Complications in Prolonged Intraoperative Ischemia Time in Free Flap Breast Reconstruction: A Systematic Review and Meta-Analysis.

BACKGROUND: Autologous tissue transfer is an effective option for breast reconstruction post-mastectomy, with microsurgical techniques continually evolving. However, a comprehensive analysis of the relationship between prolonged ischemia time during free flap-based breast reconstruction and increased postoperative complications is still lacking. METHODS: A systematic review and meta-analysis were conducted following PRISMA guidelines. Methodological quality was evaluated using the MINORS criteria. Studies meeting inclusion criteria were analyzed for total complications, complete and partial flap loss, and secondary outcomes. Data heterogeneity and risk ratios were assessed. RESULTS: Seventeen studies encompassing 5636 patients and 6884 free flaps were included. The mean age of patients was 49.43 years (95% CI: 48.27-50.60), with a mean BMI of 26.09 (95% CI: 21.97-30.21), and an average post-harvesting free flap ischemia time of 70.35 min (95% CI: 56.71-83.98). These analyses revealed a heightened risk of total complications (RR: 1.99, 95% CI: 1.61-2.46), complete flap loss (RR: 3.15, 95% CI: 1.32-7.52), partial flap loss (RR: 1.91, 95% CI: 0.92-4.00), hematoma (RR: 1.79, 95% CI: 0.96-3.32), and infection (RR: 2.12, 95% CI: 1.32-3.42) in cases with ischemia time exceeding 60 min. Venous complications predominated in free flap failure cases. CONCLUSIONS: Effectively managing ischemia time could be crucial in free flap breast reconstruction to potentially reduce postoperative complications. Although there is a correlation between managing ischemia time and reducing postoperative complications, further research is needed to investigate the possible causation behind this relationship. LEVEL OF EVIDENCE I: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Nursing teleconsultation in primary health care: scoping review.

OBJECTIVE: to map nurses' skills for nursing teleconsultation in Primary Health Care. METHOD: this is a scoping review guided by the recommendations of the Joanna Briggs Institute Reviewer's Manual, carried out in seven databases and repositories of theses and dissertations. The selection of studies was carried out in Rayyan by two independent, blind reviewers. Data analysis was carried out descriptively. RESULTS: 23 studies were selected, which showed that the skills necessary for nursing teleconsultation in primary care were: communication, clinical, technological and ethical. The lack of digital infrastructure was identified as one of the main barriers to the implementation of teleconsultation. The lack of access to information and communications technology and/or the internet, the severity of the clinical condition and the patient's non-adherence to the remote consultation were also identified. CONCLUSION: nursing teleconsultation in primary care is an emerging way of providing health care. However, for its implementation it is necessary to train nurses in the following skills: communication, clinical, technological, ethical and those related to the infrastructure of the teleconsultation environment.

A New Era in Perforator Flap Surgery for Breast Reconstruction: A Comparative Study of Robotic versus Standard Harvest of Bilateral Deep Inferior Epigastric Artery Perforator Flaps.

BACKGROUND: Traditional deep inferior epigastric artery perforator (DIEP) flap harvest splits the anterior sheath, weakening the abdominal wall and predisposing patients to bulge or hernia. Abdominal wall morbidity may be decreased using minimally invasive techniques. We refined a transabdominal approach to the robotic harvest of bilateral DIEP flaps. METHODS: A retrospective medical record study involving all patients who underwent bilateral or bipedicled robotic DIEP (rDIEP) or standard DIEP (sDIEP) flap harvest between July 2021 and September 2022. Outcomes included abdominal wall morbidity, total operative time, length of stay (LOS), and complications. RESULTS: Forty-seven patients were included (48 sDIEP flaps, 46 rDIEP flaps) with no significant difference in patient characteristics. Fascial incision length in the rDIEP group was shorter (4.1 vs. 11.7 cm, p < 0.001). Mesh reinforcement of the abdominal wall was used in 13/24 sDIEP and none in rDIEP patients (p < 0.001). Operative time was longer in the rDIEP cohort (739 vs. 630 minutes, p = 0.013), although subanalysis showed no difference in the second half of the cohort. The average robotic dissection time was 135 minutes, which decreased significantly with the surgeon's experience. There were no intraoperative complications from using the robot. LOS was shorter with rDIEP but not statistically significant (3.9 vs. 4.3 days, p = 0.157). CONCLUSION: This study represents the most extensive cohort analysis of bilateral rDIEP flap harvest, offering a comprehensive comparison to traditional sDIEP. The initial results underscore the viability of robotic techniques for flap harvesting, highlighting potential advantages including reduced fascial incision length and decreased abdominal disruption. Furthermore, using robotics may obviate the necessity for fascial reinforcement with mesh.

