Comparison of distortion correction preprocessing pipelines for DTI in the upper limb.

PURPOSE: DTI characterizes tissue microstructure and provides proxy measures of nerve health. Echo-planar imaging is a popular method of acquiring DTI but is susceptible to various artifacts (e.g., susceptibility, motion, and eddy currents), which may be ameliorated via preprocessing. There are many pipelines available but limited data comparing their performance, which provides the rationale for this study. METHODS: DTI was acquired from the upper limb of heathy volunteers at 3T in blip-up and blip-down directions. Data were independently corrected using (i) FSL's TOPUP & eddy, (ii) FSL's TOPUP, (iii) DSI Studio, and (iv) TORTOISE. DTI metrics were extracted from the median, radial, and ulnar nerves and compared (between pipelines) using mixed-effects linear regression. The geometric similarity of corrected b = 0 images and the slice matched T1-weighted (T1w) images were computed using the Sörenson-Dice coefficient. RESULTS: Without preprocessing, the similarity coefficient of the blip-up and blip-down datasets to the T1w was 0·80 and 0·79, respectively. Preprocessing improved the geometric similarity by 1% with no difference between pipelines. Compared to TOPUP & eddy, DSI Studio and TORTOISE generated 2% and 6% lower estimates of fractional anisotropy, and 6% and 13% higher estimates of radial diffusivity, respectively. Estimates of anisotropy from TOPUP & eddy versus TOPUP were not different but TOPUP reduced radial diffusivity by 3%. The agreement of DTI metrics between pipelines was poor. CONCLUSIONS: Preprocessing DTI from the upper limb improves geometric similarity but the choice of the pipeline introduces clinically important variability in diffusion parameter estimates from peripheral nerves.

International, prospective cohort study comparing non-absorbable versus absorbable sutures for skin surgery: CANVAS service evaluation.

BACKGROUND: Absorbable or non-absorbable sutures can be used for superficial skin closure following excisional skin surgery. There is no consensus among clinicians nor high-quality evidence supporting the choice of suture. The aim of the present study was to determine current suture use and complications at 30 days after excisional skin surgery. METHODS: An international, prospective service evaluation of adults undergoing excision of skin lesions (benign and malignant) in primary and secondary care was conducted from 1 September 2020 to 15 April 2021. Routine patient data collected by UK and Australasian collaborator networks were uploaded to REDCap©. Choice of suture and risk of complications were modelled using multivariable logistic regression. RESULTS: Some 3494 patients (4066 excisions) were included; 3246 (92.9 per cent) were from the UK and Ireland. Most patients were men (1945, 55.7 per cent), Caucasian (2849, 81.5 per cent) and aged 75-84 years (965, 27.6 per cent). The most common clinical diagnosis was basal cell carcinoma (1712, 42.1 per cent). Dermatologists performed most procedures, with 1803 excisions (44.3 per cent) on 1657 patients (47.4 per cent). Most defects were closed primarily (2856, 81.9 per cent), and there was equipoise in regard to use of absorbable (2127, 57.7 per cent) or non-absorbable (1558, 42.2 per cent) sutures for superficial closure. The most common complications were surgical-site infection (103, 2.9 per cent) and delayed wound healing (77, 2.2 per cent). In multivariable analysis, use of absorbable suture type was associated with increased patient age, geographical location (UK and Ireland), and surgeon specialty (oral and maxillofacial surgery and plastic surgery), but not with complications. CONCLUSION: There was equipoise in suture use, and no association between suture type and complications. Definitive evidence from randomized trials is needed.

The Effectiveness of Different Nerve Transfers in the Restoration of Elbow Flexion in Adults Following Brachial Plexus Injury: A Systematic Review and Meta-Analysis.

