A nomogram for predicting outcomes following pedicled flap reconstruction of the lower extremity.

INTRODUCTION: Lower extremity reconstructions with soft tissue flaps account for a significant proportion of reconstructive surgery. Pedicled flaps are a procedure of choice, particularly in multimorbid patients and those with small to medium-sized defects. Complication rates are high and should not be underestimated, with accurate preoperative risk factor assessment being imperative. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program Database (2008-2021), we analyzed all patients who underwent pedicled flap reconstruction of the lower extremity. Demographic data, comorbidities, and perioperative data were extracted. We identified risk factors of major surgical complications within 30 days of surgery through uni- and multivariate regression analyses. On this basis, a nomogram for predicting the risk of complications was developed to allow for feasible point-of-care risk assessment. RESULTS: A total of 6475 adult patients were identified. The most common comorbidities were hypertension (n = 3363, 51.9%) and obesity (n = 2306, 35.6%) and most common American Society of Anesthesiologists (ASA) class was class 3 (n = 3703, 57.2%). The most common complication was bleeding/transfusion (n = 1293, 19.9%). Multivariate regression revealed longer procedures, inpatient setting, higher ASA scores, hypertension, and procedures performed by orthopedic and vascular surgeons as predictors for higher risk of post-operative complications. CONCLUSION: Leveraging a risk- and case-mix-adjusted multi-institutional database, a nomogram for post-operative surgical complications within 30 days after pedicled flap reconstruction in the lower extremity was developed. This broadly applicable risk prediction tool can aid in decision-making when assessing patient eligibility.

The free vastus lateralis-And conjoined vastus lateralis anterolateral thigh/tensor fascia lata flap for oncological chest wall reconstruction.

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.

The Epidemiology and Outcomes of Perineal and Genital Burn Injury in Low- and Middle- Income Countries: A Global Burn Registry Study.

INTRODUCTION: The epidemiology, care, and outcomes of perineal and genital burns (PG) in high-income countries have been previously described, but an analysis of this topic in LMICs has yet to be performed. We use the World Health Organization's Global Burn Registry to fill this gap. METHODS: The GBR was searched from inception to November 2023 to identify all burn patients, excluding cases from high-income countries. Demographics and mechanism of injury were retrieved. Primary outcomes were length of hospital stay (LOHS), surgical intervention, discharge with physical impairment, and mortality. A multivariate regression analysis was performed controlling for burnt total body surface area (TBSA), age, sex, inhalation injury, mechanism of burn and care center characteristics. RESULTS: Of 9041 patients identified, 1213 (13.4 %) had PG burns with 136 (1.6 %) isolated to the PG region. PG patients had higher TBSA (p < 0.001) and more inhalation injury (p < 0.001). They had better access to rehabilitation and lower access to theater space for burns (p < 0.001). Multivariable analysis showed that PG patients had longer LOHS (p = 0.001), greater mortality (p < 0.001), were less likely to undergo surgery (p = 0.01) or be discharged home with physical impairment (p = 0.03). CONCLUSION: Similarities and differences exist between high- and low/middle-income countries in terms of the patterns of injury, care, and recovery in patients with PG burns. The longer LOHS and higher mortality among PG patients, previously reported in high-income countries, are verified. This highlights the importance of greater vigilance when caring for such patients.

The long-term intercorrelation between post-burn pain, anxiety, and depression: a post hoc analysis of the "RE-ENERGIZE" double-blind, randomized, multicenter placebo-controlled trial.

