A Decade of Nipple-Sparing Mastectomy: Lessons Learned in 3035 Immediate Implant-Based Breast Reconstructions.

BACKGROUND: Nipple-sparing mastectomy is commonly performed for breast cancer treatment or prevention. The authors present one of the largest breast reconstruction series in the literature. METHODS: A single-institution retrospective review was conducted from 2007 to 2019. RESULTS: The authors' query identified 3035 implant-based breast reconstructions after nipple-sparing mastectomy, including 2043 direct-to-implant and 992 tissue expander-to-implant reconstructions. The overall major complication rate was 9.15%, and the nipple necrosis rate was 1.20%. Therapeutic mastectomy was associated with higher overall complications and explantations compared with prophylactic mastectomy ( P < 0.01). In comparisons of unilateral and bilateral procedures, bilateral mastectomy had an increased risk for complications (OR, 1.46; 95% CI, 0.997 to 2.145; P = 0.05). Tissue-expander reconstructions had higher rates of nipple necrosis (1.9% versus 0.88%; P = 0.015), infection (4.2% versus 2.8%; P = 0.04), and explantation (5.1% versus 3.5%; P = 0.04) compared with direct-to-implant reconstruction. When assessing plane of reconstruction, the authors found similar rates of complications between subpectoral dual-plane and prepectoral reconstruction. There was no difference in complications between reconstruction with acellular dermal matrix or mesh compared with total or partial muscle coverage without acellular dermal matrix/mesh (OR, 0.749; 95% CI, 0.404 to 1.391; P = 0.361). Multivariable regression analysis revealed preoperative radiotherapy (OR, 2.465; 95% CI, 1.579 to 3.848; P < 0.001), smoking (OR, 2.53; 95% CI, 1.581 to 4.054; P < 0.001), and a periareolar incision (OR, 3.657; 95% CI, 2.276 to 5.875; P < 0.001) to be the strongest predictors of complications and nipple necrosis ( P < 0.05). CONCLUSIONS: Nipple-sparing mastectomy and immediate breast reconstruction has a low rate of complications. In this series, radiation therapy, smoking, and incision choice predicted overall complications and nipple necrosis, whereas direct-to-implant reconstruction and acellular dermal matrix or mesh did not increase risk. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Topical Nitroglycerin Ointment Reduces Mastectomy Flap Necrosis in Immediate Autologous Breast Reconstruction.

BACKGROUND: Mastectomy flap necrosis (MFN) is a common complication of immediate breast reconstruction that greatly affects patient satisfaction and cosmetic outcomes. Topical nitroglycerin ointment, with its low cost and negligible side effects, has been shown to significantly decrease the incidence of MFN in immediate implant-based breast reconstruction, but its utility has not been studied in immediate autologous reconstruction. METHODS: With institutional review board approval, a prospective cohort study was performed of all consecutive patients undergoing immediate free-flap breast reconstruction by a single reconstructive surgeon at a single institution between February of 2017 and September of 2021. Patients were divided into two cohorts: those who received 30 mg of topical nitroglycerin ointment to each breast at the conclusion of the operation (September of 2019 to September of 2021) and those who did not (February of 2017 to August of 2019). All patients underwent intraoperative SPY angiography, and mastectomy skin flaps were débrided intraoperatively based on imaging. Independent demographic variables were analyzed, and dependent outcome variables included mastectomy skin flap necrosis, headache, and hypotension requiring removal of ointment. RESULTS: A total of 35 patients (49 breasts) were included in the nitroglycerin cohort and 34 patients (49 breasts) were included in the control group. There was no significant difference in patient demographics, medical comorbidities, or mastectomy weight between cohorts. The rate of MFN decreased from 51% in the control group to 26.5% in the group that received nitroglycerin ointment ( P = 0.013). There were no documented adverse events associated with nitroglycerin use. CONCLUSION: Topical nitroglycerin ointment significantly decreases the rate of MFN in patients undergoing immediate autologous breast reconstruction without significant adverse effects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Mucor infection associated with global COVID-19 pandemic - an institutional histopathological study

