Establishing local diagnostic reference levels for mini C-arm use in upper limb surgery - A step towards national audit.

AIMS: Under the Ionising Radiation Medical Exposure Regulations, hospitals using fluoroscopy and image intensifiers should monitor doses from exposures using ionising radiation. There is a need for national diagnostic reference levels to advise Orthopaedic and Plastic surgeons on safe screening times and radiation doses for patients having upper limb surgical procedures. METHODS: Retrospective study of all patients who underwent upper limb surgical procedures requiring intra-operative mini C-arm image intensifier use at our hospital between 2013 and 2019. This included results from three machines in different rooms. Procedures were classified as closed and open procedures. RESULTS: Information on a total of 2910 procedures over 6 years (June 2013 to June 2019) were obtained. 133 procedures with incomplete data and 4 cases of lower extremities were excluded. 1719 closed procedures had a median dose area product of 0.48 cGycm2 and median screening time of 7 s, compared to 1054 open procedures, with a median dose area product of 1.88 cGycm2 and median screening time of 28 s. National diagnostic reference levels are set at the third quartile and indicate the difference between good and poor practice. For diagnostic reference levels, we suggest a dose area product of 0.82 cGycm2 and a screening time of 11 s for closed procedures and a dose area product of 3.07 cGycm2 and screening time of 40 s for open procedures. Public Health England state that national diagnostic reference levels should be derived from multiple patients, radiology rooms and hospitals. Our data meets the first two criteria and is an initial step in establishing national diagnostic reference levels for upper limb mini C-arm use. CONCLUSIONS: This large audit reports results, which, with further work across multiple hospital sites, should lead to establishing national diagnostic reference levels for mini C-arm fluoroscopy for upper limb Orthopaedic procedures.

Female-to-Male Gender-Affirming Chest Reconstruction Surgery.

There is an increased demand for gender affirmation surgery. Chest contouring, or "top" surgery, is especially important in the female-to-male (FtM) transgender population. This Continuing Medical Education (CME) article critically appraises the available literature on top surgery to allow plastic surgeons to understand current practices and determine the best surgical technique using a decision algorithm and the patient's preoperative anatomy and characteristics. Because a single best surgical approach does not exist due to significant variance in preoperative patient anatomy, and in order to provide a useful framework for decision making, surgical approaches described are categorized as: approach 1-remote incision procedures without skin excision; approach 2-procedures with periareolar skin excision; and approach 3-mastectomy procedures with skin excision other than periareolar skin excision. Decision algorithms that help determine the most suitable surgical technique for individual patients are reviewed. Data on complication rates and patient satisfaction will improve informed consent discussions and create realistic patient expectations.

Comparison of long-term outcomes of breast conservation and reconstruction after mastectomy using BREAST-Q.

AIMS: Patients' post-operative wellbeing determines the impact and effectiveness of breast reshaping and reconstruction procedures. The aim of the study was to evaluate and compare four different types of breast reconstruction: bilateral therapeutic mammaplasty, DIEP flap, ELD with immediate lipomodelling and implant-based reconstruction using BREAST-Q. METHODS: Patients who underwent breast reconstruction by one of the above-mentioned methods were identified from a retrospective register and sent BREAST-Q questionnaires. Univariate and multivariate analysis of BREAST-Q scores and clinical characteristics were performed for identifying trends between and within groups. RESULTS: A total of 240 patients were identified with a response rate of 57%. Patients receiving implants were statistically less satisfied with breast reconstruction (mean 57%) and tended to be younger with lower BMI in comparison to other groups. There were no statistical differences in psychosocial wellbeing or patient experience between groups. Despite the fact that clinically these groups were heterogeneous, satisfaction with breast was similar in the remaining three autologous groups (range 70-75%). Detailed analysis and interpretation of quality-of-life scores, clinical differences and trends identified in the multivariate analysis along with nuances between surgical techniques used in our unit for breast reshaping and reconstruction, have been performed. CONCLUSIONS: The most important goal of breast reconstruction is to restore patients' quality of life and satisfaction with breast. Identifying factors which can potentially predict poor outcomes will improve the informed consent process and patient selection.

A Novel Immunoassay for Malondialdehyde-Conjugated Low-Density Lipoprotein Measures Dynamic Changes in the Blood of Patients Undergoing Coronary Artery Bypass Graft Surgery.

Oxidized low-density lipoproteins play an important role in tissue pathology. In this study, we report a sensitive novel enzyme-linked immunosorbent assay for the detection of malondialdehyde-modified low-density lipoprotein (MDA-LDL), a key component of oxidized LDL. The assay is capable of measuring a variable presence of MDA-LDL within human plasma and serum. We demonstrate the robust nature of the assay on samples stored for over 20 months, as well as high inter-operator reproducibility (r = 0.74, p < 0.0001). The assay was capable of detecting dynamic changes in patient blood samples after coronary artery bypass graft surgery, indicating synthesis or release of MDA-LDL with the oxidative stress of surgery, followed by homeostatic clearance. This robust, sensitive and specific assay for circulating MDA-LDL will serve as a valuable translational tool for the improved detection of oxidative forms of LDL in response to a range of physiological or pathological stimuli, with potential clinical applicability.