RESUMEN
BACKGROUND: Autologous breast reconstruction is considered high-risk for deep vein thrombosis (DVT) and thromboembolism (PE). It is therefore recommended to treat patients undergoing these complex and lengthy procedures with DVT chemoprophylaxis. The optimal anticoagulation protocol is still not established. The objective of our study was to evaluate the need of a prolonged anticoagulation in patients undergoing microsurgical breast reconstruction. METHODS: This retrospective cohort study compares our former anticoagulation protocol, which was given during the in-hospital stay, with our new protocol consisting of extended anticoagulation until postoperative day 25, in terms of DVT/PE risk reduction. A logistic regression was used to evaluate the risk of DVT/PE between the two groups, while adjusting for several covariates. RESULTS: Our cohort consisted of 205 patients in the short-term anticoagulation group and 219 in the extended protocol group. Five patients (2.4%) in the short-term anticoagulation group had a DVT/PE event versus 4 patients (1.8%) in the extended protocol group. Logistic regression revealed no difference in the incidence of DVT/PE between the two groups. Similarly, there was no differences in terms of hematoma and infection rate between the two groups. Finally, we found an increased risk of DVT/PE in patients with a Caprini score equal or greater than 8. CONCLUSION: In our experience, short-term anticoagulation during the hospital stay is equivalent to extended thromboprophylaxis in terms of DVT/PE prevention.
Asunto(s)
Anticoagulantes , Mamoplastia , Tromboembolia Venosa , Humanos , Estudios Retrospectivos , Mamoplastia/métodos , Mamoplastia/efectos adversos , Femenino , Persona de Mediana Edad , Tromboembolia Venosa/prevención & control , Tromboembolia Venosa/etiología , Anticoagulantes/administración & dosificación , Anticoagulantes/uso terapéutico , Complicaciones Posoperatorias/prevención & control , Colgajo Perforante/efectos adversos , Adulto , Quimioprevención/métodos , Esquema de Medicación , Trombosis de la Vena/prevención & control , Trombosis de la Vena/etiologíaRESUMEN
INTRODUCTION: Elliptical skin-sparing mastectomy in patients with large or ptotic breasts usually leaves loose mastectomy skin flaps, which need to be either resected or gathered over the DIEP flap. This results in poor control of the breast footprint and under-projected DIEP flaps in a loose mastectomy skin pocket, that tend to slip laterally towards the axilla. We believe that the use of a Wise pattern mastectomy will allow for immediate treatment of these concerns. MATERIALS AND METHODS: A retrospective, uncontrolled analysis of a prospectively-maintained database of patients operated by the five surgeons performing breast reconstructions at the University of Montreal Hospital Centre. Study population was patients with a BMI of over 25 and grade II/III breast ptosis who underwent a Wise pattern mastectomy with immediate DIEP flap reconstruction. Analysis was performed of the complication rates of the technique in the first six months after the surgery. RESULTS: Out of a total of 53 breasts in 44 patients reconstructed with a DIEP flap immediately post Wise pattern mastectomy, we report nine cases of partial mastectomy-flap necrosis not needing revision, five cases of significant mastectomy flap necrosis needing debridement and skin grafting, and two cases of inability to adequately close the Wise pattern intraoperatively after DIEP placement, necessitating retention of DIEP skin in the inferior pole. None of the mastectomy flap complications occurred in irradiated breasts. CONCLUSION: In patients with large or ptotic breasts, the Wise pattern mastectomy before an immediate DIEP reconstruction allows for immediate shaping of the breast by controlling the breast pocket, footprint, and excess skin.