PURPOSE: Restoration of elbow flexion is an important goal in the treatment of patients with traumatic brachial plexus injury. Numerous studies have described various nerve transfers for neurotization of the musculocutaneous nerve (or its motor branches); however, there is uncertainty over the effectiveness of each method. The aim of this study was to summarize the published evidence in adults with traumatic brachial plexus injury. METHODS: Medline, Embase, medRxiv, and bioRxiv were systematically searched from inception to April 12, 2021. We included studies that reported the outcomes of nerve transfers for the restoration of elbow flexion in adults. The primary outcome was elbow flexion of grade 4 (M4) or higher on the British Medical Research Council scale. Data were pooled using random-effects meta-analyses, and heterogeneity was explored using metaregression. Confidence intervals (CIs) were generated to the 95% level. RESULTS: We included 64 articles, which described 13 different nerve transfers. There were 1,335 adults, of whom 813 (61%) had partial and 522 (39%) had pan-plexus injuries. Overall, 75% of the patients with partial brachial plexus injuries achieved ≥M4 (CI, 69%-80%), and the choice of donor nerve was associated with clinically meaningful differences in the outcome. Of the patients with pan-plexus injuries, 45% achieved ≥M4 (CI, 31%-60%), and overall, each month delay from the time of injury to reconstruction reduced the probability of achieving ≥M4 by 7% (CI, 1%-12%). CONCLUSIONS: The choice of donor nerve affects the chance of attaining a British Medical Research Council score of ≥4 in upper-trunk reconstruction. For patients with pan-plexus injuries, delay in neurotization may be detrimental to motor outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Median Nerve Palsy in Pediatric Supracondylar Humerus Fractures Recovers Faster With Open Than Closed Reduction.

BACKGROUND: Management of supracondylar humerus fractures (SCHF) with coexisting median nerve injury is controversial. Although many nerve injuries improve with the reduction and stabilization of the fracture, the speed and completeness of recovery are unclear. This study investigates median nerve recovery time using the serial examination. METHODS: A prospectively maintained database of SCHF-related nerve injuries referred to a tertiary hand therapy unit between 2017 and 2021 was interrogated. Factors related to the injury (vascularity, Gartland grade, open vs. closed fracture) and treatment (fixation modality, adequacy, timing of reduction, vascular and nerve intervention, and secondary procedures) were assessed.Primary outcomes were the motor recovery of Medical Research Council (MRC) grade 4 or 5 in flexor pollicis longus or flexor digitorum profundus (index) and detection of the 2.83 Semmes Weinstein monofilament.A retrospective clinical note review of all SCHF presenting during the same period was also conducted. RESULTS: Of 1096 SCHF, 74 (7%) had an associated median nerve palsy. Twenty-one patients [mean age 7 years (SD 1.6)] with SCHF-related median nerve injuries underwent serial examination. Nineteen (90%) were modified Gartland III or IV, and 10 (48%) were pulseless on presentation. The mean follow-up was 324 days.The mean motor recovery time was 120 days (SD 71). Four (27%) and 2 (13%) patients had not achieved MRC grade 4 by 6 months and 2 years, respectively. Only 50% attained MRC grade 5 at 2 years.When compared with closed reduction, those who underwent open reduction recovered motor function 80 days faster (mean 71 vs. 151 d, P =0.03) and sensory function 110 days faster (52 vs. 162, P =0.02). Fewer patients recovered after closed reduction (8 of 10) than open (5 of 5).Modified Gartland grade, vascular status, adequacy of reduction, and secondary surgery were not associated with recovery time. CONCLUSIONS: Median nerve recovery seems to occur slower than previously thought, is often incomplete, and is affected by treatment decisions (open vs. closed reduction). Retrospective reporting methods may overestimate median nerve recovery. LEVEL OF EVIDENCE: Level III-therapeutic.

The Comparative Efficacy of Chlorhexidine Gluconate and Povidone-iodine Antiseptics for the Prevention of Infection in Clean Surgery: A Systematic Review and Network Meta-analysis.