Background: Coronavirus disease 2019 (COVID-19) in the recent times have instilled signs of immunosuppression globally which has further precipitated increasing range of opportunistic infections. Mucormycosis is a distressing opportunistic fungal infection with a high incidence and is the third commonest acute invasive infection following candidiasis and aspergillosis. The aim of the present observational study is to delineate the enigmatic histopathological profile between mucormycosis cases seen prior to pandemic (PPM) and pandemic associated mucormycosis (PAM). Material and methods: Tissue archives of 105 histopathologically diagnosed cases of mucormycosis were included and analysed for demographical details and histopathological parameters like fungal load and localization, granuloma formation, necrosis, inflammatory infiltrate and tissue invasion. Results: 0ut of 105 included cases, 11/105 (10.48%) were reported PPM and 94/105 (89.52%) PAM. Among 94 cases of PAM, 51/94 (54%) cases also showed COVID-19 positivity, while 43/94 (46%) did not. Of all the histological variables, increased fungal load and necrosis were observed in PAM relative to PPM cases. Conclusions: The histopathological variables like fungal load, necrosis, granuloma formation and tissue invasion, could help the clinician in assessing the clinical status at the time of tissue diagnosis and improve the treatment accordingly. (AU)

Mucormycosis infection associated with global COVID-19 pandemic - an institutional histopathological study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) in the recent times have instilled signs of immunosuppression globally which has further precipitated increasing range of opportunistic infections. Mucormycosis is a distressing opportunistic fungal infection with a high incidence and is the third commonest acute invasive infection following candidiasis and aspergillosis. The aim of the present observational study is to delineate the enigmatic histopathological profile between mucormycosis cases seen prior to pandemic (PPM) and pandemic associated mucormycosis (PAM). MATERIAL AND METHODS: Tissue archives of 105 histopathologically diagnosed cases of mucormycosis were included and analysed for demographical details and histopathological parameters like fungal load and localization, granuloma formation, necrosis, inflammatory infiltrate and tissue invasion. RESULTS: 0ut of 105 included cases, 11/105 (10.48%) were reported PPM and 94/105 (89.52%) PAM. Among 94 cases of PAM, 51/94 (54%) cases also showed COVID-19 positivity, while 43/94 (46%) did not. Of all the histological variables, increased fungal load and necrosis were observed in PAM relative to PPM cases. CONCLUSIONS: The histopathological variables like fungal load, necrosis, granuloma formation and tissue invasion, could help the clinician in assessing the clinical status at the time of tissue diagnosis and improve the treatment accordingly.

Defining Mastectomy Skin Flap Necrosis: A Systematic Review of the Literature and a Call for Standardization.

BACKGROUND: Mastectomy skin flap necrosis following breast reconstruction may lead to wound dehiscence, infection, implant exposure, and reconstructive failure. The absence of a standardized definition for it has led to variation in estimated incidence, from as low as 2 percent to greater than 40 percent. The authors systematically reviewed the literature on mastectomy skin flap necrosis to characterize existing definitions and provide a framework for future classification. METHODS: A systematic review of the PubMed and Cochrane databases identified studies reporting a discrete definition of mastectomy skin flap necrosis and corresponding outcomes in breast reconstruction. Provided definitions were extracted, categorized, and comparatively analyzed. RESULTS: Fifty-nine studies met inclusion criteria, with a combined total of 14,368 patients and 18,920 breasts. Thirty-four studies (57.6 percent) reported mastectomy skin flap necrosis solely as a function of total breasts, and 11 (18.6 percent) reported mastectomy skin flap necrosis solely as a function of total patients. Only 14 studies (23.7 percent) provided two separate rates. The overall rate of mastectomy skin flap necrosis was 10.4 percent (range, 2.3 to 41.2 percent) and 15.3 percent (range, 4.7 to 39.0 percent), when reported per breast or per patient, respectively. Studies were categorized by mastectomy skin flap necrosis definition, including intervention (n = 33), depth (n = 20), area (n = 4), and timing (n = 2). Mastectomy skin flap necrosis rates were highest in studies defining necrosis by depth (15.1 percent), followed by intervention (9.6 percent), timing (6.4 percent), and area (6.3 percent). Necrosis rates among studies defining mastectomy skin flap necrosis by intervention, depth, and area were found to be statistically different (p < 0.001). CONCLUSIONS: Reported mastectomy skin flap necrosis definitions and outcomes vary significantly in the existing literature. For accurate characterization and quantification, a clear, simplified, consensus definition must be adopted.

Association of SARS-CoV-2 placental histopathology findings with maternal-fetal comorbidities and severity of COVID-19 hypoxia.