Transabdominal Robotic Harvest of Bilateral DIEP Pedicles in Breast Reconstruction: Technique and Interdisciplinary Approach.

BACKGROUND: The deep inferior epigastric artery perforator (DIEP) flap is the gold standard for autologous breast reconstruction. However, the conventional procedure's anterior sheath division, from perforating vessels to the pedicle origin, risks weakening the abdominal wall's primary strength layer. Employing the da Vinci Xi Surgical System with indocyanine green dye and near-infrared fluorescence imaging, we refined a robotic technique for bilateral DIEP flap harvest. This approach enhances safety during vessel dissection, utilizing smaller fascial incisions. This study will present this technique in detail to microsurgeons interested in robotic DIEP flaps. METHODS: In a retrospective cohort study spanning July 2021 to September 2022, female patients undergoing robotic bilateral DIEP flap reconstruction were analyzed. Following suprafascial flap dissection, the surgical robot was docked to target the pelvis, identifying and exposing deep inferior epigastric vessels intracorporeally. Mobilization and division occurred at their bases, with retrieval through a minimal anterior fascial incision, minimizing disruption to the abdominal wall and its motor innervation. RESULTS: The study comprised 23 patients (46 flaps), with a mean fascial length of 4.1 cm and mean pedicle length of 12.82 cm. Mesh usage was absent. Robotic time averaged 139 minutes, overall case length was 739 minutes, and the average length of stay was 3.9 days. Notably, no pedicle or intra-abdominal injuries were reported. CONCLUSION: This technique ensures safe and efficient pedicle dissection in robotic DIEP flap harvests. Given the limited number of plastic surgeons adept in minimally invasive abdominal surgeries, we recommend collaborative efforts, with general surgeons initially assisting microsurgeons in adopting the robotic approach. This strategy facilitates a smooth transition until plastic surgeons attain confidence and competence in independent robotic dissection.

Careful Where You Cut: Strategies for Successful Nerve-preserving Mastectomy.

Breast neurotization represents an evolving technique that is not widely practiced in most centers specializing in breast cancer treatment. Recognizing the limited educational resources available for breast and plastic surgeons concerning mastectomy techniques that emphasize nerve preservation, our study sought to bridge this gap. Specifically, we aimed to provide a comprehensive exploration of the surgical applied anatomy of breast sensory innervation and a detailed, step-by-step guide for incorporating nerve-sparing mastectomy and breast neurotization into clinical practice. The significance of this work lies in its potential to enhance the understanding and implementation of nerve-preserving techniques in mastectomy procedures, contributing to improved patient outcomes and quality of life post surgery. We hope that by familiarizing breast and reconstructive surgeons with this procedure, we can gain momentum in our research efforts and ultimately enhance the care provided to mastectomy patients.

Indocyanine Green-Guided Near-Infrared Fluorescence Enhances Vascular Anatomy in Robot-Assisted DIEP Flap Harvest.

SUMMARY: Indocyanine green-guided near-infrared fluorescence imaging has gained clinical acceptance lately. This technology can be particularly advantageous in the case of robotic flap harvest. This article presents a new approach to deep epigastric pedicle dissection using indocyanine green-guided near-infrared fluorescence in the setting of robot-assisted deep inferior epigastric perforator flaps.

Nursing teleconsultation in primary health care: scoping review / Teleconsulta de enfermagem na atenção primária à saúde: scoping review / Teleconsulta de enfermería en la atención primaria de salud: scoping review

Abstract Objective: to map nurses' skills for nursing teleconsultation in Primary Health Care. Method: this is a scoping review guided by the recommendations of the Joanna Briggs Institute Reviewer's Manual, carried out in seven databases and repositories of theses and dissertations. The selection of studies was carried out in Rayyan by two independent, blind reviewers. Data analysis was carried out descriptively. Results: 23 studies were selected, which showed that the skills necessary for nursing teleconsultation in primary care were: communication, clinical, technological and ethical. The lack of digital infrastructure was identified as one of the main barriers to the implementation of teleconsultation. The lack of access to information and communications technology and/or the internet, the severity of the clinical condition and the patient's non-adherence to the remote consultation were also identified. Conclusion: nursing teleconsultation in primary care is an emerging way of providing health care. However, for its implementation it is necessary to train nurses in the following skills: communication, clinical, technological, ethical and those related to the infrastructure of the teleconsultation environment.