OBJECTIVE: There is uncertainty around preoperative skin antisepsis in clean surgery. Network meta-analysis provides more precise estimates than standard pairwise meta-analysis and can rank interventions by efficacy, to better inform clinical decisions. BACKGROUND: Infection is the most common and costly complication of surgery. The relative efficacy of CHG and PVI based skin antiseptics in clean surgery remains unclear. METHODS: We searched for randomized or nonrandomized studies comparing the effect of different preparations of CHG and PVI on the dichotomous outcome of surgical site infection. We included studies of adults undergoing clean surgery. We excluded studies concerning indwelling vascular catheters, blood sampling, combination antiseptics or sequential applications of different antiseptics. We performed a network meta-analysis to estimate the relative efficacy of interventions using relative risks (RR). RESULTS: We included 17 studies comparing 5 antiseptics in 14,593 individuals. The overall rate of surgical site infection was 3%. Alcoholic CHG 4%-5% was ranked as the most effective antiseptic as it halved the risk of surgical site infection when compared to aqueous PVI [RR 0.49 (95% confidence interval 0.24, 1.02)] and also to alcoholic PVI, although uncertainty was larger [RR 0.51 (95% confidence interval 0.21, 1.27)]. Adverse events related to antiseptic application were only observed with patients exposed to PVI. CONCLUSIONS: Alcoholic formulations of 4%-5% CHG seem to be safe and twice as effective as PVI (alcoholic or aqueous solutions) in preventing infection after clean surgery in adults. Our findings concur with the literature on contaminated and clean-contaminated surgery, and endorse guidelines worldwide which advocate the use of alcoholic CHG for preoperative skin antisepsis. REGISTRATION: PROSPERO ID CRD42018113001.

Disseminating Hand Surgery Research Using Social Media: The Relationship Between Altmetrics and Citations.

PURPOSE: Social media adds to the traditional methods of research dissemination. It allows researchers and publishers to immediately share content directly with interested end users on a global scale. Alternative metrics (altmetrics) are new bibliometrics that describe article-level activity on platforms such as Twitter, Wikipedia, and online news media. Altmetrics are strongly associated with citation counts in numerous medical disciplines. The aim of this study was to investigate the relationship of altmetrics to citation counts in the field of hand surgery. METHODS: Altmetric Explorer was used to extract data on altmetrics and citation rates for articles published in 2017 in 6 prominent hand surgery journals. Multivariable negative binomial regression was used to estimate the relationship between citation counts and predictors (presented as the incidence rate ratio with a 95% confidence interval [CI]). RESULTS: Overall, 624 articles were included. Mentions on social media platforms were independently associated with more citations (adjusted incidence rate ratio 1.04 [95% CI 1.02-1.05]). The factor that most influenced the rate of citations was the journal in which the article was published; articles in the Journal of Hand Surgery had at least 1 more citation than articles published elsewhere (median difference 3 [interquartile range {IQR} 2-3]) and had a median Altmetric Attention Score which was 3 points higher (IQR 2-3) than articles published elsewhere. CONCLUSIONS: The dissemination of hand surgery research through social media channels is associated with substantial and measurable improvements in short-term citation rates CLINICAL RELEVANCE: Social media appears to be a valuable tool for communicating important research directly to hand surgeons in a timely and succinct manner.

The neutrophil-lymphocyte ratio and locoregional melanoma: a multicentre cohort study.

OBJECTIVES: The neutrophil-lymphocyte ratio (NLR) is an inflammatory biomarker which is useful in cancer prognostication. We aimed to investigate the differences in baseline NLR between patients with localised and metastatic cutaneous melanoma and how this biomarker changed over time with the recurrence of disease. METHODS: This multicentre cohort study describes patients treated for Stage I-III cutaneous melanoma over 10 years. The baseline NLR was measured immediately prior to surgery and again at the time of discharge or disease recurrence. The odds ratios (OR) for sentinel node involvement are estimated using mixed-effects logistic regression. The risk of recurrence is estimated using multivariable Cox regression. RESULTS: Overall 1489 individuals were included. The mean baseline NLR was higher in patients with palpable nodal disease compared to those with microscopic nodal or localised disease (2.8 versus 2.4 and 2.3, respectively; p < 0.001). A baseline NLR ≥ 2.3 was associated with 30% higher odds of microscopic metastatic melanoma in the sentinel lymph node [adjusted OR 1.3 (95% CI 1.3, 1.3)]. Following surgery, 253 patients (18.7%) developed recurrent melanoma during surveillance although there was no statistically significant association between the baseline NLR and the risk of recurrence [adjusted HR 0.9 (0.7, 1.1)]. CONCLUSION: The NLR is associated with the volume of melanoma at presentation and may predict occult sentinel lymph metastases. Further prospective work is required to investigate how NLR may be modelled against other clinicopathological variables to predict outcomes and to understand the temporal changes in NLR following surgery for melanoma.

