Increased Risk Of Complications Research Articles

Risk assessment and management strategies in older patients with acute pulmonary embolism

IntroductionManaging older patients with acute pulmonary embolism (PE) is challenging due to their underrepresentation in clinical trials, comorbidities and increased complication risk. This study evaluates risk assessment and management outcomes in older PE patients focussing on home and reperfusion treatment. MethodsA retrospective analysis was conducted on patients aged ≥70 years diagnosed with acute PE at an academic medical centre (2015-2022). Results242 patients with a mean age of 77 years were included. All 59 patients with negative Hestia criteria were discharged ≤24h, and in total 81 patients (35%) received home treatment. Among these 14-day mortality and recurrent venous-thromboembolism were 0% and major bleeding occurred in 1.3% (one patient, 95%CI 0.11-6.1). European Society of Cardiology (ESC) risk-classification showed 9 low-risk PE (3.9%), 199 intermediate-risk (87%), and 20 high-risk PE patients (8.8). In 5 of the 20 high-risk patients, hypotension was mainly caused by another condition, i.e. sepsis. Eight high-risk patients received reperfusion therapy. Fourteen-day mortality was 51% in high-risk patients (95%CI 27-71); 5 out of 8 patients receiving reperfusion treatment died within 5 days. Patients with an Acute Presenting Older Patient (APOP) score of ≥45% had higher 14-day mortality (28%; 95%CI 12-46) compared to <45% (3.2%; 95%CI 0.85-8.3; HR 10.2; 95%CI 2.6-39). ConclusionSelecting for home treatment using Hestia was safe for older PE patients in our cohort. Mortality in the high-risk group was high also when receiving reperfusion treatment. The ESC risk-classification and APOP score identified patients at higher mortality risk, suggesting their potential utility in clinical decision-making.

Additional Lesion Sets in Ablation of Outflow Tract Premature Ventricular Contractions: A Randomized Clinical Trial.

Recurrence remains a challenge after ablation of outflow tract premature ventricular contractions (OT-PVCs). Although adding additional lesions next to the index effective ablation site is sometimes performed to reinforce the ablation, it remains uncertain whether this approach is effective. To test the hypothesis that additional ablation lesions would reduce the recurrence rate compared with single-point ablation at the index effective site for the ablation of OT-PVCs. This study was a multicenter, prospective, randomized clinical trial. Patients receiving their first catheter ablation for OT-PVCs were enrolled from 18 hospitals in China between October 2021 and February 2023. Scheduled follow-up duration was 3 months after the procedure. After identifying the target point and eliminating the PVC by a single-point ablation, patients were randomized 1:1 into an additional ablation group or a control group. The primary end point of the study was freedom from PVC recurrence (≥80% reduction of PVC burden, which is the number of PVCs in 24 hours/total heartbeats in 24 hours × 100%) from baseline to 3 months postprocedure. Of 308 patients enrolled in the study, 286 (mean [SD] age, 49.2 [14.6] years; 173 female [60.5%]) were randomized to the additional ablation or the control group. The additional ablation group had a mean (SD) of 6.3 (1.1) radiofrequency applications, whereas the control group (single-point ablation group) had a mean (SD) of 1 (0) radiofrequency application. After a median (IQR) follow-up of 3.2 (0) months, the rate of freedom from PVCs was significantly higher in the additional ablation group (139 of 142 [97.9%]) compared with the control group (115 of 139 [82.7%]; P < .001). Patients in the additional ablation group also had a more substantial reduction in PVC burden than the control group (mean [SD] reduction, 23.0% [10.5%] vs 19.0% [10.4%]; P = .002). There were no severe periprocedural complications in either group. This randomized clinical trial showed a benefit of additional ablation in reducing the recurrence of OT-PVCs compared with the single-point ablation strategy, without increased complication risk. Additional ablations surrounding the index effective ablation point should be considered in OT-PVC ablation. Chinese Clinical Trials Registry Identifier: ChiCTR2200055340.