Resumo Objetivo: mapear as habilidades dos enfermeiros para a teleconsulta de enfermagem na Atenção Primária à Saúde. Método: trata-se de uma revisão de escopo guiada pelas recomendações do Joanna Briggs Institute Reviewer's Manual, realizada em sete bases de dados e repositórios de teses e dissertações. A seleção dos estudos foi realizada no Rayyan por dois revisores independentes e às cegas. A análise dos dados foi realizada de forma descritiva. Resultados: selecionou-se 23 estudos, os quais mostraram que as habilidades necessárias para a teleconsulta de enfermagem na atenção primária foram: comunicação, clínica, tecnológica e ética. A falta de infraestrutura digital foi apontada como uma das principais barreiras para a implementação da teleconsulta. A falta de acesso a tecnologias da informação e comunicação e/ou à internet, a gravidade do quadro clínico e a não adesão do paciente à consulta remota também foram identificadas. Conclusão: a teleconsulta de enfermagem na atenção primária é uma forma emergente de prestar assistência à saúde. No entanto, para sua implementação é necessária a capacitação dos enfermeiros quanto às seguintes habilidades: comunicação, clínica, tecnológica, ética e aquelas relacionadas à infraestrutura do ambiente da teleconsulta.

Resumen Objetivo: mapear las habilidades de los enfermeros para la teleconsulta de enfermería en la Atención Primaria de Salud. Método: esta es una revisión de alcance guiada por las recomendaciones del Joanna Briggs Institute Reviewer's Manual, realizada en siete bases de datos y repositorios de tesis y disertaciones. La selección de los estudios fue realizada en Rayyan por dos revisores ciegos e independientes. El análisis de los datos se realizó de forma descriptiva. Resultados: se seleccionaron 23 estudios, que demostraron que las habilidades necesarias para la teleconsulta de enfermería en atención primaria fueron: comunicación, clínica, tecnológica y ética. La falta de infraestructura digital fue identificada como una de las principales barreras para la implementación de la teleconsulta. También se identificaron la falta de acceso a las tecnologías de la información y las comunicaciones y/o a internet, la gravedad del cuadro clínico y la no adherencia a la consulta remota por parte del paciente. Conclusión: la teleconsulta de enfermería en atención primaria es una forma emergente de brindar atención de salud. Sin embargo, para su implementación es necesario capacitar a los enfermeros en las siguientes habilidades: comunicación, clínica, tecnológica, ética y aquellas relacionadas con la infraestructura del ambiente de la teleconsulta.

Long COVID neuropsychological follow-up: Is cognitive rehabilitation relevant?

BACKGROUND: Duration of neuropsychological disorders caused by long COVID, and the variables that impact outcomes, are still largely unknown. OBJECTIVE: To describe the cognitive profile of patients with long COVID post-participation in a neuropsychological rehabilitation program and subsequent reassessment and identify the factors that influence recovery. METHODS: 208 patients (mean age of 48.8 y.o.), mostly female, were reevaluated 25 months after their first COVID infection and 17 months after their initial evaluation. Patients underwent subjective assessment, Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS), Phonemic Verbal Fluency and Clock Drawing Tests (NEUPSILIN) for executive functions, Hospital Anxiety and Depression Scale (HADS) and WHOQol-Bref. RESULTS: We noted a discrete improvement of neuropsychological symptoms 25 months after the acute stage of COVID-19; nonetheless, performance was not within the normative parameters of standardized neuropsychological testing. These results negatively impact QoL and corroborate patients' subjective assessments of cognitive issues experienced in daily life. Improvement was seen in those who participated in psychoeducational neuropsychological rehabilitation, had higher levels of education, and lower depression scores on the HADS. CONCLUSION: Our data reveal the persistence of long-term cognitive and neuropsychiatric disorders in patients with long COVID. Neuropsychological rehabilitation is shown to be important, whether in-person or online.

Proposing Clinicopathological Staging and Mitotic Count as Prognostic Factors for Canine Soft Tissue Sarcomas.

