'PartBreCon' study. A UK multicentre retrospective cohort study to assess outcomes following PARTial BREast reCONstruction with chest wall perforator flaps

BACKGROUND

Partial breast reconstruction with a pedicled chest wall perforator flap (CWPF) enables breast conservation in a higher tumour: breast volume ratio scenario. Since there is limited evidence, this retrospective cohort study aimed to ascertain immediate (30-days) and medium-term (follow-up duration) surgical outcomes.

METHODS

STROBE-compliant protocol ascertained CWPF outcomes between March 2011-March 2021. UK centres known to perform CWPF were invited to participate if they performed at least 10 cases. Data were retrospectively collected, including patient demographics, tumour and treatment characteristics, and surgical and oncological outcomes. Statistical analysis (R™) included multivariable logistic regression and sensitivity analysis.

RESULTS

Across 15 centres, 507 patients with median age (54 years, IQR; 48-62), body mass index (25.4 kg/m2, IQR; 22.5-29), tumour size (26 mm, IQR; 18-35), and specimen weight (62 g, IQR; 40-92) had following flap types: LiCAP (54.1%, n = 273), MiCAP/AiCAP (19.6%, n = 99), LiCAP + LTAP (19.8%, n = 100) and TDAP (2.2%, n = 11). 30-days complication rates were in 12%: haematoma (4.3%, n = 22), wound infection (4.3%, n = 22), delayed wound healing (2.8%, n = 14) and flap loss (0.6%, n = 3; 1 full) leading to readmissions (2.6%, n = 13) and re-operations (2.6%, n = 13). Positive margins (n = 88, 17.7%) led to 15.9% (n = 79) re-excisions, including 7.5% (n = 37) at the planned 2nd of 2-stage surgery and 1.8% (n = 9) mastectomy. At median 23 months (IQR; 11-39) follow-up, there were 1.2% (n = 6) symmetrisations; recurrences: local (1%), regional/nodal (0.6%) and distant (3.2%).

CONCLUSIONS

This large multicentre cohort study demonstrates acceptable complication and margin re-excision rates. CWPF extends the range of breast conservation techniques. Further studies are required for long-term oncological outcomes.

Syndrome of inappropriate secretion of anti-diuretic hormone due to hypothalamic hamartoma: use of tolvaptan

OBJECTIVES

Hypothalamic hamartoma (HH) typically presents with gonadotrophin-dependent precocious puberty and/or seizures. Other endocrine disturbances are rare. We describe an infant with syndrome of inappropriate secretion of anti-diuretic hormone (SIADH) and a HH.

CASE PRESENTATION

A 6-week-old infant presented with seizures and life-threatening hyponatremia. A HH was identified on magnetic resonance imaging. Clinical examination and biochemistry were consistent with SIADH, and serum copeptin was high during hyponatremia, further supporting this diagnosis. Tolvaptan was effective in normalizing plasma sodium and enabling liberalization of fluids to ensure sufficient nutritional intake and weight gain and manage hunger.

CONCLUSIONS

Hyponatremia due to SIADH is novel at presentation of a HH, and can be challenging to diagnose and manage. Successful management of hyponatremia in this case was achieved using tolvaptan.

Impact of bariatric surgery on early-onset colorectal cancer risk: a systematic review and meta-analysis

The aim of this meta-analysis is to determine the impact of bariatric surgery on the risk of early-onset colorectal neoplasia. This systematic review was conducted according to PRISMA recommendations. It was registered in the PROSPERO international database. A comprehensive search was conducted in electronic databases (MEDLINE, EMBASE, and Web of Science) for completed studies until May 2022. The Search was made using a mixture of indexed terms and title, abstract and keywords. The search included terms: obese, surgical weight loss intervention, colorectal cancer, and colorectal adenomas. Studies that included bariatric intervention patient's vs non-surgical obese patients younger than 50 years were considered. Inclusion criteria were patients with BMI more than 35 kg/m² who underwent a colonoscopy. Studies with follow-up colonoscopy performed in less than 4 years after bariatric surgery and those that evaluated patients with a mean age difference of 5 or more years between groups were excluded. Outcomes analyzed in obese patients with surgical treatment vs control patients included colorectal cancer incidence. From 2008 to 2021, a total of 1536 records were identified. Five retrospective studies that included 48,916 patients were analyzed. Follow-up period ranged from 5 to 22.2 years. 20,663 (42.24%) patients underwent bariatric surgery and 28,253 (57.76%) were part of the control patients. Roux-en-Y gastric bypass was performed in 14,400 (69.7%) individuals. The intervention and control group were similar in age range, proportion of female participants and initial body mass index (35-48.3 vs 35-49.3, respectively). 126/20663 (0.61%) patients in the bariatric surgery group and 175/28253 (0.62%) individuals in the control group presented CRC. In this meta-analysis, we were unable to demonstrate a significant impact of the Bariatric Surgery on EOCRC risk. Prospective trials with longer follow-up periods should be done to prove the colorectal cancer risk reduction.

