Postoperative Prophylactic Antibiotic Use in Breast Reduction Mammoplasty: A Single Centre Retrospective Cohort Study.

Introduction: Breast reduction mammoplasty (BRM) is a common procedure performed by plastic surgeons treating patients with hypermastia. It is customary to give preoperative prophylactic intravenous antibiotics for BRM, followed by several days of postoperative prophylactic oral antibiotics, despite the lack of evidence of their effectiveness in preventing surgical site infections (SSIs). The purpose of this study is to determine if the addition of prophylactic postoperative antibiotics is more effective in preventing SSIs in comparison to a single dose of preoperative prophylactic antibiotics in BRM. Methods: A retrospective analysis of 124 elective BRM cases by a single senior plastic surgeon was completed. Two study groups were formed based on the location of surgery and each group was assigned a different antibiotic regimen. The first antibiotic regimen consisted of a single preoperative intravenous dose of antibiotics (group 1), while the second regimen consisted of a preoperative intravenous dose followed by a 5-day course of oral antibiotics (group 2). Results: Overall SSI rate was 5.6%. Infection rate in group 1 was 8.1% in comparison to 3.2% for group 2 (P value .44). Overall, the incidence of complications was 29.0%; 38.7% in group 1 and 19.4% in group 2 (P value .03). Complications consisted of 35 cases of delayed wound healing, 7 SSIs and 2 hematomas requiring evacuation. Conclusion: Study results demonstrated that the use of postoperative prophylactic antibiotics for BRM had no significant effect on the rate of SSIs.

Introduction: La mammoplastie de réduction mammaire (MRM) est une procédure couramment pratiquée par les chirurgiens plastiques traitant des patientes ayant une hypertrophie mammaire. Il est habituel d'administrer une prophylaxie intraveineuse préopératoire pour la MRM puis plusieurs jours d'antibiothérapie prophylactique postopératoire par voie orale en dépit de l'absence de données probantes de leur efficacité à prévenir les infections du site chirurgical. L'objectif de cette étude était de déterminer si l'ajout d'antibiotiques postopératoires à visée prophylactique est plus efficace pour la prévention des infections de la cicatrice opératoire que la seule administration préopératoire d'une dose unique d'antibiotiques à visée prophylactique dans la MRM. Méthodes: Une analyse rétrospective a été réalisée par un seul chirurgien plastique expérimenté de 124 cas de MRM planifiés. Deux groupes d'étude ont été constitués en fonction du lieu de la chirurgie parmi deux centres chirurgicaux et chaque groupe ayant reçu l'un des deux protocoles d'antibiothérapie suivants : le premier schéma thérapeutique était constitué d'une seule dose préopératoire administrée par voie intraveineuse (groupe 1) et le deuxième consistait en l'administration de la dose préopératoire par voie intraveineuse suivie de 5 jours d'antibiotiques par voie orale (groupe 2). Résultats: Le taux global d'infections de la cicatrice opératoire était de 5,6%. Le taux d'infections dans le groupe 1 a été de 8,1%, comparativement à 3,2% dans le groupe 2 (P = 0,44). L'incidence globale des complications a été de 29,0%; 38,7% dans le groupe 1 et 19,4% dans le groupe 2 (P = 0,03). Les complications ont été 35 cas de retard de cicatrisation, 7 cas d'infection du site chirurgical et 2 hématomes nécessitant leur évacuation. Conclusion: Les résultats de l'étude ont montré que l'utilisation postopératoire d'antibiotiques à visée prophylactique pour la mammoplastie de réduction mammaire n'avait pas d'effet significatif sur le taux d'infections du site chirurgical.

Patient-reported outcomes of neurologic and neuropsychiatric symptoms in mild COVID-19: a prospective cohort study.

