The timing of drain removal—empiricism or science?

Surgical drains are commonly used in plastic surgery. Drains are subsequently removed at arbitrary volumes depending on local protocols. The rational for when to remove a drain has not been scientifically determined. We compared removal of drains at ≤30?ml/24?h vs. ≤50?ml/24?h for 158 wounds, in 90 patients. Postoperative complications, length of hospital stay and resulting cost–benefit were considered. Prospective data were collected for two consecutive similar cohorts of patients undergoing abdominoplasty, bilateral breast reduction and breast augmentation. In the first cohort, drains were removed when drainage was ≤30?ml/24?h and the second cohort when ≤50?ml/24?h. Demographics, days of drainage, surgeon grade and duration of postoperative hospital stay were recorded. Patient records were then analysed and complications recorded, including haematoma, infection, seroma, wound breakdown and fat necrosis. The median postoperative stay for all three operations for both drainage cohorts was similar with no statistically significant difference; however, the drainage time in breast augmentation was significantly less in the <50?ml/24?h group. There were no significant differences in outcome measures between the patients undergoing abdominoplasty, breast reduction or breast augmentation. Drain removal at ≤50 vs. ≤30?ml/24?h did not result in an increase in postoperative morbidity or adverse outcome in any of the three different operation types.     

Robotic partial cystectomy for lymphangioma of the urinary bladder in an adult woman

Lymphangioma of the urinary bladder is a very rare tumour in adulthood. Robotic partial cystectomy is evolving for treatment of a limited number of bladder tumours. We describe a case of an adult woman with a bladder dome lymphangioma for which robotic partial cystectomy was carried out.     

Peritraumatic distress across the lifespan: Clinical implications of age differences during the COVID-19 pandemic

The Peritraumatic Distress Inventory (PDI) is a well-known self-report questionnaire indexing the distress experienced during and shortly after a most stressful or traumatic event. Although sociodemographic factors contributing to peritraumatic distress have been previously investigated, no research has examined the nature and severity of peritraumatic distress reactions in a non-clinical, community sample as a function of age. An international sample of 5621 adult participants were grouped according the World Health Organization's age stratification protocol. Mean scores and item endorsement on the PDI were compared across groups with respect to their worst experience of the COVID-19 pandemic. A significant between-group difference was found, F(55,615) = 30.74, p < 0.001, n² = 0.027 whereby participants aged 18–39 years old reported the highest levels of peritraumatic distress. This group also endorsed a higher proportion of items on the PDI's two main factors (emotional distress and physical reactions), and were more likely to endorse feelings of helplessness, than older participants. It appears that severity of peritraumatic distress during the pandemic has affected younger people the most. Results are discussed in light of clinical implications.     

A Comparison of the Intubation Conditions between Mivacurium and Rocuronium during Balanced Anesthesia

Background: Comparisons of the intubation conditions with mivacurium and rocuronium from previous reports are confounded by the use of varied induction regimens. The authors compared intubation conditions of mivacurium, rocuronium, and a placebo at 90 s and their recovery profiles during anesthesia with nitrous oxide, oxygen, and propofol.

Methods: After induction with midazolam, fentanyl, and propofol in a randomized blinded study, 100 patients received one of the following treatments: 0.25 mg/kg mivacurium in divided doses (0.15 mg/kg followed by 0.1 mg/kg 30 s later); 0.45, 0.6, 0.9, or 1.2 mg/kg rocuronium; or placebo. Evoked thumb adduction was measured throughout. Intubation was attempted 90 s after the initial dose of mivacurium and other treatment doses by a "blinded" physician. Intubating conditions were graded as excellent, good, poor, or not possible. Spontaneous recovery was studied until a 25% initial twitch height was reached. Mean arterial blood pressure and heart rate changes between groups were determined before induction through 6 min after administration of the study drugs.

Results: There were no important changes or intergroup differences in mean arterial blood pressure and heart rate. Intubation conditions were good or excellent for both mivacurium and rocuronium at the 0.9 mg/kg dose (93%) and at the 1.2 mg/kg dose (100%). Rocuronium at the 0.6 mg/kg dose was excellent in 27% of patients, whereas rocuronium at the 0.45 mg/kg dose had the least number of excellent conditions and the most poor or not possible assessments. Patients given placebo could not be intubated. Times to maximum blockade for 0.9 and 1.2 mg/kg rocuronium were the shortest. The times to 25% recovery for 0.6 mg/kg rocuronium (mean +/- SD = 27 +/- 8.6 min), 0.9 mg/kg (43.1 +/- 10.8), and 1.2 mg/kg (62.3 +/- 17.4 min) were significantly longer than were those for mivacurium (17.4 +/- 6.2 min).     

