Introduction
Lymphedema can be a debilitating condition, causing a great decrease in a person’s quality of life (QoL). Treatment with lymphaticovenular anastomosis (LVA), in which an anastomosis is ...created between the lymphatic and venous system, may attenuate lymphedema symptoms and reduce swelling. In this study, we share the results using LVA to treat breast cancer-related lymphedema (BCRL) at our institution.
Materials and methods
Patients were eligible for inclusion if they suffered from unilateral BCRL, if functional lymphatics were available, if compression therapy was used for at least 6 months, and if the follow-up was 12 months at minimum. Lymph vessel functionality was assessed preoperatively using indocyanine green (ICG). During surgery, 1–3 anastomoses were created and shunt patency was confirmed using ICG. Arm volumes were measured before surgery and at 6- and 12-month follow-up. QoL was measured before surgery and at 6-month follow-up. Arm volume differences between the healthy arm and affected arm were compared between the time points.
Results
Twenty-nine consecutive female patients with unilateral BCRL were included. The preoperative mean difference in arm volumes was 701 ± 435 ml (36.9%). This was reduced to 496 ± 302 ml (24.7%) at 6-month follow-up (
p
=
0.00). At 12-month follow-up, the mean difference in arm volume was 467 ± 303 ml (23.5%) (
p
=
0.02). The overall perceived QoL was increased from 5.8 ± 1.1 to 7.4 ± 0.7 (
p
=
0.00). The functionality score decreased from 2.2 to 1.8 (
p
=
0.00), the appearance score decreased from 2.6 to 1.9 (
p
=
0.00), the symptoms score decreased from 2.8 to 1.8 (
p
=
0.00), and the mood score decreased from 2.7 to 1.5 (
p
=
0.00). Fifteen patients (53.6%) were able to discontinue the use of compression garment.
Conclusion
Treatment with LVAs is effective in reducing arm volume difference in patients suffering from BCRL. Although no complete reduction of the edema was achieved at 12-month follow-up, the procedure significantly increased the patients’ QoL.
The deep nitrogen-covered basin on Pluto, informally named Sputnik Planitia, is located very close to the longitude of Pluto's tidal axis and may be an impact feature, by analogy with other large ...basins in the Solar System. Reorientation of Sputnik Planitia arising from tidal and rotational torques can explain the basin's present-day location, but requires the feature to be a positive gravity anomaly, despite its negative topography. Here we argue that if Sputnik Planitia did indeed form as a result of an impact and if Pluto possesses a subsurface ocean, the required positive gravity anomaly would naturally result because of shell thinning and ocean uplift, followed by later modest nitrogen deposition. Without a subsurface ocean, a positive gravity anomaly requires an implausibly thick nitrogen layer (exceeding 40 kilometres). To prolong the lifetime of such a subsurface ocean to the present day and to maintain ocean uplift, a rigid, conductive water-ice shell is required. Because nitrogen deposition is latitude-dependent, nitrogen loading and reorientation may have exhibited complex feedbacks.
Algal blooms can seriously affect the operation of water treatment processes including low pressure (micro- and ultra-filtration) and high pressure (nanofiltration and reverse osmosis) membranes ...mainly due to accumulation of algal-derived organic matter (AOM). In this study, the different components of AOM extracted from three common species of bloom-forming algae (Alexandrium tamarense, Chaetoceros affinis and Microcystis sp.) were characterised employing various analytical techniques, such as liquid chromatography – organic carbon detection, fluorescence spectroscopy, fourier transform infrared spectroscopy, alcian blue staining and lectin staining coupled with laser scanning microscopy to indentify its composition and force measurement using atomic force microscopy to measure its stickiness. Batch culture monitoring of the three algal species illustrated varying characteristics in terms of growth pattern, cell concentration and AOM release. The AOM produced by the three algal species comprised mainly biopolymers (e.g., polysaccharides and proteins) but some refractory compounds (e.g., humic-like substances) and other low molecular weight acid and neutral compounds were also found. Biopolymers containing fucose and sulphated functional groups were found in all AOM samples while the presence of other functional groups varied between different species. A large majority (>80%) of the acidic polysaccharide components (in terms of transparent exopolymer particles) were found in the colloidal size range (<0.4 μm). The relative stickiness of AOM substantially varied between algal species and that the cohesion between AOM-coated surfaces was much stronger than the adhesion of AOM on AOM-free surfaces. Overall, the composition as well as the physico-chemical characteristics (e.g., stickiness) of AOM will likely dictate the severity of fouling in membrane systems during algal blooms.
