Sustained Increase in Very Low Influenza Vaccination Coverage in Residents and Healthcare Workers of Long-Term Care Facilities in Austria after Educational Interventions.

Residents of long-term care facilities (LTCFs) are particularly at risk for influenza infections. We aimed to improve influenza vaccination coverage among residents and healthcare workers (HCWs) in four LTCFs by implementing educational programs and enhanced vaccination services. We compared vaccination coverage before and after the interventions (2017/18 and 2018/19 seasons). Data on vaccination adherence were recorded during a four-year observational period (2019/20 to 2022/23 seasons). Following the interventions, vaccination coverage increased significantly from 5.8% (22/377) to 19.1% (71/371) in residents and from 1.3% (3/234) to 19.7% (46/233) in HCWs (p < 0.001). During the observational period (2019/20 to 2022/23 seasons), vaccination coverage remained high in residents but decreased in HCWs. Vaccination adherence was significantly higher in residents and HCWs in LTCF 1 compared to the other three LTCFs. Our study suggests that a bundle of educational interventions and enhanced vaccination services can be an effective method for improving influenza vaccination coverage in LTCFs in both residents and HCWs. However, vaccination rates are still well below the recommended targets and further efforts are needed to increase vaccine coverage in our LTCFs.

Radiological Influencing Factors in the Diagnosis of Painful Habitual Instability of the Thumb Basal Joint as a Precursor of Carpometacarpal Arthritis of the Thumb-A Retrospective Study.

BACKGROUND: Painful habitual instability of the thumb basal joint (PHIT) is a rarely diagnosed condition that can severely impair hand function. Furthermore, it can increase the risk of developing carpometacarpal arthritis of the thumb (CMAOT). Clinical examination and radiographic imaging provide the foundation for a correct diagnosis, but early detection is still challenging. We investigated two objective, radiographically obtainable parameters as potential risk factors for PHIT. METHODS: Clinical data and radiographic images of 33 patients suffering from PHIT were collected and compared to those of 35 people serving as the control group. The two main objectives, the slope angle and the bony offset of the thumb joint, were gathered from the X-rays and statistically analyzed. RESULTS: The analysis showed no differences between the study and the control group concerning the slope angle. Gender and the bony offset, on the other hand, had a significant influence. Female sex and higher offset values were associated with an increased risk of PHIT. CONCLUSIONS: The results of this study prove a connection between a high bony offset and PHIT. We believe this information can be valuable in early detection and will allow more efficient treatment of this condition in the future.

Minimally Invasive Treatment of Trapeziometacarpal Osteoarthritis: Results of a Blinded Randomized Controlled Trial.

BACKGROUND: Surgical therapy for widespread first carpometacarpal (CMC1) arthritis permanently alters the physiologic anatomy of the hand. The injection of autologous substances into the thumb saddle joint could achieve temporary pain relief and delay surgical indications. This trial aimed to compare the pain-reducing effects of autologous fat and/or platelet-rich plasma (PRP) with saline 0.9% in the infiltration therapy of carpometacarpal arthritis of the thumb (CMC1 arthritis). METHODS: A blinded, randomized controlled trial was conducted. Ninety-five patients with CMC1 arthritis were included in the study. The mean follow-up period was 2 years. Participants were injected with 1.5 mL of autologous fat, PRP, autologous fat and PRP, or 0.9% saline solution into the CMC1 joint, depending on the group allocation. The primary outcome of this study was the evaluation of pain reduction in each treatment group. RESULTS: The combination of fat and PRP was the only treatment that resulted in a significantly greater reduction in pain compared with 0.9% saline ( P = 0.003). Similarly, fat and PRP in combination was the only therapy group to achieve clinically relevant Quick Disabilities of Arm, Shoulder, and Hand score reduction, and the only group that showed a significantly better Medical Outcomes Study 36-Item Short-Form Health Survey score than 0.9% saline ( P = 0.016). No major complications were noted. CONCLUSIONS: In addition to pain reduction, the combination of autologous fat and PRP yields a relevant improvement in hand function and a corresponding improvement in quality of life. This treatment seems to be a viable and safe alternative to short-acting glucocorticoids. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Establishing breakpoints for amoxicillin/clavulanate and ampicillin/sulbactam for rapid antimicrobial susceptibility testing directly from positive blood culture bottles.

