Superior Pedicle Breast Reduction: Multivariate Analysis of Complication Risk Factors and Building a Predictive Score in 1306 Patients

BACKGROUND

Breast reduction surgery for hypertrophy is one of the most commonly performed procedures in plastic surgery. This surgery exposes patients to complications that are well-documented in the literature. The objective of this study is to identify risk factors to establish an estimate of the risk of developing complications. The authors propose the first predictive score of postoperative complications, including continuous preoperative variables such as body mass index (BMI) and suprasternal notch-to-nipple distance (SSN:N).

METHODS

An analytic observational retrospective cohort study was conducted including 1306 patients who underwent superior pedicle reduction mammaplasty at the Rennes University Hospital (France) between January 1, 2011, and December 31, 2016. The primary endpoint was to study the association between known preoperative risk factors and occurrence of any complications using multivariable logistic regression to identify independent risk factors. A secondary endpoint was to establish a score to estimate a probability of occurrence of complications.

RESULTS

A total of 1306 patients were analyzed. Multivariable logistic regression showed three independent risk factors: active smoking [OR, 6.10 (95% CI: 4.23, 8.78); P < 0.0001], BMI [OR, 1.16 (95% CI: 1.11, 1.22); P < 0.0001], and SSN:N [OR, 1.14 (95% CI: 1.08, 1.21); P < 0.0001]. The Rennes Plastic Surgery Score estimating the occurrence of postoperative complications was determined, integrating regression coefficients of each risk factor.

CONCLUSIONS

Active smoking, BMI, and SSN:N distance are independent preoperative risk factors for the occurrence of breast reduction complications. The Rennes Plastic Surgery Score including the continuous values of BMI and SSN:N allows us to provide our patients with a reliable estimation of the risk of occurrence of these complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

[Translation into French and republication of: "Anticoagulant treatment of cancer-associated thromboembolism"]

Venous thromboembolism (VTE) is a frequent and potentially fatal complication in patients with cancer. During the initial period after the thromboembolic event, a patient receiving anticoagulant treatment is exposed both to a risk of VTE recurrence and also to an elevated bleeding risk conferred by the treatment. For this reason, the choice of anticoagulant is critical. The choice should take into account patient-related factors (such as functional status, age, body mass index, platelet count and renal function), VTE-related factors (such as severity or site), cancer-related factors (such as activity and progression) and treatment related factors (such as drug-drug interactions), which all potentially influence bleeding risk, and patient preference. These should be evaluated carefully for each patient during a multidisciplinary team meeting. For most patients, apixaban or a low molecular-weight heparin is the most appropriate initial choice for anticoagulant treatment. Such treatment should be offered to all patients with active cancer for at least 6months. The patient and treatment should be re-evaluated regularly, and anticoagulant treatment changed when necessary. Continued anticoagulant treatment beyond 6months is justified if the cancer remains active or if the patient experienced recurrence of VTE in the first 6months. In other cases, the interest of continued anticoagulant treatment may be considered on an individual patient basis in collaboration with oncologists.

Towards Optimizing Sub-Normothermic Machine Perfusion in Fasciocutaneous Flaps: A Large Animal Study

Machine perfusion has developed rapidly since its first use in solid organ transplantation. Likewise, reconstructive surgery has kept pace, and ex vivo perfusion appears as a new trend in vascularized composite allotransplants preservation. In autologous reconstruction, fasciocutaneous flaps are now the gold standard due to their low morbidity (muscle sparing) and favorable functional and cosmetic results. However, failures still occasionally arise due to difficulties encountered with the vessels during free flap transfer. The development of machine perfusion procedures would make it possible to temporarily substitute or even avoid microsurgical anastomoses in certain complex cases. We performed oxygenated acellular sub-normothermic perfusions of fasciocutaneous flaps for 24 and 48 h in a porcine model and compared continuous and intermittent perfusion regimens. The monitored metrics included vascular resistance, edema, arteriovenous oxygen gas differentials, and metabolic parameters. A final histological assessment was performed. Porcine flaps which underwent successful oxygenated perfusion showed minimal or no signs of cell necrosis at the end of the perfusion. Intermittent perfusion allowed overall better results to be obtained at 24 h and extended perfusion duration. This work provides a strong foundation for further research and could lead to new and reliable reconstructive techniques.

Modified nanofat grafting: Stromal vascular fraction simple and efficient mechanical isolation technique and perspectives in clinical recellularization applications

Background: Nanofat grafting (NG) is a simple and cost-effective method of lipoaspirates with inter-syringe passages, to produce stromal vascular fraction (SVF) and isolate adipose-derived stem cells (ASCs). This represents a tremendous interest in the future clinical needs of tissue engineering. In this study, we optimized the NG technique to increase the yield of ASC extractions.