Primary retrograde urinary drainage using image and endoscopy guidance via urostomies

AIM

To report the technical success of image and endoscopy-guided retrograde trans-urostomy urinary drainage as a primary catheter placement method performed by interventional radiology (IR).

MATERIALS AND METHODS

Nine patients (15 attempted drain placements) with ureteric obstruction following radical cystectomy and urostomy creation were included. The patients were referred to IR for urinary drainage. All patients underwent primary image and endoscopy-guided retrograde trans-urostomy urinary drainage.

RESULTS

Primary image and endoscopy-guided retrograde trans-urostomy urinary drainage was successful in 13/15 (86.6%) attempts. The proposed technique had a limited complication rate omitting the percutaneous nephrostomy access step.

CONCLUSION

Primary image and endoscopy guided retrograde trans-urostomy urinary drainage should be considered before percutaneous nephrostomy in all patients with a urostomy.

ECG changes in psychiatric patients on psychotropic medications

Funding Acknowledgements

Type of funding sources: None.

Background

Suicide and euthanasia accounts for 14.3% of deaths in those with psychiatric conditions. The rest are attributed to preventable causes such as cardiovascular disease, respiratory disease, and infections. Several psychotropic medications have been associated with sudden death due to their effect on prolonging QT interval, resulting in the development of a polymorphic ventricular arrhythmia, Torsades de Pointes (TdP). TdP may be self-limiting or lead to sudden cardiac arrest and death.

Purpose

This study aims to evaluate the cardiotoxic effects of psychotropic medications.

Method

This is a descriptive retrospective study of patients submitted to the local psychiatric wards within one year. Patients with psychotropic drug prescriptions were included while patients below 18 years old, pregnant, or did not have ECG performed were excluded. The control group consisted of sex- and age- matched patients with ECG conducted for occupational health purposes. Multiple regression models were conducted to investigate the predictors of significant ECG differences.

Result

Of the 154 psychiatric inpatients admitted, exclusions were 44 patients due to exclusion criteria and 19 patients due to difficulty in physical file access. The study population (n = 91) had a mean age of 36.7 years old with 40.7% female and 59.3% male. The predominant diagnoses were schizophrenia and delusional disorders (58.2%). 86 psychiatric patients (94.5%) were prescribed antipsychotic drugs (APD).

A significantly higher proportion of psychiatric patients has a history of smoking (p < 0.001), alcohol consumption (p = 0.001), and illicit drug use (p < 0.001). They also exhibited significantly more co-morbid illnesses including hypertension (p = 0.022), hyperlipidaemia (p = 0.013), diabetes (p = 0.026) and thyroid disease (p = 0.023) than the control population.

Psychiatric patients had a significantly higher mean heart rate (79.9 vs 69.6 ms; p < 0.001) and QTc interval (452.2 vs 418.6ms; p < 0.001). Mean QTc interval was significantly longer for psychiatric patients in both male (454.2 vs 414.5ms; p < 0.001) and female (449.3 vs 425.6 ms; p = 0.029) gender. Psychotropic drug use is a significant predictor for both prolonged heart rate (p < 0.001) and prolonged QTc interval (p < 0.001). Electrolyte imbalance is a significant predictor of prolonged QTc interval only (p = 0.036). One year follow of both groups detected only 1 psychiatric patient with palpitation.

Conclusion

Psychiatric patients on psychotropic medications have a longer baseline heart rate and QTc interval, which was not associated with MACE at 1 year. None of the underlying comorbidities and lifestyle choices were significant predictors of this. Electrolyte abnormalities and psychotropic drug use significantly predicted QTc prolongation. However, these findings were largely driven by APD use. A follow-up study of a longer period is recommended to investigate whether patients with prolonged QTc interval are of higher risk of MACE occurrence.

