Urine Galactomannan-to-Creatinine Ratio for Detection of Invasive Aspergillosis in Patients with Hematological Malignancies.

Galactomannan (GM) testing of urine specimens may provide important advantages, compared to serum testing, such as easy noninvasive sample collection. We evaluated a total of 632 serial urine samples from 71 patients with underlying hematological malignancies and found that the urine GM/creatinine ratio, i.e., (urine GM level × 100)/urine creatinine level, which takes urine dilution into account, reliably detected invasive aspergillosis and may be a promising diagnostic tool for patients with hematological malignancies. (This study has been registered at ClinicalTrials.gov under registration no. NCT01576653.).

BMI and Revision Surgery for Abdominoplasties: Complication Definitions Revisited Using the Clavien-Dindo Classification.

After body contouring surgery of the lower trunk (CSLT), the definition, rate (4%-70%), and documentation of complications vary. Objectives: We analyzed the effect of risk factors on the outcome based on the Clavien-Dindo classification (CDC) after CSLT surgery and polled postoperative satisfaction among patients. Methods: All patients undergoing CSLT from 2001 to 2016 were included and were classified according to the CDC for postoperative events. Statistical analysis included proportional odds logistic regression analysis. We polled patients to grade their satisfaction with the postoperative result and whether they would have the operation performed again. Results: A total of 265 patients were included: 60 (22.6%), 25 (9.4%), 28 (10.6%), and 21 (7.9%) were in CDC grades I, II, IIIa, and IIIb, respectively. A high preoperative body mass index significantly increased the odds for a postoperative event requiring revision surgery under general anesthesia (CDC grade IIIb, odds ratio 0.93, 95% confidence interval 0.89-0.97, P = 0.001). One-hundred twenty-eight patients (48.3%) participated in the poll: 101 (78.9%) were either happy or content with the postoperative results, and 117 (91.4%) would have the procedure performed again, including all nine patients with CDC grade IIIb. Conclusions: Our results confirm that a high body mass index is a statistically significant risk factor for requiring major revision surgery after CSLT. Despite being a complication prone intervention, postoperative satisfaction after CSLT was ranked favorably in our sample. We recommend that the CDC be used in all surgical specialties to evaluate complications and permit future comparability of pooled data.

The reverse latissimus dorsi flap: An anatomical study and retrospective analysis of its clinical application.

The segmental paraspinous and intercostal blood vessels form the blood supply and represent the pivot point for the reverse latissimus dorsi flap. Aim of this study was to confirm the exact location of the blood supply and the most caudal pivot point to assess the suitability of the reverse latissimus dorsi flap for pedicled reconstructions of the trunk as well as sacral area. Our study comprised a human cadaver study, where 30 latissimus dorsi flaps were assessed in 15 specimens, and a clinical study with 49 patients who underwent distally based latissimus dorsi flap reconstructions in our division. 74% of all perforators were located in a bilateral 7 cm broad area, which spread from the 6th intercostal space to the subcostal plane. In a second clinical part of this study we evaluated forty-nine patients, who underwent reconstruction with the reverse latissimus dorsi flap. We demonstrated that the pivot point can also be planned below the 12th rib, thus reaching tissue defects in the sacral area. To the best of our knowledge, this is the first study to define a caudal "hotspot" for the safest blood supply of the reverse latissimus dorsi flap.

BMI and specimen weight: impact on personalized risk profiling for optimized informed consent in breast reduction surgery?

We aimed to evaluate the interaction between individual risk factors and institutional complication rates after reduction mammaplasties to develop a chart for a personalized written patient informed consent. We retrospectively reviewed charts of 804 patients who underwent bilateral breast reduction between 2005 and 2015. The Clavien-Dindo classification was used to classify postoperative complications. Relevant predictors were found by applying a stepwise variable selection procedure. Multilevel predictors were assessed through chi-square tests on the respective deviance reductions. 486 patients were included. The most common complications were wound healing problems (n = 270/56%), foreign body reactions (n = 58/12%), wound infections (n = 45/9, 3%) and fat tissue necrosis (n = 41/8%). The risk factors for the personalized patient chart for the most common complications influencing the preoperative informed consent were: smoking, operative technique, resection weight for wound healing problems; body mass index and allergies for wound infections; and patients' age, resection weight for fat tissue necrosis. The resultant chart of institutionally encountered most common complications based on individual risk factors is a graphical template for obtaining patient informed consent in the future. Whether this approach influences patient information retainment, incidence of filed lawsuits or behavioral change needs to be prospectively tested in future studies.

