (β = 0.06, p  < 0.01). Using logistic regression, MOSI was highly associated with achieving ≥4 high-quality embryos (odds ratio = 2.80, 95%CI:1.90–4.13), ≥2 blastocysts (odds ratio = 3.40, 95%CI:2.33–4.95), and ≥ 35% blastocysts formation rate (odds ratio = 1.96, 95%CI:1.31–2.92). This effect was independent of age, BMI, and antral follicle count. For implantation, MOSI was significantly associated with successful implantation (odds ratio = 1.79, 95%CI:1.25–2.57). For the prospective study, MOSI was highly accurate at predicting ≥6 high-quality embryos on Day 2 (accuracy = 68.5%), ≥6 blastocysts (accuracy = 68.0%), and a blastocyst formation rate of ≥35% (accuracy = 61.4%). Conclusion MOSI was highly correlated with key IVF parameters that are associated with achieved pregnancy. Using this index with antagonist cycles, clinicians may opt to stop an IVF cycle, under the assumption that the cycle will fail to produce good blastocysts, preventing wasting the patient’s resources and time.

Capsular contracture is a common adverse outcome following implant breast reconstruction, often associated with radiation treatment. The authors hypothesize that muscle fibrosis is the main contributor of breast reconstruction contracture after radiation. Retrospective chart review identified patients that underwent DTI reconstruction with pre-or post-operative breast irradiation. Signs of capsular contracture were assessed using clinic notes and independent graders reviewing two-dimensional images and anatomic landmarks. Capsular contracture rate was greater in the subpectoral vs. prepectoral group (n = 28, 51.8% vs. n = 12, 30.0%, p = 0.02). When compared to prepectoral DTI reconstruction in irradiated patients, subpectoral implant placement was nearly 4 times as likely to result in capsular contracture (p < 0.01). Rates of explantation, infection, tissue necrosis, and hematoma were comparable between groups. We also found that when subpectoral patients present with breast contracture, chemoparalysis of the muscle alone can resolve breast asymmetry, corroborating that muscle is a key contributor to breast contracture. As prepectoral breast reconstruction is gaining popularity, there have been questions regarding outcome following radiation treatment. This study suggest that prepectoral breast reconstruction is safe in an irradiated patient population, and in fact compares favorably with regard to breast contracture.

Goals/Purpose Traditional rhinoplasty tip grafts often lead to visibility issues, prompting patients to seek revision surgery. The mastoid fascia tissue graft (MFTG) provides a natural-looking alternative with fewer complications. MFTG remains less visible through the skin, enhancing long-term aesthetic results. This eight-year study on 193 patients examines MFTG's effectiveness in nasal tip refinement, evaluating revision and infection rates. Methods/Technique A retrospective analysis of MFTG use for nasal tip refinement during open rhinoplasty in the senior author's practice was conducted from July 2014 to June 2022. Inclusion criteria encompassed open rhinoplasty cases using mastoid tissue for tip refinement with at least 12 months of follow-up. Among 2003 cases, 193 met these criteria and were evaluated for subsequent revision and infection rates. Results/Complications The average patient age was 34.2 years (175 females, 18 males). Primary rhinoplasties were done on 114 patients, with 79 receiving revision surgeries. Average follow-up was 14.8 months. 6 patients (3.1%) needed extended antibiotics. Overall, 6 (3.1%) patients required revision rhinoplasty, comprising of 2 (1.8%) primary and 4 (5.1%) secondary rhinoplasty patients. These revisions were unrelated to the use of MFTG for nasal tip refinement. Conclusion MFTG use for nasal tip refinement is associated with low revision rates for both primary and secondary rhinoplasty compared to rates in current literature, without increase in complications or prolonged operative durations. MFTG for nasal tip refinement is a safe and convenient technique delivering excellent aesthetic outcomes with minimal morbidity.