Soft tissue sarcomas (STSs) are a heterogeneous group of malignant mesenchymal tumors with similar histological features and biological behaviors. They are characterized by a low to moderate local recurrence rate and low metastasis, affecting approximately 20% of patients. Although this tumor set is vital in veterinary medicine, no previous unified staging system or mitotic count has been associated with patient prognosis. Therefore, this study proposed a new clinicopathological staging method and evaluated a cut-off value for mitosis related to the survival of dogs affected by STS. This study included 105 dogs affected by STS, treated only with surgery, and a complete follow-up evaluation. The new clinicopathological staging system evaluated tumor size (T), nodal involvement (N), distant metastasis (M), and histological grading criteria (G) to categorize the tumor stage into four groups (stages I, II, III, and IV). The proposed tumor staging system was able to differentiate patients' prognoses, with dogs with stage IV disease experiencing the lowest survival time and dogs with stage I disease having the highest survival time (p < 0.001). Moreover, we assessed the median mitosis (based on mitotic count) and its association with overall survival. Our study's median mitosis was 5, and patients with ≤5 mitoses had a higher survival time (p = 0.006). Overall, the proposed staging system and mitotic count seemed promising in the prediction of patient prognosis.

PRL-R Variants Are Not Only Associated With Prolactinomas But Also With Dopamine Agonist Resistance.

CONTEXT: Knockout prolactin receptor gene (PRL-R) mice are animal models for prolactinomas and PRL acts via autocrine/paracrine inhibiting lactotroph proliferation. Recently, variants of the PRL-R were identified in prolactinoma patients and their frequency was higher compared to individuals from the genomic database. OBJECTIVE: We analyzed PRL-R variants frequency in an extensive cohort of prolactinoma patients and evaluated their association with clinical, laboratorial, and imaging characteristics and hormonal response to cabergoline. DESIGN: Observational, retrospective, and cross-sectional study. SETTING: This study took place at the Neuroendocrinology Unit of Clinics Hospital, Medical School of University of São Paulo, Brazil, a tertiary referral center. PATIENTS AND METHODS: Study participants included adults with sporadic prolactinomas treated with cabergoline, where response to therapy was defined by prolactin normalization with up to 3 mg/week doses. DNA was extracted from blood samples and the PRL-R was analyzed by polymerase chain reaction techniques and automatic sequencing. The association of PRL-R variants with serum prolactin levels, maximal tumor diameter, tumor parasellar invasiveness, and response to cabergoline was analyzed. RESULTS: We found 6 PRL-R variants: p.Ile100(76)Val, p.Ile170(146)Leu, p.Glu400(376)Gln/p.Asn516(492)Ile, p.Glu470Asp e p.Ala591Pro; the last 2 are newly described in prolactinomas' patients. The variants p.Glu400(376)Gln/p.Asn516(492)Ile and p.Ala591Pro were more frequent amongst patients compared to genomic databases, and the p.Asn516(492)Ile showed pathogenic potential using in silico analysis as previously described. PRL-R variants were associated with male sex (P = 0.015), higher serum PRL levels (P = 0.007), larger tumors (P = 0.001), and cabergoline resistance (P < 0.001). CONCLUSIONS: The prolactin/prolactin receptor system seems to be related to prolactinoma tumorigenesis and cabergoline resistance. Additional studies are needed to better understand the PRL-R variants' role and their potential as therapeutic targets.

Intervenção de enfermagem para prevenção de queda da pessoa idosa com transtorno mental / Nursing intervention to prevent fall of the elderly person with mental disorder / Intervención enfermera para evitar que los ancianos caigan con transtorina mental

