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Purpose: Resection arthroplasty (RA) is still the most common surgical intervention for the treatment of symptomatic trapeziometacarpal (TMC) joint osteoarthritis. The implantation of a dual mobility prosthesis may represent a joint function preserving alternative. The aim of the presented study is to prospectively compare the outcomes of RA with dual mobility prosthesis. Methods: In this 2-center non-randomized prospective study, we compared results of RA (n = 22) with implantation of a dual mobility prosthesis (n = 49) (Touch®) at a minimum of 3-year follow-up. The patients underwent preoperative assessments and postoperative follow-up at 6 weeks, 3, 6, 12, 24, and 36 months. Comparisons were conducted, covering pain assessment via the visual analogue scale (VAS), thumb range of motion (ROM), pinch and grip strength, as well as functional scores and radiological examinations. Results: The time intervals from surgery until absence of pain on the VAS (3 months: 3 vs 1, p = 0.0001), recovery of ROM in radial (3 months: 33° vs 42°, p = 0.0001), and palmar abduction (3 months: 33° vs 48°, p = 0.0001), were significantly longer for the RA group compared with the prosthesis group. At 3-year follow-up there was no significant difference in absence of pain, ROM and grip strength between both groups. Key pinch strength was significantly weaker in the RA group compared to prosthesis group at 3 months (2.6 kg vs 4.6 kg, p = 0.001), to 3-year follow-up (3.1 kg vs 5.7 kg, p = 0.0001). The final mean DASH (15.5 vs 13.2, p = 0.01) and MHQ scores (78 vs 82, p = 0.01) were significantly better in the prosthesis group. Conclusion: Both techniques show high patient satisfaction in mid-term follow-up. Dual mobility TMC joint arthroplasty seems to be associated with a superior pinch strength and shorter time of recovery as compared to patients after RA.
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OBJECTIVE: To assess the impact of ejaculatory dysfunction (EjD; failure of emission or retrograde ejaculation) on health-related quality of life (HRQoL) after retroperitoneal lymph node dissection (RPLND) for testicular cancer and explore the efficacy of pseudoephedrine hydrochloride as treatment. PATIENTS AND METHODS: In a single arm, phase II trial, patients at ≥6 months after RPLND were invited to complete patient-reported outcome measures (European Organisation for Research and Treatment of Cancer [EORTC] quality of life questionnaire [QLQ]-30-item core, EORTC QLQ-testicular cancer-26, and Brief Male Sexual Function Inventory) evaluating HRQoL and sexual function in follow-up (ACTRN12622000537752/12622000542796). If EjD was reported, post-ejaculatory urine ± semen analysis was undertaken. In eligible patients, pseudoephedrine hydrochloride 60 mg was administered orally every 6 h for six doses. The primary endpoint was sperm count >39 million sperm/ejaculate (>5th centile) following treatment. The trial was powered to detect a clinically relevant 36% achieving sperm count of >39 million sperm/ejaculate. Secondary endpoints included semen volume >1.5 mL, total motile sperm count, safety, and HRQoL impacts. RESULTS: Of the 58 patients enrolled, the median (interquartile range [IQR]) age was 35 (29-41) years, with a median (IQR) of 37 (18-60) months from RPLND. EjD was reported in 33 (57%), including 27/52 (52%) receiving follow-up at our centre. There were no differences in global HRQoL; however, role functioning (P = 0.045), sexual problems (P < 0.005), and sexual enjoyment (P = 0.005) was poorer if EjD was present. In all, 24/33 (73%) patients with EjD consented to pseudoephedrine treatment. Of 22 evaluable patients, four (18%) achieved a sperm count of >39 million/ejaculate (P = 0.20), and four (18%) had a semen volume of >1.5 mL (P = 0.20). There was a mean increase of 105 million sperm/ejaculate (P = 0.051) and 1.47 mL increase in semen volume (P = 0.01). No safety concerns arose. CONCLUSION: Ejaculatory dysfunction is common after RPLND but did not impact global HRQoL in our cohort. Pseudoephedrine improved EjD for some; however, its efficacy was lower than expected. Pseudoephedrine may be considered on an individualised basis.