OBJECTIVE: SARS-CoV-2 is known to impact multiple organ systems, with growing data to suggest the potential for placental infection and resultant pathology. Understanding how maternal COVID-19 disease can affect placental histopathology has been limited by small study cohorts with mild disease, review by multiple pathologists, and potential confounding by maternal-fetal comorbidities that can also influence placental findings. This study aims to identify pathologic placental findings associated with COVID-19 disease and severity, as well as to distinguish them from changes related to coexisting maternal-fetal comorbidities. METHODS: This is an observational study of 61 pregnant women with confirmed SARS-CoV-2 infection who delivered and had a placental histological evaluation at NYU Langone Health between March 19, 2020 and June 30, 2020. Primary outcomes were the prevalence of placental histopathologic features and their association with maternal-fetal comorbidities and severity of COVID-19 related hypoxia. Analysis was performed using Fisher's exact test and t-test with p < 0.05 considered significant. RESULTS: Sixty-one placentas were included in the study cohort, 71% from pregnancies complicated by at least one maternal-fetal comorbidity. Twenty-five percent of placentas were small for gestational age and 77% exhibited at least one feature of maternal vascular malperfusion. None of the histopathologic features in the examined placentas were associated with the presence of any specific maternal-fetal comorbidity. Thirteen percent of the cohort required maternal respiratory support for COVID-19 related hypoxia. Villous trophoblast necrosis was associated with maternal supplemental oxygen requirement (67 vs. 33%, p = 0.04) and intubation (67 vs. 33%, p = 0.01). CONCLUSION: In pregnancies complicated by COVID-19 disease, there was a high prevalence of placental histopathologic changes identified, particularly features of maternal vascular malperfusion, which could not be attributed solely to the presence of maternal-fetal comorbidities. The significantly increased prevalence of villous trophoblast necrosis in women needing respiratory support suggests a connection to the severity of COVID-19 illness.

Global patterns of necrotizing soft tissue infections: A systematic review and meta-analysis.

BACKGROUND: Frequency, microbiology, and outcomes of necrotizing soft tissue infections vary based on locoregional and environmental factors; however, there has been no global survey of these patterns. We performed a systematic review/meta-analysis on published reports of necrotizing soft tissue infections from across the globe. METHODS: Peer-reviewed empirical studies examining rates of polymicrobial and monomicrobial necrotizing soft tissue infections with microbial isolation and overall mortality rate were extracted along with geographic location using PubMed, Scopus, ProQuest, and Web of Science. Random-effects meta-analyses and sensitivity analyses were performed, adjusting for publication bias. Meta-regression analyses examined moderator effects of risk factors. RESULTS: One hundred and five studies (8,718 total patients) were included. Pooled prevalence of polymicrobial and monomicrobial infections were 53% and 37.9%, respectively. Truncal necrotizing soft tissue infections were commonly polymicrobial (P < .001), whereas monomicrobial infections prevailed in extremities (P = .008). Global prevalence of monomicrobial necrotizing soft tissue infections was observed to increase by 1.1% annually (P = .003). Staphylococcus aureus was the most common organism globally and in North America, Asia, the Middle East, and Africa, followed by Streptococcus pyogenes and Escherichia coli. Methicillin-resistant S. aureus accounted for 16% of necrotizing soft tissue infections globally. Overall mortality was 23.1%, observed to decline globally over the last decade (P = .020). No regional differences were noted for mortality. CONCLUSION: Although polymicrobial infections remain predominant worldwide, the incidence of monomicrobial infections is increasing. The observed decline in necrotizing soft tissue infection-related mortality is encouraging and may reflect advances in management, despite major variations in available healthcare resources globally.

Mandibular Reconstruction with Scapular Systems: A Single-Center Case Series Involving 208 Flaps.