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•Three algal species showed different mechanisms of releasing algal organic matter (AOM).•Six analytical techniques applied for physico-chemical characterisation of AOM.•AOM mainly comprise biopolymers but some also comprise refractory (humic-like) compounds.•Algal biopolymers containing fucose and sulphated functional groups were ubiquitous.•Adhesive/cohesive bonding ability of algal biopolymers can be associated with membrane fouling.
•In a low-income country the prevalence of burn scar contractures was high at one year post-injury.•From discharge up to one year post-injury half of the joint contractures resolved to normal ...flexibility.•Joints that developed a contracture over time were limited in performing daily activities.•Predictors for developing contractures were prolonged patient delay and large, deep burns.•Patients who developed burn scar contractures reported more disability and lower quality of life.•To limit the development of contractures, timely access to safe burn care should be improved in low-income countries.
The aim of this study was to assess the development of burn scar contractures and their impact on joint function, disability and quality of life in a low-income country.
Patients with severe burns were eligible. Passive range of motion (ROM) was assessed using lateral goniometry. To assess the development of contractures, the measured ROM was compared to the normal ROM. To determine joint function, the normal ROM was compared to the functional ROM. In addition, disability and quality of life (QoL) were assessed. Assessments were from admission up to 12 months after injury.
Thirty-six patients were enrolled, with a total of 124 affected joints. The follow-up rate was 83%. Limited ROM compared to normal ROM values was observed in 26/104 joints (25%) at 12 months. Limited functional ROM was observed in 55/115 joints (48%) at discharge and decreased to 22/98 joints (22%) at 12 months. Patients who had a contracture at 12 months reported more disability and lower QoL, compared to patients without a contracture (median disability 0.28 versus 0.17 (p = 0.01); QoL median 0.60 versus 0.76 (p = 0.001)). Significant predictors of developing joint contractures were patient delay and the percentage of TBSA deep burns.
The prevalence of burn scar contractures was high in a low-income country. The joints with burn scar contracture were frequently limited in function. Patients who developed a contracture reported significantly more disability and lower QoL. To limit the development of burn scar contractures, timely access to safe burn care should be improved in low-income countries.
The use of free vascularized fibula grafts (FVFG) in complex spinal deformity surgery intends to allow for life-long stability of the spine with good long-term clinical outcome. However, these ...long-term outcomes of this technique are still lacking. The objective of this study is to report the long-term postoperative outcomes and establish the long-term viability of this method for spinal reconstruction.
A retrospective cohort study was conducted in all patients who underwent spinal reconstructive surgery utilizing a FVFG at a tertiary medical centre.
Questionnaires taken from the participants were the Numeric Pain Rating Scale (NPRS), Oswestry Low Back Pain Disability (also known as Oswestry Disability Index (ODI)), Scoliosis Research Society 22r (SRS-22), the EQ-5D-5L and a self-assembled questionnaire regarding donor site comorbidities and patient satisfaction.
Over a period of 24 years (1995–2019), we used FVFG for spinal reconstruction in 31 patients. A total of 25 patients were included in this study, 8 patients were deceased at the time of this study, and sixteen patients responded to the questionnaires. Patient satisfaction was rated 6.8 out of 10, the average SRS-22r score was 3.6, EQ-5D-5L score was 0.725, and the ODI score showed a minimal disability (0–20%) postoperatively. Overall complication-free survival was 8.9 years. Nine patients underwent a re-operation in the spinal area; five for the removal of the spinal instrumentation.
Patients reported satisfied and good long-term outcomes following FVFG surgical procedure for complex spinal deformities. Therefore, considering the alternatives, this procedure provides a good long-term solution for complex spinal deformity surgery.