The Geometry of the roots of the Brachial Plexus.

Diffusion tensor magnetic resonance imaging (DTI) can be used to reconstruct the brachial plexus in 3D via tracts connecting contiguous diffusion tensors with similar primary eigenvector orientations. When creating DTI tractograms, the turning angle of connecting lines (step angle) must be prescribed by the user; however, the literature is lacking detailed geometry of brachial plexus to inform such decisions. Therefore, the spinal cord and brachial plexus of 10 embalmed adult cadavers were exposed bilaterally by posterior dissection. Photographs were taken under standardised conditions and spatially calibrated in MATLAB. The roots of the brachial plexus were traced from the dorsal root entry zone for 5 cm laterally using a 2.5-mm2 Cartesian grid overlay. The trace was composed of points connected by lines, and the turning angle between line segments (the step angle) was resolved. Our data show that the geometry of the roots increased in tortuosity from C5 to T1, with no significant differences between sides. The 1st thoracic root had the most tortuous course, turning through a maximum angle of 56° per 2.5 mm (99% CI 44° to 70°). Significantly higher step angles and greater variability were observed in the medial 2 cm of the roots of the brachial plexus, where the dorsal and ventral rootlets coalesce to form the spinal root. Throughout the brachial plexus, the majority of step angles (>50%) were smaller than 20° and <1% of step angles exceeded 70°. The geometry of the brachial plexus increases in tortuosity from C5 to T1. To reconstruct 99% of tracts representing the roots of the brachial plexus by DTI tractography, users can either customise the step angle per root based on our findings or select a universal threshold of 70°.

Hydrosurgical debridement versus conventional surgical debridement for acute partial-thickness burns.

BACKGROUND: Burn injuries are the fourth most common traumatic injury, causing an estimated 180,000 deaths annually worldwide. Superficial burns can be managed with dressings alone, but deeper burns or those that fail to heal promptly are usually treated surgically. Acute burns surgery aims to debride burnt skin until healthy tissue is reached, at which point skin grafts or temporising dressings are applied. Conventional debridement is performed with an angled blade, tangentially shaving burned tissue until healthy tissue is encountered. Hydrosurgery, an alternative to conventional blade debridement, simultaneously debrides, irrigates, and removes tissue with the aim of minimising damage to uninjured tissue. Despite the increasing use of hydrosurgery, its efficacy and the risk of adverse events following surgery for burns is unclear. OBJECTIVES: To assess the effects of hydrosurgical debridement and skin grafting versus conventional surgical debridement and skin grafting for the treatment of acute partial-thickness burns. SEARCH METHODS: In December 2019 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that enrolled people of any age with acute partial-thickness burn injury and assessed the use of hydrosurgery. DATA COLLECTION AND ANALYSIS: Two review authors independently performed study selection, data extraction, 'Risk of bias' assessment, and GRADE assessment of the certainty of the evidence. MAIN RESULTS: One RCT met the inclusion criteria of this review. The study sample size was 61 paediatric participants with acute partial-thickness burns of 3% to 4% total burn surface area. Participants were randomised to hydrosurgery or conventional debridement. There may be little or no difference in mean time to complete healing (mean difference (MD) 0.00 days, 95% confidence interval (CI) -6.25 to 6.25) or postoperative infection risk (risk ratio 1.33, 95% CI 0.57 to 3.11). These results are based on very low-certainty evidence, which was downgraded twice for risk of bias, once for indirectness, and once for imprecision. There may be little or no difference in operative time between hydrosurgery and conventional debridement (MD 0.2 minutes, 95% CI -12.2 to 12.6); again, the certainty of the evidence is very low, downgraded once for risk of bias, once for indirectness, and once for imprecision. There may be little or no difference in scar outcomes at six months. Health-related quality of life, resource use, and other adverse outcomes were not reported. AUTHORS' CONCLUSIONS: This review contains one randomised trial of hydrosurgery versus conventional debridement in a paediatric population with low percentage of total body surface area burn injuries. Based on the available trial data, there may be little or no difference between hydrosurgery and conventional debridement in terms of time to complete healing, postoperative infection, operative time, and scar outcomes at six months. These results are based on very low-certainty evidence. Further research evaluating these outcomes as well as health-related quality of life, resource use, and other adverse event outcomes is required.