Objetivo: aplicar intervenções de enfermagem sobre prevenção de quedas a pessoas idosas com transtornos mentais. Material e Método: Trata-se de uma pesquisa- cuidado, para subsidiar a aplicação das intervenções de enfermagem foi utilizado componentes do Modelo Teórico de Promoção da Saúde, desenvolvido por Nola J. Pender. A primeira etapa do estudo foi desenvolvida em um Centro de Atenção Psicossocial e a segunda etapa no domicilio dos idosos. A coleta de dados foi realizada entre os meses de agosto a novembro de 2022, com idosos de idade igual ou superior a 60 anos, que estivessem sendo acompanhados no serviço. A amostra foi composta por 15 idosos. Para a coleta de dados, foi utilizado um formulário estruturado com variáveis sociodemográficas, investigação de saúde e doença e características do domicílio e um instrumento utilizado para avaliar o risco de quedas em idosos. A análise descritiva dos dados, ocorreu por meio do cálculo de frequências absolutas e relativas. Os aspectos éticos da resolução 466/12 foram respeitados em todas as fases do estudo. Resultados: Predominaram mulheres (80,00%), casadas (53,33%), com uma média de idade de 70,52 anos, de cor branca (53,33%) e analfabetos (55,33%). No que se refere às condições de saúde e doença, foi possível observar que o tipo de transtorno mental que mais predominou foi a depressão (60,00%) e a ansiedade (33,33%). Grande parte dos participantes do estudo (73,33%) relataram que já caíram ao menos 6 vezes, em um tempo médio de 1 ano. Ressalta-se que (93,33%) dos idosos não receberam orientações sobre prevenção de quedas no domicilio. Todos os idosos apresentaram alto risco de quedas. As intervenções de enfermagem foram realizadas aos idosos com transtornos mentais com alto risco para quedas. Considerações Finais: A maioria dos idosos tiveram quedas dentro do domicilio, a ocorrência de quedas nesse espaço está relacionada a insegurança do ambiente. Diante disso, a realização da intervenção foi de grande importância para a prevenção a quedas com enfoque na saúde do idoso direcionados aos gestores, profissionais e comunidade.

Objective: To apply nursing interventions on prevention of falls to elderly people with mental disorders. Material and Method: It is a research-care, to subsidise the application of nursing interventions was used components of the Theoretical Model of Health Promotion, developed by Nola J. Pender. The first stage of the study was developed at a Psychosocial Care Centre and the second stage in the home of the elderly. Data collection has been conducted between August and November 2022, with elderly people aged 60 and over, who were being accompanied in the service. The sample consisted of 15 elderly people. For the data collection, a structured form was used with sociodemographic variables, health and disease research and characteristics of the household, and an instrument used to assess the risk of falls in the elderly. Descriptive analysis of the data, occurred by calculating absolute and relative frequencies. The ethical aspects of resolution 466/12 were respected at all stages of the study. Results: Women predominated (80.00%), married (53.33%), with an average age of 70.52 years, white (53.33%) and illiterate (55.33%). With regard to health and illness conditions, it was observed that the type of mental disorder that predominated most was depression (60.00%) and anxiety (33.33%). A large number of the study's participants (73.33%) reported that they have already fallen at least 6 times, in an average time of 1 year. It should be noted that (93.33%) of the elderly did not receive guidelines on the prevention of falls in the home. All older adults were at high risk of falls. Nursing interventions were performed for elderly with mental disorders at high risk for falls. Final Considerations: Most of the elderly have had falls within the home, the occurrence of falls in this space is related to environmental insecurity. In view of this, the implementation of the intervention was of great importance for the prevention of falls with a focus on the health of the elderly directed towards managers, professionals and community.

Objetivo: aplicar intervenciones de enfermería en la prevención de caídas a personas mayores con trastornos mentales. Material y método: Se trata de una investigación cuidadosa, para subsidiar la aplicación de las intervenciones de enfermería, se utilizaron componentes del Modelo Teórico para la Promoción de la Salud, desarrollado por Nola J. Pender. La primera etapa del estudio se desarrolló en un Centro de Atención Psicosocial y la segunda etapa en los hogares de ancianos. La colección de datos tiene entre agosto y noviembre de 2022, se llevaron a cabo con personas mayores de 60 años que estaban acompañadas en el servicio. La muestra consistió en 15 ancianos. Para la recolección de datos se utilizó una forma estructurada con variables sociodemográficas, investigación de la salud y las enfermedades y características del hogar, así como un instrumento utilizado para evaluar el riesgo de caída en los ancianos. El análisis descriptivo de los datos se realizó mediante el cálculo de frecuencias absolutas y relativas. En todas las etapas del estudio se respetaron los aspectos éticos de la resolución 466/12. Resultados: mujeres predominantes (80,00%), casadas (53,33%), con una edad media de 70,52 años, blancas (53,33%) y analfabetas (55,33%). En cuanto a la salud y las enfermedades, se observó que el tipo de trastorno mental más prevalente fue depresión (60,00%) y ansiedad (33,33%). Un gran número de participantes en el estudio (73,33%) informó que ya habían caído al menos seis veces en un período medio de un año. Cabe señalar que (93,33%) de las personas de edad avanzada no recibieron directrices sobre la prevención de las caídas desde el hogar. Todos los ancianos mostraron un alto riesgo de caída. Las intervenciones de enfermería se realizaron en ancianos con trastornos mentales con alto riesgo de caída. Consideraciones finales: La mayoría de las personas de edad se habían refugiado en el hogar, la aparición de caídas en este espacio está relacionada con la inseguridad del medio ambiente. A la luz de ello, la aplicación de la intervención fue de gran importancia para la prevención de caídas, centrándose en la salud de las personas de edad, dirigida a los directivos, los profesionales y la comunidad. PALABRAS CLAVE: Salud Mental; Enfermería; Ancianos; Crash.

