COVID-associated complications after reconstructive breast surgery: a retrospective cohort study.

PURPOSE: The COVID pandemic significantly influenced reconstructive breast surgery regimens. Many surgeries were cancelled or postponed. COVID entails not only respiratory, but also coagulative symptoms. It, therefore, potentially increases the risk of postoperative complications. The incidence of perioperative COVID infection and its influence on postoperative recovery after reconstructive breast surgery is still unknown. METHODS: This dual center retrospective cohort study included patients that underwent reconstructive breast surgery between March 2020 and July 2021. Post-mastectomy autologous or implant-based breast reconstruction (ABR; IBR), as well as post-lumpectomy oncoplastic partial breast reconstruction (PBR) were eligible. Patient data were extracted from electronic medical records. Data regarding COVID-19 infection was collected through a questionnaire. The primary outcome was complication rate. RESULTS: The ABR, IBR and PBR groups consisted of 113 (12 COVID-positive), 41 (2 COVID-positive) and 113 (10 COVID-positive) patients. In the ABR and PBR groups, postoperative complications occurred significantly more often in patients with perioperative COVID-infection. Especially impaired wound healing occurred significantly more often in the ABR and PBR breasts, but also at the donor site of ABR patients with perioperative COVID. CONCLUSION: Perioperative COVID-infection increases susceptibility to complicated wound healing after reconstructive breast surgery. A possible explanation lies in the dysregulation of haemostasis by the virus, and its direct effects on microvasculature. A hypercoagulable state results. We recommend to postpone elective breast surgery for 4-6 weeks after COVID-19 infection. Also, precautionary measures remain important to minimize the risk of perioperative COVID-19 infection.

A computed tomography study investigating the effects of botulinum toxin injections prior to complex abdominal wall reconstruction.

OBJECTIVE: To explore how intramuscular injection of botulinum toxin A (BTA) affects the lateral abdominal wall (LAW) musculature, abdominal- and hernia dimensions, and muscle structure on computed tomography (CT) in patients scheduled for complex abdominal wall reconstruction (CAWR). METHODS: Retrospective analysis of prospectively registered patients who received bilateral intramuscular BTA injections into all three muscles of the LAW. Only patients for which a CT was available before and 3-6 weeks after BTA treatment prior to surgery were analyzed. RESULTS: Fifty-two patients were analyzed. Median hernia width in all patients decreased with 0.4 cm (IQR - 2.1;0.6) (p = 0.023). Median intra-abdominal transverse diameter increased with 0.9 cm (IQR - 0.2;3.3) (p = 0.001) and the intra-abdominal anterior-posterior diameter decreased with 0.5 cm (IQR - 1.3;0.5) (p = 0.017), making the abdomen more oval. Median LAW muscle length increased with 0.9 cm (IQR 0.0;2.4) per side (p < 0.001), muscle thickness decreased with 0.5 cm (IQR - 0.8;- 0.2) (- 25.0%) per side (p < 0.001), and muscle mass decreased with 3.9 cm2 (IQR - 6.4;-1.5) (- 15.8%) per side (p < 0.001). Median HU of the psoas muscles (density) increased with 4.8 HU (IQR 0.4;9.7) (10.3%) per side (p < 0.001). Effects of BTA were more pronounced in patients with a loss of domain (LoD) ≥ 20%. CONCLUSIONS: The main effect of BTA injections is elongation and thinning of the LAW muscles, more than a decrease in hernia width. Concomitantly, the abdomen becomes more oval. An increase of psoas muscles density is seen, associated with offloading of the LAW muscles. Patients with large LoD have a proportionally higher effect of BTA.

A systematic review and meta-analysis of technical aspects and clinical outcomes of botulinum toxin prior to abdominal wall reconstruction.