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INTRODUCTION: A reconstructive option for extensive chest wall reconstruction is the free myocutaneous vastus lateralis muscle (VL) flap which can be performed in isolation or in conjunction with a fasciocutaneus anterolateral thigh (cVLALT) and/or myofasciocutaneous tensor fascia lata flap (cVLTFL). We aimed to directly compare the outcomes of these reconstructive options. METHODS: Patients who underwent oncological chest wall reconstruction with a free VL, cVLALT, or cVLTFL flap between February 2010 and 2022 were included in this retrospective study. Patient demographics, surgical characteristics, as well as medical and reconstructive outcomes, were evaluated. The operative outcomes between myocutaneous VL, cVLALT, and cVLTFL flap reconstructions were compared. RESULTS: A total of 41 patients underwent chest wall reconstruction with a free myocutaneous VL (n = 25; 61%), cVLALT (n = 14; 34%), or cVLTFL Three acute flap thromboses occurred in the entire cohort (3/41, 7%), with one myocutaneous VL flap failing because of recurrent venous thrombosis during the salvage procedure. Total flap necrosis was seen in two cases (5%; VL flap: n = 1; cVLALT flap: n = 1), and partial flap necrosis in one VL flap (1/25, 4%) and in the distal ALT portion of three cVLALT flaps (3/14, 21%). No significant difference was seen between isolated VL and conjoined VL flaps regarding the partial (p = .28) or total flap necrosis rate (p = .9). CONCLUSION: The free (conjoined) VL flap provides reliable outcomes for obliterating dead space achieving durable reconstruction of complex chest wall defects.
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Fascia Lata , Colgajos Tisulares Libres , Procedimientos de Cirugía Plástica , Músculo Cuádriceps , Muslo , Pared Torácica , Humanos , Masculino , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Procedimientos de Cirugía Plástica/métodos , Pared Torácica/cirugía , Fascia Lata/trasplante , Colgajos Tisulares Libres/trasplante , Anciano , Adulto , Muslo/cirugía , Músculo Cuádriceps/trasplante , Músculo Cuádriceps/cirugía , Colgajo Miocutáneo/trasplante , Neoplasias Torácicas/cirugía , Resultado del TratamientoRESUMEN
INTRODUCTION: Immunoglobulins (Ig) reactive with α-melanocyte-stimulating hormone (α-MSH), an anorexigenic neuropeptide, are present in humans and were previously associated with eating disorders. In this longitudinal study involving patients with anorexia nervosa (AN), we determined whether α-MSH in serum is bound to IgG and analyzed long-term dynamics of both α-MSH peptide and α-MSH-reactive Ig in relation to changes in BMI and gut microbiota composition. METHODS: The study included 64 adolescents with a restrictive form of AN, whose serum samples were collected at hospital admission, discharge, and during a 1-year follow-up visit and 41 healthy controls, all females. RESULTS: We found that in both study groups, approximately 40% of serum α-MSH was reversibly bound to IgG and that levels of α-MSH-reactive IgG but not of α-MSH peptide in patients with AN were low at hospital admission but recovered 1 year later. Total IgG levels were also low at admission. Moreover, BMI-standard deviation score correlated positively with α-MSH IgG in both groups studied but negatively with α-MSH peptide only in controls. Significant correlations between the abundance of specific bacterial taxa in the gut microbiota and α-MSH peptide and IgG levels were found in both study groups, but they were more frequent in controls. CONCLUSION: We conclude that IgG in the blood plays a role as an α-MSH-binding protein, whose characteristics are associated with BMI in both patients with AN and controls. Furthermore, the study suggests that low production of α-MSH-reactive IgG during the starvation phase in patients with AN may be related to altered gut microbiota composition.
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Bone marrow adipose tissue (BMAT) comprises >10% of total adipose mass in healthy humans. It increases in diverse conditions, including ageing, obesity, osteoporosis, glucocorticoid therapy, and notably, during caloric restriction (CR). BMAT potentially influences skeletal, metabolic, and immune functions, but the mechanisms of BMAT expansion remain poorly understood. Our hypothesis is that, during CR, excessive glucocorticoid activity drives BMAT expansion. The enzyme 11ß-hydroxysteroid dehydrogenase type 1 (11ß-HSD1) amplifies glucocorticoid activity by catalysing intracellular regeneration of active glucocorticoids from inert 11-keto forms. Mice lacking 11ß-HSD1 resist metabolic dysregulation and bone loss during exogenous glucocorticoid excess; thus, we hypothesised that 11ß-HSD1 knockout mice would also resist excessive glucocorticoid action during CR, thereby restrining BMAT expansion and bone loss. To test this, we first confirmed that 11ß-HSD1 is expressed in mouse and human bone marrow. We then investigated the effects of CR in male and female control and 11ß-HSD1 knockout mice from 9 to 15 weeks of age. CR increased Hsd11b1 mRNA in adipose tissue and bone marrow. Deletion of Hsd11b1 did not alter bone or BMAT characteristics in mice fed a control diet and had little effect on tibial bone microarchitecture during CR. Notably, Hsd11b1 deletion attenuated the CR-induced increases in BMAT and prevented increases in bone marrow corticosterone in males but not females. This was not associated with suppression of glucocorticoid target genes in bone marrow. Instead, knockout males had increased progesterone in plasma and bone marrow. Together, our findings show that knockout of 11ß-HSD1 prevents CR-induced BMAT expansion in a sex-specific manner and highlights progesterone as a potential new regulator of bone marrow adiposity.