Methods: We analyzed three groups of SVF obtained by 20, 30, and 40 inter-syringe passages. The control group was an SVF obtained by enzymatic digestion with Celase. We studied their cell composition by flow cytometry, observed their architecture by confocal microscopy, and observed immunomodulatory properties of the ASCs from each of the SVFs by measuring inflammatory markers of macrophages obtained by an ASC monocyte co-culture.

Results: We have established the first cell mapping of the stromal vascular fraction of adipose tissue. The results showed that SVF obtained by 20 inter-syringe passages contains more statistically significant total cells, more cells expressing the ASC phenotype, more endothelial cells, and produces more CFU-F than the SVF obtained by 30 and 40 passages and by enzymatic digestion. Confocal microscopy showed the presence of residual adipocytes in SVF obtained by inter-syringe passages but not by enzymatic digestion. The functional study indicates an orientation toward a more anti-inflammatory profile and homogenization of their immunomodulatory properties.

Conclusion: This study places mechanically dissociated SVF in the center of approaches to easily extract ASCs and a wide variety and number of other progenitor cells, immediately available in a clinical setting to provide both the amount and quality of cells required for decellularized tissues.

Gustilo IIIA Open Bimalleolar Fracture Dislocation of Ankle with Ipsilateral Achilles Tendon Rupture: A Case Report and Review of Literature

CASE

Although rare, a medial malleolus fracture plus ipsilateral Achilles tendon rupture has been described in previous case reports. We present a unique case of an open bimalleolar fracture dislocation with ipsilateral Achilles tendon rupture after a motorcycle crash. His Achilles injury was diagnosed intraoperatively during external fixator placement. He presented in a delayed fashion to our institution, where he underwent open reduction internal fixation and Achilles tendon reconstruction.

CONCLUSION

Although most commonly described with isolated medial malleolus fractures, Achilles tendon injuries can also be associated with bimalleolar ankle fractures. These associated injuries are frequently missed.

[Plastic surgery and fighting: Our experience during Nagorno-Karabakh war in 2020]

INTRODUCTION

This work relates the experience of three French surgical missions in the care of the war wounded during the armed conflict in Nagorno Karabakh which took place from September 27 to November 10, 2020.

MATERIALS AND METHODS

Three surgical missions were carried out in Armenia between October 2020 and January 2021. Surgeons intervened in different hospitals, at different times of the conflict and on various war wounds.

RESULTS

The presence of a plastic surgeon proved to be essential in the care of war wounded, especially in delayed emergency and secondary care. The ortho-plastic treatment offered during these missions has proven to be effective in the reconstruction of limbs. These missions made it possible to introduce the induced membrane technique of Masquelet AC in Armenia. During our visit to the Yerevan burn center, we mentioned the very probable use of white phosphorus as an etiology in several of the cases analyzed.

CONCLUSION

We relate the particular experience of civilian surgeons in the context of a modern armed conflict. The presence of a plastic surgeon proved to be indispensable in the care of war wounded and especially in their secondary reconstructions.

Hydro-climatic changes of wetlandscapes across the world

Assessments of ecosystem service and function losses of wetlandscapes (i.e., wetlands and their hydrological catchments) suffer from knowledge gaps regarding impacts of ongoing hydro-climatic change. This study investigates hydro-climatic changes during 1976-2015 in 25 wetlandscapes distributed across the world's tropical, arid, temperate and cold climate zones. Results show that the wetlandscapes were subject to precipitation (P) and temperature (T) changes consistent with mean changes over the world's land area. However, arid and cold wetlandscapes experienced higher T increases than their respective climate zone. Also, average P decreased in arid and cold wetlandscapes, contrarily to P of arid and cold climate zones, suggesting that these wetlandscapes are located in regions of elevated climate pressures. For most wetlandscapes with available runoff (R) data, the decreases were larger in R than in P, which was attributed to aggravation of climate change impacts by enhanced evapotranspiration losses, e.g. caused by land-use changes.

The perception of plastic surgery by physiotherapists: a French national descriptive study

Background

Plastic surgery is a transversal discipline that many people misunderstand, including general practitioners, medical students, paramedics and the public. Plastic surgeons often collaborate with physiotherapists for post-acute care and rehabilitation. They ensure optimal post-operative recovery of the patient. Herein, the authors assessed the medical knowledge and perceptions of plastic surgery by physiotherapists working outside health centers and explored their attitudes towards classic reconstructive surgery scenarios.