Introduction. In 2018, EUCAST released guidelines on rapid antimicrobial susceptibility testing (RAST) directly from positive blood culture bottles for selected bacterial species and antimicrobial agents, but not for the commonly used agents amoxicillin/clavulanate (AMC) and ampicillin/sulbactam (SAM).Hypothesis/Gap statement. This work addresses the Enterobacterales RAST capability gap for betalactam/betalactamase inhibitor combinations.Aim. We aimed to determine RAST breakpoints for AMC and SAM for Escherichia coli and Klebsiella pneumoniae after 4 and 6 h of incubation directly from positive blood cultures.Methodology. Blood culture bottles were spiked with clinical isolates of E. coli (n=89) and K. pneumoniae (n=81). RAST was performed according to EUCAST guidelines and zones were read after 4 and 6 h. Breakpoints were defined to avoid very major errors.Results. The proportion of readable zone diameters after 4 h of incubation were 90.8 % in E. coli and 85.8 % in K. pneumoniae isolates. After 6 h of incubation all zone diameters could be read. The proposed breakpoints for E. coli after 6 h of incubation were ≥16 mm S (susceptible), 14-15 mm ATU (area of technical uncertainty) and <14 mm R (resistant) for AMC; ≥15 mm S, 12-14 mm ATU and <12 mm R for SAM; for K. pneumoniae these were ≥16 mm S, 14-15 mm ATU and <14 mm R for AMC; ≥13 mm S, 12 mm ATU, <12 mm R for SAM. Applying our newly set breakpoints, major errors were infrequent (2.6 %).Conclusion. We propose novel AMC and SAM breakpoints for RAST directly from positive blood cultures for reading after 4 and 6 h of incubation.

Suction Drain Volume following Axillary Lymph Node Dissection for Melanoma-When to Remove Drains? A Retrospective Cohort Study.

Postoperative complications such as seroma formation and wound-site infection occur following completion axillary lymph node dissection (ALND) for melanoma. We analyzed the impact of time-to-drain removal and drainage volume on seroma formation after ALND. We retrospectively analyzed data from 118 patients after completion ALND for melanoma. Primary endpoints were daily amount of drainage volume, seroma formation and time-to-drain removal. Secondary endpoints included patient-related, disease-specific and perioperative parameters as well as the number of histologically analyzed lymph nodes and surgical complications graded by the Clavien−Dindo classification (CDCL). Statistical analyses were performed using logistic regression models. Drain removal around the 8th postoperative day was statistically associated with a lower risk for the occurrence of seroma formation (p < 0.001). Patients with an increased drainage volume during the early postoperative days were more prone to develop seroma after drain removal. With 49% (CDCL I and II), most complications were managed conservatively, while only 5.9% (CDCL III) required revision surgery (CDCL overall: 55.9%). ALND is a safe procedure with a low rate of severe CDCL III type of complications. To decrease seroma evacuation, our results imply that drains should be removed around the 8th postoperative day to reduce the risk of infection, readmission or prolonged hospitalization.

A Randomized Controlled Trial of Three Advanced Wound Dressings in Split-Thickness Skin Grafting Donor Sites-A Personalized Approach?

Background: Split-thickness skin grafting (STSG) is a frequently used reconstructive technique, and its donor site represents a standardized clinical model to evaluate wound dressings. We compared hydroactive nanocellulose-based, silver-impregnated and ibuprofen-containing foam wound dressings. Methods: A total of 46 patients scheduled for elective surgery were evaluated on the STSG donor site for wound healing (time-to-healing, Hollander Wound Evaluation Scale), pain level (Visual Analogue Scale), and handling (ease of use), as well as scar quality (Patient Scar Assessment Scale, Vancouver Scar Scale) after 3, 6 and 12 months. Results: Almost all dressings compared equally well. We observed statistically relevant differences for pain level favoring the ibuprofen-containing dressing (p = 0.002, ΔAIC = 8.1), and user friendliness in favor of nanocellulose (dressing removal: p = 0.037, ΔAIC = 2.59; application on patient: p = 0.042, ΔAIC = 2.33; wound adhesion: p = 0.017, ΔAIC = 4.16; sensation on skin: p = 0.027, ΔAIC = 3.21). We did not observe any differences for wound healing across all groups. Treatment with hydroactive nanocellulose and the ibuprofen-containing foam revealed statistically relevant better scar appearances as compared to the silver wound dressing (p < 0.001, ΔAIC = 14.77). Conclusion: All wound dressings performed equally well, with the detected statistical differences hinting future directions of clinical relevance. These include the reserved use of silver containing dressings for contaminated or close to contaminated wounds, and the facilitated clinical application of the nanocellulose dressing, which was the only suitable candidate in this series to be impregnated with a range of additional therapeutic agents (e.g., disinfectants and pain-modulating drugs). Personalized donor site management with the tested dressings can meet individual clinical requirements after STSG and improve management strategies and ultimately patient outcomes.