Polyadenosine diphosphate-ribose polymerase inhibition modulates skeletal muscle injury following ischemia reperfusion

HYPOTHESIS: Polyadenosine diphosphate-ribose polymerase (PARP) has been implicated as a mediator of inflammation and tissue necrosis in murine models of human stroke and myocardial infarction. This study was designed to determine whether PARP modulates skeletal muscle injury and cytokine-growth factor levels during ischemia-reperfusion. DESIGN: Prospective controlled animal study. SETTING: Medical school-affiliated university hospital. INTERVENTIONS: Mice were divided into 2 groups-treated (PJ) and untreated; all mice were subjected to unilateral hind limb tourniquet ischemia followed by 4 or 48 hours of reperfusion. In treated mice, PJ34, an ultrapotent-specific PARP inhibitor was given immediately before ischemia and prior to reperfusion. A group of PARP-1 knockout mice (PARP-/-) were also subjected to hind limb ischemia followed by 48 hours of reperfusion. MAIN OUTCOME MEASURES: After ischemia-reperfusion, muscle was harvested for measurement of edema, viability, cytokine, and vascular endothelial growth factor content. RESULTS: The PJ34-treated mice had increased skeletal muscle viability when compared with the untreated mice after 4 and 48 hours of reperfusion (P<.01). Viability between PARP-/- and PJ34-treated mice were similar at 48 hours of reperfusion (P>.05), and it exceeded that of untreated mice (P<.01). Tissue edema was unaltered by PARP inhibition. Tissue levels of cytokine were only different (P<.05) in PJ34-treated vs untreated mice at 48 hours of reperfusion. Vascular endothelial growth factor levels in PJ34-treated mice were markedly reduced when compared with untreated mice only after 4 hours of reperfusion (P<.01), and in PARP-/- mice (P<.01) at 48 hours of reperfusion. CONCLUSIONS: Polyadenosine diphosphate-ribose polymerase modulates skeletal muscle viability, cytokine and vascular endothelial growth factor synthesis during reperfusion. Polyadenosine diphosphate-ribose polymerase inhibition may represent a novel method to modulate skeletal muscle ischemia-reperfusion injury.     

Wound infection in the management of hip fractures: a comparison between low-molecular weight heparin and mechanical prophylaxis

A review of 205 consecutive patients was carried out to determine the association of low molecular weight heparin (LMWH) and the development of wound infection in patients having undergone surgery for a femoral neck fracture: 114 patients treated with LMW Heparin (Group A) and 91 patients with mechanical prophylaxis (Group B). The wounds were assessed using the ASEPSIS Score. Deep vein thrombosis (DVT) and pulmonary embolism (PE) were also noted. Twenty-two patients (19%) in group A developed infection; 9 patients (8%) showed severe infection. Eight patients (8%) in group B developed infection; one patient (1%) showed severe infection. The differences between these two groups regarding infection (p < 0.034) and severity of the infection (p < 0.001) were statistically significant. None of the patients developed PE; however 9 patients were diagnosed with a DVT. Based on these findings, it appears that the use of LMWH for DVT prophylaxis may increase the likelihood of developing a severe wound infection.     

Management of non-acute gastrointestinal defects using the over-the-scope clips (OTSCs): a retrospective single-institution experience

Introduction

Advanced endoscopic techniques provide novel therapies for complications historically treated with surgical interventions. Over-the-scope clips (OTSCs) have recently been shown to be effective at endoscopic closure of gastrointestinal (GI) defects. We hypothesize that by following classic surgical principles of fistula management, a high rate of long-term success can be achieved with endoscopic closure of non-acute GI tract defects.

Methods

A retrospective review of a single-institution prospectively maintained database (2012–2015) of all patients referred for the management of GI leaks or fistulae who underwent attempted closure with the OTSC system (Ovesco, Germany) was performed. Acute perforations were excluded. The primary endpoint was long-term success defined by the absence of radiographic or clinical evidence of leak or fistula during follow-up. Patients were stratified by success or failure of OTSC closure and compared with Fisher’s exact and Mann–Whitney U tests.