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Neoplasias de la Mama , Mamoplastia , Femenino , Humanos , Mastectomía , Necrosis , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Pompholyx and eczematous reactions are known adverse reactions to intravenous immunoglobulins (IVIg) infusion, but little is known about their clinical characteristics, associated outcomes and management. OBJECTIVE: To describe IVIg-induced eczematous skin reactions. METHODS: We conducted a retrospective study on cases of delayed skin reactions post-IVIg infusion notified to the French Regional Pharmacovigilance Centre from 1985 to 2020. RESULTS: A total of 27 patients were identified, of whom 85% were male. IVIg infusions were given in a neurological indication in 82% of cases. Eczematous skin reactions occurred in two-thirds of cases after the first infusion, with a median time to onset of 11 days. Palmoplantar pompholyx was the most common presentation, being seen in 63% of patients. Other eruptions were erythemato-squamous or maculopapular. Eight patients were classified as severely affected and developed extensive lesions (>50% BSA). One third of the 27 patients required hospitalization. All of the severe eczematous reactions involved males receiving high doses of IVIg for neurological diseases. Biopsies of severe cases revealed a common non-specific eczematous pattern. Relapses were frequent and more severe than the initial reaction. Reintroduction of the same IVIg product consistently resulted in relapse, whereas switching IVIg type produced relapse in only 53% of patients. CONCLUSION: We present the largest retrospective study of delayed skin reactions after IVIg infusions. This side-effect may be severe and have a polymorphic presentation. Relapse occurs frequently but less consistently after IVIg switch.
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Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos , Eccema Dishidrótico , Eccema , Humanos , Masculino , Femenino , Eccema Dishidrótico/inducido químicamente , Eccema Dishidrótico/tratamiento farmacológico , Inmunoglobulinas Intravenosas/efectos adversos , Estudios Retrospectivos , Eccema/patología , RecurrenciaRESUMEN
INTRODUCTION: The distinction between epidermal necrolysis [EN; including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN) and overlap syndrome] and erythema multiforme major (EMM) in children is confusing. We aimed to better describe and compare these entities. MATERIALS AND METHODS: This French retrospective multicentre study included children ≤18 years old referred for EN or EMM between 1 January 2008 and 1 March 2019. According to pictures, children were reclassified into TEN/overlap, SJS or EMM/unclassified (SJS/EMM) groups and compared for epidemiological and clinical data, triggers, histology and follow-up. RESULTS: We included 62 children [43 boys, median age 10 years (range 3-18)]: 16 with TEN/overlap, 11 SJS and 35 EMM. The main aetiologies were drugs in EN and infections (especially Mycoplasma pneumoniae) in EMM (P < 0.001), but 35% of cases remained idiopathic (TEN/overlap, 47%; SJS, 24%; EMM, 34%). The typical target lesions predominated in EMM (P < 0.001), the trunk was more often affected in EN (P < 0.001), and the body surface area involved was more extensive in EN (P < 0.001). Mucosal involvement did not differ between the groups. Two patients with idiopathic TEN died. Histology of EMM and EN showed similar features. The recurrence rate was 42% with EMM, 7% with TEN/overlap and 0 with SJS (P < 0.001). Sequelae occurred in 75% of EN but involved 55% of EMM. CONCLUSION: Clinical features of EN and EMM appeared well demarcated, with few overlapping cases. Idiopathic forms were frequent, especially for EN, meaning that a wide and thorough infectious screening, repeated if needed, is indicated for all paediatric cases of EN/EMM without any trigger drug. We propose a comprehensive panel of investigations which could be a standard work-up in such situation. Sequelae affected both EN and EMM.
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Eritema Multiforme , Síndrome de Stevens-Johnson , Adolescente , Niño , Preescolar , Estudios de Cohortes , Eritema Multiforme/diagnóstico , Eritema Multiforme/epidemiología , Humanos , Masculino , Mycoplasma pneumoniae , Estudios Retrospectivos , Síndrome de Stevens-Johnson/epidemiologíaRESUMEN
Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) can lead to severe ophthalmologic sequelae. The main risk factor is the severity of the initial ocular involvement. There are no recommendations for ocular management during acute phase.We conducted a national audit of current practice in the 11 sites of the French reference center for toxic bullous dermatoses and a review of the literature to establish therapeutic consensus guidelines. We sent a questionnaire on ocular management practices in SJS/ TEN during acute phase to ophthalmologists and dermatologists. The survey focused on ophthalmologist opinion, pseudomembrane removal, topical ocular treatment (i.e. corticosteroids, antibiotics, antiseptics, artificial tear eye drops, vitamin A ointment application), amniotic membrane transplantation, symblepharon ring use, and systemic corticosteroid therapy for ophthalmologic indication. Nine of 11 centers responded. All requested prompt ophthalmologist consultation. The majority performed pseudomembrane removal, used artificial tears, and vitamin A ointment (8/9, 90%). Combined antibiotic-corticosteroid or corticosteroid eye drops were used in 6 centers (67%), antibiotics alone and antiseptics in 3 centers (33%). Symblepharon ring was used in 5 centers (55%) if necessary. Amniotic membrane transplantation was never performed systematically and only according to the clinical course. Systemic corticosteroid therapy was occasionally used (3/9, 33%) and discussed on a case-by-case basis.The literature about ocular management practice in SJS/ TEN during acute phase is relatively poor. The role of specific treatments such as local or systemic corticosteroid therapy is not consensual. The use of preservatives, often present in eye drops and deleterious to the ocular surface, is to be restricted. Early amniotic membrane transplantation seems to be promising.