BACKGROUND: Various neurologic manifestations have been reported in patients with COVID-19, mostly in retrospective studies of patients admitted to hospital, but there are few data on patients with mild COVID-19. We examined the frequency and persistence of neurologic/neuropsychiatric symptoms in patients with mild COVID-19 in a 1-year prospective cohort study, as well as assessment of use of health care services and patient-reported outcomes. METHODS: Participants in the Alberta HOPE COVID-19 trial (hydroxychloroquine v. placebo for 5 d), managed as outpatients, were prospectively assessed 3 months and 1 year after their positive test result. They completed detailed neurologic/neuropsychiatric symptom questionnaires, the telephone version of the Montreal Cognitive Assessment (T-MoCA), the Kessler Psychological Distress Scale (K10) and the EuroQol EQ-5D-3L (measure of quality of life). Close informants completed the Mild Behavioural Impairment Checklist (MBI-C) and the Informant Questionnaire on Cognitive Decline in the Elderly. We also tracked use of health care services and neurologic investigations. RESULTS: The cohort consisted of 198 participants (87 female [43.9%] median age 45 yr, interquartile range 37-54 yr). Of the 179 participants with symptom assessments, 139 (77.6%) reported at least 1 neurologic symptom, the most common being anosmia/dysgeusia (99 [55.3%]), myalgia (76 [42.5%]) and headache (75 [41.9%]). Forty patients (22.3%) reported persistent symptoms at 1 year, including confusion (20 [50.0%]), headache (21 [52.5%]), insomnia (16 [40.0%]) and depression (14 [35.0%]); 27/179 (15.1%) reported no improvement. Body mass index (BMI), a history of asthma and lack of full-time employment were associated with the presence and persistence of neurologic/neuropsychiatric symptoms; female sex was independently associated with both (presence: odds ratio [OR] adjusted for age, race, BMI, history of asthma and neuropsychiatric history 5.04, 95% confidence interval [CI] 1.58 to 16.10). Compared to participants without persistent symptoms, those with persistent symptoms had more hospital admissions and family physician visits, and worse MBI-C scores and less frequent independence for instrumental activities at 1 year (83.8% v. 97.8%, p = 0.005). Patients with any or persistent neurologic symptoms had worse psychologic distress (K10 score ≥ 20: adjusted OR 12.1, 95% CI 1.4 to 97.2) and quality of life (median EQ-5D-3L visual analogue scale rating 75 v. 90, p < 0.001); 42/84 (50.0%) had a T-MoCA score less than 18 at 3 months, as did 36 (42.9%) at 1 year. Participants who reported memory loss were more likely than those who did not report such symptoms to have informant-reported cognitive-behavioural decline (1-yr MBI-C score ≥ 6.5: adjusted OR 15.0, 95% CI 2.42 to 92.60). INTERPRETATION: Neurologic/neuropsychiatric symptoms were commonly reported in survivors of mild COVID-19, and they persisted in 1 in 5 patients 1 year later. Symptoms were associated with worse participant- and informant-reported outcomes. Trial registration: ClinicalTrials.gov, no. NCT04329611.

Quality of life, respiratory symptoms, and health care utilization 1 year following outpatient management of COVID-19: a prospective cohort study.

The long-term impact of COVID-19 among those with mild infections is not well characterized. Among 81 adults who completed online assessments at 3- and 12-months following infection, quality of life scores did not significantly improve over time. Among 62 subjects who also completed telephone interviews, respiratory symptoms or exercise limitation were reported by 42% at a median follow-up of 387 days (IQR 251-402 days). Those with persistent respiratory symptoms scored lower on the EQ-5D visual analog score compared to those without. Persistent respiratory symptoms were associated with a lower likelihood of full-time employment at 1 year (aOR 0.09, 95%CI 0.01-0.91; P = 0.041). In an adjusted linear regression, persistent respiratory symptoms (P = 0.037) and female sex (P = 0.016) were both independent risks for increased visits to a primary care provider. This cohort study demonstrates that respiratory symptoms are frequent at 1 year following COVID-19 and more importantly, are associated with negative impacts on employment, quality of life, and health care utilization. Further research is needed to determine the pathophysiology and risk factors for persistent symptoms as well as optimal management strategies to improve the level of functioning and quality of life.

Sleep-wake states change the interictal localization of candidate epileptic source generators.

