Patient-reported outcomes post prophylactic risk-reducing mastectomy: improved breast and psychosocial satisfaction yet poorer physical well-being.

BACKGROUND: Few studies have investigated patient-reported outcomes (PROs) for patients with high breast cancer risk undergoing elective risk reduction mastectomy and reconstruction. These patients incur operative risk in the absence of active cancer, which renders their treatment experience unique. This study aimed to identify longer-term quality of life (QoL) issues that persist in this patient cohort. METHODS: A cross-sectional cohort study assessed PROs in 48 women with high breast cancer risk who attended the Royal Melbourne Hospital Risk Management Clinic, at least 12 months post-mastectomy and reconstruction, with surgery between 2011 and 2020, using the BREAST-Q© Likert surveys. The BREAST-Q© internationally validated QoL instrument scales survey data from 0 (worst) to 100 (best) in 14 domains addressing satisfaction and psychosocial issues. RESULTS: There was higher overall breast and psychosocial satisfaction, with scores of 11 and four, respectively, yet lower chest, abdomen and sexual well-being scores with 14, three and four, respectively, in contrast to normative BREAST-Q© data from >1000 women without prior breast cancer or breast operations. High average scores >90 were found for patient satisfaction with surgical, medical and office staff. Twenty-one patients had an average score of 63 for satisfaction with breast implants, while 27 patients post-DIEP had average scores >72 for abdominal well-being, appearance and overall outcomes. Higher mean QoL outcomes were found with DIEP flap in all domains, compared with breast implant reconstruction. CONCLUSION: QoL assessment with PROs 12 months post-risk reduction mastectomy and reconstruction demonstrated higher psychosocial well-being, yet highlights physical implications, with patients experiencing reduced chest, abdomen and sexual well-being, compared with normative BREAST-Q© control data. Higher mean QoL outcomes were found with DIEP flap compared with breast implant reconstruction. PROs studies can identify unmet needs and facilitate change in service provision.

Investigation of abrasive saw kickback.

Saw kickback can cause fatal injuries, but only woodcutting saws have regulations and assessment methodologies for kickback. These regulations do not apply to abrasive cutting saws, as their cutting mechanism and dominant kickback mode differ from those of woodcutting saws. This work combines theoretical and experimental tools to investigate abrasive saw kickback. A theoretical model based on frictional engagement during a pinch-based kickback event is shown to predict resultant kickback energy in good agreement with experimental measurements. These measurements were obtained using a specialized machine that generates pinch-based kickback events and measures resultant kickback energy. Upon validating the model, two representative saws, a circular cutoff saw and a chainsaw, were tested using the prototype machine to evaluate their comparative kickback risk. This work demonstrates that pinch-based kickback is a potential safety risk for abrasive cutting saw operators and provides a testing machine design and analytical framework for evaluating this risk.

Reconfigurable system for automated optimization of diverse chemical reactions.

Chemical synthesis generally requires labor-intensive, sometimes tedious trial-and-error optimization of reaction conditions. Here, we describe a plug-and-play, continuous-flow chemical synthesis system that mitigates this challenge with an integrated combination of hardware, software, and analytics. The system software controls the user-selected reagents and unit operations (reactors and separators), processes reaction analytics (high-performance liquid chromatography, mass spectrometry, vibrational spectroscopy), and conducts automated optimizations. The capabilities of this system are demonstrated in high-yielding implementations of C-C and C-N cross-coupling, olefination, reductive amination, nucleophilic aromatic substitution (SNAr), photoredox catalysis, and a multistep sequence. The graphical user interface enables users to initiate optimizations, monitor progress remotely, and analyze results. Subsequent users of an optimized procedure need only download an electronic file, comparable to a smartphone application, to implement the protocol on their own apparatus.

Use of thrombin-based haemostatic matrix in head and neck reconstructions: a potential risk factor for pulmonary embolism.

BACKGROUND: Haemostatic agents including thrombin-based haemostatic matrix are widely used in patients undergoing cardiac, vascular and spinal surgery. These agents promote local haemostasis through activation of the clotting cascade. To our knowledge, this case series is the first report of pulmonary embolization associated with FloSeal following head and neck oncology resection and free flap reconstruction. METHODS: We present five patients who were diagnosed with symptomatic pulmonary embolism after oncologic head and neck free flap reconstructions in 2014 and 2015. RESULTS: There were five patients consisting of three males and two females. The mean age was 67 years, ranging from 60 to 74 years. Pulmonary embolism occurred between 3 and 30 days with a mean of 12 days. Four out of the five reported cases showed involvement of more than one lobe, and two cases had bilateral pulmonary involvement. All but one patient underwent infratemporal fossa dissections as part of the cancer resection. Ten millilitres of FloSeal was applied to the pterygoid plexi in the four patients to achieve haemostasis. All patients received heparin infusion followed by warfarin therapy for at least 6 months with no mortality or complications relating to pulmonary embolism to date. CONCLUSION: Although inconclusive due to study design and small numbers, this series raises the possibility that there may be an association between the use of haemostatic matrix in head and neck oncologic reconstructions and pulmonary embolism. Haemostatic matrix must be used in caution when there is a direct contact with venous endolumens such as the pterygoid plexus and soleus.