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Oftalmopatías , Síndrome de Stevens-Johnson , Corticoesteroides/uso terapéutico , Amnios , Oftalmopatías/etiología , Oftalmopatías/terapia , Humanos , Estudios Prospectivos , Estudios Retrospectivos , Síndrome de Stevens-Johnson/complicaciones , Síndrome de Stevens-Johnson/tratamiento farmacológicoRESUMEN
BACKGROUND: The use of hormone therapy (tamoxifen and aromatase inhibitors) has been shown to increase venous thromboembolism. However, while estrogens play a crucial role in wound healing, no study has assessed the impact of tamoxifen or aromatase inhibitors on other postoperative breast reconstruction complications, including infections, necrosis, capsular contracture and seroma. As breast cancer patients undergoing Implants-ADMs breast reconstruction are often receiving hormone therapy, it is unclear whether this increased infection risk is associated with increased infections cases. METHODS: A prospective study was performed on patients undergoing breast reconstruction at an academic institution from 2013 to 2016. Patients were divided by use of hormone therapy at the time of surgery. Complication rates, including infections, necrosis, seroma and hematomas, were compared and analyzed using univariate and logistic regression models. RESULTS: Among a total of 112 patients (183breasts), 58 patients (91 breasts) were receiving hormone therapy and 54 patients (92 breasts) were not. The hormone therapy group had a higher incidence of postoperative mastectomy skin infection (20.7% versus 7.4%; P=0.0447), we didn't find any significant differences in necrosis. CONCLUSIONS: Hormone therapy was associated with a higher incidence of Infections after breast reconstruction with ADMs and implants. The authors propose an individualized approach to the preoperative cessation of tamoxifen or aromatase inhibitors. Immediate breast reconstruction surgery with expander/direct implant and use of acellular dermal matrix: does hormone therapy increases the risk of infection?
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Dermis Acelular , Neoplasias de la Mama , Mamoplastia , Neoplasias de la Mama/cirugía , Femenino , Hormonas , Humanos , Mastectomía , Estudios Prospectivos , Estudios RetrospectivosAsunto(s)
Dermacentor , Dermatosis del Cuero Cabelludo/diagnóstico , Rickettsiosis Exantemáticas/diagnóstico , Infestaciones por Garrapatas/diagnóstico , Animales , Dermacentor/fisiología , Femenino , Humanos , Persona de Mediana Edad , Cuello/parasitología , Cuello/patología , Cuero Cabelludo/parasitología , Cuero Cabelludo/patología , Dermatosis del Cuero Cabelludo/etiología , Rickettsiosis Exantemáticas/patología , Síndrome , Infestaciones por Garrapatas/complicacionesAsunto(s)
Antituberculosos/efectos adversos , Erupciones por Medicamentos/etiología , Hipersensibilidad a las Drogas/etiología , Exantema/inducido químicamente , Hipersensibilidad Tardía/inducido químicamente , Algoritmos , Antituberculosos/uso terapéutico , Erupciones por Medicamentos/diagnóstico , Erupciones por Medicamentos/terapia , Hipersensibilidad a las Drogas/diagnóstico , Hipersensibilidad a las Drogas/terapia , Exantema/diagnóstico , Exantema/terapia , Humanos , Hipersensibilidad Tardía/diagnóstico , Hipersensibilidad Tardía/terapia , Guías de Práctica Clínica como AsuntoAsunto(s)
Antivirales/efectos adversos , Síndrome de Hipersensibilidad a Medicamentos/etiología , Valaciclovir/efectos adversos , Anciano , Clobetasol/uso terapéutico , Síndrome de Hipersensibilidad a Medicamentos/diagnóstico , Síndrome de Hipersensibilidad a Medicamentos/tratamiento farmacológico , Femenino , Infecciones por Herpesviridae/tratamiento farmacológico , Infecciones por Herpesviridae/prevención & control , Humanos , Masculino , Persona de Mediana Edad , Pruebas del ParcheAsunto(s)