BACKGROUND: The scapular flap is the most versatile composite flap used for mandibular reconstruction. The purpose of this study was to review and summarize findings of cases of mandibular reconstruction with a scapular flap and describe associated outcomes and complications. METHODS: A total of 208 microvascular scapular free flaps were performed for mandibular reconstruction in a total of 205 patients from 2003 to 2018. This study involved a retrospective review of all eligible patients' medical records. RESULTS: There were seven cases (3.4 percent) of microvascular thrombosis. Postoperative bone union was achieved by 201 patients, except for five with total flap necrosis and two with partial flap necrosis. There were four cases (1.9 percent) of mandibular condyle dislocation. Two major types of complications were observed at the donor site, including four cases of infection and six cases of scapular body fracture. Postoperative denture prosthesis was introduced to 97 patients (47.3 percent). Implant treatment was performed in 10 patients (4.9 percent). Functional and aesthetic outcomes were good to excellent. CONCLUSIONS: The scapular composite free flap for mandibular reconstruction was associated with favorable outcomes and demonstrated satisfactory results. Although scapular bone fracture is rare, patients who have undergone mandibular reconstruction using a scapular flap should be monitored for its presence. . CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Digital ischaemia aetiologies and mid-term follow-up: A cohort study of 323 patients.

ABSTRACT: Upper extremity digital ischaemia (UEDI) is a rare heterogeneous condition whose frequency is 40 times less than that of toe ischaemia. Using a large cohort, the aim of this study was to evaluate aetiologies, prognosis and midterm clinical outcomes of UEDI.All patients with UEDI with or without cutaneous necrosis in a university hospital setting between January 2000 to December 2016 were included. Aetiologies, recurrence of UEDI, digital amputation and survival were analyzed retrospectively.Three hundred twenty three patients were included. UEDI due to cardio-embolic disease (DICE) was the highest occurring aetiology with 59 patients (18.3%), followed by DI due to Systemic Sclerosis (SSc) (16.1%), idiopathic causes (11.7%), Thromboangiitis obliterans (TAO) (9.3%), iatrogenic causes (9.3%), and cancer (6.2%). DICE patients tended to be older and featured more cases with arterial hypertension whereas TAO patients smoked more tobacco and cannabis. During follow-up, recurrences were significantly more frequent in SSc than in all other tested groups (P < .0001 vs idiopathic and DICE, P = .003 vs TAO) and among TAO patients when compared to DICE patients (P = .005). The cumulated rate of digital amputation was higher in the SSc group (n = 18) (P = .02) and the TAO group (n = 7) (P = .03) than in DICE (n = 2).This retrospective study suggests that main aetiologies of UEDI are DICE, SSc and idiopathic. This study highlights higher frequency of iatrogenic UEDI than previous studies. UEDI associated with SSc has a poor local prognosis (amputations and recurrences) and DICE a poor survival. UEDI with SSc and TAO are frequently recurrent.

Systematic review of partial breast reconstruction with pedicled perforator artery flaps: Clinical, oncological and cosmetic outcomes.

The use of chest wall perforator flaps (CWPFs) following breast conservation surgery for breast cancer has become a useful tool in the armamentarium of the oncoplastic breast surgeon, however robust evidence for the technique is lacking. The aim of this study was to conduct a systematic review appraising the current evidence for the use of CWPFs, evaluating clinical, oncological and cosmetic outcomes. A PRISMA-compliant systematic review, with PROSPERO published protocol a priori and search of all relevant database and trial registries between 1990 to July 2020. Eleven studies amounting to 432 cases were reviewed and considered to be at high risk of bias due to small sample size, selective outcome reporting and selection bias. Heterogeneity due to lack of consensus of outcome measures prevented meaningful analysis. Fifty-two (12.3%) clinical complications were recorded: seroma (n = 9; 2.1%), fat necrosis (n = 9; 2.4%), haematoma (n = 8; 1.9%), infection (n = 9; 2.1%), and flap necrosis (n = 9; 2.1%). Thirty-four (10.8%) patients had an involved positive margin, 29 patients underwent re-excision (9.3%) and four underwent completion mastectomy (1.3%). One local recurrence and six distant recurrences were observed during a mean follow up of 21 months (1-49). A pooled patient cosmetic satisfaction descriptor of good or excellent was described in 93% of cases. CWPFs are a safe method of partial breast reconstruction following BCS. They are associated with a low complication rate, acceptable short-term oncological outcomes and satisfactory cosmetic outcome. There is a relative paucity in quality of data in this field and larger prospective studies are needed to investigate outcomes further.

Analysis and Clinical Characteristics of 23 Cases of Bone Marrow Necrosis.