Análise epidemiológica e espacial da sífilis congênita em uma região de saúde do nordeste brasileiro / Epidemiological and spatial analysis of congenital syphilis in a health region of Northeast Brazil

Resumo Introdução A Sífilis Congênita (SC) permanece como desafio e a sua ocorrência evidencia fragilidades nos serviços de saúde. Objetivo Analisar a associação da taxa de incidência de Sífilis Congênita com as variáveis maternas, atenção ao pré-natal, indicadores sociodemográficos e de cobertura dos serviços de saúde, segundo análise espacial em uma região do nordeste brasileiro. Método Estudo ecológico misto analítico, cuja população foi composta por todos os casos de SC da região de saúde de 2010 a 2017, totalizando 522 casos. Resultados Na distribuição espacial da taxa de incidência de Sífilis Congênita, dois municípios apresentaram as maiores taxas, o Índice Global de Moran obteve associação espacial positiva e foram construídos os mapas Lisa e Moran. O coeficiente espacial autorregressivo foi significativo, bem como as variáveis "Taxa de analfabetismo em maiores de 15 anos", "Diagnóstico de sífilis materna durante o pré-natal", "Esquema de tratamento não realizado" e "Média anual da cobertura populacional estimada da ESF". Conclusão As informações evidenciadas são pertinentes ao planejamento e monitoramento da transmissão vertical da sífilis, com direcionamento de recursos a áreas mais vulneráveis visando melhorar o quadro epidemiológico da Sífilis Congênita.

Abstract Background Congenital syphilis (CS) remains a challenge and its occurrence exposes flaws in Brazilian health services. Objective analyze the association between CS incidence and maternal variables, prenatal care, sociodemographic variables and health service coverage indicators, employing spatial analysis, in a region of the Brazilian Northeast. Method Analytical mixed ecological study, with a population composed of all CS cases in the health region between 2010 to 2017, totaling 522 cases. Results Two towns presented the highest incidence rates for CS spatial distribution. Global Moran's I presented a positive spatial association and the Moran and Lisa maps were plotted. The autoregressive spatial coefficient was statistically significant, as well as the variables "Illiteracy rate > 15 years old", "Diagnosis of maternal syphilis during prenatal", "treatment plan not completed" and "Annual average for estimated population coverage of ESF". Conclusion The information presented is relevant for planning and undertaking monitoring of vertical syphilis transmission, targeting resources for more vulnerable areas, and aiming to improve epidemiological outcomes for CS.

A retrospective review of submuscular implant-based breast reconstruction: The influence of dermal matrix (ADM) on complications and aesthetic outcomes.

PURPOSE: The use of acellular dermal matrix changed the breast reconstruction algorithm facilitating implant coverage and direct to implant technique. This study aims to evaluate the effect of the ADM surgical complications, breast aesthetics, and patient satisfaction. METHODS: In a tertiary hospital, patients that underwent implant-based breast reconstructions during a three-year period had their charts retrospectively reviewed, received post-operative BreastQ, and had their post-operative photos evaluated by a three-member panel using a multi-parameter breast specific scale (scored 1-5). The complication information was analysed per reconstructed breast while the analysis of aesthetic and patient-reported outcomes was done per patient. RESULTS: A total of 501 patients (990 breasts) were evaluated. In the complication analysis group, 20.3% of the breasts had ADM. Overall complications and major complications were more frequent in the ADM group. During the first 30 postoperative days the most frequent complications were: skin necrosis/delayed wound healing and haematoma, after 30 days was infection, and complications after 1 year being less than 1%. On the outcome analysis group, ADM was used in 21.5% patients, 44% had post-operative photos, and 29% answered the BreastQ. Factors associated with higher appearance score were bilateral reconstruction, prophylactic surgery, and nipple presence. ADM demonstrated no difference in satisfaction with breasts. CONCLUSION: In implant-based breast reconstructions ADM has been shown to increase rate of complications. The use of acellular dermal matrix did not influence the overall appearance or the patient-reported outcome. A good aesthetic outcome is positively influenced by bilateral reconstructions with preservation of the nipple.