STUDY OBJECTIVES: To compare estimated epileptic source localizations from 5 sleep-wake states (SWS): wakefulness (W), rapid eye movement sleep (REM), and non-REM 1-3. METHODS: Electrical source localization (sLORETA) of interictal spikes from different SWS on surface EEG from the epilepsy monitoring unit at spike peak and take-off, with results mapped to individual brain models for 75% of patients. Concordance was defined as source localization voxels shared between 2 and 5 SWS, and discordance as those unique to 1 SWS against 1-4 other SWS. RESULTS: 563 spikes from 16 prospectively recruited focal epilepsy patients across 161 day-nights. SWS exerted significant differences at spike peak but not take-off. Source localization size did not vary between SWS. REM localizations were smaller in multifocal than unifocal patients (28.8% vs. 54.4%, p = .0091). All five SWS contributed about 45% of their localizations to converge onto 17.0 ± 15.5% voxels. Against any one other SWS, REM was least concordant (54.4% vs. 66.9%, p = .0006) and most discordant (39.3% vs. 29.6%, p = .0008). REM also yielded the most unique localizations (20.0% vs. 8.6%, p = .0059). CONCLUSIONS: REM was best suited to identify candidate epileptic sources. sLORETA proposes a model in which an "omni-concordant core" of source localizations shared by all five SWS is surrounded by a "penumbra" of source localizations shared by some but not all SWS. Uniquely, REM spares this core to "move" source voxels from the penumbra to unique cortex not localized by other SWS. This may reflect differential intra-spike propagation in REM, which may account for its reported superior localizing abilities.

Anterior Interosseous-to-Ulnar Motor Nerve Transfers: A Single Center's Experience in Restoring Intrinsic Hand Function.

Background: Transfer of the anterior interosseous nerve (AIN) into the ulnar motor branch improves intrinsic hand function in patients with high ulnar nerve injuries. We report our outcomes of this nerve transfer and hypothesize that any improvement in intrinsic hand function is beneficial to patients. Methods: A retrospective review of all AIN-to-ulnar motor nerve transfers, including both supercharged end-to-side (SETS) and end-to-end (ETE) transfers, from 2011 to 2018 performed by 2 surgeons was conducted. All adult patients who underwent this nerve transfer for any reason with greater than 6 months' follow-up and completed charts were included. Primary outcome measures were motor function using the British Medical Research Council (BMRC) grading system and subjective satisfaction with surgery using a visual analog scale. Secondary outcome measures included complications and donor site deficits. Results: Of the 57 patients who underwent nerve transfer, 32 patients met the inclusion criteria. The average follow-up and average time to surgery were 12 and 15.6 months, respectively. The overall average BMRC score was 2.9/5, with a trend toward better recovery in patients who received earlier surgery (<12 months = BMRC 3.7, ≥12 months = BMRC 2.2; P < .01). Patients with an SETS transfer had better results that those with an ETE transfer (SETS = 3.2, ETE = 2.6). There were no donor deficits after operation. One patient developed complex regional pain syndrome. Conclusions: Patients with earlier surgery and an in-continuity nerve (receiving an SETS transfer) showed improved recovery with a higher BMRC grade compared with those who underwent later surgery. Any improvements in intrinsic hand function would be beneficial to patients.

Surgeon-administered Ultrasound-guided Peripheral Nerve Blocks in Outpatient Procedures of the Upper Extremity.

Outpatient hand surgery is often performed in the operating room, which can result in prolonged waiting times for patients when operating room resources are limited. Few studies have explored the application of ultrasound-guided nerve blocks in the setting of outpatient hand surgery. Fifty patients were enrolled in this prospective study. Ultrasound-guided peripheral nerve blocks were performed at the level of the elbow and proximal forearm for outpatient hand surgeries. A timer was used to record the time to administer the block and time to affect. A post-procedure survey was administered, which included a numerical analogue scale (0-10) and Likert rating scale questions to characterize the patients' pain experience for receiving the block and pain during the procedure: pain experienced by patients receiving the ultrasound-guided nerve block(s) (0-10), mean: 1.84; pain experienced by patients during a procedure (0-10), mean: 0.56; surgeon satisfaction during the procedure (0-10), mean 9.78. Average time to perform the ultrasound-guided nerve block(s) was 4 minutes 58 seconds; average time from completion of the block to effect reported by patients, 5 minutes 42 seconds; the average time for performing the procedure, 21 minutes 30 seconds. Our study shows that the use of ultrasound to block peripheral nerves of the forearm is effective; <10% of patients required additional local anesthetic. The technique is safe; no complications were reported. The technique is efficient in an outpatient hand surgery setting.

