Drug-induced pancreatitis (DIP) is considered a relative rare disease entity, perhaps due to lack of recognition. The objective of this study was to evaluate the prevalence of pancreatitis-associated ...drugs in a Dutch cohort of patients admitted for acute pancreatitis (AP) and to identify the proportion AP possibly attributable to the use of drugs.
This was a multicenter observational study (EARL study). Etiology, disease course, use of pancreatitis-associated drugs at hospital admittance, and discontinuation of these drugs were evaluated. Drugs were scored by means of an evidence-based DIP classification system.
The first documented hospital admissions of 168 patients were analyzed. In all, 70 out of 168 (41.6%; 95% confidence interval (CI): 34.5-49.2%) patients used pancreatitis-associated drugs at admission. In 26.2% (44/168; 95% CI: 20.1-33.3%) of cases, at least one class I pancreatitis-associated drug was used. Possibly DIP was present in 12.5% (21/168; 95% CI: 8.3-18.4%); in less than half of these patients (9/21 or 42.9%; 95% CI: 24.5-63.5%), the prescribed drugs were actually discontinued, with no recurrence of AP later on. Among the remaining 12 patients without discontinuation of their drugs use and in absence of an alternative etiologic cause of AP, 8 patients used a class I pancreatitis-associated drug, representing 4.8% (8/168, 95% CI: 2.4-9.1%) of the total study population.
In this series, a remarkably high percentage of patients who were admitted because of an attack of AP used pancreatitis-associated drugs. Physicians should be more aware of the possibility of DIP in patients with otherwise unexplained AP and act appropriately by discontinuation of the drug.
Purpose
With the BODY-Q, one can assess outcomes, such as satisfaction with appearance, in weight loss and body contouring patients using multiple scales. All scales can be used independently in any ...given combination or order. Currently, the BODY-Q cannot provide overall appearance scores across scales that measure a similar super-ordinate construct (i.e., overall appearance), which could improve the scales’ usefulness as a benchmarking tool and improve the comprehensibility of patient feedback. We explored the possibility of establishing overall appearance scores, by applying a bifactor model to the BODY-Q appearance scales.
Methods
In a bifactor model, questionnaire items load onto both a primary specific factors and a general factor, such as satisfaction with appearance. The international BODY-Q validation patient sample (
n
= 734) was used to fit a bifactor model to the
appearance
domain. Factor loadings, fit indices, and correlation between bifactor
appearance
domain and
satisfaction with body
scale were assessed.
Results
All items loaded on the general factor of their corresponding domain. In the
appearance
domain, all items demonstrated adequate item fit to the model. All scales had satisfactory fit to the bifactor model (RMSEA 0.045, CFI 0.969, and TLI 0.964). The correlation between the
appearance
domain summary scores and
satisfaction with body
scale scores was found to be 0.77.
Discussion
We successfully applied a bifactor model to BODY-Q data with good item and model fit indices. With this method, we were able to produce reliable overall appearance scores which may improve the interpretability of the BODY-Q while increasing flexibility.
BACKGROUND:Three-dimensional (3D) camera systems are increasingly used for computerized volume calculations. In this study we investigate whether the Vectra XT 3D imaging system is a reliable tool ...for determination of breast volume in clinical practice. It is compared with the current gold standard in literature, magnetic resonance imaging (MRI), and current clinical practice (plastic surgeon’s clinical estimation).
METHODS:Breast volumes of 29 patients (53 breasts) were evaluated. 3D images were acquired by Vectra XT 3D imaging system. Pre-existing breast MRI images were collected. Both imaging techniques were used for volume analyses, calculated by two independent investigators. Breast volume estimations were done by plastic surgeons during outpatient consultations. All volume measurements were compared using paired samples t-test, intra-class correlation coefficient, Pearson’s correlation, and Bland–Altman analysis.
RESULTS:Two 3D breast volume measurements showed an excellent reliability (intra-class correlation coefficient0.991), which was comparable to the reliability of MRI measurements (intra-class correlation coefficient0.990). Mean (SD) breast volume measured with 3D breast volume was 454 cm (157) and with MRI was 687 cm (312). These volumes were significantly different, but a linear association could be foundy(MRI) = 1.58 × (3D) – 40. Three-dimensional breast volume was not significantly different from volume estimation made by plastic surgeons (472 cm (69), P = 0.323).