BACKGROUND: Despite the growing prevalence of burn survivors, a gap persists in our understanding of the correlation between acute burn trauma and the long-term impact on psychosocial health. This study set out to investigate the prevalence of long-term pain and symptoms of anxiety and depression in survivors of extensive burns, comparing this to the general population, and identify injury and demographic-related factors predisposing individuals to psychosocial compromise. METHODS: RE-ENERGIZE was an international, double-blinded, randomized-controlled trial that enrolled 1200 patients with partial- or full-thickness burns that required surgical treatment. For the post hoc analysis, we excluded participants who did not complete the Short Form Health Survey (SF-36) questionnaire. Normative data were taken from the 2021 National Health Interview Survey dataset. Propensity score matching was performed using the nearest-neighbor 1-to-1 method, and the two cohorts were compared in terms of chronic pain, and symptoms of anxiety and depression. A multivariable analysis was performed on the burns cohort to identify factors predicting post-discharge pain and symptoms of anxiety and depression. RESULTS: A total of 600 burn patients and 26,666 general population adults were included in this study. Following propensity score matching, both groups comprised 478 participants each, who were predominately male, white, overweight and between 20 and 60 years old. Compared to the general population, burn patients were significantly more likely to report the presence of moderate and a lot of pain (p = 0.002). Symptoms of anxiety were significantly higher in the burn population in two of four levels (most of the time; some of the time; p < 0.0001 for both). Responders in the burn population were significantly less likely to report the absence of depressive symptoms (p < 0.0001). Burn patients were also significantly more likely to report that their mental health affects their social life. TBSA, history of depression, and female sex were identified as independently associated factors for pain, anxiety, and depressive symptoms. The presence of chronic pain and anxiety symptoms independently predicted for symptoms of depression. CONCLUSIONS: Analyzing the largest multicenter cohort of patients with extensive burns, we find that burn injury is associated with chronic pain, and symptoms of anxiety and depression. In addition, TBSA-burned and history of depression directly correlate with the prevalence of chronic pain, and symptoms of anxiety and depression. Finally, pain, and symptoms of anxiety and depression are interrelated and may have interactive effects on the process of recovery following burn injury. Burn patients would, therefore, benefit from a multidisciplinary team approach with early mobilization of pain and mental health experts, in order to promptly prevent the development of psychosocial challenges and their consequences.

The significance of timing in breast reconstruction after mastectomy: An ACS-NSQIP analysis.

BACKGROUND: A variety of breast reconstruction (BR) options are available. The significance of timing on outcomes remains debated. This study aims to compare complications in breast cancer patients undergoing implant-based and autologous BR immediately after mastectomy or at a delayed time point. METHODS: We reviewed the ACS-NSQIP database (2008-2021) to identify all female patients who underwent BR for oncological purposes. Outcomes were stratified by technique (implant-based versus autologous) and timing (immediate versus delayed), and included 30-day mortality, reoperation, (unplanned) readmission, and surgical and medical complications. RESULTS: A total of 21,560 patients were included: 11,237 (52%) implant-based (9791/87% immediate, 1446/13% delayed) and 10,323 (48%) autologous (8378/81% immediate, 1945/19% delayed). Complications occurred in 3666 (17%) patients (implant-based: n = 1112/11% immediate, n = 64/4.4% delayed cohorts; Autologous: n = 2073/25% immediate, n = 417/21% delayed cohorts). In propensity score weighting (PSW) analyses, immediate BR was associated with significantly more complications than delayed BR (p < 0.0001). This was the case for both implant-based and autologous BR, with a greater difference between the two time points noted in implant-based. Confounder-adjusted multivariable analyses confirmed these results. CONCLUSION: At the 30-day time point, delayed BR is associated with significantly lower complication rates than immediate BR, in both the implant-based and autologous cohorts. These findings are not a blanket recommendation in favor of immediate and/or delayed BR. Instead, our insights may guide surgeons and patients in decision-making and help refine patients' eligibility in a case-by-case workup.

Reconstruction of Hand and Foot Defects with Free Serratus Carpaccio Flap and Free Serratus Fascia Flap: A Comparative Retrospective Study of Surgical Outcomes.

