Does surgeon handedness or experience predict immediate complications after mastectomy? A critical examination of outcomes in a single health system.

Surgeons often seek to perfect their technical dexterity, and hand dominance of the surgeon is an important factor given the constraints of operative field laterality. However, experience often dictates how surgeons are able to compensate. While surgeons have experienced preference for the ipsilateral breast, the impact of surgeon handedness, experience, and volume has not been directly examined in a single study. A retrospective chart review of five breast surgeons (2 LHD) at a single institution identified 365 mastectomy patients, totaling 594 breasts, between January 2015 and June 2018. The breasts were identified as ipsilateral or contralateral based on the surgeons' handedness. Surgeons were grouped based on length of surgical experience, three with ≥15 years and two with <15 years. Surgeons with greater experience were the highest volume surgeons in this series. Data included patient demographics, breast and oncologic history, surgical techniques, and surgical outcomes including complications. A total of 270 nonprophylactic and 324 prophylactic mastectomies were identified, of which 529 were performed by surgeons with greater than 15 years of experience and 65 by surgeons with less than 15 years. The overall complication rate was 33.5% (n = 199), of which 18.0% (n = 107) were on the ipsilateral breast and 15.5% (n = 92) were on the contralateral breast. 9.1% of complications required re-operation (n = 54). The odds of any complication on the ipsilateral breast were 2.9 times higher than complications on the contralateral breast when looking exclusively at surgeons with <15 years of experience (P = .0353, OR = 2.92, 1.06-8.03). Surgeons with <15 years of experience have a 2.71 (P = .05, OR 2.71, 1.361-5.373) increase in any ischemic complication and a 16 times (P < .0001, OR = 16.01, 5.038-50.933) increase in major operative ischemic complications. Our study finds that surgeons with less than 15 years of surgical experience have a 2.9 times higher rate of overall complication when operating on the ipsilateral breast. However, years of experience and surgeon volume have a much greater impact on any and ischemic complications after mastectomy.

The significance of clinical features in the prognosis of acute renal infarction: single center experience.

OBJECTIVE: Acute renal infarct (ARI) is a common renovascular disease caused by the abrupt interruption of renal blood flow. Since the presenting symptoms are often non-specific, a major concern in ARI has been prompt diagnosis, and its long-term outcome has never been studied. MATERIALS AND METHODS: From January 2000 through to December 2009, adult patients with ARI were enrolled in this study. We retrospectively reviewed their clinical data, and followed them up until July 2011. Renal outcome and all-cause mortality were measured. RESULTS: A total of 67 patients were finally enrolled in this study. Their mean age was 56.1 ± 16.4 years, and 52.2% of them were male. Over 76% of patients were identified to have more than one comorbidity and concurrent thromboembolic events occurred in 16.4% of the patients. Although, acute kidney injury (AKI) was present in 40.7% of the patients, long-term renal outcome was relatively good. In all cases, AKI was resolved within a month, and renal loss was found in only one patient. In-hospital mortality was 8.9% and during the median follow-up period of 40.6 months, long-term mortality was 19.7%. Independent risk factors for mortality were age, atrial fibrillation, myocardial infarction and hematuria [hazard ratio (HR) 1.051, 95% confidence interval (CI) 1.008-1.096; HR 3.322, 95% CI 1.119-9.860; HR 9.315, 95% CI 1.555-55.796 and HR 7.745, 95% CI 1.606-37.353, respectively]. CONCLUSIONS: Our study suggested that in-hospital and long-term outcomes of ARI were closely related to the comorbidities or underlying disease of ARI, rather than the disease itself.

IL-33 exacerbates acute kidney injury.

Inflammation contributes to the pathogenesis of acute kidney injury (AKI). IL-33 is a proinflammatory cytokine, but its role in AKI is unknown. Here we observed increased protein expression of full-length IL-33 in the kidney following induction of AKI with cisplatin. To determine whether IL-33 promotes injury, we administered soluble ST2 (sST2), a fusion protein that neutralizes IL-33 activity by acting as a decoy receptor. Compared with cisplatin-induced AKI in untreated mice, mice treated with sST2 had fewer CD4 T cells infiltrate the kidney, lower serum creatinine, and reduced acute tubular necrosis (ATN) and apoptosis. In contrast, administration of recombinant IL-33 (rIL-33) exacerbated cisplatin-induced AKI, measured by an increase in CD4 T cell infiltration, serum creatinine, ATN, and apoptosis; this did not occur in CD4-deficient mice, suggesting that CD4 T cells mediate the injurious effect of IL-33. Wildtype mice that received cisplatin and rIL-33 also had higher levels of the proinflammatory chemokine CXCL1, which CD T cells produce, in the kidney compared with CD4-deficient mice. Mice deficient in the CXCL1 receptor also had lower serum creatinine, ATN, and apoptosis than wildtype mice following cisplatin-induced AKI. Taken together, IL-33 promotes AKI through CD4 T cell-mediated production of CXCL1. These data suggest that inhibiting IL-33 or CXCL1 may have therapeutic potential in AKI.

Gabapentin Decreases Narcotic Usage: Enhanced Recovery after Surgery Pathway in Free Autologous Breast Reconstruction.

The opioid crisis is public health emergency, in part due to physician prescribing practices. As a result, there is an increased interest in reducing narcotic use in the postsurgical setting. METHODS: From January 1, 2018, to October 31, 2018, we employed a multidisciplinary, multimodal Enhanced Recovery After Surgery (ERAS) pathway abdominally based free tissue transfer involving the rectus. Preoperative, intraoperative, and postoperative nonnarcotic modalities were emphasized. Factors in reducing narcotic consumption, pain scores, and antiemetic use were identified. RESULTS: Forty-two patients were included for a total of 66 free flaps, with a 98.4%(65/66) success rate. Average postoperative in-hospital milligram morphine equivalent (MME) use was 37.5, but decreased 85% from 80.9 MME per day to 12.9 MME per day during the study period. Average pain scores and antiemetic doses also decreased. Postoperative gabapentin was associated with a significant 59.8 mg decrease in postoperative MME use, 21% in self-reported pain, and a 2.5 fewer doses of antiemetics administered but increased time to ambulation by 0.89 days. Postoperative acetaminophen was associated with a significant 3.0 point decrease in self-reported pain. CONCLUSIONS: This study represents our early experience. A shift in the institutional mindset of pain control was necessary for adoption of the ERAS protocol. While the ERAS pathway functions to reduce stress and return patients to homeostasis following surgery, postoperative gabapentin resulted in the greatest reduction in postoperative opioid use, self-reported pain, and postoperative nausea vomiting compared to any other modality.

Erratum: Use of low-dose sulodexide in IgA nephropathy patients on renin-angiotensin system blockades [Volume 31, Issue 3, September 2012, Pages 163-169].

[This corrects the article DOI: 10.1016/j.krcp.2012.06.006.].

Cavity-dumped 2.70 microm erbium laser using optomechanical shutter.

A cavity-dumped 2.70 microm erbium laser with a frustrated total internal reflection (FTIR) shutter was investigated and compared with a Q-switched erbium laser using the FTIR shutter. The Q-switched and the cavity-dumped 2.70 microm laser outputs were obtained with a dichroic coated mirror with high reflectance at 2.70 microm and high transmittance at 2.79 microm. For the Q-switched operation, a maximum peak power of 33.5 kW was achieved, and its pulse width was 1.3 mus. For the cavity-dumped operation, the laser pulse energy was optimized by changing the switching time of the FTIR shutter. When the pulse width is reduced to 210 ns, the peak power increases to 154 kW.