MRI for Detecting Root Avulsions in Traumatic Adult Brachial Plexus Injuries: A Systematic Review and Meta-Analysis of Diagnostic Accuracy.

Background Traumatic brachial plexus injuries affect 1% of patients involved in major trauma. MRI is the best test for traumatic brachial plexus injuries, although its ability to differentiate root avulsions (which require urgent reconstructive surgery) from other types of nerve injury remains unknown. Purpose To evaluate the accuracy of MRI for diagnosing root avulsions in adults with traumatic brachial plexus injuries. Materials and Methods For this systematic review, MEDLINE and Embase were searched from inception to August 20, 2018. Studies of adults with traumatic nonpenetrating unilateral brachial plexus injuries were included. The target condition was root avulsion. The index test was preoperative MRI, and the reference standard was surgical exploration. A bivariate meta-analysis was used to estimate summary sensitivities and specificities of MRI for avulsion. Results Eleven studies of 275 adults (mean age, 27 years; 229 men) performed between 1992 and 2016 were included. Most participants had been injured in motorcycle collisions (84%). All studies were at risk of bias, and there were high applicability concerns for the index test (ie, MRI) in four studies given the lack of diagnostic criteria, inadequate descriptions of pulse sequences, and multiplicity of reporting radiologists. Overall, 72% of patients with brachial plexus injuries had at least one root avulsion (interquartile range [IQR]: 53%-86%); meta-analysis of patient-level data was not performed because of sparse and heterogeneous data. With the nerve root as the unit of analysis, 583 of 918 roots were avulsed (median, 55%; IQR: 38%-71%); the mean sensitivity of MRI for root avulsion was 93% (95% confidence interval [CI]: 77%, 98%) with a mean specificity of 72% (95% CI: 42%, 90%). Conclusion On the basis of limited data, MRI offers modest diagnostic accuracy for traumatic brachial plexus root avulsion(s), and early surgical exploration should remain as the preferred method of diagnosis. Published under a CC BY 4.0 license. Online supplemental material is available for this article.

Baseline Neutrophil-Lymphocyte and Platelet-Lymphocyte Ratios as Biomarkers of Survival in Cutaneous Melanoma: A Multicenter Cohort Study.

BACKGROUND: In the peripheral blood, the neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) change in response to malignancy. These biomarkers are associated with adverse outcomes in numerous cancers, but the evidence is limited in relation to melanoma. This study sought to investigate the association between these biomarkers and survival in Stages I-III cutaneous melanoma. METHODS: This multicenter cohort study investigated a consecutive series of patients who underwent wide excision of biopsy-proven cutaneous melanoma and sentinel lymph node biopsy during a 10-year period. The baseline NLR and PLR were calculated immediately before sentinel lymph node biopsy. Adjusted hazard ratios (HRs) for overall and melanoma-specific survival were generated. RESULTS: Overall, 1351 patients were included in the study. During surveillance, 184 of these patients died (14%), with 141 of the deaths (77%) attributable to melanoma. Worse overall survival was associated with a baseline NLR lower than 2.5 [HR 2.2; 95% confidence interval (CI) 2.0 to 2.3; p < 0.001] and a baseline PLR lower than 100 (HR 1.8; 95% CI 1.7 to 1.8; p < 0.001). Melanoma-specific survival also was worse, with a baseline NLR lower than 2.5 (HR 1.9; 95% CI 1.6 to 2.2; p < 0.001) and a baseline PLR lower than 100 (HR 1.9; 95% CI 1.7 to 2.2; p < 0.001). The 5-year survival for patients with sentinel lymph node metastases and a low NLR and PLR was approximately 50%. CONCLUSION: This study provides important new data on biomarkers in early-stage melanoma, which contrast with biomarker profiles in advanced disease. These biomarkers may represent the host inflammatory response to melanoma and therefore could help select patients for adjuvant therapy and enhanced surveillance.