Emergency department presentations with mammalian bite injuries: risk factors for admission and surgery.

OBJECTIVES: The incidence of animal bite injuries in Australia is high. There is currently no established method for reliably predicting whether a patient with a bite injury will require admission to hospital or surgery. DESIGN: A retrospective audit of mammalian bite injuries at seven major hospitals in Melbourne, Victoria, over a 2-year period. The associations between each predictor and outcome of interest were analysed with univariate and multiple regression analyses. SETTING: Seven major hospitals in Melbourne, Victoria: the Alfred Hospital, Austin Hospital, Frankston Hospital, Monash Medical Centre, Royal Melbourne Hospital, St Vincent's Hospital and Western Hospital. PARTICIPANTS: Patients presenting to emergency departments with mammalian bite injuries. MAIN OUTCOME MEASURES: Hospital admission, intravenous antibiotic therapy, surgery, reoperation, readmission. RESULTS: We identified 717 mammalian bite injuries. The mean age of the patients was 36.5 years (median, 34 years; range, 0-88 years), with an equal number of males and females. The overall rate of hospital admission was 50.8%, and the mean length of stay was 2.7 days. Intravenous antibiotics were administered in 46% of cases; surgery was undertaken in 43.1% of cases. The re-operation rate was 4.5%, the re-admission rate was 3%. CONCLUSIONS: Our study provides a detailed epidemiological analysis of animal bite injuries at seven major hospitals in Victoria. Risk factors for hospitalisation and surgery may assist in identifying patients who require admission and surgical intervention.

Accuracy of surgical wound drainage measurements: an analysis and comparison.

BACKGROUND: Surgical drain tube readings can influence the clinical management of the post-operative patient. The accuracy of these readings has not been documented in the current literature and this experimental study aims to address this paucity. METHODS: Aliquots (10, 25, 40 and 90 mL) of black tea solution prepared to mimic haemoserous fluid were injected into UnoVac, RedoVac and Jackson-Pratt drain tubes. Nursing and medical staff from a tertiary hospital were asked to estimate drain volumes by direct observation; analysis of variance was performed on the results and significance level was set at 0.05. RESULTS: Doctors and nurses are equally accurate in estimating drain tube volumes. Jackson-Pratt systems were found to be the most accurate for intermediate volumes of 25 and 40 mL. For extreme of volumes (both high and low), all drainage systems were inaccurate. CONCLUSION: This study suggests that for intermediate volumes (25 and 40 mL), Jackson-Pratt is the drainage system of choice. The accuracy of volume measurement is diminished at the extremes of drain volumes; emptying of drainage systems is recommended to avoid overfilling of drainage systems.

The functional free innervated medial gastrocnemius flap.

BACKGROUND: The functional free innervated medial gastrocnemius flap has been described in four previous articles for the management of foot drop, Volkmann contracture, and upper limb muscle defects. We expand the indications by describing the use of free innervated medial gastrocnemius musculocutaneous flap in functional reconstruction of the tongue and upper limb musculature. METHODS: The right medial gastrocnemius muscles were raised as myocutaneous flaps in six patients. These flaps were elevated in the supine position and the flaps included a motor nerve from the sciatic nerve and a sensory nerve from the sural nerve. The average size of flap was 15 × 8 cm. RESULTS: The flaps were transferred successfully with no flap loss and showed consistent reinnervation during follow-up. In particular, all patients who underwent tongue reconstruction exhibited intelligible speech and returned to full oral diet with no aspiration. In patients who underwent upper limb muscle reconstructions, there was moderate to full restoration of power. All donor sites exhibited excellent symmetry in both power and appearance to the contralateral calf. CONCLUSIONS: To our knowledge, this study is the first to describe the use of the innervated medial gastrocnemius free flap in the reconstruction of the tongue and deltoid. The advantages of this flap include its thin reliable skin paddle, strong bulky bipennate muscle, and low donor site morbidity.

Delayed/non-union of upper limb fractures with bisphosphonates: systematic review and recommendations.