Goals/Purpose Smoking negatively impacts tissue perfusion and wound healing, raising concerns about infection and delayed recovery in surgical patients. While smoking remains a strict contraindication in some procedures with extensive dissection, such as abdominoplasty and facelift surgery, the risks of smoking in rhinoplasty patients are not well known. Given the nasal region's robust vascular supply, the risk of smoking complications may be less in rhinoplasty. This study explores whether smoking should be considered a contraindication for rhinoplasty by comparing postoperative infection rates and the need for revision surgery between smokers and nonsmokers. Using a decade of patient data, we aim to assess whether there is an increased risk of infection or revision surgery in smokers. The findings will provide valuable insights to guide plastic surgeons in making informed decisions and ensuring safe, successful outcomes for both smokers and nonsmokers. Methods/Technique A retrospective review was conducted on the senior author’s (R.G.R.) rhinoplasty cases from July 2014 to June 2022, including all patients treated in this period. The study was approved by the BRANY Institutional Review Board. All patients underwent open rhinoplasty under general anesthesia, prioritizing septal cartilage for reconstruction. If septal cartilage was inadequate, fresh frozen cartilage (FFCC) from MTF Biologics was used; no alloplastic materials were utilized. Patients were categorized as active smokers, former smokers, and non-smokers. Active smokers used any inhaled tobacco products (e.g., cigarettes, cigars, vaping) within 4 weeks before and/or after surgery. Former smokers had quit over 4 weeks prior to surgery with no intent to resume, and non-smokers had no history of tobacco use. Patients with less than one-year follow-up were excluded. After reviewing 2003 cases of rhinoplasty, 1884 patients were found to match both the inclusion and exclusion criteria. Patient demographics and surgical outcomes were collected through manual chart review. Primary outcomes included infection and revision rates, with infections identified by clinical signs requiring antibiotics or further intervention post-prophylactic antibiotics. Revision rhinoplasty was defined as any subsequent open procedure. Infection and revision rates were compared across active smokers, former smokers, and non-smokers, with subgroups for primary and revision rhinoplasty patients. Results/Complications A total of 1884 patients consisting of 1673 (88.80%) females and 211 (11.20%) males met inclusion criteria with an average age of 30.7 years and BMI of 22.47 kg/m2. Among these patients, 1421 (75.42%) were primary rhinoplasty cases and 463 (41.5%) were revisions. The average length of follow-up was 23.8 months. This study’s rhinoplasty patient population consists of 81 (4.30%) active smokers, 38 (2.02%) former smokers, and 1765 (93.68%) non-smokers (Table 1). In our patient population, we included patients who underwent both primary and revision rhinoplasty. In the overall population, there were 62 (3.29%) patients that underwent subsequent revision. 36 of 1421 (2.53%) of these patients belonged to the primary rhinoplasty group and 26 of 463 (5.62%) to the revision rhinoplasty population. In comparison, revisions were performed on 3 of 80 (3.75%) active smokers, 1 of 39 (2.56%) former smokers, and 58 of 1,765 (3.29%) non-smokers. Among these groups, all 3 of 71 (4.23%) revision patients were among primary rhinoplasty patients in the active smoker population, whereas in the non-smoker population, the distribution was 32 (2.42%) for primary and 26 (5.83%) for revision cases. No statistically significant difference was observed between groups (Table 2). Overall, 32 of 1884 (1.70%) of patients required 5-7 days of additional postoperative antibiotics for cellulitis. This was in addition to the standard postoperative antibiotic prophylaxis. 21 of 1421 (1.48%) of these patients belonged to the primary rhinoplasty group and 11 of 463 (2.38%) to the revision rhinoplasty patient population. 3 of 80 (3.75%) of patients requiring additional postoperative antibiotics were active smokers and 29 of 1765 (1.64%) were non-smokers. There was no incidence of use of additional postoperative antibiotics in the former smoker rhinoplasty population. Again, no statistically significant differences were found among the groups (Table 3). Conclusion The results of this study indicate that active smoking should not be considered a contraindication for rhinoplasty, as there is no significant increase in the need for revision surgeries in actively smoking patients compared to nonsmokers. While smoking is commonly associated with impaired wound healing and increased risk of infection due to its negative effects on tissue perfusion and immune response, our data demonstrate that these concerns can be managed effectively in the context of rhinoplasty. Among the 1884 patients included in this study, the revision rates for smokers (3.75%) and nonsmokers (3.29%) were comparable. This finding is particularly notable as it challenges the assumption that smokers are inherently at higher risk for suboptimal surgical outcomes. Despite the known systemic effects of smoking on vascular health and tissue healing, rhinoplasty in smokers appears to result in satisfactory outcomes when proper postoperative care is implemented.