Optimal design of robust resilient automatic voltage regulators

Uncertainties in the plant model parameters and perturbations in the controller gains imposed by implementation errors represent a challenge to ensure robust stability and controller non-fragility simultaneously. Optimal design of robust non-fragile proportional-integral-derivative (PID) controller is presented for an automatic voltage regulator (AVR). The PID design relies basically on Kharitonov theorem and optimization by future search algorithm (FSA). The proposed algorithm has low computational complexity and fast convergence rate because it utilizes both local and global search methods. Further, FSA can improve the exploration characteristic and prevent trapping in local optima by updating its random initial. The PID controller is optimized by FSA to cope with expected parametric uncertainties of the plant model and tolerate its gain perturbations such that robust stability and controller non-fragility are simultaneously met. An interval plant model is suggested to account for model uncertainties where only eight extreme plants derived by Kharitonov theorem are considered in design. FSA-based PID optimization is constrained by the stability conditions of Kharitonov's plants derived using Routh-Hurwitz. A new figure-of-demerit (FoD) based performance index is suggested to enforce simultaneous minimization of the time domain specifications. The suggested objective function is represented by a weighted sum of FoD of nominal response and the sum of reciprocals of the perturbation radii of PID gains. The output results of the recommended design are compared to that of artificial bee colony (ABC) algorithm and teaching-learning based optimization (TLBO) algorithm, multi-objective extremal optimization (MOEO), and non-dominated sorting genetic algorithm II (NSGA II). The results can confirm better response of the suggested technique measured up to other techniques where robustness and non-fragility are simultaneously ensured.

Defying challenges: mid-term outcomes of international collaborations for a successful heart transplantation program in the middle east

Introduction

Heart transplantation (HTx) is a successful treatment strategy for advanced heart failure. Survival rates exceed those achieved by medical therapy alone. Lack of suitable donors and cultural perception remain obstacles for receiving this novel therapy.

Methods

Overcoming challenges we adopted a first-of-a-kind multicenter HTx program, collaborating between Cardiac Centers in India and the United Arab Emirates (UAE). Patients were worked up as part of our newly established HTx program in the UAE, then referred to India for successful HTx. All post HTx follow-up care was continued in the UAE thereafter.

Results

We assessed 10 HTx recipients, [90% male; mean age 34 yrs]. Five patients required inotropes while one LVAD support pre transplant. Our data outline short waiting-list time and excellent 3 years clinical outcomes.

All patients are maintained on Tacrolimus and Mycophenolate Mofetil. Two patient developed acute rejection (celluar and humoral) with graft dysfunction within 18 months.

Seventy percent had non-ischemic cardiomyopathy pre-transplant. Three acquired donor transmitted coronary vascular disease. One patient developed aggressive allograft vasculopathy requiring coronary artery bypass grafting. Acute kidney injury requiring renal replacement therapy occurred in 1 patient.

Conclusion

Defying logistic challenges, donor availability and long HTx waiting list times, we have established a successful multi-center new concept HTx program with excellent mid-term outcome result. Diverse genetic background is evident in the presence of early coronary vascular disease in young donor hearts, requiring extra care in donor screening. This international collaboration has a promising future for new programs in the Middle East.

Funding Acknowledgement

Type of funding source: None

Sensitivity and Specificity Estimation for the Clinical Diagnosis of Highly Pathogenic Avian Influenza in the Egyptian Participatory Disease Surveillance Program

Many developing countries lack sufficient resources to conduct animal disease surveillance. In recent years, participatory epidemiology has been used to increase the cover and decrease the costs of surveillance. However, few diagnostic performance assessments have been carried out on participatory methods. The objective of the present study was to estimate the diagnostic performance of practitioners working for the Community-Based Animal Health and Outreach (CAHO) program, which is a participatory disease surveillance system for the detection of highly pathogenic avian influenza outbreaks in Egypt. CAHO practitioners' diagnostic assessment of inspected birds was compared with real-time reverse-transcriptase polymerase chain reaction (RRT-PCR) test results at the household level. Diagnostic performance was estimated directly from two-by-two tables using RRT-PCR as a reference test in two different scenarios. In the first scenario, only results from chickens were considered. In the second scenario, results for all poultry species were analyzed. Poultry flocks in 916 households located in 717 villages were inspected by CAHO practitioners, who collected 3458 bird samples. In the first scenario, CAHO practitioners presented sensitivity (Se) and specificity (Sp) estimates of 40% (95% confidence interval [CI]: 21%-59%) and 92% (95% CI: 91%-94%), respectively. In the second scenario, diagnostic performance estimates were Se = 47% (95% CI: 29%-65%) and Sp = 88% (95% CI: 86%-90%). A significant difference was observed only between Sp estimates (P < 0.01). Practitioners' diagnostics and RRT-PCR results were in very poor agreement with kappa values of 0.16 and 0.14 for scenarios 1 and 2, respectively. However, the use of a broad case definition, the possible presence of immunity against the virus in replacement birds, and the low prevalence observed during the survey would negatively affect the practitioners' performance.

