Reduction mammoplasty and mastopexy in the previously irradiated breast - a systematic review and meta-analysis.

Breast cancer is the most common cancer diagnosed in women, and early stages are treated with lumpectomy and irradiation. Irradiation, however, leads to reduced vascularization and fibrosis, which may influence the cosmetic outcome unfavourably and increase complications after subsequent surgery on irradiated breasts. Patients with significant asymmetry after treatment may desire corrective reduction mammoplasty or mastopexy, but this may be associated with increased complication rates. This systematic review and meta-analysis aimed to investigate postoperative complication rates after bilateral reduction mammoplasty or mastopexy in women who had undergone unilateral lumpectomy and irradiation. PubMed, Medline, EMBASE and Cochrane databases were searched for eligible studies. After screening titles and abstracts, 14 full text studies were reviewed, and 7 of these were included in the analysis. The meta-analysis showed a significantly higher complication rate in the irradiated breast compared to the non-irradiated breast, rate ratio 4.82 (95% CI: 1.58, 14.70), p = 0.006. The complication rate was 54% in the irradiated breast (58/107) compared to 8% (9/107) in the non-irradiated breast (p = 0.034). This study suggests that reduction mammoplasty or mastopexy in the previously irradiated breast is associated with a significantly increased risk of complications. Careful patient selection and information are paramount in the treatment of this patient group.

Interventions for frostbite injuries.

BACKGROUND: Frostbite is a thermal injury caused when tissue is exposed to sub-zero temperatures (in degrees Celsius) long enough for ice crystals to form in the affected tissue. Depending on the degree of tissue damage, thrombosis, ischaemia, necrosis (tissue death), gangrene and ultimately amputation may occur. Several interventions for frostbite injuries have been proposed, such as hyperbaric oxygen therapy, sympathectomy (nerve block), thrombolytic (blood-thinning) therapy and vasodilating agents such as iloprost, reserpine, pentoxifylline and buflomedil, but the benefits and harms of these interventions are unclear. OBJECTIVES: To assess the benefits and harms of the different management options for frostbite injuries. SEARCH METHODS: On 25 February 2020, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase (OvidSP), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED), Conference Proceedings Citation Index-Science (CPCI-S), as well as trials registers. Shortly before publication, we searched Clinicaltrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform, OpenGrey and GreyLit (9 November 2020) again. We investigated references from relevant articles, and corresponded with a trial author. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that compared any medical intervention, e.g. pharmacological therapy, topical treatments or rewarming techniques, for frostbite injuries to another treatment, placebo or no treatment. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data. We used Review Manager 5 for statistical analysis of dichotomous data with risk ratio (RR) with 95% confidence intervals (CIs). We used the Cochrane 'Risk of bias' tool to assess bias in the included trial. We assessed incidence of amputations, rates of serious and non-serious adverse events, acute pain, chronic pain, ability to perform activities of daily living, quality of life, withdrawal rate from medical therapy due to adverse events, occupational effects and mortality. We used GRADE to assess the quality of the evidence. MAIN RESULTS: We included one, open-label randomised trial involving 47 participants with severe frostbite injuries. We judged this trial to be at high risk of bias for performance bias, and uncertain risk for attrition bias; all other risk of bias domains we judged as low. All participants underwent rapid rewarming, received 250 mg of aspirin and 400 mg intravascular (IV) buflomedil (since withdrawn from practice), and were then randomised to one of three treatment groups for the following eight days. Group 1 received additional IV buflomedil 400 mg for one hour per day. Group 2 received the prostacyclin, iloprost, 0.5 ng to 2 ng/kg/min IV for six hours per day. Group 3 received IV iloprost 2 ng/kg/min for six hours per day plus fibrinolysis with 100 mg recombinant tissue plasminogen activator (rtPA) for the first day only. The results suggest that iloprost and iloprost plus rtPA may reduce the rate of amputations in people with severe frostbite compared to buflomedil alone, RR 0.05 (95% CI 0.00 to 0.78; P = 0.03; very low-quality evidence) and RR 0.31 (95% CI 0.10 to 0.94; P = 0.04; very low-quality evidence), respectively. Iloprost may be as effective as iloprost plus rtPA at reducing the amputation rate, RR 0.14 (95% CI 0.01 to 2.56; P = 0.19; very low-quality evidence). There were no reported deaths or withdrawals due to adverse events in any of the groups; we assessed evidence for both outcomes as being of very low quality. Adverse events (including flushing, nausea, palpitations and vomiting) were common, but not reported separately by comparator arm (very low-quality evidence). The included study did not measure the outcomes of acute pain, chronic pain, ability to perform activities of daily living, quality of life or occupational effects. AUTHORS' CONCLUSIONS: There is a paucity of evidence regarding interventions for frostbite injuries. Very low-quality evidence from a single small trial indicates that iloprost, and iloprost plus rtPA, in combination with buflomedil may reduce the need for amputation in people with severe frostbite compared to buflomedil alone. However, buflomedil has been withdrawn from use. High quality randomised trials are needed to establish firm evidence for the treatment of frostbite injuries.