CONCLUSIONS:The 3D imaging system measures lower volumes for breasts than MRI. However, 3D measurements show a linear association with MRI and have excellent reliability, making them an objective and reproducible measuring method suitable for clinical practice.
Summary Background The evidence justifying the use of acellular dermal matrices (ADMs) in implant-based breast reconstruction (IBBR) is limited. We did a prospective randomised trial to compare the ...safety of IBBR with an ADM immediately after mastectomy with that of two-stage IBBR. Methods We did an open-label, randomised, controlled trial in eight hospitals in the Netherlands. Eligible women were older than 18 years with breast carcinoma or a gene mutation linked with breast cancer who intended to undergo skin-sparing mastectomy and immediate IBBR. Randomisation was done electronically, stratified per centre and in blocks of ten to achieve roughly balanced groups. Women were assigned to undergo one-stage IBBR with ADM (Strattice, LifeCell, Branchburg, NJ, USA) or two-stage IBBR. The primary endpoint was quality of life and safety was assessed by the occurrence of adverse outcomes. Analyses were done per protocol with logistic regression and generalised estimating equations. This study is registered at Nederlands Trial Register, number NTR5446. Findings 142 women were enrolled between April 14, 2013, and May 29, 2015, of whom 59 (91 breasts) in the one-stage IBBR with ADM group and 62 (92 breasts) in the two-stage IBBR group were included in analyses. One-stage IBBR with ADM was associated with significantly higher risk per breast of surgical complications (crude odds ratio 3·81, 95% CI 2·67–5·43, p<0·001), reoperation (3·38, 2·10–5·45, p<0·001), and removal of implant, ADM, or both (8·80, 8·24–9·40, p<0·001) than two-stage IBBR. Severe (grade 3) adverse events occurred in 26 (29%) of 91 breasts in the one-stage IBBR with ADM group and in five (5%) of 92 in the two-stage IBBR group. The frequency of mild to moderate adverse events was similar in the two groups. Interpretation Immediate one-stage IBBR with ADM was associated with adverse events and should be considered very carefully. Understanding of selection of patients, risk factors, and surgical and postsurgical procedures needs to be improved. Funding Pink Ribbon, Nuts-Ohra, and LifeCell.
The aims of this study were to assess whether sensory nerve coaptation in free flap breast reconstruction is subject to learning, and to elucidate challenges of this technique.
In this single-center ...retrospective cohort study, we reviewed consecutive free flap breast reconstructions performed between March 2015 and August 2018. Data were extracted from medical records, and missing values were imputed. We assessed learning by exploring associations between case number and probability of successful nerve coaptation using a multivariable mixed-effects model. Sensitivity analysis was performed in a subgroup of cases with evidence of attempted coaptation. Recorded reasons for failed coaptation attempts were grouped into thematic categories. Multivariable mixed-effects models were used to examine associations between case number and postoperative mechanical detection threshold.
Nerve coaptation was completed in 250 of 564 (44%) included breast reconstructions. Success rates varied considerably between surgeons (range 21-78%). In the total sample, the adjusted odds of successful nerve coaptation increased 1.03-fold for every unit increase in case number (95% confidence interval 1.01-1.05,
< 0.05), but sensitivity analysis refuted this apparent learning effect (adjusted odds ratio 1.00, 95% confidence interval 1.00-1.01,
= 0.34). The most frequently recorded reasons for failed nerve coaptation attempts were inability to locate a donor or recipient nerve. Postoperative mechanical detection thresholds showed a negligible, positive association with case number (estimate 0.00, 95% confidence interval 0.00-0.01,
< 0.05).
This study does not provide evidence in support of a learning process for nerve coaptation in free flap breast reconstruction. Nevertheless, the identified technical challenges suggest that surgeons may benefit from training visual search skills, familiarizing with relevant anatomy, and practicing techniques for achieving tensionless coaptation. This study complements prior studies exploring therapeutic benefit of nerve coaptation by addressing technical feasibility.