Comparison of supine and prone mini percutaneous nephrolithotomy in obese patients: a retrospective study.

To compare the safety and effectiveness of Mini Percutaneous Nephrolithotomy (m-PNL) operations performed in the supine and prone positions in obese patients. We retrospectively analysed data from obese patients (BMI ≥ 30) who underwent prone or supine mPCNL between January 2014 and June 2021 in our clinic. Kidney anomalies, coagulopathy, solitary kidney, skeletal deformity, and patients under 18 were excluded. Outcomes measures included operation time, fluoroscopy time, duration of hospitalisation, stone-free rate, and complications classified by Clavien-Dindo. Statistical analysis was performed using SPSS version 26. The study included 338 patients (100 supine, 238 prone). Supine mPCNL had a shorter mean operation time (89.6 vs. 100.3 minutes, p=0.001), fluoroscopy time, and duration of hospitalisation (60.7 vs. 112.0 hours, p=0.001). Overall complication rates were comparable, but major complications were higher in the prone group (p=0.041). Logistic regression identified stone size >25 mm and prone position as significant risk factors for major complications. Supine and prone mPCNL are both effective for treating kidney stones in obese patients. Supine mPCNL offers benefits, such as shorter operation time, reduced radiation exposure, and fewer major complications. Careful monitoring is recommended for patients with high CCI scores or larger stones due to increased complication risks.

Body Mass Index Improvement Reduces Total Knee Arthroplasty Complications Among Patients Who Have Extreme, but Not Severe, Obesity

BackgroundWhile morbid obesity has been associated with increased complication risk in primary total knee arthroplasty (TKA), limited evidence is available to attribute decreased surgical complication rates with body mass index (BMI) reduction. MethodsWe retrospectively assessed 464 unilateral TKAs performed in morbidly obese patients, including 158 extremely obese (BMI ≥ 45) and 306 severely obese patients (BMI 40 to 44.9). A detailed medical record review identified concurrent modifiable risk factors and successful preoperative BMI reduction, reaching either a contemporary risk target (BMI < 40) or an institutionally accepted threshold (BMI < 45). Postoperative blood glucose levels and 1-year adverse outcomes (periprosthetic joint infection, wound dehiscence, knee manipulation, periprosthetic fracture) were compared to 557 contemporary control subjects with expected slightly lower (moderate obesity, BMI 35 to 39.9) or sufficiently lower complication risk (overweight, BMI 25 to 29.9). ResultsPeriprosthetic joint infection and postoperative hyperglycemia were identified more frequently among morbidly obese patients in comparison with a moderately obese control group. Extremely obese patients (BMI ≥ 45) whose BMI improved below 45 had no measurable difference in infection risk from the control group (odds ratio [OR] 0.84, 95% confidence interval [CI] 0.04 to 16.88), while those with a nonimproved BMI had a significantly higher risk (OR 7.70, 95% CI 1.89 to 31.41). No significant differences in the risk for infection were observed between severely obese patients (BMI 40 to 44.9) with preoperative BMI improvement (1.5% rate, OR 1.70, 95% CI 0.17 to 16.57) or nonimprovement (1.7% rate, OR 1.87, 95% CI 0.41 to 8.43). ConclusionsPreoperative medical optimization may decrease postoperative TKA complications. The findings of this study support BMI improvement for extremely obese patients (BMI ≥ 45). The assignment of 40 BMI as a threshold for otherwise healthy patients may exclude patients from potential surgical benefits without realizing risk reduction.

Disease burden, management strategies, and unmet needs in α-thalassemia due to hemoglobin H disease.

Alpha-thalassemia is an inherited blood disorder caused by impaired α-globin chain production, leading to anemia and other complications. Hemoglobin H (HbH) disease is caused by a combination of mutations generally affecting the expression of three of four α-globin alleles; disease severity is highly heterogeneous, largely driven by genotype. Notably, non-deletional mutations cause a greater degree of ineffective erythropoiesis and hemolysis, higher transfusion burden, and increased complication risks versus deletional mutations. There are limited treatment options for HbH disease, and effective therapies are needed. This review discusses the pathophysiology of HbH disease, current management strategies, unmet needs, and emerging treatment options.