PURPOSE: To systematically review technical aspects and treatment regimens of botulinum toxin A (BTA) injections in the lateral abdominal wall musculature. We also investigated the effect of BTA on abdominal muscle- and hernia dimensions, and clinical outcome. METHODS: PubMed, EMBASE, CENTRAL, and CINAHL were searched for studies that investigate the injection of BTA in the lateral abdominal wall muscles. Study characteristics, BTA treatment regimens, surgical procedures, and clinical outcomes are presented descriptively. The effect of BTA on muscle- and hernia dimensions is analyzed using random-effects meta-analyses, and exclusively for studies that investigate ventral incisional hernia patients. RESULTS: We identified 23 studies, comprising 995 patients. Generally, either 500 units of Dysport® or 200-300 units of Botox® are injected at 3-5 locations bilaterally in all three muscles of the lateral abdominal wall, about 4 weeks prior to surgery. No major procedural complications are reported. Meta-analyses show that BTA provides significant elongation of the lateral abdominal wall of 3.2 cm per side (95% CI 2.0-4.3, I2 = 0%, p < 0.001); 6.3 cm total elongation, and a significant but heterogeneous decrease in transverse hernia width (95% CI 0.2-6.8, I2 = 94%, p = 0.04). Furthermore, meta-analysis shows that BTA pretreatment in ventral hernia patients significantly increases the fascial closure rate [RR 1.08 (95% CI 1.02-1.16, I2 = 0%, p = 0.02)]. CONCLUSION: The injection technique and treatment regimens of botulinum toxin A as well as patient selection require standardization. Bilateral pretreatment in hernia patients significantly elongates the lateral abdominal wall muscles, making fascial closure during surgical hernia repair more likely. STUDY REGISTRATION: A review protocol for this meta-analysis was registered at PROSPERO (CRD42020198246).

Outcomes of mid-term and long-term degradable biosynthetic meshes in single-stage open complex abdominal wall reconstruction.

OBJECTIVE: To assess clinical outcomes in patients that underwent open single-stage complex abdominal wall reconstruction (CAWR) with biosynthetic mesh. METHODS: Retrospective observational study of two prospectively registered series of consecutive patients undergoing CAWR with either long-term degradable (LTD) Phasix™ or mid-term degradable (MTD) BIO-A® biosynthetic mesh in a single institution between June 2016 and December 2019. RESULTS: From 169 patients with CAWR, 70 consecutive patients were identified who underwent CAWR with either LTD or MTD biosynthetic mesh. More than 85% of patients had an incisional hernia that could be classified as moderately complex to major complex due to a previous wound infection (67%), one or more complicating comorbidities (87.1%), one or more complicating hernia characteristics (75.7%) or contaminated or dirty defects (37.1%). Concomitant component separation was performed in 43 of 70 patients (61.4%). Overall surgical site infection (SSI) rate in these CAWR patients was 45.7%. Seventeen of 70 patients (24.3%) had computed tomography (CT) - and culture-confirmed SSI in direct contact of mesh, suspicious of mesh infection. Mesh removal for persistent local infection occurred in 10% (7 of 70) after a median of 229 days since surgery. Salvage rate of mesh after direct contact with infection was 58.8%. All removed meshes were in the LTD group. Seven patients (10%) had a recurrence; four patients in the LTD group (10%) had a recurrence at a median follow-up of 35 months and three patients in the MTD group (10%) at a median follow-up of 11 months. Three of the seven recurrences occurred in patients with SSI in persistent and direct contact with mesh. CONCLUSIONS: Comorbid patients undergoing open complex abdominal wall reconstruction are at high risk of postoperative wound complications regardless of which type of biosynthetic mesh is used. When in persistent and direct contact with infection, long-term biodegradable biosynthetic meshes may need to be removed, whereas mid-term biodegradable biosynthetic meshes can be salvaged.

The development and validation of risk-stratification models for short-term outcomes following contaminated complex abdominal wall reconstruction.

BACKGROUND: Short-term outcomes for patients undergoing contaminated complex abdominal wall reconstruction (CCAWR), including risk stratification, have not been studied in sufficiently high numbers. This study aims to develop and validate risk-stratification models for Clavien-Dindo (CD) grade ≥ 3 complications in patients undergoing CCAWR. METHODS: A consecutive cohort of patients who underwent CCAWR in two European national intestinal failure centers, from January 2004 to December 2015, was identified. Data were collected retrospectively for short-term outcomes and used to develop risk models using logistic regression. A further cohort, from January 2016 to December 2017, was used to validate the models. RESULTS: The development cohort consisted of 272 procedures performed in 254 patients. The validation cohort consisted of 114 patients. The cohorts were comparable in baseline demographics (mean age 58.0 vs 58.1; sex 58.8% male vs 54.4%, respectively). A multi-variate model including the presence of intestinal failure (p < 0.01) and operative time (p < 0.01) demonstrated good discrimination and calibration on validation. Models for wound and intra-abdominal complications were also developed, including pre-operative immunosuppression (p = 0.05), intestinal failure (p = 0.02), increasing operative time (p = 0.04), increasing number of anastomoses (p = 0.01) and the number of previous abdominal operations (p = 0.02). While these models showed reasonable ability to discriminate patients on internal assessment, they were not found to be accurate on external validation. CONCLUSION: Acceptable short-term outcomes after CCAWR are demonstrated. A robust model for the prediction of CD ≥ grade 3 complications has been developed and validated. This model is available online at www.smbari.co.uk/smjconv2.