Explantation is the proposed treatment for breast implant illness (BII). Little is known about which medical specialists are visited and what diagnoses are made before explantation is provided as the ...treatment.
This study investigated medical specialist care utilization in women with cosmetic breast implants who underwent explantation compared to women who chose breast implant replacement surgery and to women without breast implants.
Retrospective cohort study using data linkage with the Dutch Breast Implant Registry and the Dutch health insurance claims database. Visits to medical specialists were examined over the 3 years before explantation. A total of 832 explantation patients were matched and compared to 1463 breast implant replacement patients and 1664 women without breast implants.
Explantation patients were more likely to have visited > 5 different medical specialties compared to both replacement patients (12.3% vs. 5.7%; p < 0.001) and women without breast implants (12.3% vs. 3.7%; p < 0.001). Among explantation patients, women who underwent explantation because of BII were more likely to have visited > 5 different medical specialties compared to women who underwent explantation because of other reasons (25.0% vs. 11.0%; p < 0.001).
Women who underwent explantation of breast implants had higher utilization of medical specialist care in the years before explantation compared to women who underwent breast implant replacement surgery and women without breast implants. Medical specialist care use was especially high among women for whom BII was the registered reason for explantation. These findings suggest further research is needed into the link between BII and the use of medical specialist care.
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 .
Mastectomy skin flap necrosis (MSFN) and partial DIEP (deep inferior epigastric artery perforator) flap loss represent two frequently reported complications in immediate autologous breast ...reconstruction. These complications could be prevented when areas of insufficient tissue perfusion are detected intraoperatively. Hyperspectral imaging (HSI) is a relatively novel, non-invasive imaging technique, which could be used to objectively assess tissue perfusion through analysis of tissue oxygenation patterns (StO
%), near-infrared (NIR%), tissue hemoglobin (THI%), and tissue water (TWI%) perfusion indices. This prospective clinical pilot study aimed to evaluate the efficacy of HSI for tissue perfusion assessment and to identify a cut-off value for flap necrosis. Ten patients with a mean age of 55.4 years underwent immediate unilateral autologous breast reconstruction. Prior, during and up to 72 h after surgery, a total of 19 hyperspectral images per patient were acquired. MSFN was observed in 3 out of 10 patients. No DIEP flap necrosis was observed. In all MSFN cases, an increased THI% and decreased StO
%, NIR%, and TWI% were observed when compared to the vital group. StO
% was found to be the most sensitive parameter to detect MSFN with a statistically significant lower mean StO
% (51% in the vital group versus 32% in the necrosis group,
< 0.0001) and a cut-off value of 36.29% for flap necrosis. HSI has the potential to accurately assess mastectomy skin flap perfusion and discriminate between vital and necrotic skin flap during the early postoperative period prior to clinical observation. Although the results should be confirmed in future studies, including DIEP flap necrosis specifically, these findings suggest that HSI can aid clinicians in postoperative mastectomy skin flap and DIEP flap monitoring.
Given the rising popularity in body-contouring procedures (BCPs) in the United States, it is important to assess the currently unknown association between resident involvement and postoperative ...complications. As such, the aim of this study was to evaluate the impact of resident involvement on outcomes in BCPs using a large national database.
METHODSA retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database was performed (2006–2012) to identify patients undergoing BCPs, using relevant Current Procedural Terminology codes. Outcome measures included postoperative complications, hospital length of stay, and operation time.Multivariate regression models were used to assess the impact of resident involvement and resident experience on outcomes.
RESULTSA total of 9638 cases were identified, of which 3311 involved resident participation.Resident involvement was associated with significantly higher rates of complications (7.8% vs 4.4%; P = 0.003) and longer operation times (180.7 vs 171.9 minutes; P = 0.005). For each year increase of resident postgraduate year, there was a significant decrease in odds of complications (odds ratio, 0.906; P = 0.013) and operative time (−2.7 minutes; P = 0.001).
CONCLUSIONSResident involvement in BCPs was associated with an increased rate of overall complications in a large, national database. However, the clinical significance of these outcomes may be debated. Increased postgraduate year experience as a surgical resident was inversely associated with overall complications. Guided resident autonomy and earlier exposure to BCPs could lead to an optimization of clinical outcomes and resident education.
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