Antibacterianos/uso terapéutico , Antivirales/uso terapéutico , Eritema Multiforme/epidemiología , Glucocorticoides/uso terapéutico , Adulto , Factores de Edad , Eritema Multiforme/diagnóstico , Eritema Multiforme/tratamiento farmacológico , Eritema Multiforme/microbiología , Femenino , Francia/epidemiología , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
PURPOSE: The dermatological toxicity of cancer treatments is frequent and sometimes debilitating. Its reference classification, the NCI-CTCAE (National Cancer Institute-Common Terminology Criteria for Adverse Events), is sometimes difficult to use and does not include yet the newest toxicities. Our objective was to create a guide, TOXICAN, based on the CTCAE, which is easy to use in everyday practice and which facilitates the recognition and grading of these dermatological toxicities. METHODS: This guide was developed by a working group ("GESTIM") comprising oncodermatologists, allergists, pathologists, and researchers from Nantes University Hospital. It was based on the dermatological toxicities found in the CTCAE and adapted to daily practice. These toxicities were grouped into categories and associated with photographs of typical cases to aid recognition. A simplified grading scale derived from the CTCAE was also created. This booklet was validated by means of user evaluation, and then the Delphi consensus method. RESULTS: We selected 32 dermatological toxicities, including 12 created by our group, sorted into 7 categories: skin rash, dry skin/pruritus, hyperkeratotic papules, palmoplantar changes, hair and nail changes, mucosal changes, and others. Our simplified grading scale only differed from the CTCAE for one item, urticaria. Three items were modified after evaluation by the user group and 11 after application of the Delphi method. CONCLUSION: The objective of our practical guide is to facilitate the use of the CTCAE for recognizing and grading dermatological toxicity of cancer treatments in order to provide optimal guidance for therapeutic adaptations. Its impact on clinical practice remains to be evaluated.
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Antineoplásicos/efectos adversos , Exantema/inducido químicamente , Neoplasias/complicaciones , Piel/efectos de los fármacos , Femenino , Humanos , Clasificación del Tumor , Neoplasias/patología , Piel/patologíaRESUMEN
BACKGROUND: Staged expander-to-implant breast reconstruction is plagued by a high prevalence of complications. We have employed an alternative approach of using the infra-mammary crease (IMF) for expander-to-implant exchange. The IMF approach was thought to utilize healthier tissues, which are believed to be less affected by the process of tissue expansion, and reside distant from the field of the radiotherapy boost. METHODS: A retrospective chart review was performed on all patients undergoing a staged implant-based breast reconstruction from 2009 to 2014. Patients were divided into those that received an IMF vs. a mastectomy scar (MS) approach in the second stage of expander-to-implant exchange. Patient characteristics and postoperative complications were extracted. RESULTS: A total of 75 patients undergoing 96-staged reconstructions were included (70 cases MS vs. 26 cases IMF). Patient demographics and implant characteristics were similar between groups. There were no significant differences in overall complications between the groups (11.4% MS vs. 7.7% IMF, P=0.72). All cases of implant exposure occurred in the MS group and had a history of radiation. However, there was no statistical difference in implant exposure between groups (4.3% MS vs. 0% IMF, P=0.56) or in the irradiated patients subgroup (20% MS vs. 0% IMF, P=0.25). CONCLUSIONS: In conclusion, the IMF approach for the second stage of expander-to-implant exchange is an alternative technique with a similar prevalence of complications as the traditional mastectomy scar approach. This technique may prove useful in reducing postoperative incisional dehiscence and implant exposure, especially in the context of radiotherapy.