Is There an Impact of Sex on Acute Postthoracotomy Pain? A Retrospective Analysis.

BACKGROUND: Current knowledge about sex-related differences states that pain is generally more frequent and intense in women. Because severe postthoracotomy pain is associated with complications, sufficient pain control is essential. Data on sex-related aspects in the context of pain after thoracotomy are scarce. The study attempted to determine whether sex significantly affects pain and pain treatment after thoracotomy. METHODS: This retrospective study assessed visual analogue scale (VAS) scores and analgesic consumption (opioids and diclofenac) during the first 5 days after surgery and the point in time when analgesics were changed from the intravenous to the oral route in patients who had open lung surgery. The influences of sex, PCEA (patient-controlled epidural analgesia), age, and surgical factors were evaluated with mixed-model analysis. RESULTS: The study was able to include 344 patients (130 female, 214 male). The VAS scores model did not consider sex as relevant. The opioid model showed a PCEA-time-sex interaction with increasing opioid demand after day 3 that predominantly affected male patients (P < .001). Diclofenac doses where significantly higher in an interaction of female sex and small extent of surgery (P = .007). Posterolateral thoracotomy led to significantly higher VAS scores (P < .001) and higher demand for opioids (P = .007) and diclofenac (P = .012). CONCLUSIONS: The study concluded that there are no general sex-related differences in pain intensity and analgesic requirement after thoracotomy. Anterolateral thoracotomy was the less painful surgical approach. PCEA had favorable results, although there seemed to a rebound pain phenomenon after epidural catheter removal on postoperative day 3 that mainly affected male patients.

BMI and specimen weight: impact on personalized risk profiling for optimized informed consent in breast reduction surgery?

We aimed to evaluate the interaction between individual risk factors and institutional complication rates after reduction mammaplasties to develop a chart for a personalized written patient informed consent. We retrospectively reviewed charts of 804 patients who underwent bilateral breast reduction between 2005 and 2015. The Clavien-Dindo classification was used to classify postoperative complications. Relevant predictors were found by applying a stepwise variable selection procedure. Multilevel predictors were assessed through chi-square tests on the respective deviance reductions. 486 patients were included. The most common complications were wound healing problems (n = 270/56%), foreign body reactions (n = 58/12%), wound infections (n = 45/9, 3%) and fat tissue necrosis (n = 41/8%). The risk factors for the personalized patient chart for the most common complications influencing the preoperative informed consent were: smoking, operative technique, resection weight for wound healing problems; body mass index and allergies for wound infections; and patients' age, resection weight for fat tissue necrosis. The resultant chart of institutionally encountered most common complications based on individual risk factors is a graphical template for obtaining patient informed consent in the future. Whether this approach influences patient information retainment, incidence of filed lawsuits or behavioral change needs to be prospectively tested in future studies.

The reverse latissimus dorsi flap: An anatomical study and retrospective analysis of its clinical application.

The segmental paraspinous and intercostal blood vessels form the blood supply and represent the pivot point for the reverse latissimus dorsi flap. Aim of this study was to confirm the exact location of the blood supply and the most caudal pivot point to assess the suitability of the reverse latissimus dorsi flap for pedicled reconstructions of the trunk as well as sacral area. Our study comprised a human cadaver study, where 30 latissimus dorsi flaps were assessed in 15 specimens, and a clinical study with 49 patients who underwent distally based latissimus dorsi flap reconstructions in our division. 74% of all perforators were located in a bilateral 7 cm broad area, which spread from the 6th intercostal space to the subcostal plane. In a second clinical part of this study we evaluated forty-nine patients, who underwent reconstruction with the reverse latissimus dorsi flap. We demonstrated that the pivot point can also be planned below the 12th rib, thus reaching tissue defects in the sacral area. To the best of our knowledge, this is the first study to define a caudal "hotspot" for the safest blood supply of the reverse latissimus dorsi flap.

Official definitions for undesirable medical events : Are they correctly applied in medicine?

BACKGROUND: In Austria, elaborate definitions exist for the undesirable medical events side effect, adverse event, complication and medical malpractice. We aimed at investigating whether the official definitions for the abovementioned terms can be understood by a sample population representing a cross-section of the Austrian population. METHODS: In this study 1021 Austrian citizens were interviewed. Demographic parameters (age, gender, occupation, level of education, monthly income, number of inhabitants at place of residence) were assessed. Participants were told the official definitions for complication, side effect, adverse event and medical malpractice and asked to select the correct definition for "complication". The impact of sample characteristics on the ability to identify the correct definition was investigated. RESULTS: Of the participants 315 (31%) identified the correct definition of a complication. Almost the same number (n = 302, 30%; χ2 for single samples: p = 0.087) falsely selected the definition for side effect. Significantly fewer (both p < 0.001) chose the definitions for adverse event (n = 220, 22%) and medical malpractice (n = 155, 15%). Only the respective state of origin showed significant influence on the probability of choosing the correct definition out of the four. The probability was highest in Vorarlberg (0.400) and lowest in Upper Austria (0.216, p < 0.001). CONCLUSION: For the majority the present official definitions for undesirable medical events are too complex to understand. Simple definitions for undesirable medical events should be included into patient education.