Results

We identified 22 patients with 28 defects (22 fistulae and 6 leaks). Most patients were female (59 %) with a mean age of 54 years (±14), median BMI of 29, and prior bariatric procedure (55 %). Comorbidities included smoking history (68 %) and diabetes (23 %). The majority of defects were solitary (64 %), involved the upper GI tract (82 %), and had been present for >30 days (50 %). Multiple therapeutic interventions were necessary in 46 % of defects. There were no adverse outcomes related to OTSC placement or misfiring. Endoscopic adjuncts were used in 61 % of cases. Overall success rate was 82 % (100 % for leaks and 76 % for fistulae) at a median follow-up of 4.7 months (IQR 2.1–8.4 months). Predictors of success and failure could not be distinguished due to limited sample size.

Conclusions

Over-the-scope clips can be safely and effectively used in patients presenting with GI leaks and fistulae. Further research is required to characterize the determinants of long-term success and risk factors for failure.

     

Computer-assisted analysis contour lines of aesthetic unit for the assessment of lip augmentation

Background

Lip augmentation and changing contour lines have become more popular ways of improving the appearance. However, validated measures of lip fullness for quantification of outcomes are needed; ethnic background and personal goals can optimise outcomes while tailoring lip enhancement treatment to each individual’s anatomy. The aim of this study is to analyse the morphological features of the lip in detail and to clarify the objective parameters in related with the subjective ones regarding the lip augmentation and lip reconstruction.

Methods

Standard photographs of the lips of 200 young Anatolian adults were calculated with linear and angular components. The features of the lower third of the face were analysed with the software program. Linear analyses (heights of the upper lip, the upper vermilion, the lower lip height, the lower vermillion and the chin height) and angular analyses (the upper lip, the lower lip, the apex and Cupid’s bow angles) were measured as reference points. The lip shape was classified into five groups: thin, very thin, medium, full and very full.

Results

The lower third of the face was divided into three segments (Sn–Sto, Sm–Me and Sto–Sm), and the largest portion of the lower face was occupied by the chin and the smallest by the lower lip height in both genders. The upper vermilion height was 8.07?±?1.8 mm in males and 7.08?±?1.5 mm in females. The lower vermilion height was 10.1?±?2.4 mm in males and 9.7?±?1.9 mm in females. The upper lip angle was calculated as 30.3?±?9.6° in males and 24.2?±?6.2°mm in females. The lower lip angle was calculated as 38.3?±?9.7° in males and 36.5?±?6.4° in females. Meanwhile, the angular measurements of Cupid’s bow (i.e., the apex and the central angle of Cupid’s bow) were smaller in men than in women. When the lip was analyzed, the medium and full types in upper and lower lips accounted for substantial fractions in men, whereas medium and thin types were predominant also in women.

Conclusions

With the help of certain software, this research has made possible to define the best cosmetical redesign solution of lip construction and augmentation with a natural appearance for the patient.Level of Evidence: Level III, diagnostic study.

     

PJ34, a poly-ADP-ribose polymerase inhibitor, modulates visceral mitochondrial activity and CD14 expression following thoracic aortic ischemia-reperfusion

Background

Visceral ischemia-reperfusion injury (VI) contributes to adverse outcomes following the repair of thoracoabdominal aneurysms. Experiments were designed to determine whether a poly-adenosine diphosphate-ribose polymerase (PARP) inhibitor modulates indexes of metabolic function (mitochondrial activity), inflammatory cell activation, and tissue inflammation (lipopolysaccharide receptor CD14 messenger ribonucleic acid) following VI.

Methods

129S1/SvImj mice were subjected to thoracic aortic occlusion followed by 48 hours of reperfusion. Normal saline was administered to 25 untreated control mice and PJ34 to 21 mice before and immediately after thoracic aortic ischemia-reperfusion. Sham mice (n = 13) underwent median sternotomy alone. At 48 hours, all animals were euthanized and tissues harvested for quantitative analysis.

Results

PJ34 improved intestinal (P < .05) but not hepatic mitochondrial activity following reperfusion. CD14 messenger ribonucleic acid levels in liver (P < .004), kidney (P < .003), and spinal cord (P < .03) tissue were less in PJ34-treated mice.

Conclusions

PJ34 preserved the metabolic function of intestinal but not hepatic tissue during reperfusion. PJ34 uniformly decreased the expression of an important marker of inflammatory cell activation and tissue inflammation in visceral tissue following VI. PARP inhibitors may serve as a therapeutic modality to abrogate the stress response to VI.