Absorbable versus non-absorbable sutures for skin closure after carpal tunnel decompression surgery.

BACKGROUND: Carpal tunnel syndrome is a common problem and surgical decompression of the carpal tunnel is the most effective treatment. After surgical decompression, the palmar skin may be closed using either absorbable or non-absorbable sutures. To date, there is conflicting evidence regarding the ideal suture material and this formed the rationale for our review. OBJECTIVES: To assess the effects of absorbable versus non-absorbable sutures for skin closure after elective carpal tunnel decompression surgery in adults on postoperative pain, hand function, scar satisfaction, wound inflammation and adverse events. SEARCH METHODS: We searched the following databases on 30 October 2017: the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, and Embase. We searched two clinical trials registries on 30 October 2017. SELECTION CRITERIA: We considered all randomised or quasi-randomised controlled trials comparing absorbable and non-absorbable sutures for skin closure after any form of carpal tunnel decompression surgery in adults. DATA COLLECTION AND ANALYSIS: The unit of analysis was the hand rather than the patient. We performed meta-analysis of direct comparisons to generate standardised mean differences (SMDs) with 95% confidence intervals (CIs) in pain scores and risk ratios (RRs) with 95% CIs for dichotomous outcomes, such as wound inflammation. The primary outcome was postoperative pain. Secondary outcomes included hand function, scar satisfaction, scar inflammation and adverse events (complications). We assessed the quality of evidence for key outcomes using GRADE. MAIN RESULTS: We included five randomised trials (255 participants). The trials were all European (UK, Republic of Ireland, Denmark and the Netherlands). Where quoted, the mean age of participants was between 48 and 53 years. The trials measured outcomes between one and 12 weeks postoperatively.Meta-analysis of postoperative pain scores for absorbable versus non-absorbable sutures at 10 days following open carpal tunnel decompression (OCTD) produced a SMD of 0.03 (95% CI -0.43 to 0.48; 3 studies, number of participants (N) = 137; I2 = 43%); the SMD suggests little or no difference, but with a high degree of uncertainty because of very low-quality evidence. At 10 days following endoscopic carpal tunnel decompression (ECTD), the SMD for postoperative pain with use of absorbable versus non-absorbable sutures was -0.81 (95% CI -1.36 to -0.25; 1 study; N = 54); although the SMD is consistent with a large effect, the very low-quality evidence means the results are very uncertain. Only the OCTD studies provided pain data at 6 weeks, when the SMD was 0.06 (95% CI -0.72 to 0.84; 4 studies; N = 175; I2 = 84%), which indicates little or no evidence of difference, but with a high degree of uncertainty (very low-quality evidence). The RR for wound inflammation using absorbable versus non-absorbable sutures after OCTD was 2.28 (95% CI 0.24 to 21.91; N = 95; I2 = 90%) and after ECTD 0.93 (95% CI 0.06 to 14.09; 1 study, N = 54). Any difference in effect on wound inflammation is uncertain because the quality of evidence is very low. One study reported postoperative hand function but found no evidence of a difference between suture types at two weeks (mean difference (MD) -0.10, 95% CI -0.53 to 0.33, N = 36), with similar findings at six and 12 weeks. Only the ECTD trial reported scar satisfaction, with 25 out of 28 people reporting a 'nice' result in the absorbable-suture group, versus 18 out of 26 in the group who received non-absorbable sutures (RR 1.29, 95% CI 0.97 to 1.72, N = 54). These findings are also very uncertain as we judged the quality of the evidence to be very low. All studies were at high risk of bias for most domains. No trials reported adverse events. AUTHORS' CONCLUSIONS: It is uncertain whether absorbable sutures confer better, worse or equivalent outcomes compared to non-absorbable sutures following carpal tunnel decompression, because the quality of evidence is very low. Use of absorbable suture eliminates the need for suture removal, which could confer considerable savings to patients and healthcare providers alike. We need rigorously-performed, non-inferiority randomised trials with economic analyses to inform choice of suture.