Goals/Purpose The nasal dorsum is a cornerstone of rhinoplasty aesthetics, playing a vital role in achieving facial harmony and balance. Achieving a smooth, refined nasal profile remains a significant challenge, particularly in thin-skinned patients who are more susceptible to contour irregularities. Many techniques are used to address this problem, including diced cartilage, fascia, acellular dermal matrices, and silicone implants. This study aims to evaluate the effectiveness of using morselized bone grafts (MBG)–specifically, unused bone rasp material that is typically discarded–as a technique for contouring and refining the nasal dorsum after dorsal reduction. Methods/Technique The senior surgeon exclusively utilizes an open approach to rhinoplasty, and all cases are performed under general anesthesia. After performing a dorsal hump reduction with a bone rasp, the MBG is stored on the back table for later use in the same case. After addressing other components of the rhinoplasty procedure, attention is turned back to the nasal dorsum, wherein any contour irregularities are filled with the MBG paste. A retrospective chart review of rhinoplasty cases in the senior author's practice was conducted between January 2021 and June 2022. The inclusion criteria were cosmetic or functional rhinoplasty cases in which autologous MBG was used for dorsum refinement and contouring with a minimum of 12 months of follow-up. 953 patients met the inclusion criteria and were included in the study. Outcomes of interest included the rate of postoperative infection, defined as patients with signs of infection requiring antibiotics after completing their standard course of prophylactic antibiotics, and the rate of operative revisions. Results/Complications The mean age of our study group was 31.6 years old, with 869 female patients. 640 cases were primary rhinoplasties. The mean follow-up period was 23.5 months, with a minimum of 12 months of follow up for each patient. The rate of postoperative infection in our case series was 2.7%, with 26 patients requiring postoperative antibiotics. 17 (1.8%) patients required operative revision, among whom 4 (23.5%) patients were revision cases. There were no patients who sought revision rhinoplasty for concerns related to dorsal irregularities or contour defects. Conclusion MBG use for nasal dorsum aesthetics is a safe, convenient, and effective technique in camouflaging and concealing nasal dorsum irregularities in both primary and revision rhinoplasty. Additionally, as there is no additional equipment required and minimal operative time added when performing this technique, MBG use is an efficient alternative to other techniques for addressing dorsal aesthetics with no additional donor-site morbidity when paired with boney dorsal reduction. Future steps will involve performing a five-year follow-up on this cohort of patients to assess for long-term dorsal aesthetics following MBG use.

Context:Delivering software that has value to customers is a primary concern of every software company. Prevalent in web-facing companies, controlled experiments are used to validate and deliver value in incremental deployments. At the same that web-facing companies are aiming to automate and reduce the cost of each experiment iteration, embedded systems companies are starting to adopt experimentation practices and leverage their activities on the automation developments made in the online domain.Objective:This thesis has two main objectives. The first objective is to analyze how software companies can run and optimize their systems through automated experiments. This objective is investigated from the perspectives of the software architecture, the algorithms for the experiment execution and the experimentation process. The second objective is to analyze how non web-facing companies can adopt experimentation as part of their development process to validate and deliver value to their customers continuously. This objective is investigated from the perspectives of the software development process and focuses on the experimentation aspects that are distinct from web-facing companies.Method:To achieve these objectives, we conducted research in close collaboration with industry and used a combination of different empirical research methods: case studies, literature reviews, simulations, and empirical evaluations.Results:This thesis provides six main results. First, it proposes an architecture framework for automated experimentation that can be used with different types of experimental designs in both embedded systems and web-facing systems. Second, it proposes a new experimentation process to capture the details of a trustworthy experimentation process that can be used as the basis for an automated experimentation process. Third, it identifies the restrictions and pitfalls of different multi-armed bandit algorithms for automating experiments in industry. This thesis also proposes a set of guidelines to help practitioners select a technique that minimizes the occurrence of these pitfalls. Fourth, it proposes statistical models to analyze optimization algorithms that can be used in automated experimentation. Fifth, it identifies the key challenges faced by embedded systems companies when adopting controlled experimentation, and we propose a set of strategies to address these challenges. Sixth, it identifies experimentation techniques and proposes a new continuous experimentation model for mission-critical and business-to-business.Conclusion:The results presented in this thesis indicate that the trustworthiness in the experimentation process and the selection of algorithms still need to be addressed before automated experimentation can be used at scale in industry. The embedded systems industry faces challenges in adopting experimentation as part of its development process. In part, this is due to the low number of users and devices that can be used in experiments and the diversity of the required experimental designs for each new situation. This limitation increases both the complexity of the experimentation process and the number of techniques used to address this constraint.