We consider the capacity of multiple-input multiple-output systems with reduced complexity. One link-end uses all available antennas, while the other chooses the L out of N antennas that maximize ...capacity. We derive an upper bound on the capacity that can be expressed as the sum of the logarithms of ordered chi-square-distributed variables. This bound is then evaluated analytically and compared to the results obtained by Monte Carlo simulations. Our results show that the achieved capacity is close to the capacity of a full-complexity system provided that L is at least as large as the number of antennas at the other link-end. For example, for L = 3, N = 8 antennas at the receiver and three antennas at the transmitter, the capacity of the reduced-complexity scheme is 20 bits/s/Hz compared to 23 bits/s/Hz of a full-complexity scheme. We also present a suboptimum antenna subset selection algorithm that has a complexity of N/sup 2/ compared to the optimum algorithm with a complexity of (N/sub L/).
•In this resource-limited setting patients presented after a delay with multiple complications and a high mortality risk.•Delayed skin grafting in survivors of severe burns was found to be safe and ...effective in this setting.•Over time the disability lessened and quality of life improved in the majority of cases.•There is room for improvement of the access to timely and safe burn care in underserved populations.
Only a few papers are published on the safety and effectiveness of acute burn care in low-income countries. A cohort study was therefore carried out to determine such outcomes.
The study was conducted in a rural Tanzanian hospital in 2017–2018. All patients admitted with burns were eligible. Complications were scored during admission as an indication for safety. Survivors of severe burn injuries were evaluated for time of reepithelialization, graft take, disability (WHODAS2.0) and quality of life (EQ5D-3L) up to 3 months post-injury, as an indication of effectiveness.
Patients presented on average at 5 days after injury (SD 11, median 1, IQR 0–4). Three patients died at admission. The remaining 79 were included in the cohort. Their median age was 3 years (IQR 2–9, range 0.5–49), mean TBSA burned 12% (SD10%) and mortality rate 11.4%. No surgery-related mortality or life-threatening complications were observed. Skin grafting was performed on 29 patients at a delayed stage (median 23 days, IQR 15–47). Complications of skin grafts included partial (25% of procedures) and complete graft necrosis (8% of procedures). The mean time to reepithelialization was 52 (SD 42) days after admission. Disability and quality of life improved from admission to 3 months after injury (p<0.001, p<0.001, respectively).
In this resource-limited setting patients presented after a delay and with multiple complications. The mortality during the first two weeks after admission was high. Surgery was found to be safe and effective. A significant improvement in disability and quality of life was observed.
•This is the first study globally that evaluated the functional impact of contracture release surgery.•Contracture release surgery effectively improves joint function, reduces disability, and ...improves QoL.•Regaining a functional joint after surgery is associated with less disability and higher QoL.•Future studies that evaluate joint flexibility problems should assess functional ROM, disability and QoL.
Burn scar contractures limit range of motion (ROM) of joints and have substantial impact on disability and the quality of life (QoL) of patients, particularly in a Low- and Middle-Income Country (LMIC) setting. Studies on the long-term outcome are lacking globally; this study describes the long-term impact of contracture release surgery performed in an LMIC.
This is a pre-post cohort study, conducted in a referral hospital in Tanzania. Patients who underwent burn scar contracture release surgery in 2017–2018 were eligible. ROM (goniometry), disability (WHODAS 2.0) and QoL (EQ-5D) were assessed. The ROM data were compared to the ROM that is required to perform activities of daily living without compensation, i.e. functional ROM. Assessments were performed preoperatively and at 1, 3, 6 and 12 months postoperatively.
In total, 44 patients underwent surgery on 115 affected joints. At 12 months, the follow-up rate was 86%. The mean preoperative ROM was 37.3% of functional ROM (SD 31.2). This improved up to 108.7% at 12 months postoperatively (SD 42.0, p < 0.001). Disability-free survival improved from 55% preoperatively to 97% at 12 months (p < 0.001) postoperatively. QoL improved from 0.69 preoperatively, to 0.93 (max 1.0) at 12 months postoperatively (p < 0.001). Patients who regained functional ROM in all affected joints reported significantly less disability (p < 0.001) and higher QoL (p < 0.001) compared to patients without functional ROM.