Complications in DIEP Flap Breast Reconstruction After Mastectomy for Breast Cancer: A Prospective Cohort Study Comparing Unilateral Versus Bilateral Reconstructions.

BACKGROUND: The demand for bilateral breast reconstructions is rising worldwide. In the UK, approximately 30% of breast cancer patients undergoing mastectomy choose autologous tissue breast reconstruction. Although the deep inferior epigastric perforator (DIEP) flap is gaining popularity, bilateral DIEP flap breast reconstruction remains a complex procedure and reliable outcome data are lacking. In the absence of clinical trials, evidence from cohort studies is needed to better inform clinicians and patients. METHODS: Over a 6-year period, all consecutive patients undergoing DIEP flap breast reconstruction were prospectively included and categorized as unilateral or bilateral reconstruction for comparative analyses of outcomes and complications, with the patient as the unit of analysis. RESULTS: Overall, 565 DIEP flaps were performed on 468 women (371 unilateral and 97 bilateral reconstructions [194 flaps]). Postoperative complications requiring reoperation were twice as likely for bilateral reconstructions (risk ratio [RR] 2.1, 95% CI 1.4-3.4, p = 0.002) and were mainly due to venous congestion (RR 3.1, 95% CI 1.2-7.5, p = 0.011). The risk of total flap loss was six times greater in bilateral reconstruction (RR 6.4, 95% CI 1.6-26, p = 0.011). The rates of revision breast and abdominal surgery were similar between groups. CONCLUSIONS: Both unilateral and bilateral DIEP flap breast reconstructions are safe, with a low risk of complications; however, bilateral reconstruction was associated with a higher risk of complications and total flap loss. This information should be highlighted to patients requesting bilateral breast reconstruction, particularly those requesting risk-reducing mastectomy and reconstruction.

Correction to: Reply to ''Complications in DIEP Flap Breast Reconstruction After Mastectomy for Breast Cancer: A Prospective Cohort Study Comparing Unilateral Versus Bilateral Reconstructions".

In the original article Justin C. R. Wormald's middle initials were incorrect. They are correct as reflected in this erratum. The original article has also been corrected.

Updates in diagnostic tools for diagnosing nerve injury and compressions.

Predicting prognosis after nerve injury and compression can be challenging, even for the experienced clinician. Although thorough clinical assessment can aid diagnosis, we cannot always be precise about long-term functional recovery of either motor or sensory nerves. To evaluate the severity of nerve injury, surgical exploration remains the gold standard, particularly after iatrogenic injury and major nerve injury from trauma, such as brachial plexus injury. Recently, advances in imaging techniques (ultrasound, magnetic resonance imaging [MRI] and MR neurography) along with multimodality assessment, including electrodiagnostic testing, have allowed us to have a better preoperative understanding of nerve continuity and prediction of nerve health and possible recovery. This article outlines the current and potential roles for clinical assessment, exploratory surgery, electrodiagnostic testing ultrasound and MRI in entrapment neuropathies, inflammatory neuritis and trauma. Emphasis is placed on those modalities that are improving in diagnostic accuracy of nerve assessment before any surgical intervention.

Hand and Wrist trauma: Antimicrobials and Infection Audit of Clinical Practice (HAWAII ACP) protocol.