Capsular contracture in patients with prior breast augmentation undergoing breast conserving therapy and irradiation.

Radiation is considered to be a risk factor for developing capsular contracture in augmented women, but the studies reporting on this subject show conflicting results. In this systematic review we sought to understand the risk of capsular contracture in augmented patients with breast cancer treated with breast conserving surgery and radiotherapy. A search was conducted through PubMed for studies reporting on breast cancer, breast augmentation and radiotherapy, with capsular contracture as our primary outcome. To determine if specific risk factors were significant predictors of the development of capsular contracture, we performed uni- and multivariate analysis. Our search revealed 136 articles, of which 12 were deemed eligible. A total of 237 patients were included in the analysis. Univariate analysis revealed that whole breast irradiation (WBI) was significantly associated with a higher risk of contracture (p < .001), compared to treatment with accelerated partial breast irradiation (APBI). A higher radiotherapy dose regimen was also significantly associated with a risk of capsular contracture (p < .001). When performing the multivariate analysis only the effect of increasing radiation dose remained significant (p < .05). Neither the implant location nor the age of the implant had any significant effect on the development of contracture. In conclusion this review shows that WBI is associated with a higher risk of contracture compared to treatment with APBI. Because of the limitations of the studies included, further studies with larger patient cohorts are needed to establish this correlation and evaluate other potential risk factors.

A Telemedicine Case Series for Acute Medical Emergencies in Greenland: A Model for Austere Environments.

Background: Greenland is a vast country, with immense geographical distances and often extreme weather conditions. Specialized health care is limited to larger cities, and qualified medical care is not always immediately available in rural areas. Telemedicine infrastructure is available throughout the country. Purpose: The purpose of this study was to identify the role of telemedicine in the diagnosis and treatment of acute medical emergencies in remote settlements. Materials and Methods: All medical emergencies were screened from 2015 to 2016 in remote settlements of the Avannaa Health Region in Northwest Greenland, and cases in which telemedicine was utilized were identified. Results: Three illustrative cases were identified. Diagnoses were severe asthma, bilateral pneumonia, and heart failure. All three patients were accurately diagnosed through a telemedical consultation, and early treatment was initiated. In two out of three patients, acute medical evacuation by air ambulance was avoided, and the third patient was stabilized by the time an air ambulance arrived. Conclusions: Telemedicine allows for the accurate diagnosis of acute medical emergencies in remote settlements of Greenland and facilitates timely initiation of treatment. This may reduce morbidity and mortality of acute medical illness. In addition, telemedicine may aid in the clinical decision-making on whether or not to arrange for medical evacuation. Avoiding unnecessary medical evacuations reduces cost and risk to air ambulance crews. In addition, telemedicine allows for close monitoring of the patient until the air ambulance arrives. Telemedicine also ensures diagnostic and treatment options when medical evacuation is impossible due to extreme weather conditions. From a global perspective, telemedicine may increase the availability and quality of health care in remote areas and reduce health inequalities between remote and urban areas.

Short-stay unit hospitalisation vs. standard care outcomes in older internal medicine patients-a randomised clinical trial.

Background: the effect of hospitalisation in emergency department-based short-stay units (SSUs) has not been studied in older patients. We compared SSU hospitalisation with standard care at an Internal Medicine Department (IMD) in acutely admitted older internal medicine patients. Methods: pragmatic randomised clinical trial. We randomly assigned patients aged 75 years or older, acutely admitted for an internal medicine disease and assessed to be suitable for SSU hospitalisation to SSU hospitalisation or IMD hospitalisation. SSU hospitalisation was provided by a pragmatic 'fast-track' principle. The primary outcome was 90-day mortality. Secondary outcomes included adverse events, change in Lawton Instrumental Activities of Daily Living (IADL) score within 90 days from admission, in-hospital length of stay and unplanned readmissions within 30 days after discharge. Results: between January 2015 and October 2016, 430 participants were randomised (median age 84 years in both groups). Ninety-day mortality was 22(11%) in the SSU group and 32(15%) in the IMD group (odds ratio (OR) 0.66; 95% confidence interval (CI) 0.37-1.18; P = 0.16). When comparing the SSU group to the IMD group, 16(8%) vs. 45(21%) experienced at least one adverse event (OR 0.31; 95% CI 0.17-0.56; P < 0.001); 6(3%) vs. 35(20%) experienced a reduction in IADL score within 90 days from admission (P < 0.001); median in-hospital length of stay was 73 h [interquartile range, IQR 36-147] vs. 100 h [IQR 47-169], (P < 0.001), and 26(13%) vs. 58(29%) were readmitted (OR 0.37; 95% CI 0.22-0.61; P < 0.001). Conclusions: mortality at 90 days after admission was not significantly lower in the SSU group, but SSU hospitalisation was associated with a lower risk of adverse events, less functional decline, fewer readmissions and shorter hospital stay. Trial registration: NCT02395718.