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11-beta-Hidroxiesteroide Deshidrogenasa de Tipo 1 , Adiposidad , Médula Ósea , Restricción Calórica , Ratones Noqueados , Animales , 11-beta-Hidroxiesteroide Deshidrogenasa de Tipo 1/genética , 11-beta-Hidroxiesteroide Deshidrogenasa de Tipo 1/metabolismo , Femenino , Masculino , Adiposidad/genética , Médula Ósea/metabolismo , Ratones , Humanos , Tejido Adiposo/metabolismo , Ratones Endogámicos C57BL , Glucocorticoides/metabolismo , Factores SexualesRESUMEN
This study examines the relationship between the wingbeat frequency of flying insects and ambient temperature, leveraging data from over 302,000 insect observations obtained using a near-infrared optical sensor during an eight-month field experiment. By measuring the wingbeat frequency as well as wing and body optical cross-sections of each insect in conjunction with the ambient temperature, we identified five clusters of insects and analyzed how their average wingbeat frequencies evolved over temperatures ranging from 10 °C to 38 °C. Our findings reveal a positive correlation between temperature and wingbeat frequency, with a more pronounced increase observed at higher wingbeat frequencies. Frequencies increased on average by 2.02 Hz/°C at 50 Hz, and up to 9.63 Hz/°C at 525 Hz, and a general model is proposed. This model offers a valuable tool for correcting wingbeat frequencies with temperature, enhancing the accuracy of insect clustering by optical and acoustic sensors. While this approach does not account for species-specific responses to temperature changes, our research provides a general insight, based on all species present during the field experiment, into the intricate dynamics of insect flight behavior in relation to environmental factors.
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Objectives: Addressing extensive and deep burn wounds poses considerable challenges for both patients and surgeons. The NovoSorb® Biodegradable Temporizing Matrix (BTM) emerged as a novel dermal substitute and has been subjected to evaluation in large burn wound cases, with a specific focus on identifying risk factors associated with suboptimal take rates. Methods: All patients with burn wounds greater than 10% body surface that underwent BTM treatment between March 2020 and November 2023 were eligible for inclusion. Univariate analyses and linear regression models were employed to discern risk factors and predictors influencing the take rates of both the BTM and split-thickness skin grafts (STSGs). Results: A total of 175 patients (mean age 56.2 ± 19.8 years, 70.3% male) were evaluated. The mean take rates of the BTM and STSGs were 82.0 ± 24.7% and 87.3 ± 19.0%, respectively. There were significant negative correlations between BTM take and the number of surgeries before BTM application (r = -0.19, p = 0.01), %TBSA and STSG take (r = -0.36, p = <0.001) and significant positive correlations between BTM and STSG take (r = 0.41, p ≤ 0.001) in addition to NPWT and STSG take (r = 0.21, p = 0.01). Multivariate regression analyses showed that a larger number of surgeries prior to BTM application (OR -3.41, 95% CI -6.82, -0.03, p = 0.04) was associated with poorer BTM take. Allograft treatment before BTM application (OR -14.7, 95% CI -23.0, -6.43,p = 0.01) and failed treatment with STSG before BTM application (OR -20.8, 95% CI -36.3, -5.23, p ≤ 0.01) were associated with poorer STSG take, whereas higher BTM take rates were associated with overall higher STSG take (OR -0.15, 95% 0.05, 0.26, p = 0.01). The Meek technique was used in 24 patients and showed similar take rates (BTM: 76.3 ± 28.0%, p = 0.22; STSG: 80.7 ± 21.1, p = 0.07). Conclusions: This study summarizes our findings on the application of a BTM in the context of large burn wounds. The results demonstrate that successful treatment can be achieved even in patients with extensive burns, resulting in satisfying take rates for both the BTM and STSG. The data underscore the importance of promptly applying a BTM to debrided wounds and indicate good results when using Meek.
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T cells are important for the control of acute myeloid leukemia (AML), a common and often deadly malignancy. We observed that some AML patient samples are resistant to killing by human-engineered cytotoxic CD4+ T cells. Single-cell RNA-seq of primary AML samples and CD4+ T cells before and after their interaction uncovered transcriptional programs that correlate with AML sensitivity or resistance to CD4+ T cell killing. Resistance-associated AML programs were enriched in AML patients with poor survival, and killing-resistant AML cells did not engage T cells in vitro. Killing-sensitive AML potently activated T cells before being killed, and upregulated ICAM1, a key component of the immune synapse with T cells. Without ICAM1, killing-sensitive AML became resistant to killing by primary ex vivo-isolated CD8+ T cells in vitro, and engineered CD4+ T cells in vitro and in vivo. While AML heterogeneity implies that multiple factors may determine their sensitivity to T cell killing, these data show that ICAM1 acts as an immune trigger, allowing T cell killing, and could play a role in AML patient survival in vivo.