Complications in tissue expansion: A logistic regression analysis for risk factors.

BACKGROUND: Tissue expansion is frequently used in reconstructive surgery. Although the surgical procedure is typically considered simple, reported complication rates of tissue expansions exceed 40%. There is little evidence concerning risk factors for complications in tissue expansion in body regions other than breast. The aim was to determine risk factors for complications in non-breast tissue expansion. METHODS: 34 patients treated with subcutaneous tissue expanders between 2005 and 2014 were analyzed. Demographic data, body-mass index (BMI), mean arterial blood pressure (MAP), treatment indications, expansion site, previous expansion therapies in the same body region, smoking history, as well as expander characteristics (shape, volume, and filling mechanism) were ascertained. Complications were assessed and ranked according to severity based on the Clavien-Dindo classification. Binary logistic regression analysis adjusted for clinical characteristics was used. A p<0.05 was considered as statistically significant. RESULTS: Complications were observed in 26 out of 71 expanders analyzed (36.6%), of whom 10 led to therapy failure. Expanders used in the limbs, female gender, and high expander volume turned out as significant risk factors. Patients with both a high MAP and low BMI developed tissue necrosis significantly more often (p=0.002). The use of tissue expansion after a burn was not associated with an increased risk for complications. CONCLUSIONS: This is the first study revealing female gender and low BMI as risk factors in tissue expander surgery. Thus, careful patient selection is mandatory to avoid complications in tissue expansion. Burn patients do not develop complications more often.

Standardizing the complication rate after breast reduction using the Clavien-Dindo classification.

BACKGROUND: Published complication rates for breast reduction surgery, also known as reduction mammaplasty, vary between 4% and 54%. This wide range of complication rates could be attributable to the lack of a standardized classification of complications in plastic surgery. The aim of this study was to analyze our single-center complication rates after reduction mammaplasty using the Clavien-Dindo classification. METHODS: We performed a retrospective chart review studying 804 patients between the ages of 18 and 81 years old who underwent breast reduction between 2005 and 2015 at our institution. Patients with a history of breast cancer, a previous breast operation, who did not undergo bilateral reduction mammaplasty, or who required systemic immunodeficiency/immunosuppressive drugs were excluded from our analysis. Complications were classified according to the Clavien-Dindo classification from Grades I to V. RESULTS: A total of 486 patients met the inclusion criteria for the analysis. Patients had an age (mean ± standard deviation) of 39 ± 13 years and a body mass index of 26 ± 4 kg/m2. Median follow-up was 274 days (interquartile range: 90.5-378). The overall rate of complications of reduction mammaplasty was 63%, with the majority of those being Grades I (48%) and II (9%), comprising 92% of all the complications. Operative revisions were required in 6% (1% Grade IIIA and 5% Grade IIIB). There were no complications graded in categories IV and V. CONCLUSION: Although complications occurred in more than half of the cases, the majority did not require operative reintervention. The Clavien-Dindo classification can classify the severity of complications and serve as a benchmark to compare complication rates between different practices. We believe that grading of complications should distinguish between those that do and do not require operative reinterventions.

The Austrian breast implant register: recent trends in implant-based breast surgery.