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Implantes de Mama , Neoplasias de la Mama/cirugía , Mamoplastia/métodos , Mastectomía , Complicaciones Posoperatorias/prevención & control , Dispositivos de Expansión Tisular , Neoplasias de la Mama/radioterapia , Cicatriz/cirugía , Terapia Combinada , Femenino , Humanos , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Reoperación , Estudios RetrospectivosRESUMEN
BACKGROUND: Since 2007 in France, human papilloma virus (HPV) vaccination has been licensed for use as a vaccine against HPV 6, 11, 16 and 18. The impact on the epidemiology of external genital warts (EGWs) in a large population remains unclear. OBJECTIVES: To determine epidemiologic and clinical features of patients presenting EGWs in France in the era of HPV vaccination. PATIENTS AND METHODS: In this prospective, observational study, we analyzed clinical features and treatments between January 1st, 2012 and March 31, 2012 for patients consulting for EGWs at 15 STI clinics throughout France. RESULTS: A total of 372 men and 111 women were included; mean age 31.2 years. The women were younger than the men (31.7 and 28.9 years respectively P<0.05). Among the patients, 416 (85.7%) were heterosexual, 13 bisexual and 54 (11.2%) homosexual, including one female. Males reported more sexual partners in the last 12 months (more than 3 partners in 32.6% versus 11.9%, P<0.01). Among the men, 230 had involvement of the penis alone and 46 had involvement of the anus alone. Seventy-six patients had EGWs of the anus, and of these 26 were MSM. In females, 76 had an infection of the vulva alone and 22 co-infection of the vulva and anus. MSM and females were at higher risk than heterosexual males for anal involvement (P<0.0001 and P=0.004, respectively). Three women had been vaccinated: two with Gardasil® and one with Cervarix®. Cryotherapy was the preferred treatment. CONCLUSION: With the advent of HPV vaccination, a global strategy for the prevention and treatment of EGW should be implemented.
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Enfermedades del Ano/epidemiología , Condiloma Acuminado/epidemiología , Enfermedades de los Genitales Femeninos/epidemiología , Enfermedades de los Genitales Masculinos/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Enfermedades del Ano/terapia , Condiloma Acuminado/terapia , Crioterapia , Femenino , Francia/epidemiología , Enfermedades de los Genitales Femeninos/terapia , Enfermedades de los Genitales Masculinos/terapia , Vacuna Tetravalente Recombinante contra el Virus del Papiloma Humano Tipos 6, 11 , 16, 18 , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Parejas Sexuales , Sexualidad/estadística & datos numéricos , Adulto JovenRESUMEN
Atopic dermatitis (AD) of the adult is a common skin disease. Its prevalence has greatly increased during the past decades. AD is commonly associated with other atopic disorders. Its impact on quality of life is often underestimated. Various immunopathologic mechanisms are involved in AD: innate epidermal barrier dysfunction due to filaggrin gene mutations, innate and adaptative abnormalities of the immune system (an initial Th2 phase precedes a chronic Th1 phase), intestinal and cutaneous microbiomes dysbiosis, and environmental factors. Diagnosis of AD is clinical and there is no predictive biomarker of future severity. The main differential diagnoses are: scabies, psoriasis, cutaneous adverse reaction, cutaneous T cell lymphoma, primary immunodeficiency, and Netherton's syndrome. Therapeutic management is challenging and should integrate a therapeutic education program. Topical corticosteroids are the first line treatment, including a preliminary assessment of possible topical corticosteroids phobia. Systemic treatments are recommended in severe, chronic and resistant AD, after careful evaluation in a reference centre. Dupilumab, an IL4/IL13 inhibitor, might be the first effective targeted therapy in AD, whereas therapies that specifically target the mechanisms of pruritus represent an exciting perspective.