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Molécula 1 de Adhesión Intercelular , Leucemia Mieloide Aguda , Humanos , Leucemia Mieloide Aguda/inmunología , Leucemia Mieloide Aguda/patología , Molécula 1 de Adhesión Intercelular/metabolismo , Molécula 1 de Adhesión Intercelular/genética , Linfocitos T CD4-Positivos/inmunología , Linfocitos T CD4-Positivos/metabolismo , Ratones , Animales , Linfocitos T CD8-positivos/inmunología , Linfocitos T CD8-positivos/metabolismo , Pronóstico , Citotoxicidad InmunológicaRESUMEN
The orthoplastic approach involves the collaboration of orthopedic/trauma surgeons, vascular surgeons and reconstructive microsurgeons. In cases of complex limb fractures, the aims are to optimize blood flow, restore bone stability, reconstruct soft tissue defects, and enhance function and sensitivity. The early administration of antibiotics and a timely, high-quality debridement after initial interdisciplinary assessment are carried out. This is followed by fracture stabilization and temporary wound coverage in order to plan the definitive interdisciplinary procedure. This includes definitive osteosynthesis and soft tissue reconstruction, using local tissue transfer if feasible, or free tissue transfer in cases of extensive trauma zones. The orthoplastic approach allows for faster definitive stabilization, fewer operations, shorter hospital stays, lower complication and revision rates, higher cost-effectiveness and improved long-term function.
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Fracturas Abiertas , Grupo de Atención al Paciente , Procedimientos de Cirugía Plástica , Humanos , Fracturas Abiertas/cirugía , Procedimientos de Cirugía Plástica/métodos , Grupo de Atención al Paciente/organización & administración , Traumatismos de los Tejidos Blandos/cirugía , Fijación Interna de Fracturas/métodos , DesbridamientoRESUMEN
Anion exchange membrane water electrolyzers (AEMWEs) have an intrinsic advantage over acidic proton exchange membrane water electrolyzers through their ability to use inexpensive, stable materials such as stainless steel (SS) to catalyze the sluggish oxygen evolution reaction (OER). As such, the study of active oxide layers on SS has garnered great interest. Potential cycling is a means to create such active oxide layers in situ as they are readily formed in alkaline solutions when exposed to elevated potentials. Cycling conditions in the literature are rife with unexplained variations, and a complete account of how these variations affect the activity and constitution of SS oxide layers remains unreported, along with their influence on AEMWE performance. In this paper, we seek to fill this gap in the literature by strategically cycling SS felt (SSF) electrodes under different scan rates and ranges. The SSF anodes were rapidly activated within the first 50 cycles, as shown by the 10-fold decline in charge transfer resistance, and the subsequent 1000 cycles tuned the metal oxide surface composition. Cycling the Ni redox couple (RC) increases Ni content, which is further enhanced by lowering the cycling rate, while cycling the Fe RC increases Cr content. Fair OER activity was uncovered through cycling the Ni RC, while Fe cycling produced SSF electrodes active toward both the OER and the hydrogen evolution reaction (HER). This indicates that inert SSF electrodes can be activated to become efficient OER and HER electrodes. To this effect, a single-cell AEMWE without any traditional catalyst or ionomer generated 1.0 A cm-2 at 1.94 V ± 13.3 mV with an SSF anode, showing a fair performance for a cell free of critical raw materials.
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The arteriovenous loop (AVL) model allows the in vivo engineering of axially vascularized flaps, the so-called AVL flaps. Although AVL flaps can be transplanted microsurgically to cover tissue defects, they lack an epithelial layer on the surface. Therefore, the objective of this study was to engineer axially vascularized AVL flaps with an accompanying epithelial layer for local defect reconstruction. In this study, AVLs were established in 20 male Lewis rats. Minimally invasive injection of keratinocytes onto the surface of the AVL flaps was performed on postoperative day (POD) 21. AVL flaps were explanted from 12 rats on POD 24 or POD 30, then the epithelium formed by the keratinocytes on the surface of the flaps was evaluated using immunofluorescence staining. In six other rats, the AVL flap was locally transposed to cover a critical defect in the rats' leg on POD 30 and explanted for analysis on POD 40. In two control rats, sodium chloride was applied instead of keratinocytes. These control flaps were also transplanted on POD 30 and explanted on POD 40. Our results revealed that 3 days after keratinocyte application, a loose single-layered epithelium was observed histologically on the AVL flaps surface, whereas after 9 days, a multilayered and structured epithelium had grown. The epithelium on the transplanted AVL flaps showed its physiological differentiation when being exposed to an air-liquid interface. Histologically, a layered epithelium identical to the rats' regular skin was formed. In the sodium chloride control group, no epithelium had been grown. This study clearly demonstrates that axially vascularized AVL flaps can be processed in the subcutaneous chamber by minimally invasive injection of keratinocytes. Thus, AVL flaps with an intact epithelial layer were engineered and could be successfully transplanted for local defect coverage in a small animal model.