Methods

To assess physiotherapists' medical knowledge and perceptions of plastic surgery, the authors conducted an online questionnaire survey. A total of 1,262 physiotherapists responded.

Results

The physiotherapists confirmed the suspected lack of knowledge regarding the plastic surgery field. Although they were generally aware that plastic surgeons perform cosmetic procedures and treat burns, they were largely unaware that plastic surgeons perform hand surgeries and microsurgical operations. More than 70% of them stated that they did not have the necessary knowledge to properly manage patients in this specialty. This lack of knowledge can sometimes have a negative impact on patients' recovery, particularly for fear of making a mistake.

Conclusions

Physiotherapists, outside the hospital, have an incomplete conception of plastic surgery. They would need a specific plastic surgery training in order to manage these patients in an optimal way.

Effectiveness of Therapeutic Patient Education Interventions for Older Adults with Cancer: A Systematic Review

The incidence of cancer increases with age and demographics shows that the population of western countries is dramatically ageing. The new discipline of Geriatric Oncology is emerging aiming at providing tailored and patient-centred support to older adults with cancer. With the development of oral cancer therapy and outpatient treatments, Therapeutic Patient Education (TPE), aiming at enabling the patient and their relatives to cope with the disease in partnership with health professionals, appears to be an interesting and useful tool. The purpose of this paper is to search for evidence of the effectiveness of educational interventions for patients in older adults with cancer. The first screening found 2,617 articles, of which 150 were eligible for review. Among them, fourteen finally met the inclusion criteria: experimental and quasi-experimental studies enrolling older adults (over 65 years old), suffering from cancer and receiving an educational intervention. The types of educational intervention were diverse in these studies (support by phone and web base material). The results appear to be positive on anxiety, depression and psychological distress, patient knowledge and pain. However, data currently available on the effectiveness of a TPE program in Geriatric Oncology is lacking. Further studies are needed to assess the effectiveness of TPE programs adapted to the specific circumstances of the older adult.

Extravasation of calcium solution in the child: Value of negative-pressure wound therapy

The extravasation of a calcium solution into soft tissue constitutes a medical emergency, and a lack of adequate management can lead to significant functional and cosmetic sequelae. Here, we report on the management of and long-term outcome in two children who experienced calcium infusion leakage. We also describe the emergency procedures used in cases of extravasation and discuss the role of negative pressure wound therapy as an appropriate adjunct to conventional techniques for dealing with serious extravasation-related injuries.

[The role of electromagnetic navigation bronchoscopy in the diagnosis of peripheral pulmonary lesions]

INTRODUCTION

Electromagnetic navigation bronchoscopy (ENB) is a recent, minimally invasive procedure utilized to guide endoscopic diagnostic tools to peripheral pulmonary nodules. The place of this technology among other diagnostic procedures remains uncertain.

METHOD

We analyzed our 30 first months of ENB used in the diagnosis of 106 lesions in 101 patients, from June 2016 to December 2018. Follow-up and final diagnosis was completed for 95 lesions (90%).

RESULTS

ENB was performed for 3.5% of all patients referred for abnormal findings on pulmonary imaging, and represented 19% of second line procedures for peripheral pulmonary lesions. Procedures were performed under general anesthesia, with a mean duration of 35min. The sensitivity of ENB was 64% (95%CI: 52-74%) for lesions with a mean diameter of 21mm, with an improvement over time (sensitivity 69% in the last 18 months). The presence of a bronchus within the lesion (bronchus sign) was associated with an increased sensitivity of 74%. Pneumothorax occurred in 5 patients (5%) of which 4 required drainage. There was no hemoptysis, and no death related to the procedure.

CONCLUSION

ENB is a minimally invasive procedure reaching acceptable sensitivity in the most difficult patients. ENB can be recommended for the diagnosis of peripheral pulmonary nodules when no other procedure is successful or possible. Its use as a first choice procedure is, for the moment, limited by the cost, but must be weighed against that of non-diagnostic procedures, and the cost of complications of trans-thoracic lung biopsies.