BACKGROUND: Bisphosphonates (BPs) are widely used for the treatment of osteoporosis. Oversuppression of bone turnover with BPs may paradoxically limit the reserve capacity of bone to heal. The aim of this review was to study the predisposition of some patients to delayed/non-union of upper limb fractures associated with BPs and give recommendations on how they should be treated. METHODS: A systematic search of two electronic databases was conducted to identify relevant studies for inclusion. All relevant studies found were included and assessed through methodology criteria predetermined by two independent reviewers. RESULTS: Six papers comprising of three case reports, one nested case control study, one restrospective review and one randomized clinical trial were used. In comparative studies of pre-fracture BP use, a 6-day delay in average healing times was reported among BP users. There was no elevation in risk of non-union. Post-fracture BP use was associated with an approximate doubling of the risk of non-union. Timing of BP therapy initiation following a fracture was not associated with a difference in healing times. An atypical ulna fracture treated conservatively resulted in non-union, there was no effect of type of surgical treatment on distal radius fracture healing and there was insufficient evidence to comment on humeral fracture treatment. CONCLUSIONS: Differences in union time between BP users and non-users are not significant enough to change current practice patterns and do not outweigh the benefits of BP therapy. There is no evidence to encourage early surgical management of BP-related upper limb fractures.

The arterial supply of the cervical and thoracic spinal muscles and overlying skin: Anatomical study with implications for surgical wound complications.

Postoperative spinal wound dehiscence is a significant complication following the posterior midline approach. It is postulated that this approach disrupts the vasculature supplying the paraspinal muscles and overlying skin. Although the spinal vasculature has been investigated previously, the smaller arterioles have not been described in the context of the posterior midline approach. Eight cadaveric neck and posterior torso specimens were dissected after injection with a radio-opaque lead oxide mixture and subsequent radiographs taken were analyzed. The deep cervical, vertebral, superficial cervical, and occipital arteries consistently supplied the cervical paraspinal muscles. The latter two arteries also vascularized the overlying skin. The deep cervical arteries were found to be located lateral to the C3 to C6 vertebrae, vulnerable to damage with the posterior approach. In the thoracic region, the superior and posterior intercostal arteries consistently supplied the spinal muscles. In all specimens, two small anastomotic vessels posterior to the laminae were found connecting the intercostal artery perforators. Both the arterial perforators and their anastomotic channels were situated in the surgical field and susceptible to damage with the posterior approach. It is likely that the disruption in spinal vasculature contributes to the multifactorial problem of wound dehiscence with the posterior midline approach.

Wrisberg variant of the discoid lateral meniscus with flipped meniscal fragments simulating bucket-handle tear: MRI and arthroscopic correlation.

An MRI diagnosis of the Wrisberg variant discoid lateral meniscus should be considered in patients presenting with an anteriorly flipped posterior horn fragment without a definable peripheral rim. We present four cases discovered on arthroscopy that were thought to resemble bucket-handle tears on preoperative MRI. Posterior hypermobility poses a surgical challenge as excessive debridement without careful attention to underlying meniscal morphology may lead to further instability. Although this diagnosis can be difficult to make on MRI, alerting the orthopedic surgeon preoperatively may influence repair technique and meniscus conservation.

The role of H-current in regulating strength and frequency of thalamic network oscillations.

Intrathalamic oscillations related to sleep and epilepsy depend on interactions between synaptic mechanisms and intrinsic membrane excitability. One intrinsic conductance implicated in the genesis of thalamic oscillations is the H current - a cationic current activated by membrane hyperpolarization. Activation of H current promotes rebound excitation of thalamic relay neurons and can thus enhance recurrent network activity.We examined the effects of H current modulation on bicuculline-enhanced network oscillations (2-4 Hz) in rat thalamic slices. The adrenergic agonist norepinephrine, a known regulator of H current, caused an alteration of the internal structure of the oscillations - they were enhanced and accelerated as the interval between bursts was shortened. The acceleration was blocked by the ß-adrenergic antagonist propranolol. The ß agonist isoproterenol mimicked the effect of norepinephrine on oscillation frequency and truncated the responses suggesting that a ß-adrenergic upregulation of H current modifies the internal structure (frequency) of thalamic oscillations. Consistent with this, we found that H channel blockade by Cs(+) or ZD7288 could decelerate the oscillations and produce more robust (longer lasting) responses. High concentrations of either Cs(+) or ZD7288 blocked the oscillations.These results indicate that a critical amount of H current is necessary for optimal intrathalamic oscillations in the delta frequency range. Up- or downregulation of H current can not only alter the oscillation frequency but also retard or promote the development of thalamic synchronous oscillations. This conclusion has important implications regarding the development of epilepsy in thalamocortical circuits.