A/B testing is gaining attention in the automotive sector as a promising tool to measure causal effects from software changes. Different from the web-facing businesses, where A/B testing has been well-established, the automotive domain often suffers from limited eligible users to participate in online experiments. To address this shortcoming, we present a method for designing balanced control and treatment groups so that sound conclusions can be drawn from experiments with considerably small sample sizes. While the Balance Match Weighted method has been used in other domains such as medicine, this is the first paper to apply and evaluate it in the context of software development. Furthermore, we describe the Balance Match Weighted method in detail and we conduct a case study together with an automotive manufacturer to apply the group design method in a fleet of vehicles. Finally, we present our case study in the automotive software engineering domain, as well as a discussion on the benefits and limitations of the A/B group design method.

Randomised field experiments, such as A/B testing, have long been the gold standard for evaluating the value that new software brings to customers. However, running randomised field experiments is not always desired, possible or even ethical in the development of automotive embedded software. In the face of such restrictions, we propose the use of the Bayesian propensity score matching technique for causal inference of observational studies in the automotive domain. In this paper, we present a method based on the Bayesian propensity score matching framework, applied in the unique setting of automotive software engineering. This method is used to generate balanced control and treatment groups from an observational online evaluation and estimate causal treatment effects from the software changes, even with limited samples in the treatment group. We exemplify the method with a proof-of-concept in the automotive domain. In the example, we have a larger control (\\(N_c=1100\\)) fleet of cars using the current software and a small treatment fleet (\\(N_t=38\\)), in which we introduce a new software variant. We demonstrate a scenario that shipping of a new software to all users is restricted, as a result, a fully randomised experiment could not be conducted. Therefore, we utilised the Bayesian propensity score matching method with 14 observed covariates as inputs. The results show more balanced groups, suitable for estimating causal treatment effects from the collected observational data. We describe the method in detail and share our configuration. Furthermore, we discuss how can such a method be used for online evaluation of new software utilising small groups of samples.

Context: Delivering software that has value to customers is a primary concern of every software company. One of the techniques to continuously validate and deliver value in online software systems is the use of controlled experiments. The time cost of each experiment iteration, the increasing growth in the development organization to run experiments and the need for a more automated and systematic approach is leading companies to look for different techniques to automate the experimentation process. Objective: The overall objective of this thesis is to analyze how to automate different types of experiments and how companies can support and optimize their systems through automated experiments. This thesis explores the topic of automated online experiments from the perspectives of the software architecture, the algorithms for the experiment execution and the experimentation process, and focuses on two main application domains: the online and the embedded systems domain. Method: To achieve the objective, we conducted this research in close collaboration with industry using a combination of different empirical research methods: case studies, literature reviews, simulations and empirical evaluations. Results and conclusions: This thesis provides five main results. First, we propose an architecture framework for automated experimentation that can be used with different types of experimental designs in both embedded systems and web-facing systems. Second, we identify the key challenges faced by embedded systems companies when adopting controlled experimentation and we propose a set of strategies to address these challenges. Third, we develop a new algorithm for online experiments. Fourth, we identify restrictions and pitfalls of different algorithms for automating experiments in industry and we propose a set of guidelines to help practitioners select a technique that minimizes the occurrence of these pitfalls. Fifth, we propose a new experimentation process to capture the details of a trustworthy experimentation process that can be used as basis for an automated experimentation process. Future work: In future work, we plan to investigate how embedded systems can incorporate experiments in their development process without compromising existing real-time and safety requirements. We also plan to analyze the impact and costs of automating the different parts of the experimentation process.