Contracture release surgery performed in an LMIC significantly improved functional ROM, disability and QoL. Results showed that regaining a functional joint is associated with less disability and higher QoL.
Background
Implant‐based breast reconstruction (IBBR) is the most commonly performed reconstructive procedure and its economic impact is significant. This study aimed to analyse whether a direct ...one‐stage IBBR with use of an acellular dermal matrix (ADM) is more cost‐effective than two‐stage (expander‐implant) breast reconstruction.
Methods
The BRIOS (Breast Reconstruction In One Stage) study was an open‐label multicentre RCT in which women scheduled for skin‐sparing mastectomy and immediate IBBR were randomized between one‐stage IBBR with ADM or two‐stage IBBR. Duration of surgery and hospital stay, and visits for the primary surgery, unplanned and cosmetic procedures were recorded. Costs were estimated at an institutional level. Health status was assessed by means of the EuroQol Five Dimensions 5L questionnaire.
Results
Fifty‐nine patients (91 breasts) underwent one‐stage IBBR with ADM and 62 patients (92 breasts) two‐stage IBBR. The mean(s.d.) duration of surgery in the one‐stage group was significantly longer than that for two‐stage IBBR for unilateral (2·52(0·55) versus 2·02(0·35) h; P < 0·001) and bilateral (4·03(1·00) versus 3·25(0·58) h; P = 0·017) reconstructions. Costs were higher for one‐stage compared with two‐stage IBBR for both unilateral (€12 448 (95 per cent c.i. 10 722 to 14 387) versus €9871 (9373 to 10 445) respectively; P = 0·025) and bilateral (€16 939 (14 887 to 19 360) versus €13 383 (12 414 to 14 669); P = 0·002) reconstructions. This was partly related to the use of relatively expensive ADM. There was no difference in postoperative health status between the groups.
Conclusion
One‐stage IBBR with ADM was associated with higher costs, but similar health status, compared with conventional two‐stage IBBR. Registration number: NTR5446 (
http://www.trialregister.nl).
In this multicentre open‐label RCT, women scheduled for skin‐sparing mastectomy and immediate implant‐based breast reconstruction (IBBR) were randomized to undergo one‐stage IBBR with acellular dermal matrix (ADM) or two‐stage IBBR. Fifty‐nine patients (91 breasts) underwent one‐stage IBBR with ADM and 62 patients (92 breasts) two‐stage IBBR. One‐stage IBBR with ADM was associated with higher costs, which was partly explained by the relatively expensive ADM, and similar health status, compared with conventional two‐stage IBBR.
One‐stage not cost‐effective
Lymphedema is a condition which heavily impacts patients QoL. For patients who desire autologous breast reconstruction, lymph nodes can be included in the Deep Inferior Epigastric Artery (DIEP) flap ...combining vascularized lymph node transfer and autologous breast reconstruction.
Patients who received autologous breast reconstruction with a DIEP flap in combination with vascularized lymph nodes were included in this study. Volume measurements pre and post-surgery were analyzed and surveys including two versions of the ULL-27 questionnaire to measure QoL before and after surgery were send.
In total, 45 out of 64 patients returned the questionnaires. The average follow up was 51 months. The total ULL-27 score increased with 12.6 points on average (p = 0.00). The subdomain scores (physical, psychological and social) also significantly increased (p = 0.00). In addition 69% of patients were able to decrease physiotherapy, 63% of patients were able to decrease compression garment usage and the incidence of skin infections decreased in 6 patients out of 7 patients who had recurrent skin infections prior to surgery. The volume difference between the affected and the healthy arm did not significantly change (407 ml–406 ml, p = 0.988).
Vascularized lymph node transfer in combination with DIEP flap breast reconstruction can cause a significant improvement on lymphedema related QoL, even when a volume difference decrease is absent. It can also decrease compression garment usage and reduce the need for physiotherapy. Future prospective studies should evaluate these findings and identify patients that benefit most from such procedures.
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