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Human adaptive immunity is orchestrated by effector and regulatory T (Treg) cells. Natural Tregs arise in the thymus where they are shaped to recognize self-antigens, while type 1 Tregs or Tr1 cells are induced from conventional peripheral CD4 + T cells in response to peripheral antigens, such as alloantigens and allergens. Tr1 cells have been developed as a potential therapy for inducing antigen-specific tolerance, because they can be rapidly differentiated in vitro in response to a target antigen. However, the epigenetic landscape and the identity of transcription factors (TFs) that regulate differentiation, phenotype, and functions of human antigen-specific Tr1 cells is largely unknown, hindering Tr1 research and broader clinical development. Here, we reveal the unique epigenetic signature of antigen-specific Tr1 cells, and TFs that regulate their differentiation, phenotype and function. We showed that in vitro induced antigen-specific Tr1 cells are distinct both clonally and transcriptionally from natural Tregs and other conventional CD4 + T cells on a single-cell level. An integrative analysis of Tr1 cell epigenome and transcriptome identified a TF signature unique to antigen-specific Tr1 cells, and predicted that IRF4, BATF, and MAF act as their transcriptional regulators. Using functional genomics, we showed that each of these TFs play a non-redundant role in regulating Tr1 cell differentiation, suppressive function, and expression of co-inhibitory and cytotoxic proteins. By using the Tr1-specific TF signature as a molecular fingerprint, we tracked Tr1 cells in peripheral blood of recipients of allogeneic hematopoietic stem cell transplantation treated with adoptive Tr1 cell therapy. Furthermore, the same signature identified Tr1 cells in resident CD4 + T cells in solid tumors. Altogether, these results reveal the epigenetic signature and the key transcriptional regulators of human Tr1 cells. These data will guide mechanistic studies of human Tr1 cell biology and the development and optimization of adoptive Tr1 cell therapies.
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Background: Sparsity of recipient vessels poses a challenge for microsurgical free flap reconstruction of sternal defects following deep sternal wound infection after cardiac surgery. Methods: From January 2013, a standardized algorithm for dealing with sparse recipient vessels was strictly followed. In this retrospective study including 75 patients, we compared operative details, surgical complications, and reconstructive outcomes of patients treated according to this algorithm (group A: January 2013-May 2021; nâ =â 46) with a historical control group (group B: January 2000-December 2012, nâ =â 29). Results: The left internal mammary artery had been harvested for arterial bypass grafting in 40 of 46 cases (87%) in group A and in all cases in group B. The right internal mammary artery (RIMA) and right internal mammary vein (RIMV) were the first choice as recipient vessels. In case of unsuitability of the RIMV, a right cephalic vein (CV) turndown was used for venous outflow. If both RIMA and RIMV proved insufficient, a single-stage arterio-venous loop (AVL) between the CV and subclavian artery (CV-SA AVL), CV and thoracoacromial artery (CV-TA AVL), or subclavian artery and subclavian vein (SA-SV AVL) was established. The algorithmic approach significantly reduced partial flap necrosis [group A: nâ =â 3 (7%) versus group b: nâ =â 7 (24%); P = 0.04], and overall operation time [group A: 360â ±â 88 min versus group B: 415â ±â 80 min; P = 0.01]. Conclusions: Standardized approaches improve clinical outcomes in microsurgical free flap sternal reconstruction after cardiac surgery.
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INTRODUCTION: Extensive full-thickness soft-tissue defects remain a challenge in reconstructive surgery. NovoSorb® Biodegradable Temporising Matrix (BTM) represents a novel dermal substitute and was evaluated in wounds deriving from different aetiologies and to highlight risk factors for poor take rates. METHODS: All patients treated with BTM at our department between March 2020 and October 2022 were included. Differences in univariate and linear regression models identified predictors and risk factors for take rates of BTM and split-thickness skin grafts (STSG). RESULTS: Three hundred patients (mean age 54.2 ± 20.1 years, 66.3% male, 59.7% burns, 19.7% trauma and 20.6% others) were evaluated. Mean take rates of BTM and STSG after BTM delamination were 82.7 ± 25.2% and 86.0 ± 22.6%, respectively. Multiple regression analyses showed that higher body mass index (BMI, OR 0.43, 95% CI 0.86, -0.01, p = 0.44), prior allograft transplantation (OR 15.12, 95% CI 26.98, -3.31, p = 0.041), longer trauma-to-BTM-application intervals (OR 0.01, 95% CI 0.001, -0.001, p = 0.038), positive wound swabs before BTM (OR 7.15, 95% CI 13.50, -0.80, p = 0.028) and peripheral artery disease (OR 10.80, 95% CI 18.63, -2.96, p = 0.007) were associated with poorer BTM take. Higher BMI (OR 0.40, 95% CI 0.76, -0.08, p = 0.026), increasing BTM graft surface areas (OR 0.58, 95% CI -1.00, -0.17, p = 0.005), prior allograft (OR 12.20, 95% CI -21.99, -2.41, p = 0.015) or autograft transplantations (OR 22.42, 95% CI 38.69, -6.14, p = 0.001), tumour as the aetiology of the wound (OR 37.42, 95% CI 57.41, -17.83, p = 0.001), diabetes (OR 6.64, 95% CI 12.80, -0.48, p = 0.035) and impaired kidney function (OR 5.90, 95% CI 10.94, -0.86, p = 0.021) were associated with poorer STSG take after delamination of BTM, whereas higher BTM take rates were associated with better STSG take (OR 0.40, 95% CI 0.31,0.50, p < 0.001). CONCLUSION: Extensive complex wounds of different aetiologies unsuitable for immediate STSG can be successfully reconstructed by means of two-staged BTM application and subsequent skin grafting. Importantly, presence of wound contamination or infection and prior allograft coverage appear to jeopardise good BTM and STSG take.