What can we learn from sonication results of breast implants?

BACKGROUND: Different research groups have identified microorganisms on breast implants by sonication with significant correlation to the rate of capsular contracture. This substantiated the hypothesis of an infectious etiology of capsular contracture. However, no clinical consequence has been drawn from these results yet. Aim of this study was to review sonication results from breast implants and to evaluate the current preoperative antibiotic regime for breast-implant surgery. METHODS: We compared breast implant sonication culture results from published reports and our own database. Current perioperative antibiotic recommendations were compared with the susceptibility profile of the found organisms. RESULTS: We found Coagulase-negative staphylococci and Propionibacteria to be the main group of microorganism found by sonication on explanted breast implants. Most guidelines recommend cephalosporins for preoperative antibiotical prophylaxis for breast-implant surgery. CONCLUSION: There is a discrepancy between antibiotic activity of commonly used antibiotics for preoperative prophylaxis of surgical site infections, and microorganisms found by sonication on breast implants, suspected to trigger the formation of capsular contracture. A targeted antibiotic prophylaxis for breast implant surgery with glycopeptides (e.g. Vancomycin) should be considered for the prevention of capsular contracture.

Standardizing the complication rate after breast reduction using the Clavien-Dindo classification.

BACKGROUND: Published complication rates for breast reduction surgery, also known as reduction mammaplasty, vary between 4% and 54%. This wide range of complication rates could be attributable to the lack of a standardized classification of complications in plastic surgery. The aim of this study was to analyze our single-center complication rates after reduction mammaplasty using the Clavien-Dindo classification. METHODS: We performed a retrospective chart review studying 804 patients between the ages of 18 and 81 years old who underwent breast reduction between 2005 and 2015 at our institution. Patients with a history of breast cancer, a previous breast operation, who did not undergo bilateral reduction mammaplasty, or who required systemic immunodeficiency/immunosuppressive drugs were excluded from our analysis. Complications were classified according to the Clavien-Dindo classification from Grades I to V. RESULTS: A total of 486 patients met the inclusion criteria for the analysis. Patients had an age (mean ± standard deviation) of 39 ± 13 years and a body mass index of 26 ± 4 kg/m2. Median follow-up was 274 days (interquartile range: 90.5-378). The overall rate of complications of reduction mammaplasty was 63%, with the majority of those being Grades I (48%) and II (9%), comprising 92% of all the complications. Operative revisions were required in 6% (1% Grade IIIA and 5% Grade IIIB). There were no complications graded in categories IV and V. CONCLUSION: Although complications occurred in more than half of the cases, the majority did not require operative reintervention. The Clavien-Dindo classification can classify the severity of complications and serve as a benchmark to compare complication rates between different practices. We believe that grading of complications should distinguish between those that do and do not require operative reinterventions.

Prognostic potential of 1,3-beta-d-glucan levels in bronchoalveolar lavage fluid samples.

OBJECTIVES: The objective of this study was to investigate the prognostic potential of 1,3-beta-d-glucan (BDG) testing in bronchoalveolar lavage fluid (BALF) samples. METHODS: A total of 300 BALF samples from 252 patients were investigated for BDG (Fungitell(®) assay). Prognostic potential of BALF BDG was evaluated by using: i.) Kaplan-Meier analysis, and ii.) multivariable Cox hazard regression analyses. RESULTS: BALF BDG levels were found to be significantly higher in samples with Candida spp. colonization (p < 0.001). A total of 61/252 patients (24.2%) died within 90-days of BALF sampling (18.1% of patients with BALF BDG <200 pg/mL, 32.4% with BALF BDG ≥200 pg/mL). Kaplan-Meier analysis revealed that overall cumulative 90-day mortality was significantly higher in those with BALF BDG levels ≥200 pg/mL when compared to those with levels <200 pg/mL (log-rank p = 0.006, Breslow p = 0.005 and Tarone-Ware p = 0.005). The multivariable Cox regression analysis showed that BALF BDG levels were a strong predictor of 90-day overall mortality, with a hazard ratio of 1.048 (per 100 pg/mL increase of BALF BDG). CONCLUSION: False positive BALF BDG results in the presence of Candida spp. colonization of the lower respiratory tract may explain the limited diagnostic potential of BALF BDG testing. In contrast, prognostic potential of BALF BDG may be promising.