Educational technology to promote father involvement in childbirth and birth.

OBJECTIVES: to build and validate an educational booklet to promote the involvement of parents in labor and birth. METHODS: methodological study developed in five stages: situational diagnosis; bibliographic survey; construction of illustrations, layout, design and texts; content and appearance validation by judges (25 experts) and calculation of the Flesch Readability Index; and validation with the target audience (12 parents). A minimum Content Validity Index of 0.80 was considered. RESULTS: the booklet was entitled "Father Presence" and was developed in 11 topics. In Content and Appearance Validation, the Validity Index obtained an overall score of 0.97. Cronbach's alpha was 0.92, indicating excellent reliability of its content. A global score of 74% for readability was obtained, considered easy to understand. CONCLUSIONS: the material was successful in the validation process, and it can be recommended for parents to use it during the prenatal period, promoting the inclusion of the partner and preparing them for labor and birth.

Beauty Is in the Eye of the Beholder: Factors Influencing Disparity in Perceptions of Breast Reconstruction Aesthetic Outcomes.

BACKGROUND: Patient-reported outcomes are the primary measurement of breast reconstruction success, but results may be affected by nontechnical factors such as socioemotional determinants. Third-party observers provide an independent assessment of aesthetic outcomes. Factors associated with disparity between patient and observer perceptions of outcomes are not well understood. METHODS: One hundred forty-seven patients underwent breast reconstruction at the authors' institution between 2009 and 2011, completed the BREAST-Q, and had photographs graded by a diverse panel using the Validated Breast Aesthetic Scale. Patient satisfaction with breasts scores that aligned with observer scores were categorized as group 2; patient satisfaction that exceeded observer scores were group 1; and those lower than observer scores were group 3. Statistical analysis was performed using SPSS, with values of p < 0.05 considered statistically significant. RESULTS: Twenty-eight patients (19 percent) were categorized as group 1, 93 (63 percent) in group 2, and 26 (18 percent) in group 3. Median overall appearance was highest in group 3 (median, 4.0; interquartile range, 4 to 4) and lowest in group 1 (median, 3.0; interquartile range, 2 to 3) ( p < 0.001). Psychosocial, sexual, and physical well-being were significantly associated with disparity (group 1 or 3 status) ( p < 0.01). Satisfaction with outcomes, nipples, abdomen, and breasts were significantly associated with disparity. Factors not significantly associated with disparity include age, body mass index, autologous or implant-based, adjuvant therapies, and timing of reconstruction. CONCLUSIONS: Incongruously high patient satisfaction with breast reconstruction aesthetics relative to third-party perception of aesthetic outcomes is associated with high quality-of-life scores. Incongruously low patient satisfaction with breast cosmesis compared with higher third-party perceptions was associated with low quality-of-life scores. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Melatonin restores zinc levels, activates the Keap1/Nrf2 pathway, and modulates endoplasmic reticular stress and HSP in rats with chronic hepatotoxicity.

BACKGROUND: Melatonin (MLT) is a potent antioxidant molecule that is shown to have a beneficial effect in various pathological situations, due to its action against free radicals. AIM: To evaluate the effect of MLT on carbon tetrachloride (CCl4) induced liver injury in rats in terms of oxidative stress, reticular stress, and cell damage. METHODS: Twenty male Wistar rats (230-250 g) were divided into four groups: Control rats, rats treated with MLT alone, rats treated with CCl4 alone, and rats treated with CCl4 plus MLT. CCl4 was administered as follows: Ten doses every 5 d, ten every 4 d, and seven every 3 d. MLT was administered intraperitoneally at a dose of 20 mg/kg from the 10th wk to the end of the experiment (16th wk). RESULTS: MLT was able to reduce the release of liver enzymes in the bloodstream and to decrease oxidative stress in CCl4 treated rats by decreasing the level of thiobarbituric acid reactive substances and increasing superoxide dismutase activity, with a lower reduction in serum zinc levels, guaranteeing a reduction in liver damage; additionally, it increased the expression of nuclear factor (erythroid-derived 2)-like 2 and decreased the expression of Kelch-like ECH-associated protein 1. MLT also decreased the expression of the proteins associated with endoplasmic reticulum stress, i.e., glucose-regulated protein 78 and activating transcription factor 6, as well as of heat shock factor 1 and heat shock protein 70. CONCLUSION: MLT has a hepatoprotective effect in an experimental model of CCl4-induced liver injury, since it reduces oxidative stress, restores zinc levels, and modulates endoplasmic reticulum stress.