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Implantes Absorbibles , Trasplante de Piel , Piel Artificial , Humanos , Masculino , Persona de Mediana Edad , Femenino , Trasplante de Piel/métodos , Trasplante de Piel/efectos adversos , Adulto , Traumatismos de los Tejidos Blandos/cirugía , Traumatismos de los Tejidos Blandos/etiología , Factores de Riesgo , Procedimientos de Cirugía Plástica/métodos , Procedimientos de Cirugía Plástica/efectos adversos , Anciano , Estudios RetrospectivosRESUMEN
INTRODUCTION: Significant morbidity and mortality are hallmarks of the functional decline seen in physically frail patients. The modified frailty index 5 (mFI-5) represents a risk predictor score that has been validated as a comorbidity-based scale in surgery. Serum albumin levels of <3.5 g/dL (hypoalbuminemia) have also been implicated with poor postoperative outcomes. However, the association between these two parameters remains to be investigated. We aimed to elucidate the interdependence of preoperative albumin levels and frailty, as evaluated by the mFI-5 score, and its reliability to prognosticate postoperative results in free flap reconstruction (FFR). METHODS: We conducted a multicenter, retrospective cohort study and accessed the ACS National Surgical Quality Improvement Program (ACS-NSQIP) from 2008 to 2021. We identified all adult patients (≥18 years of age) who underwent a FFR. We extracted perioperative data and lab values including albumin. Multivariable linear and logistic regression analyses were performed to identify independent risk predictors. Main outcomes involved mortality, length of hospital stay, reoperation, medical and surgical complications, and discharge destination within the 30-day postoperative period. RESULTS: A total of 34,571 patients were included in the study, with an average age of 53.9 years (standard deviation [SD] 12.2) and an average body mass index (BMI) of 28.8 (SD 6.1). Of these patients, 7484 were male (21.6%), whereas 22,363 (64.7%) had no frailty (mFI = 0). Additionally, 9466 patients had a frailty score of 1 (27.4%), 2505 had a score of 2 (7.2%), 226 had a score of 3 (0.7%), and 11 had a score of 4 or higher (0.0%). Albumin levels were available for 16,250 patients (47.0%), and among them, 1334 (8.2%) had hypoalbuminemia. Regression analyses showed that higher mFI scores were independent predictors of any, surgical, and medical complications, as well as increased rates of reoperations, unplanned readmissions, and prolonged hospital stays. Hypoalbuminemia independently predicted any, surgical, and medical complications, and higher mortality, reoperation, and longer hospital stay. When both frailty and albumin levels (mFI-5 and albumin) were considered together, this combined assessment was found to be a more accurate predictor of all major outcomes (any, medical and surgical complications, mortality, and reoperation). Further, our analysis identified a weak negative correlation between serum albumin levels and mFI scores (Spearman R: -.1; p < .0001). CONCLUSION: In conclusion, this cohort study highlights the association of hypoalbuminemia with adverse postoperative outcomes, including those not directly related to frailty. Simultaneously, higher mFI scores independently predicted outcomes not associated with hypoalbuminemia. Stemming from these findings, we recommend considering both serum albumin levels and frailty in patients receiving FFR. This perioperative algorithm may help provide more individualized planning including multidisciplinary care and pre and posthabilitation.