BACKGROUND: Bone marrow necrosis (BMN) is a rare secondary disorder of many discrepant neoplastic processes. The etiology is diverse, and malignancy is the most common background disease. PATIENTS AND METHODS: Between 2005 and 2019, a total of 23 cases of BMN were detected and analyzed at Zhujiang Hospital and Nanfang Hospital. RESULTS: In our study, the 40-60-year-old age group was the one with the highest incidence of BMN (n = 12, 52.2%). The background diseases of patients with BMN varied. Eighteen (78.3%) of 23 patients were diagnosed with hematologic diseases at the same time, most of which were acute B lymphocytic leukemia (n = 8, 34.8%). The complete blood count of these 23 patients noted a decrease in hemoglobin (100%), a decrease or increase in white blood cells and neutrophils, and thrombocytopenia (78.3%). The levels of lactate dehydrogenase (> 300 U/L) and serum ferritin (> 500 µg/L) were elevated in all patients, and 16 (94.1%) of 17 patients presented with increased d-dimer levels. The 2-week cumulative survival and 2-year cumulative survival of patients with BMN were 56.5% and 47.4%, respectively. The mortality probability within 2 weeks was 43.5%, and the adjusted mortality probability was 26.7% within 2 weeks to 2 years, indicating that patients with BMN had the greatest risk of death within 2 weeks. CONCLUSION: BMN patients with B lymphocytic leukemia as the background disease had a better prognosis than those with other background diseases. BMN of unknown etiology may have an extremely poor prognosis. Therefore, diagnosing the background disease plays an important role in the treatment of BMN.

Utilisation of distally based sural fasciocutaneous flaps in lower extremity reconstruction: a single-centre experience with 88 paediatric patients.

BACKGROUND: No large series have analysed distally based sural fasciocutaneous (DBSF) flaps in paediatric patients. The aims of this study were to assess the reliability and analyse the potential risk factors for these flaps and to describe complications in the donor site and the functional follow-up results. METHODS: Between June 2002 and November 2017, 88 DBSF flaps were used to reconstruct soft tissue defects in paediatric patients. Potential risk factors, reconstruction outcomes, and complications in the donor site of the flaps were analysed. RESULTS: Among the 88 flaps, partial necrosis developed in 8 flaps (9.1%). The partial necrosis rate was significantly higher in flaps with the top edge located in the 9th zone (26.1%), with a length-width ratio (LWR) ≥ 5:1 (28.6%), and with a dimension of the skin island ≥ 100 cm2 (22.7%). Partial necrosis did not occur in flaps with a dimension of the skin island < 80.0 cm2 or with a skin-island width < 7.0 cm. The reconstruction outcomes in most paediatric patients were evaluated as "excellent" or "good". The incidence of obvious scarring was higher in the donor site. CONCLUSIONS: Partial necrosis of DBSF flaps will significantly increase when the top edge of the flap is located in the 9th zone, when the LWR of the flap is ≥ 5:1, or when the dimension of the skin island is ≥ 100.0 cm2. Flaps with a skin-island width < 7.0 cm or with a dimension of the skin island < 80 cm2 are relatively safe and reliable.

Vaginal necrosis: A rare late toxicity after radiation therapy.

Vaginal necrosis is a late radiation tissue injury with serious morbidity complications. It is rare, and its incidence is not well assessed in prospective trials. Patient comorbidities and radiation dose can significantly increase the risk. As treatment of gynecologic malignancies often involve a multidisciplinary approach, timely diagnosis and appropriate management by physicians of the team are crucial. Untreated vaginal necrosis can lead to infection, hemorrhage, necrosis-related fistulation to the bladder or rectum, perforation, and death. In this review, we describe the pathophysiology of vaginal necrosis, its clinical course, and management options.

Predictors of bowel necrosis in patients with acute mesenteric ischemia: systematic review and meta-analysis.

Acute mesenteric ischemia (AMI) is a serious medical condition that can progress to transmural bowel necrosis. Prediction of the onset of bowel necrosis in AMI is crucial to justify surgical intervention before more severe consequences supervene. This systematic review aimed to identify the significant predictors of bowel necrosis in AMI in the current literature. In adherence to the PRISMA guidelines, electronic databases were searched for studies that reported significant independent predictors of bowel necrosis in AMI. The quality of the studies was assessed with MINORS score. The main outcomes of the review were the incidence and predictors of bowel necrosis in patients with AMI and the mortality rate. This systematic review comprised nine articles that included 963 patients of a median age of 57 years. Irreversible bowel necrosis was found in 402 (41.7%) patients. The significant predictors of bowel necrosis were subdivided into eight clinical, seven biochemical, and six radiologic parameters. Eight parameters were reported by two or more studies, whereas 13 were reported by a single study. Based on the weight and odds ratio of the predictive parameters, a prognostic scoring system, Emile-Khan Score, was proposed. Several clinical, biochemical, and radiologic predictors of bowel necrosis were reported in the literature. Pooling of odds ratios was feasible for eight factors that were reported by more than one study. Further studies are needed to ascertain the utility of the other predictive factors.Level of evidence: Level II (systematic review and meta-analysis).