BACKGROUND: Defects of the hand and foot often require an individualized reconstructive approach, due to their unique functional and aesthetic characteristics. Transferred tissues should be thin, pliable, and durable, with free fascial flaps meeting these requirements. This study aimed to evaluate the serratus fascia flap and the serratus carpaccio flap, which is a modification of the fascia flap, by including a thin muscle layer, with the goal of enhancing flap resilience and lowering morbidity rates. METHODS: Between January 2000 and December 2017, 31 patients underwent microsurgical reconstruction of the hand or foot either by serratus fascia flap (fascia group) or serratus carpaccio flap (carpaccio group). The serratus fascia flaps were mainly harvested between 2000 and 2012, and the serratus carpaccio flaps between 2013 and 2017. Patient records were reviewed retrospectively, regarding demographics, complications, overall flap survival, additional revision surgeries, and surgical outcome. Categorical variables were compared using Fisher's exact test and continuous data with the Mann-Whitney tests. Logistic regression was used to examine the correlation between comorbidities and postoperative complication rates. Differences were considered significant when p < 0.05. RESULTS: The fascia group consisted of 17 patients and the carpaccio group of 14 patients. The average patient age in the fascia group was 39.2 ± 10.5 years, and it was 39.1 ± 14.7 years in the carpaccio group. Overall complication rates were significantly lower in the carpaccio group than in the fascia group (28.6% vs. 70.6%, p = 0.03). The rates of overall flap survival (85.7% in the carpaccio group vs. 74.5% in the fascia group, p = 0.66) and partial flap loss (14.3% in the carpaccio group vs. 47.1% in the fascia group, p = 0.07) did not differ significantly among both groups. One postoperative hematoma of the donor site requiring revision surgery was reported in the carpaccio group (7.1%, p = 0.45) while no donor-site morbidity was reported in the fascia group. CONCLUSIONS: Our findings indicate that the serratus carpaccio flap presents a promising alternative to the serratus fascia flap. This modification has proven to be effective in substantially reducing postoperative complications requiring additional surgical interventions. Therefore, the serratus carpaccio flap can be considered a dependable reconstructive option for addressing complex soft tissue defects of the hand and foot, with complication rates that are within an acceptable range.

Combined versus Single Perforator Propeller Flaps for Reconstruction of Large Soft Tissue Defects: A Retrospective Clinical Study.

Sufficient wound closure of large soft tissue defects remains a challenge for reconstructive surgeons. We aimed to investigate whether combined perforator propeller flaps (PPFs) are suitable to expand reconstructive options. Patients undergoing PPF reconstruction surgery between 2008 and 2021 were screened and evaluated retrospectively. Of 86 identified patients, 69 patients received one perforator propeller flap, while 17 patients underwent combined PPF reconstruction with multiple flaps. We chose major complications as our primary outcome and defined those as complications that required additional surgery. Postoperatively, 27 patients (31.4%) suffered major complications. The propeller flap size, the type of intervention as well as the operation time were not associated with a higher risk of major complications. A defect size larger than 100 cm2, however, was identified as a significant risk factor for major complications among single PPFs but not among combined PPFs (OR: 2.82, 95% CI: 1.01-8.36; p = 0.05 vs. OR: 0.30, 95% CI: 0.02-3.37; p = 0.32). In conclusion, combined PPFs proved to be a reliable technique and should be preferred over single PPFs in the reconstruction of large soft tissue defects at the trunk and proximal lower extremity.

The Contribution of the Age Distribution of Cases to COVID-19 Case Fatality Across Countries : A Nine-Country Demographic Study.