A Novel Validated Breast Aesthetic Scale.

BACKGROUND: Breast aesthetics impacts patients' quality of life after breast reconstruction, but patients and surgeons frequently disagree on the final aesthetic evaluation. The need for a comprehensive, validated tool to evaluate breast aesthetics independently from the patient motivated this study. METHODS: The 13-item Validated Breast Aesthetic Scale was developed after several internal meetings, and worded to be understood by a nonspecialist. Three items are common for both breasts, with the remaining being side-specific. To test the internal consistency of the scale subitems, postoperative photographs after different breast reconstruction techniques were graded by a six-member panel. To test interrater and intrarater correlation across time, four physicians evaluated the results of abdominally based breast reconstructions following nipple-sparing mastectomies. RESULTS: Graded aesthetic outcomes of 53 patients showed that the Cronbach alpha of the subitems of the scale was 0.926, with no single item that, if excluded, would increase it. Twenty-two patients underwent aesthetic outcomes grading at four different time points. The mean overall appearance was 3.71 ± 0.62. The mean grade for overall nipple appearance was 4.0 ± 0.57. The coefficient alpha of the panel overall aesthetic grade across different time points was 0.957; whereas intragrader reliability for graders 1 through 4 individually showed alpha coefficients of 0.894, 0.9, 0.898, and 0.688, respectively. Similar results were found for the other items of the scale. CONCLUSIONS: The proposed aesthetic scale evaluates different aspects of the breast reconstruction aesthetic result with excellent internal consistency among its subitems. Grading by a gender-balanced, diverse four-member panel using postoperative photographs showed higher reliability and reproducibility compared to single graders.

Neurotization Does not Prolong Operative Time in Free Flap Breast Reconstruction.

BACKGROUND: Neurotization during the breast reconstruction process can improve patient quality-of-life and satisfaction with reconstructive outcomes. One concern with neurotization is increased total operative time due to the need for additional dissection and nerve coaptation. The purpose of this study was to compare total operative time between neurotized and non-neurotized abdominal-based, free flap breast reconstruction. METHODS: A retrospective review was conducted of consecutive patients who underwent unilateral, abdominal-based, free flap breast reconstruction between 2016 and 2018 at a single tertiary care center. Data were collected on patient demographics, surgical techniques, and length of surgery. Data analysis was performed using chi-square test, independent t-test, and multivariate linear regression analysis. A p-value ≤0.05 was considered statistically significant. RESULTS: Seventy-three patients were included in this study. Twenty-three patients (31.50%) underwent flap neurotization (N group) and 50 (68.49%) underwent standard breast reconstruction without neurotization (NO group). The groups were similar in age, BMI, smoking status, and ASA class. No difference was found between the two groups in timing of reconstruction (p = 0.388). Average operative times were 467.73 ± 145.52 minutes and 455.28 ± 111.19 minutes for the N and NO groups, respectively, with no significant difference between the two groups (two-tailed p-value = 0.72). CONCLUSION: Seamless integration of neurotization in abdominal-based, free flap breast reconstruction is possible without significant prolongation of total operative time. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The use of closed incision negative pressure therapy for incision and surrounding soft tissue management: Expert panel consensus recommendations.

As the use of closed incision negative pressure therapy (ciNPT) becomes more widespread, dressing designs have evolved to address implementation challenges and meet surgeon demand. While traditional application of ciNPT was limited to the immediate suture line, a novel dressing that covers the incision and additional surrounding tissues has become available. To expand upon previous ciNPT recommendations and provide guidance on this new dressing, an expert panel of plastic surgeons convened to review the current literature, identify challenges to the implementation and sustainability of ciNPT, and use a modified Delphi technique to form a consensus on the appropriate use of ciNPT with full-coverage dressings. After three rounds of collecting expert opinion via the Delphi method, consensus was reached if 80% of the panel agreed upon a statement. This manuscript establishes 10 consensus statements regarding when ciNPT with full-coverage foam dressings should be considered or recommended in the presence of patient or incision risk factors, effective therapeutic settings and duration, precautions for use, and tools and techniques to support application. The panel also discussed areas of interest for future study of ciNPT with full-coverage dressings. High-quality, controlled studies are needed to expand the understanding of the benefits of ciNPT over the incision and surrounding tissues.