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Fragilidad , Colgajos Tisulares Libres , Hipoalbuminemia , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Fragilidad/complicaciones , Hipoalbuminemia/complicaciones , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Reproducibilidad de los Resultados , Estudios Retrospectivos , Medición de Riesgo/métodos , Factores de Riesgo , Albúmina SéricaRESUMEN
BACKGROUND: Robot-assisted pelvic lymph node dissection (rPLND) has been reported in heterogenous groups of patients with melanoma, including macroscopic or at-high-risk-for microscopic metastasis. With changing indications for surgery in melanoma, and availability of effective systemic therapies, pelvic dissection is now performed for clinically detected bulky lymph node metastasis followed by adjuvant drug therapy. rPLND has not been compared with open pelvic lymph node dissection (oPLND) for modern practice. METHODS: All patients undergoing pelvic node dissection for macroscopic melanoma at a single institution were reviewed as a cohort, observational study. RESULTS: Twenty-two pelvic lymph node dissections were identified (8 oPLND; 14 rPLND). The number of pelvic lymph nodes removed was similar (median oPLND 6.5 (interquartile range [IQR] 6.0-12.5] versus rPLND 6.0 [3.75-9.0]), with frequent matted nodes (11/22, 50.0%). Operative time (median oPLND 130 min [IQR 95.5-182] versus rPLND 126 min [IQR 97.8-160]) and complications (Clavien-Dindo scale) were similar. Length of hospital stay (median 5.34 days (IQR 3.77-6.94) versus 1.98 days (IQR 1.39-3.50) and time to postoperative adjuvant therapy (median 11.6 weeks [IQR 10.6-18.5] versus 7.71 weeks [IQR 6.29-10.4]) were shorter in the rPLND group. No differences in pelvic lymph node recurrence (p = 0.984), distant metastatic recurrence (p = 0.678), or melanoma-specific survival (p = 0.655) were seen (median follow-up 21.1 months [rPLND] and 25.7 months [oPLND]). CONCLUSIONS: rPLND is an effective way to remove bulky pelvic lymph nodes in melanoma, with a shorter recovery and reduced interval to initiating adjuvant therapy compared with oPLND. This group of patients may especially benefit from neoadjuvant systemic approaches to management.
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Linfadenopatía , Melanoma , Robótica , Humanos , Melanoma/tratamiento farmacológico , Melanoma/cirugía , Melanoma/patología , Ganglios Linfáticos/cirugía , Ganglios Linfáticos/patología , Escisión del Ganglio Linfático , Pelvis/cirugía , Linfadenopatía/cirugía , Estudios Retrospectivos , Espacio Retroperitoneal/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND: Noncompliance with evidence-based interventions and guidelines contributes to significant and variable recurrence and progression in patients with non-muscle-invasive bladder cancer (NMIBC). The implementation of a quality performance indicator (QPI) programme in Scotland's National Health Service (NHS) aimed to improve cancer outcomes and reduce nationwide variance. OBJECTIVE: To evaluate the effect of hospitals achieving benchmarks for two specific QPIs on time to recurrence and progression in NMIBC. DESIGN, SETTING, AND PARTICIPANTS: QPIs for bladder cancer (BC) were enforced nationally in April 2014. NHS health boards collected prospective data on all new BC patients. Prospectively recorded surveillance data were pooled from 12 collaborating centres. INTERVENTION: QPIs of interest were (1) hospitals achieving detrusor muscle (DM) sampling target at initial transurethral resection of bladder tumour (TURBT) and (2) use of single instillation of mitomycin C after TURBT (SI-MMC). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary and secondary endpoints were time to recurrence and progression, respectively. Kaplan-Meier and Cox multivariable regression analyses were performed. KEY FINDINGS AND LIMITATIONS: Between April 1, 2014 and March 31, 2017, we diagnosed 3899 patients with new BC, of which 2688 were NMIBC . With a median follow up of 60.3 mo, hospitals achieving the DM sampling target had a 5.4% lower recurrence rate at 5 yr than hospitals not achieving this target (442/1136 [38.9%] vs 677/1528 [44.3%], 95% confidence interval [CI] = 1.6-9.2, p = 0.005). SI-MMC was associated with a 20.4% lower recurrence rate (634/1791 [35.4%] vs 469/840 [55.8%], 95% CI = 16.4-24.5, p < 0.001). On Cox multivariable regression, meeting the DM target and SI-MMC were associated with significant improvement in recurrence (hazard ratio [HR] 0.81, 95% CI = 0.73-0.91, p = 0.0002 and HR 0.66, 95% CI = 0.59-0.74, p < 0.004, respectively) as well as progression-free survival (HR 0.62, 95% CI = 0.45-0.84, p = 0.002 and HR 0.65, 95% CI = 0.49-0.87, p = 0.004, respectively). We did not have a national multicentre pre-QPI control. CONCLUSIONS: Within a national QPI programme, meeting targets for sampling DM and SI-MMC in the real world were independently associated with delays to recurrence and progression in NMIBC patients. PATIENT SUMMARY: Following the first 3 yr of implementing a novel quality performance indicator programme in Scotland, we evaluated compliance and outcomes in non-muscle-invasive bladder cancer. In 2688 patients followed up for 5 yr, we found that achieving targets for sampling detrusor muscle and the single instillation of mitomycin C during and after transurethral resection of bladder tumour, respectively, were associated with delays in cancer recurrence and progression.