BACKGROUND: There is wide variation in coronavirus disease 2019 (COVID-19) case-fatality rates (CFRs) across countries, leading to uncertainty about the true lethality of the disease. A large part of this variation may be due to the ages of individuals who are tested and identified. OBJECTIVE: To measure the contribution of distortions from the age distributions of confirmed cases to CFRs within and across populations. DESIGN: Cross-sectional demographic study using aggregate data on COVID-19 cases and deaths by age. SETTING: Population-based data from China, France, Germany, Italy, the Netherlands, South Korea, Spain, Switzerland, and the United States. PARTICIPANTS: All individuals with confirmed COVID-19, as reported by each country as of 19 April 2020 (n = 1 223 261). MEASUREMENTS: Age-specific COVID-19 CFRs and age-specific population shares by country. RESULTS: The overall observed CFR varies widely, with the highest rates in Italy (9.3%) and the Netherlands (7.4%) and the lowest rates in South Korea (1.6%) and Germany (0.7%). Adjustment for the age distribution of cases explains 66% of the variation across countries, with a resulting age-standardized median CFR of 1.9%. Among a larger sample of 95 countries, the observed variation in COVID-19 CFRs is 13 times larger than what would be expected on the basis of just differences in the age composition of countries. LIMITATION: The age-adjusted rates assume that, conditional on age, COVID-19 mortality among diagnosed cases is the same as that among undiagnosed cases and that individuals of all ages are equally susceptible to severe acute respiratory syndrome coronavirus 2 infection. CONCLUSION: Selective testing and identification of older cases considerably warps estimates of the lethality of COVID-19 within populations and comparisons across countries. Removing age distortions and focusing on differences in age-adjusted case fatality will be essential for accurately comparing countries' performance in caring for patients with COVID-19 and for monitoring the epidemic over time. PRIMARY FUNDING SOURCE: Alexander von Humboldt Foundation.

Anaemia among men in India: a nationally representative cross-sectional study.

BACKGROUND: Population-based studies on anaemia in India have mostly focused on women and children, with men with anaemia receiving much less attention despite anaemia's adverse effect on health, wellbeing, and economic productivity. This study aimed to determine the national prevalence of anaemia among men in India; how the prevalence of anaemia in men varies across India among states and districts and by sociodemographic characteristics; and whether the geographical and sociodemographic variation in the prevalence of anaemia among men is similar to that among women to inform whether anaemia reduction efforts for men should be coupled with existing efforts for women. METHODS: In this cross-sectional study, we analysed data from a nationally representative household survey carried out from January, 2015, to December, 2016, among men aged 15-54 years and women aged 15-49 years in all 29 states and seven Union Territories of India. Haemoglobin concentration was measured using the portable HemoCue Hb 201+ (HemoCue AB, Ängelholm, Sweden) and a capillary blood sample. In addition to disaggregating anaemia prevalence (separately in men and women) by state and age group, we used mixed-effects Poisson regression to determine individual-level and district-level predictors of anaemia. FINDINGS: 106 298 men and 633 305 women were included in our analysis. In men, the prevalence of any anaemia was 23·2% (95% CI 22·7-23·7), moderate or severe anaemia was 5·1% (4·9-5·4), and severe anaemia was 0·5% (0·5-0·6). An estimated 21·7% (20·9-22·5) of men with any degree of anaemia had moderate or severe anaemia compared with 53·2% (52·9-53·5) of women with any anaemia. Men aged 20-34 years had the lowest probability of having anaemia whereas anaemia prevalence among women was similar across age groups. State-level prevalence of any anaemia in men varied from 9·2% (7·7-10·9) in Manipur to 32·9% (31·0-34·7) in Bihar. The individual-level predictors of less household wealth, lower education, living in a rural area, smoking, consuming smokeless tobacco, and being underweight and the district-level predictors of living in a district with a lower rate of primary school completion, level of urbanisation, and household wealth were all associated with a higher probability of anaemia in men. Although some important exceptions were noted, district-level and state-level prevalence of anaemia among men correlated strongly with that among women. INTERPRETATION: Anaemia among men in India is an important public health problem. Because of the similarities in the patterns of geographical and sociodemographic variation of anaemia between men and women, future efforts to reduce anaemia among men could target similar population groups as those targeted in existing efforts to reduce anaemia among women. FUNDING: Alexander von Humboldt Foundation.