A New Method to Assess the Difficulty of a Medical Diagnosis: Application to Electrocardiographic Interpretation

A new method to assess the relative difficulty of a medical diagnosis and the efficacy of a diagnostic procedure is described. The cases within a population are classified by N independent interpreters, i. e., medical experts or computer programs. The percentages of correctly diagnosed cases by N (unanimity), N-1, N-2, ..., zero interpreters, respectively, are calculated. These Nl + 1 percentages are presented in a histogram. A cumulative plot is derived from the “unanimity” value. The ratio “unanimity value”/“zero value” is proposed as an index of diagnostic performance. An application to the CSE database is presented which is composed of 1,220 electrocardiographic tracings interpreted by 13 cardiologists and 15 computer programs. The cumulative plots, the performance index and Log (index) values, established for eight different diagnostic statements, clearly show the relative degree of diagnostic difficulty for each of them and the particular efficacy of each approach, i. e., electrocardiography versus vectorcardiography, and computerized versus human interpretation.

Assessing clinical probability of pulmonary embolism: prospective validation of the simplified Geneva score

Essentials The simplified Geneva score allows easier pretest probability assessment of pulmonary embolism (PE). We prospectively validated this score in the ADJUST-PE management outcome study. The study shows that it is safe to manage patients with suspected PE according to this score. The simplified Geneva score is now ready for use in routine clinical practice.

SUMMARY

Background Pretest probability assessment by a clinical prediction rule (CPR) is an important step in the management of patients with suspected pulmonary embolism (PE). A limitation to the use of CPRs is that their constitutive variables and corresponding number of points are difficult to memorize. A simplified version of the Geneva score (i.e. attributing one point to each variable) has been proposed but never been prospectively validated. Aims Prospective validation of the simplified Geneva score (SGS) and comparison with the previous version of the Geneva score (GS). Methods In the ADJUST-PE study, which had the primary aim of validating the age-adjusted D-dimer cut-off, the SGS was prospectively used to determine the pretest probability in a subsample of 1621 study patients. Results Overall, PE was confirmed in 294 (18.1%) patients. Using the SGS, 608 (37.5%), 980 (60.5%) and 33 (2%) were classified as having a low, intermediate and high clinical probability. Corresponding prevalences of PE were 9.7%, 22.4% and 45.5%; 490 (30.1%) patients with low or intermediate probability had a D-dimer level below 500 μg L-1 and 653 (41.1%) had a negative D-dimer test according to the age-adjusted cut-off. Using the GS, the figures were 491(30.9%) and 650 (40.9%). None of the patients considered as not having PE based on a low or intermediate SGS and negative D-dimer had a recurrent thromboembolic event during the 3-month follow-up. Conclusions The use of SGS has similar efficiency and safety to the GS in excluding PE in association with the D-dimer test.

Reproducibility of clinical events adjudications in a trial of venous thromboembolism prevention

Essentials The reproducibility of Clinical Events Committee (CEC) adjudications is almost unexplored. A random selection of events from a venous thromboembolism trial was blindly re-adjudicated. 'Unexplained sudden deaths' (possible fatal embolism) explained most discordant adjudications. A precise definition for CEC adjudication of this type of events is needed and proposed.

SUMMARY

Background When clinical trials use clinical endpoints, establishing independent Clinical Events Committees (CECs) is recommended to homogenize the interpretation of investigators' data. However, the reproducibility of CEC adjudications is almost unexplored. Objectives To assess the reproducibility of CEC adjudications in a trial of venous thromboembolism (VTE) prevention. Methods The PREVENU trial, a multicenter trial of VTE prevention, included 15 351 hospitalized medical patients. The primary endpoint was the composite of symptomatic VTE, major bleeding or unexplained sudden death (interpreted as possible fatal pulmonary embolism [PE]) at 3 months. The CEC comprised a chairman and four pairs of adjudicators. Of 2970 adjudicated clinical events, a random selection of 179 events (121 deaths, 40 bleeding events, and 18 VTE events) was blindly resubmitted to the CEC. Kappa values and their 95% confidence intervals (CIs) were calculated to measure adjudication agreement. Results Overall, 18 of 179 (10.1%, 95% CI 6.5-15.3%) adjudications proved discordant. Agreement for the PREVENU composite primary endpoint was good (kappa = 0.73, 95% CI 0.61-0.85). When analyzed separately, agreements were very good for non-fatal VTE events (1, 95% CI not applicable), moderate for all (fatal and non-fatal) VTE events (0.58, 95% CI 0.34-0.82), good for fatal and non-fatal major bleeding events (0.71, 95% CI 0.55-0.88), and moderate for all fatal events (0.60, 95% CI 0.40-0.81). Unexplained sudden death interpreted as possible fatal PE was responsible for nine of 18 (50%) discordant adjudications. Conclusion The reproducibility of CEC adjudications was good or very good for non-fatal VTE and bleeding events, but insufficient for VTE-related deaths, for which more precise and widely accepted definitions are needed.