Awake craniotomy in pediatric low-grade glioma: barriers and future directions.

The goal of surgical management in pediatric low-grade gliomas (pLGGs) is gross total resection (GTR), as it is considered curative with favorable long-term outcomes. Achieving GTR can be challenging in the setting of eloquent-region gliomas, in which resection may increase risk of neurological deficits. Awake craniotomy (AC) with intraoperative neurofunctional mapping (IONM) offers a promising approach to achieve maximal resection while preserving neurological function. However, its adoption in pediatric cases has been hindered, and barriers to its adoption have not previously been elucidated. This review includes two complementary investigations. First, a survey study was conducted querying pediatric neurosurgeons on their perceived barriers to the procedure in children with pLGG. Next, these critical barriers were analyzed in the context of existing literature. These barriers included the lack of standardized IONM techniques for children, inadequate surgical and anesthesia experience, concerns regarding increased complication risks, doubts about children's ability to tolerate the procedure, and perceived non-indications due to alternative monitoring tools. Efforts to overcome these barriers include standardizing IONM protocols, refining anesthesia management, enhancing patient preparation strategies, and challenging entrenched beliefs about pediatric AC. Collaborative interdisciplinary efforts and further studies are needed to establish safety guidelines and broaden the application of AC, ultimately improving outcomes for children with pLGG.

Association of maximum uterine diameter with postoperative complications in laparoscopic supracervical hysterectomy: A retrospective cohort study.

To determine the maximum uterine diameter threshold associated with an elevated risk of complications following laparoscopic supracervical hysterectomy (LSH). This was a retrospective cohort study from a single tertiary referral center. We enrolled patients who underwent LSH for benign indications at our hospital between January 2013 and June 2023. The primary outcome was the occurrence of surgical complications within the 30-day timeframe of hysterectomy. The covariate included the year of the procedure, patient age, body mass index, parity, American Society of Anesthesiologists classification, comorbidities, history of previous abdominal and pelvic surgery, and preoperative anemia, blood loss, surgical time, hospital stay and pathology. The exclusion criteria comprised those who underwent hysterectomy for malignancy, individuals who underwent total vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy, and those with missing data on uterine maximum diameter, study outcomes, or covariates. We included a final sample of 120 patients, revealing a median uterine diameter of 9.12 cm, with 9.2% experiencing complications. The median uterine weight among 40 patients was 275 g. Receiver operating characteristic (ROC) curve analysis suggested a potential cutoff of 11.55 cm for predicting complications, with an area under the ROC curve of 0.67. Multivariate logistic regression confirmed a significant association between uterine diameter exceeding the cutoff and increased complication risk (OR 33.925, 95% CI: 2.294-501.690, P = 0.0103). A correlation (r = 0.762, P < 0.001) between uterine weight and diameter indicated the latter's suitability for preoperative assessment of uterine weight. The maximum uterine diameter with an optimal cutoff of 11.55 cm was associated with increased complication risk.

The Impact of Higher BMI on Wound Complications Following Adolescent Breast Reduction: A Retrospective Study of 1215 Cases.