Long-term outcomes after contaminated complex abdominal wall reconstruction.

PURPOSE: Complex abdominal wall repair (CAWR) in a contaminated operative field is a challenge. Available literature regarding long-term outcomes of CAWR comprises studies that often have small numbers and heterogeneous patient populations. This study aims to assess long-term outcomes of modified-ventral hernia working group (VHWG) grade 3 repairs. Because the relevance of hernia recurrence (HR) as the primary outcome for this patient group is contentious, the need for further hernia surgery (FHS) was also assessed in relation to long-term survival. METHODS: A retrospective cohort study with a single prospective follow-up time-point nested in a consecutive series of patients undergoing CAWR in two European national intestinal failure centers. RESULTS: In long-term analysis, 266 modified VHWG grade 3 procedures were included. The overall HR rate was 32.3%. The HR rates for non-crosslinked biologic meshes and synthetic meshes when fascial closure was achieved were 20.3% and 30.6%, respectively. The rates of FHS were 7.2% and 16.7%, and occurred only within the first 3 years. Bridged repairs showed poorer results (fascial closure 22.9% hernia recurrence vs bridged 57.1% recurrence). Overall survival was relatively good with 80% en 70% of the patients still alive after 5 and 10 years, respectively. In total 86.6% of the patients remained free of FHS. CONCLUSIONS: In this study of contaminated CAWR, non-crosslinked biologic mesh shows better results than synthetic mesh. Bridging repairs with no posterior and/or anterior fascial closure have a higher recurrence rate. The overall survival was good and the majority of patients remained free of additional hernia surgery.

Automated coaching to help parents increase their children's brushing frequency: an exploratory trial.

UNLABELLED: Advances in digital communication, such as the internet, now provide a cost effective channel to reach and help families struggling to establish good oral hygiene in their homes. This paper describes a novel internet based oral hygiene intervention whose design draws from advances in social cognitive models of behaviour change. Intervention components included role-modelling cartoons for children, a guide for parents on using rewards, a personalised plan with clear steps, tips to follow and a weekly 10-minute review of progress. OBJECTIVE: To evaluate the efficacy of the online coaching programme; specifically we expected that those in the intervention group would brush their teeth more frequently during the intervention period than those in the control group. BASIC RESEARCH DESIGN: An exploratory trial using a randomised controlled parallel approach. PARTICIPANTS: Children aged 5 to 9 years from 44 families (23 control and 21 intervention). MAIN OUTCOME MEASURE: An objective monitoring of tooth brushing. RESULTS: In the 3-week intervention period, children from families assigned to the coaching programme brushed their teeth 38% more often than those in the control group. CONCLUSIONS: The programme was effective in a number of respects. Opportunities for further research are discussed, including the need to create a more engaging system and so increase compliance.

Persistence of middle ear dysfunction after recurrent acute otitis media.

The presence of otitis media with effusion (OME) and high negative pressure (-200 to -400 mm H2O), were investigated in the follow-up of a randomized double-blind placebo-controlled trial on the efficacy of amoxicillin/clavulanic acid in the treatment of acute otitis media. All children in this study were recruited from a general practice population. Tympanometry results 1 month from the start of an episode of acute otitis media were taken as outcome criteria. Bilateral middle ear dysfunction was defined as bilateral OME, unilateral OME and contralateral or bilateral high negative pressure. Bilateral middle ear dysfunction was present in 47.9% of the patients. Of all the investigated factors of possible influence (age, sex, season, laterality of acute otitis media, therapy, and clinical course of acute otitis media), only season showed a statistically significant influence on the persistence of OME/high negative pressure (P = 0.001). Bilateral middle ear dysfunction was shown to be of prognostic value for the risk of a recurrence of acute otitis media (odds ratio 3.75).

A review of clinical trials regarding treatment of acute otitis media.

A survey was made of the English language literature on clinical trials of therapy in acute otitis media. The articles were analysed systematically for 24 parameters related to study design. We retrieved 50 studies published between 1965 and 1989. Surprisingly, the combination of a double-blind method, clearly defined inclusion criteria, and criteria for outcome was found in only 13 studies. Most of these 13 compared different antibiotic regimens and only 4 were placebo-controlled. A recommendation based on the conclusions reached can, even in these 13 studies, hardly be obtained due to failure to show an overall difference in favour of a specific treatment regimen. Our study shows that many trials are methodologically flawed which makes it difficult to accept their results. In view of current controversy on management of acute otitis media, well conducted placebo-controlled clinical trials are still needed.