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BACKGROUND: Free flap-based soft-tissue reconstruction comes at the price of donor-site morbidity. The arteriovenous loop (AVL) technique can overcome this issue by allowing for the de novo generation of axially vascularized soft-tissue flaps from vein grafts embedded into different matrices. Application of the AVL technique has been limited by insufficient long-term volume retention and poor tissue stability. The authors investigated the suitability of a novel human dermal scaffold to improve volume retention and tissue stability. METHODS: AVLs were created in 28 immunocompetent rats and embedded in either decellularized human dermal scaffolds (experimental group, n = 14) (Epiflex) or bovine collagen/elastin matrices (control group, n = 14) (MatriDerm) in subcutaneous polytetrafluoroethylene chambers. The weight and volume of engineered tissues, the extent of angiogenesis, and the proportion of proliferating cells were compared between groups on postoperative days (PODs) 21 and 28 by means of immunohistochemistry and micro-computed tomography. RESULTS: On POD 28, both groups displayed homogeneous microvascular networks on histopathology and micro-computed tomography. Mean microvessel counts and surface areas and the percentage of proliferating cells did not differ between the groups. However, the experimental human scaffold group displayed significantly smaller volume loss and significantly less tissue degradation compared with bovine matrix controls (volume retention, 102% ± 5% versus 27% ± 7% on POD 21, and 79% ± 12% versus 12% ± 7% on POD 28, respectively; P < 0.0001). CONCLUSION: Compared with bovine matrices, decellularized human scaffolds allow for superior volume retention and tissue stability of de novo engineered soft-tissue AVL flaps in rats. CLINICAL RELEVANCE STATEMENT: AVLs allow for the de novo generation of vascularized soft-tissue flaps. However, insufficient long-term volume retention is still an issue. The authors' study shows that decellularized human matrices guarantee superior volume stability of de novo grown soft-tissue flaps in rats.
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Colágeno , Andamios del Tejido , Humanos , Ratas , Animales , Bovinos , Microtomografía por Rayos X , Colgajos Quirúrgicos/irrigación sanguínea , Ingeniería de Tejidos/métodos , ElastinaRESUMEN
ABSTRACT: Initial findings of hand infections warrant a thorough treatment strategy depending on the progress of the infection. The decision for surgical treatment can be unclear. Searching to improve the quality of diagnostics, we reviewed the literature regarding the use of point-of-care ultrasound (PCUS) in hand infections and analyzed patients undergoing decision-making with PCUS. We searched PubMed, Scopus, Cochrane Register, and Google Scholar for the use of PCUS in therapy planning in infections of the hand. In addition, we screened our patients from July 1, 2020, to November 30, 2020, to validate the potential benefit of ultrasound examination in suspected hand infections. We evaluated initial clinical examinations versus blinded sonographic assessments in the context of correct decision to proceed with surgery or conservative treatment. Two thousand forty-eight studies within the topic were identified, but only 9 studies were found eligible to be included with a total of 88 patients. The studies illustrate that ultrasound can be performed on all patients, including children and pregnant women, and can be performed in a timely manner. In our retrospective analysis of 20 patients with suspected hand infection, the clinical and ultrasound assessment led to surgery in 13 cases. Of those 13 patients, 7 revealed intraoperative pus. By retrospective assessment of solely the ultrasound images, surgery would have been indicated in 9 cases, including all 7 cases with intraoperative pus. Clinical examination and ultrasound can help in detecting infections of the hand. Ultrasound examination, however, seems to yield a lower false-positive rate than clinical examination. Ultrasound could be a valuable addition to clinical examination.
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Toma de Decisiones Clínicas , Infecciones , Sistemas de Atención de Punto , Ultrasonografía , Humanos , Estudios Retrospectivos , Supuración , Mano/patología , Infecciones/diagnóstico por imagenRESUMEN
OBJECTIVES: Infused sedatives are often utilised to alleviate distress at the end of life. Which sedative best achieves this is unknown. This study compares breakthrough medication requirements of patients treated with the novel agent dexmedetomidine compared with patients treated with standard-care sedatives. METHODS: A retrospective cross-cohort comparison. Two studies of patients at the end of life under sedation at the same palliative care unit, one utilising novel sedatives, and the other standard care were compared. Breakthrough medication requirements were compared using paired t-tests, including opioids, benzodiazepines and anticholinergics. Changes in background infusions were compared. RESULTS: The dexmedetomidine cohort required less breakthrough interventions per day compared with the standard care group, the reduction was significant (2.2 vs 3.9, p=0.003). There was a significant difference in benzodiazepine requirements, with the dexmedetomidine cohort requiring fewer doses per day than the standard care cohort (1.1 vs 0.6, p=0.03). Anticholinergics were more commonly utilised in the standard care cohort but there was no significant difference (p=0.22). Opioid requirements were similar across cohorts with comparable rates of breakthrough use and infusion increases. CONCLUSIONS: This study demonstrates a reduction in breakthrough medication requirements, particularly benzodiazepines, for patients sedated with dexmedetomidine at end of life.