INTRODUCTION: Due to the fact that the number of breast implant surgeries for cosmetic and medical purposes is rising yearly, a discussion about the quality of service for both patients and physicians is more important than ever. To this end, we reviewed the Austrian Breast Implant Register with one specific question in mind: What are the trends? MATERIALS AND METHODS: In the statistical analysis of the Austrian Breast Implant Register, we were able to identify 13,112 registered breast implants between 2004 and 2012. The whole dataset was then divided into medical and cosmetic groups. We focused on device size, surface characteristics, filling material, device placement and incision site. All factors were considered for all examined years. RESULTS: In summary, the most used device had a textured surface (97 %) and silicone gel as the filling material (93 %). The mean size of implants for the cosmetic group was 240 cc, placement was submuscular (58 %) and the incision site was inframammary (67 %). In the medical group, the mean size was 250 cc. Yearly registrations had their peak in 2008 (1,898 registered devices); from this year on, registrations decreased annually. A slight trend away from subglandular placement in the cosmetic group was noted. Also, the usage of implants with polyurethane surface characteristics has increased since 2008. The smooth surface implants had a peak usage in 2006 and their usage decreased steadily from then on whereas the textured surface was steady over the years. DISCUSSION AND CONCLUSION: Keeping the problems related to the quality of breast implants in mind, we could recommend an obligatory national register. Organisations of surgeons and governments should develop and establish these registers. Furthermore, an all-encompassing international register should be established by the European Union and the American FDA (Food and Drug Administration); this might be useful in comparing the individual country registers and also would help in delivering "evidence based" medicine in cosmetic and medical procedures. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Onset and duration of effect of incobotulinumtoxinA, onabotulinumtoxinA, and abobotulinumtoxinA in the treatment of glabellar frown lines: a randomized, double-blind study.

BACKGROUND: Three botulinum neurotoxin type A preparations (incobotulinumtoxinA, onabotulinumtoxinA, and abobotulinumtoxinA) are widely approved in Europe and in the US for the treatment of glabellar frown lines. The purpose of this study was to determine and compare the time to onset and duration of treatment effect of incobotulinumtoxinA, onabotulinumtoxinA, and abobotulinumtoxinA for the treatment of glabellar frown lines. SUBJECTS AND METHODS: Subjects aged 20-60 years with moderate to severe glabellar frown lines received one treatment of either 21 units (U) incobotulinumtoxinA, 21 U onabotulinumtoxinA, or 63 U abobotulinumtoxinA. Assessments were made over a period of 180 days. Onset of treatment effect was defined as the day that the observer noted a decrease in glabellar muscle activity compared with baseline photographs and videos. Duration of treatment effect was defined as the time until glabellar muscle action returned to the baseline level. Analyses were performed using a Weibull log(T) regression model. RESULTS: The study enrolled 180 subjects; 60 per group. For all three products, onset of treatment effect occurred earlier in female subjects compared to male subjects. For both sexes, a significantly earlier time to onset of treatment effect was seen for incobotulinumtoxinA compared to onabotulinumtoxinA and abobotulinumtoxinA; in female subjects these times were 3.02 days, 5.29 days, and 5.32 days, respectively. The duration of treatment effect was longer for incobotulinumtoxinA compared to onabotulinumtoxinA and abobotulinumtoxinA; for all products, treatment effect duration was longer in females than in males. Time to onset was not a predictor of treatment duration. CONCLUSION: IncobotulinumtoxinA demonstrated a more rapid onset and a longer duration of treatment effect than onabotulinumtoxinA (1:1 dose ratio) and abobotulinumtoxinA (1:3 dose ratio). Onset of effect was faster and duration of effect was longer in female subjects compared to male subjects.

Analysis of functional outcome after posttraumatic thumb reconstruction in comparison to nonreconstructed amputated thumbs at the proximal phalanx of the thumb ray: a mid-term follow-up with special attention to the Manchester-modified M2 DASH questionnaire and effect size of Cohen's d.

BACKGROUND: Pollicization, toe to thumb transfer, and osteoplastic thumb reconstruction, along with free tissue transfer, are the most reported reconstructive procedures after traumatic amputation at the proximal and middle third of the thumb. We will present our clinical studies on functional outcomes with special attention to the M2 DASH questionnaire and effect size of Cohen's d. METHODS: Eleven patients (2 women and 9 men) with posttraumatic thumb reconstruction (three pollicizations of the index or index stump, four free lateral arm osteocutaneous neurosensory flaps, and four microvascular second toe to thumb transfers), performed during the period 2000 to 2007, were reexamined after 4.2 (SD ±2.1) years (range, 2-7 years postinjury). To ensure homogeneity among the patients' data, we selected only patients with isolated thumb amputations at the level of the proximal phalanx. RESULTS: The total M2-DASH score after thumb reconstruction was 18.55 (SD ±16.79). The M2-DASH score of patients with nonreconstructed thumbs was 32.77 (SD ±18.87). Pairwise comparisons between reconstructed and amputated thumbs showed statistically significant differences (Wilcoxon rank-sum test, p value = 0.03) and a highly effective improvement of hand function (Cohen's d = 1.10) after thumb reconstruction relative to amputated thumbs. CONCLUSION: Before selecting a candidate for thumb reconstruction, it is critical to decide on an individualized treatment plan. Factors such as the patient's occupation and the importance of the aesthetic appearance of the thumb must be carefully considered. The surgeon must investigate the patient's current use pattern and functional requirements before considering a reconstructive treatment.