Gouty Stenosing Tenosynovitis: Trigger Finger as a First Presentation of Tophaceous Gout.

Gout can lead to the deposition of tophi and chronic arthritis, for which surgical management is indicated when tophi interfere with the function of the finger. This case report discusses the management of a 37-year-old man with a past medical history of gout who presented with triggering of his small finger from gouty infiltration of his flexor digitorum profundus (FDP) tendon. An exploratory procedure that included tenolysis and release of the A1 pulley was performed. Gouty infiltration of the FDP tendon was noted intraoperatively and biopsied, which was later confirmed by histopathological analysis as being gouty tophus. The patient regained full function of the affected finger postoperatively and has since had no recurrence. Gouty tenosynovitis is a rare cause of trigger finger and should be considered as part of the differential diagnosis. Treatment for gouty tenosynovitis consists of A1 pulley release and careful excision of gouty tophus to restore tendon glide and hand function.

Can REM Sleep Localize the Epileptogenic Zone? A Systematic Review and Analysis.

Epilepsy is a common and debilitating neurological disease. When medication cannot control seizures in up to 40% of cases, surgical resection of epileptogenic tissue is a clinically and cost- effective therapy to achieve seizure freedom. To simultaneously resect minimal yet sufficient cortex, exquisite localization of the epileptogenic zone (EZ) is crucial. However, localization is not straightforward, given relative difficulty of capturing seizures, constraints of the inverse problem in source localization, and possible disparate locations of symptomatogenic vs. epileptogenic regions. Thus, attention has been paid to which state of vigilance best localizes the EZ, in the hopes that one or another sleep-wake state may hold the key to improved accuracy of localization. Studies investigating this topic have employed diverse methodologies and produced diverse results. Nonetheless, rapid eye movement sleep (REM) has emerged as a promising sleep-wake state, as epileptic phenomena captured in REM may spatially correspond more closely to the EZ. Cortical neuronal asynchrony in REM may spatially constrain epileptic phenomena to reduce propagation away from the source generator, rendering them of high localizing value. However, some recent work demonstrates best localization in sleep-wake states other than REM, and there are reports of REM providing clearly false localization. Moreover, synchronistic properties and basic mechanisms of human REM remain to be fully characterized. Amidst these uncertainties, there is an urgent need for recording and analytical techniques to improve accuracy of localization. Here we present a systematic review and quantitative analysis of pertinent literature on whether and how REM may help localize epileptogenic foci. To help streamline and accelerate future work on the intriguing anti-epileptic properties of REM, we also introduce a simple, conceptually clear set-theoretic framework to conveniently and rigorously describe the spatial properties of epileptic phenomena in the brain.

Donor Site Scar Preference in Patients Requiring Free Flap Reconstruction.

INTRODUCTION: In traumatic reconstruction, surgeons frequently harvest flaps from donor sites that they are comfortable performing and with favourable tissue characteristics without determining the patients preferred site. The study's goal was to determine participants free flap donor site preference based on aesthetics as it relates to the size of the defect being reconstructed. METHODOLOGY: Participants were asked to imagine that they were in a trauma that resulted in a wound of variable sizes. They were presented with a selection of common donor site scars produced from harvesting small, medium, and large free flaps. They were instructed to rank the donor sites in order of preference and score each donor site of 10. RESULTS: Two hundred eighty-seven participants (mean age: 28, female: 62%) completed the survey. For small reconstructions, the preferred donor site scars were on the leg or back compared to arm or abdomen. For medium size reconstructions, scars on the back and upper thigh were preferred over scars on the abdomen and anterior thigh. In small and medium reconstructions, the midline abdominal scar scored significantly lower than other donor sites. Participants preferred donor sites on the back, the thigh, and lower abdomen for large reconstructions. CONCLUSION: Participants preferred back, thigh, and hip locations perhaps relating to the ability to conceal these scars under clothing. If multiple flaps sites could be harvested, providing options to trauma patients undergoing free tissue transfer may result in increased satisfaction.