Are There Factors Predictive of Postoperative Complications in Circumferential Contouring of the Lower Trunk? A Meta-Analysis

BACKGROUND

The massive weight loss patient may require a circumferential contouring of the lower trunk.

OBJECTIVES

To summarize the complication rates and explore the possibility of predictive risk factors for complications.

METHODS

We performed a systematic review using the PubMed and Cochrane databases to identify published articles on the topic. Random effects meta-analyses and meta-regression were conducted to synthesize the data gathered.

RESULTS

The analysis included 28 studies and 1380 patients. All but one were retrospective cohorts or case studies. Circumferential contouring of the lower trunk resulted in 37% [95%-CI 30%; 44%] overall complications; 17% [95%-CI 12%; 24%] wound dehiscences; 4% [95%-CI 3%; 5%] skin necrosis; 5% [95%-CI 3%; 9%] infections; 3% [95%-CI 2%; 4%] hematomas; 13% [95%-CI 9%; 18%] seromas; 12% [95%-CI 7%; 21%] scar irregularities; 3% [95%-CI 2%; 5%] thromboembolism; and 5% [95%-CI 3%; 8%] revisions for complications. Lower body lift-related techniques were associated with a higher rate of overall complications than belt lipectomy-related techniques (P = .002). No difference in complication rate was shown when performing a gluteal augmentation with flap. Due to insufficient data reported in the studies, risk factors for postoperative complications could not be assessed.

CONCLUSIONS

The whole literature provides very low reliable information. Confusion factors could not be ruled out to explain the increased complications rate for the lower body lift compared to the belt lipectomy. This finding needs to be confirmed in randomized trials. Collaborative efforts must be made to improve the evidence level of our practices and to serve patients in an optimal way.

LEVEL OF EVIDENCE

3 Therapeutic.

[Endobronchial ultrasonography (EBUS) for the internist]

Endobronchial ultrasonography (EBUS) is a recent mini-invasive technique allowing transbronchial needle aspiration (TBNA) of mediastinal lymph nodes as well as peribronchial lesions. EBUS was initially developed for lung cancer mediastinal staging. Over the years, indications for EBUS have been progressively extended to the scope of inflammatory disorders, mediastinal lymphomas, and infectious diseases. Particularly in immunosuppressed patients, including HIV-infected patients, EBUS allows the diagnosis of several diseases that involve the mediastinum, avoiding invasive surgical explorations such as mediastinoscopy or thoracoscopy. This review aims at discussing the technical aspects, and specifies indications, results, and limits of EBUS for the internist.

[Care pathway for high urinary tract infection: an update in an emergency department of a French military hospital]

Objectives Assessing the impact of professional practices on a patient's course is an interesting way to optimize health care pathway. The aim of our study is to update and evaluate the compliance to the recommendations of the Societe de Pathologie Infectieuse de Langue Francaise with regards to professional practices and the route of patients admitted to the emergency department of a French military hospital for high urinary tract infection. Patients and methods A retrospective study was carried out on patients admitted to the emergency department and treated for high urinary tract infection from January 1st, 2015 to April 30th, 2015. Clinical and administrative data, medical exams, and antibiotic prescriptions were extracted from computerized patient medical files and from emergency medical files. Results Out of 91 medical cares, 57% were compliant with the recommendations. For 60% of the patients, blood cultures were not argued and in 70% of cases, imaging wasn't justified. Antibiotic prescriptions were not compliant in 31% of cases, mostly due to long prescription durations. Two third of patients received outpatient care. All hospitalizations were argued. Conclusions Drawing up a caring protocol, regularly raising awareness to the good use of antibiotics, as well as reinforcing a cross disciplinary approach will allow optimizing health care pathways for patients coming to the emergency department with high urinary tract infection.

[Malignant infantile osteopetrosis: Case report of a 5-month-old boy]

Malignant infantile osteopetrosis is a rare congenital disease characterized by a dysfunction of osteoclasts followed by an abnormal bone densification. We report the case of a 5-month-old infant in whom this disease was suspected because of the clinical (hepatosplenomegaly, gingival hypertrophy), hematological (pancytopenia and hypocalcemia), and radiological criteria (abnormal bone density, periosteal reaction). The genetic investigation confirmed the diagnosis. Compound heterozygous mutations in the CLCN7 gene were identified, including an as yet undescribed mutation. The second mutation had already been described as being responsible for severe and irreversible neurological damage in patients with osteopetrosis. Since this patient presented severely delayed development, he was not eligible for bone marrow transplantation.