Aims: Hand trauma, consisting of injuries to both the hand and the wrist, are a common injury seen worldwide. The global age-standardized incidence of hand trauma exceeds 179 per 100,000. Hand trauma may require surgical management and therefore result in significant costs to both healthcare systems and society. Surgical site infections (SSIs) are common following all surgical interventions, and within hand surgery the risk of SSI is at least 5%. SSI following hand trauma surgery results in significant costs to healthcare systems with estimations of over £450 per patient. The World Health Organization (WHO) have produced international guidelines to help prevent SSIs. However, it is unclear what variability exists in the adherence to these guidelines within hand trauma. The aim is to assess compliance to the WHO global guidelines in prevention of SSI in hand trauma. Methods: This will be an international, multicentre audit comparing antimicrobial practices in hand trauma to the standards outlined by WHO. Through the Reconstructive Surgery Trials Network (RSTN), hand surgeons across the globe will be invited to participate in the study. Consultant surgeons/associate specialists managing hand trauma and members of the multidisciplinary team will be identified at participating sites. Teams will be asked to collect data prospectively on a minimum of 20 consecutive patients. The audit will run for eight months. Data collected will include injury details, initial management, hand trauma team management, operation details, postoperative care, and antimicrobial techniques used throughout. Adherence to WHO global guidelines for SSI will be summarized using descriptive statistics across each criteria. Discussion: The Hand and Wrist trauma: Antimicrobials and Infection Audit of Clinical Practice (HAWAII ACP) will provide an understanding of the current antimicrobial practice in hand trauma surgery. This will then provide a basis to guide further research in the field. The findings of this study will be disseminated via conference presentations and a peer-reviewed publication.

Intraoperative esophageal Doppler hemodynamic monitoring in free perforator flap surgery.

Goal-directed fluid therapy optimizes cardiac output and flap perfusion during anesthesia. Intraoperative esophageal Doppler (ED) monitoring has been reported as more accurate and reliable, demonstrating improved surgical outcomes compared with central venous pressure and arterial catheter monitoring. A prospective study of patients undergoing free perforator (deep inferior epigastric artery perforator/anterolateral thigh) flap surgery with intraoperative ED monitoring (51 patients) or central venous pressure monitoring (53 patients) was undertaken. Fluid input included crystalloids, colloids, or blood products. Fluid output included urine, blood, or suctioned fluid. Postoperative fluid balance was calculated as fluid input - output. Fluid input between groups was not different. Fluid output was greater in the ED group (P = 0.008). The ED group showed less fluid balance (P = 0.023), less anesthetic time (P = 0.001), less hospital stay (mean 1.9 days; P = 0.147), less monitoring and flap complications (P = 0.062). ED monitoring demonstrated no monitoring complications, provides a favorable postoperative fluid balance, and may reduce flap complications and hospital stay.

Bacterial sensitivity to chlorhexidine and povidone-iodine antiseptics over time: a systematic review and meta-analysis of human-derived data.

Surgical site infection (SSI) is the most common complication of surgery, increasing healthcare costs and hospital stay. Chlorhexidine (CHX) and povidone-iodine (PVI) are used for skin antisepsis, minimising SSIs. There is concern that  resistance to topical biocides may be emergeing, although the potential clinical implications remain unclear. The objective of this systematic review was to determine whether the minimum bactericidal concentration (MBC) of topical preparations of CHX or PVI have changed over time, in microbes relevant to SSI. We included studies reporting the MBC of laboratory and clinical isolates of common microbes to CHX and PVI. We excluded studies using non-human samples and antimicrobial solvents or mixtures with other active substances. MBC was pooled in random effects meta-analyses and the change in MBC over time was explored using meta-regression. Seventy-nine studies were included, analysing 6218 microbes over 45 years. Most studies investigated CHX (93%), with insufficient data for meta-analysis of PVI. There was no change in the MBC of CHX to Staphylococci or Streptococci over time. Overall, we find no evidence of reduced susceptibility of common SSI-causing microbes to CHX over time. This provides reassurance and confidence in the worldwide guidance that CHX should remain the first-choice agent for surgical skin antisepsis.