INTRODUCTION: Lors des reconstructions traumatiques, les chirurgiens prélèvent souvent des lambeaux aux sites qu'ils se sentent à l'aise d'utiliser et tiennent compte des caractéristiques favorables des tissus sans déterminer les préférences des patients. L'étude visait à déterminer le site de lambeaux que préféraient les participants en fonction de l'esthétique et de la dimension de l'anomalie à reconstruire. MÉTHODOLOGIE: Les participants ont été invités à imaginer qu'ils avaient été victimes d'un traumatisme responsable de plaies de diverses dimensions. Ils se sont fait présenter une sélection de cicatrices courantes aux sites du donneur, produites après le prélèvement de lambeaux de petite, moyenne ou grande dimension. Ils ont dû classer chacun de ces sites sur une note de dix, par ordre de préférence. RÉSULTATS: Au total, 287 participants (âge moyen de 28 ans, 62 % de femmes) ont participé au sondage. Pour les petites reconstructions, la jambe ou le dos était le site privilégié des cicatrices plutôt que le bras ou l'abdomen. Pour les reconstructions moyennes, les cicatrices sur le dos et le haut de la cuisse étaient favorisées à celles de l'abdomen et de la cuisse antérieure. Pour les reconstructions petites et moyennes, la cicatrice abdominale médiane obtenait une note significativement plus faible que les autres. Les participants préféraient le dos, la cuisse et le bas-ventre pour les reconstructions importantes. CONCLUSION: Les participants préfèrent le dos, la cuisse et la hanche, peut-être parce que les cicatrices peuvent alors être dissimulées sous des vêtements. S'il est possible de prélever des lambeaux de multiples sites, le fait de donner des choix aux patients traumatisés qui subissent un transfert de tissus libres pourrait engendrer une plus grande satisfaction.

Critically ill benign EEG variants: Is there such a thing?

Despite growing use of critical care electroencephalography (ccEEG) to detect seizures and status epilepticus in the intensive care unit (ICU), integrating ccEEG findings with traditionally described benign EEG variants (BEVs) is a relatively new concept. BEV-like waveforms are now increasingly encountered in the ICU, and have also been explicitly included in proposed definitions of brief potentially ictal rhythmic discharges (BIRDs) in the ICU, bringing to the fore the question of if and which EEG patterns in critically ill patients can be safely deemed "benign". Though well-characterized as benign in healthy outpatients at low pre-test risk for neurologic disease, the significance of BEVs in the ICU remains largely unknown. Simultaneously, there has been mounting evidence to suggest that certain BEVs can arise from heterogeneous intracranial sources, including some pathologic generators. We conducted an extensive literature review on all known BEVs to assess what is known of BEVs in the ICU. Here we discuss critically ill BEVs and how to interpret them.

Vascularized Pedicled Proximal Phalanx Flap for Spare Part for Reconstruction of Metacarpal Avulsion Injury.

Traumatic injuries to the hand with significant loss of bone or soft tissue can be quite difficult to reconstruct and often require an innovative and flexible surgical plan for reconstruction. We present a case of a young manual laborer with a significant crush avulsion injury involving his third and fourth metacarpals. We were able to preserve his fourth metacarpophalangeal joint by utilizing a pedicled vascularized proximal phalanx flap from the nonsalvageable third digit to reconstruct and provide osseous stability to the fourth metacarpal. The patient had excellent functional and aesthetic outcomes with full return to work at his farm by less than 12 months postoperatively.