The Addition of Partial or Circumferential Liposuction to Abdominoplasty Is Not Associated With a Higher Risk of Skin Necrosis.

BACKGROUND: Combining abdominoplasty with liposuction is a common practice for optimal patient aesthetic outcomes. In the past, several practitioners have argued against liposuction due to the potential for vascular insufficiency, especially with central liposuction. Despite these concerns for flap damage with resultant necrosis, the incidence of this complication has not been comprehensively investigated. OBJECTIVES: The authors therefore examined the incidence of necrotic complications, including skin and fat necrosis as well as partial/total flap loss, in patients who underwent abdominoplasty alone (AA) or abdominoplasty with partial or circumferential liposuction (APCL). METHODS: Literature searches were performed in PubMed/Medline and Embase with no query limits. For the systematic review, data from the studies were extracted into a form including primary author, publication year, study design, number of AA and APCL patients, abdominal zone(s) treated with liposuction, average lipoaspirate volume, follow-up time, necrotic complications, and revision procedures. A meta-analysis was separately performed for 13 studies that included patients who underwent both AA and APCL. RESULTS: The overall rate of necrotic complications was lower in the APCL group (0.39%) compared with the AA group (1.01%). The incidence of necrotic complications was low for all patients, with a pooled partial flap loss rate of 0.24% and a pooled skin necrosis rate of 0.23%. The forest plots revealed that patients who underwent APCL do not face a higher risk of skin necrosis or revision compared with those who underwent AA. CONCLUSIONS: Performing APCL is a safe combined procedural approach and can confer added benefits of improved patient satisfaction and aesthetic outcomes.

Nonenteric Lesions of Necrotic Enteritis in Commercial Chickens in California: 25 Cases (2009-2018).

Necrotic enteritis (NE) is an important enteric disease affecting a wide variety of avian species, including poultry, caused by Clostridium perfringens type G and, rarely, type C. Significant economic losses can result from elevated mortality rates and poor performance, such as decreased weight gain associated with intestinal damage and impaired absorption of nutrients. Additional losses can result from elevated condemnation at the processing plant because of a high incidence of cholangiohepatitis. Nonenteric lesions associated with NE have been rarely reported. This paper describes uncommon presentations of NE in commercial chickens received by the California Animal Health and Food Safety Laboratory (Turlock and Tulare branches) between 2009 and 2018. Overall, extraintestinal lesions associated with C. perfringens were diagnosed in 25 cases of NE involving commercial broiler chickens. The extraintestinal sites most commonly affected included liver, followed by gizzard, bursa of Fabricius, gall bladder, and spleen. The etiology of these lesions, C. perfringens, was confirmed from a combination of gross, bacteriologic, microscopic, and immunohistochemical findings. The most common predisposing factors for NE identified were coccidiosis (56%, 14/25) and immunosuppressive disease agents, including infectious bursal disease virus (16%, 4/25) and fowl adenovirus group 1 (4%, 1/25). Additionally, four cases (16%) had microscopic lesions compatible with cystic enteritis, probably of viral etiology. This study describes the incidence of extraintestinal lesions of NE in chickens, underlying the role of enteric disorders and immunosuppression as major predisposing factors for the development of NE.

Persistence of a Clostridium perfringens Strain in a Broiler Chicken Farm over a Three-Year Period.