Co-amoxiclav in recurrent acute otitis media: placebo controlled study.

OBJECTIVE: To determine the efficacy of coamoxiclav in children aged 6 months to 12 years with recurrent acute otitis media. DESIGN: A randomised double blind placebo controlled clinical trial. SETTING: General practice in the Netherlands. PATIENTS: 121 children with recurrent acute otitis media, defined by onset of otalgia and otoscopic signs of middle ear infection within four to 52 weeks after the previous attack. Confirmation of diagnosis and randomisation was done by otolaryngologists. INTERVENTION: Oral co-amoxiclav or placebo in weight related doses for seven days. MAIN OUTCOME MEASURE: An irregular clinical course defined as the presence of otalgia or a body temperature greater than or equal to 38 degrees C, or both, after three days. RESULTS: Eleven (16%; 95% confidence interval 9% to 28%) children had an irregular course in the co-amoxiclav group and 10 (19%; 9% to 31%) in the placebo group (difference not significant). Age, dichotomised at 2 years, was the only significant prognostic factor for irregular course of the disease (odds ratio 5.9; 1.8 to 19.1). Among children aged below 2 years, 28% (4/14) in the co-amoxiclav group and 58% (7/12) in the placebo group had irregular courses. For children 2 years and older these percentages were 13% (7/52) and 7% (3/41). CONCLUSION: Children with recurrent acute otitis media are at greater risk of an irregular clinical course of the disease than children with a first episode of acute otitis media. Co-amoxiclav has no significant benefit over placebo in treating children over 2 years with acute otitis media.

[Adenoid hypertrophy as initial symptom of an infection with the human immunodeficiency virus]. / Adenoïdhypertrofie als eerste verschijnsel van een infectie met het humane immunodeficiëntievirus.

A woman aged 25 yr consulted the Department of Otorhinolaryngology with complaints of persistent nasal obstruction caused by adenoid hypertrophy recurring shortly after recent adenoidectomy. Previous elaborate investigations did not reveal the cause of this unexplained phenomenon. Testing for human immunodeficiency virus (HIV) was positive. In case of an unexplained recurrent adenoid hypertrophy, an infection with the human immunodeficiency virus should be considered in the differential diagnosis.

Epidural administration of morphine for control of cancer pain: long-term efficacy and complications.

The long-term analgesic effects and the complications of epidural narcotic analgesia (ENA) were investigated in 40 cancer patients in whom systemic narcotic therapy failed to relieve pain or caused unacceptable side effects. In 32 patients, an externally fixated polyamide epidural catheter was used ("external group"), and in 8 patients, a polyurethane epidural catheter was tunneled and connected to a subcutaneous access port ("internal group"). The average duration of catheter treatment was 80.9 days (range 9-533 days). Twenty-five patients were treated as outpatients, and 15 remained hospitalized. Initially, all patients had significant or complete pain relief from 10 mg morphine/day, but the daily epidural morphine requirement showed a threefold increase during the first 3 weeks. During ENA, other methods of pain relief (radiotherapy, chemotherapy, surgery, epidural administration of local anesthetics, and nerve blocks) were necessary in 14 patients. Pharmacological side effects were of minor importance, with transient pruritus being the main subjective complaint. In the "external" group, 31 catheter replacements were necessary, mostly due to backflow of injected morphine outside the catheter. In two patients of the internal group, neurological complications occurred, but these disappeared spontaneously after removal of the system. They were presumably due to epidural fibrosis with compression of the spinal cord. Further technical improvements are necessary for the easier use and higher safety of the catheter technique.

Reversed phase chromatography of isoaccepting tRNA's from healthy and crown gall tissues from Nicotiana tabacum.

RPC 5 (Reversed Phase Chromatography) of aminoacyl-tRNA's from healthy and crown gall (induced by Agrobacterium tume-faciens strain B6) tobacco tissues were compared for eleven amino acids. For ten amino acids: alanine, arginine, glutamic acid, glycine, isoleucine, leucine, lysine, methionine, tyrosine, and valine, no qualitative or quantitative differences could be detected between aminoacyl-tRNA's from both sources. Phenylalanyl-tRNA's from crown gall tissues gave two peaks on RPC 5; the minor early eluting species (peak 1) was always absent in elution profiles of phenylalanyl-tRNA's from healthy tissues or from tobacco leaves. After the "Y" base was removed by pH 2.9 treatment, peak 2 of phenylalanine tRNA was shifted to the position of peak 1.