Imaging of haemophilic arthropathy in growing joints: pitfalls in ultrasound and MRI

The purpose of this review was to summarize the current knowledge on the utilization of magnetic resonance imaging (MRI) and ultrasound (US) for assessing arthropathy in children and adolescents with haemophilia and to recognize the limitations of each imaging modality and pitfalls in the diagnosis of soft tissue and osteochondral abnormalities. Awareness of MRI and US limitations and pitfalls in the assessment of joints in persons with haemophilia is essential for accurate diagnosis and optimal management of haemophilic arthropathy.

Nanoscale subsurface imaging

The ability to probe structures and functional properties of complex systems at the nanoscale, both at their surface and in their volume, has drawn substantial attention in recent years. Besides detecting heterogeneities, cracks and defects below the surface, more advanced explorations of chemical or electrical properties are of great interest. In this article, we review some approaches developed to explore heterogeneities below the surface, including recent progress in the different aspects of metrology in optics, electron microscopy, and scanning probe microscopy. We discuss the principle and mechanisms of image formation associated with each technique, including data acquisition, data analysis and modeling for nanoscale structural and functional imaging. We highlight the advances based on atomic force microscopy (AFM). Our discussion first introduces methods providing structural information of the buried structures, such as position in the volume and geometry. Next we present how functional properties including conductivity, capacitance, and composition can be extracted from the modalities available to date and how they could eventually enable tomography reconstructions of systems such as overlay structures in transistors or living systems. Finally we propose a perspective regarding the outstanding challenges and needs to push the field forward.

Eastern Mediterranean Health Journal (EMHJ): a 20-year overview (1995-2014)

The EMHJ was established in 1995 to provide a peer-reviewed platform for health professionals to share their research with the scientific community. The objective of this review was to examine EMR public health research trends, as reflected by EMHJ publications in 20 years (1995-2014), through secondary data analysis. Published articles were categorized according to EMR strategic priority areas (93%), i.e. health systems strengthening (25%); reproductive and child health (22%); communicable diseases (26%); noncommunicable diseases (25%); emergency preparedness (1.5%). Most papers were original research articles (85 %), published in English (94 %), but just over half (52 %) mentioned obtaining a form of ethical clearance in the text. Six countries had each over 100 papers published during the study period, i.e. Iran, Egypt, Saudi Arabia, Jordan, Iraq, Pakistan. Half EMHJ publications during this period came from 4 countries only (Iran, Egypt, Saudi Arabia, Jordan), which calls for further study to evaluate why other EMR nations are less well represented and how to encourage greater contribution from them over the coming years.

Assessing outcome of diabetic foot ulcers and multidisciplinary foot clinic

Foot problem has been increasingly recognised as a major complication of diabetes, which is associated with a very high mortality and morbidity. Therefore Multi-Disciplinary Foot Clinics (MDFC) have been established all over the world to provide holistic care to these patients. There is a wide variation in the availability of a range of professional skills in the MDFC in different health economy. Therefore the care provided by these MDFC can vary from one place to other. It is very important to measure the outcome of these MDFC so that patients, regulatory authorities and funding bodies can compare them. Traditionally ulcer related outcomes such as the healing rate and the proportion of ulcers healed have been measured in many foot ulcer studies. Similarly the amputation rate is measured to determine the efficacy of diabetic foot management in an area of the health economy. However, these measures do not take into account other important factors such as the functional ability and the quality of life of patients. Therefore patient related outcomes such as the recurrence of ulcer, number of working days lost, the mobility of patient following treatment, survival following first episode of ulceration etc also needs to be measured, which are very important from the patient's perspective. This review looks into various patient related outcomes that can and should be measured to assess the quality of care provided by the MDFC.

Conservative management of diabetic foot osteomyelitis

In this retrospective study, 130 patients with diabetic foot osteomyelitis were analysed. 66.9% of these healed with antibiotic treatment alone and 13.9% needed amputation, of which 1.5% were major. Presence of MRSA was associated with adverse outcome (53.3% vs 21.1%, p=0.04) which was defined as death, amputation and failure to heal.