Clostridium perfringens, a commensal of the intestinal tract of many animal species, has been associated with necrotic enteritis (NE), an economically significant poultry disease. Clostridium perfringens is known to survive in the environment for extended periods of time through the formation of spores. These spores have the potential to be transmitted to subsequent flocks. Persistence of a single C. perfringens strain in a broiler chicken farm environment has, however, been poorly documented. The aim of this study was to compare multiple isolates of C. perfringens collected over time in a single farm with recurrent episodes of NE. Isolates were recovered from the intestines of chickens affected with NE (2014 and 2016 outbreaks) and from healthy chickens (2017), as well as from environmental samples (2016). PCR characterization of those isolates showed that all sampling groups contained netB-positive isolates except for the environmental samples. Moreover, results showed that all environmental isolates were positive for the cna adhesin whereas other groups had lower numbers of cna-positive isolates. Biofilm formation assays showed that most of the isolates were able to form biofilm. Pulsed-field gel electrophoresis analysis showed that one clone was present in every sampling group, with the exception of the 2014 outbreak. However, one clone found in the latter group was highly similar, having 94% similarity with the persistent C. perfringens clone. This study describes for the first time the persistence of a C. perfringens strain on a broiler chicken house over a 3-yr period.

Acute Postoperative Complications in Prepectoral versus Subpectoral Reconstruction following Nipple-Sparing Mastectomy.

BACKGROUND: Nipple-sparing mastectomy is associated with improved aesthetics and oncologic safety. Recently, there has been a resurgence in prepectoral reconstruction. Because of limited data comparing complication rates on patients undergoing prepectoral breast reconstruction, this study compared 30-day postoperative complications by plane of prosthetic placement. METHODS: A retrospective review was conducted on all consecutive patients undergoing nipple-sparing mastectomy with implant-based reconstruction with either prepectoral or subpectoral placement from 2014 to 2018. The primary outcome was a composite, acute 30-day postoperative complication, including nipple-areola complex necrosis, mastectomy flap necrosis, wound dehiscence, infection, hematoma, and seroma. Secondary outcomes included nipple loss and rates of unintended reoperations. Univariate and mixed effects multivariate logistic regression were used to compare outcomes. RESULTS: A total of 228 patients and 405 breasts were included in the final cohort, with 202 in the subpectoral cohort and 203 in the prepectoral cohort. The overall complication rate was 7.65 percent, with no significant difference between subpectoral and prepectoral cohorts (9.41 percent versus 5.91 percent, respectively; p = 0.148). Prepectoral reconstruction was associated with significantly reduced ischemic complications, including nipple loss because of necrosis (2.97 percent versus 0.49 percent, respectively; p = 0.015) and mastectomy flap necrosis (5.45 percent versus 0 percent; p = 0.003). There were no significant differences in rates of infection, hematoma, seroma, or implant loss/exchange. CONCLUSIONS: Prepectoral reconstruction is associated with similar overall 30-day postoperative complications and reoperations compared to traditional subpectoral implants. However, prepectoral reconstruction was associated with significantly decreased ischemic complications, including mastectomy flap necrosis and nipple-areola complex loss because of necrosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Cs-131 brachytherapy for patients with recurrent glioblastoma combined with bevacizumab avoids radiation necrosis while maintaining local control.

PURPOSE: Re-irradiation of recurrent glioblastoma (GBM) may delay further recurrence but re-irradiation increases the risk of radionecrosis (RN). Salvage therapy should focus on balancing local control (LC) and toxicity. We report the results of using intraoperative Cesium-131 (Cs-131) brachytherapy for recurrent GBM in a population of patients who also received bevacizumab. METHODS AND MATERIALS: Twenty patients with recurrent GBM underwent maximally safe neurosurgical resection with Cs-131 brachytherapy between 2010 and 2015. Eighty Gy was prescribed to 0.5 cm from the surface of the resection cavity. All patients previously received adjuvant radiotherapy and temozolomide, and received bevacizumab before or after salvage brachytherapy. Seven of 20 (35%) tumors were multiply recurrent and had been previously salvaged with external beam radiotherapy. Patients received MRI scans every 2 months monitored for recurrence, progression, and RN. RESULTS: Median tumor diameter was 4.65 cm (range, 1.2-6.3 cm). Median number of seeds pace was 41 (range, 20-74) with total seed activity 96.8U (range, 41.08-201.3U). At a median followup of 19 months, crude LC was 85% and median overall survival was 9 months (range, 5-26 months). There were two postoperative wound infections (10%), three seizures (15%), and 0% incidence of RN. CONCLUSIONS: Our study demonstrates that while LC and survival are similar to other studies of postoperative external beam radiotherapy, no RN occurred in any of these patients, including 7 multiply re-irradiated patients. Of interest, there were patients with multiple recurrences whose survival extended beyond 20 months. These findings suggest that the use of highly conformal Cs-131 brachytherapy is a promising treatment for patients with recurrent GBM with minimal risk of development of RN.