Macromastia is a physically and psychologically distressing condition for adolescents. While reduction mammaplasty is often the best treatment, risk factors for adolescent wound complications remain unclear. This study aims to investigate the impact of obesity and other predictors of postoperative wound complications following adolescent reduction mammaplasty using a national database. The 2012-2019 National Surgical Quality Improvement Program Pediatric (NSQIP-P) databases were reviewed to identify primary reduction mammaplasty encounters. World Health Organization Body Mass Index (BMI), alongside patient and case characteristics, were assessed for association for 30-day wound disruption or surgical site complications. Statistical analyses were performed to identify independent predictors for complications and determine a potential BMI cutoff for risk stratification. There were 1215 patients with an average age of 16.6 years. The average BMI was 30.7 kg/m2, and 593 (48.8%) patients were nonobese while 622 (51.2%) were obese. The incidence of complications was 5.27%. Independent predictors of complications included a BMI 35-39.9, BMI > 40, and an American Society of Anesthesiologists (ASA) Classification > 3. A receiver operating characteristic curve determined that a BMI of 34.6 can be a potential cutoff for increased complication risk. Higher obesity increases risk of wound complications; however, complication rates remain low. A BMI of 34.6 is a potential screening metric for counseling and monitoring patients. Reduction mammaplasty should remain a viable option as it can significantly improve quality of life. 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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Safety and efficacy of percutaneous cryoablation for primary and metastatic pleural based tumors

PurposeAssess safety and local tumor progression-free survival (LTPFS) of percutaneous cryoablation for pleural-based thoracic malignancies. Materials and methodsRetrospective study of 46 patients (17 treated for palliation; 9 for oligoprogression; 20 for curative intent), with 62 pleural-based thoracic lesions, treated in 59 cryoablation sessions. Patients were treated from 9/2005–11/2021 with CryoCare CS (Varian, Irvine, CA) or IceFORCE (Boston Scientific, Marlborough, MA) systems.For tumors treated with curative intent and/or oligoprogression, LTPFS of the treated tumor(s) and overall survival (OS) were estimated using Kaplan–Meier method. Post-operative complications were reported for all sessions, including those with palliative intent; univariate analyses were used to calculate factors associated with increased complication risk. ResultsMedian number of tumors treated in a single treatment session was 1 (range 1–4). Largest dimension of the treated tumor was 2.1 cm [IQR:0.9–5 cm]. Of the 59 treatments, 98.3 % were technically successful.Median LTPFS was 14.4 (95 % CI: 9.4–25.6) months. Tumor size was a significant predictor of LTPFS (HR: 1.21, 95 % CI: 1.03–1.44, p = 0.023). Median OS was 52.4 (28.1-NR) months.Complications occurred in 28/59 sessions (47.5 %); 2/59 (3.4 %) were ≥ grade D by Society of Interventional Radiology adverse event criteria (death; hypoxia requiring supplemental oxygen upon discharge). Pain and pneumothorax were the most common complications. The length of lung parenchyma traversed was a significant predictor of pneumothorax: HR 0.48 (95 %CI: 0.14–0.83), p = 0.0024. ConclusionPercutaneous cryoablation for pleural lesions is associated with a long duration of local control and most complications were minor and self-limited.

509 Data-Driven Preoperative Hemoglobin Strata that Maximize the Likelihood of Blood Transfusion following Single-Level Lumbar Fusion Are Also Predictive of Major Complications and Deep Infections

INTRODUCTION: Optimizing patients undergoing single-level lumbar spine fusion helps reduce the use of blood transfusions which are associated with an increased risk of major complications and deep infection. Current hemoglobin thresholds for anemia severity were published in 1968 and are not surgery specific. METHODS: A retrospective cohort analysis was performed using a national database to identify patients undergoing primary single-level lumbar fusion with recorded hemoglobin values 30 days before surgery. Stratum-specific likelihood ratio (SSLR) analysis defined sex-based hemoglobin strata associated with the risk of 90-day postoperative blood transfusion. Each stratum was propensity-score matched to the highest identified hemoglobin stratum. Incidence rates and risk of 90-day major complications and 2-year deep infection between strata were observed. RESULTS: For 90-day blood transfusion, SSLR identified three female [Strata, Likelihood ratio (5.0-10.9, 2.41; 11.0-12.4, 1.35; 12.5-17.0, 0.78)] and three male hemoglobin strata (5.0-11.9, 2.95; 12.0-13.4, 1.46; 13.5-13.9, 0.71). Increased risk of 90-day major complications was associated with two female (11.0-12.4 [RR: 1.52; p &lt; 0.001], 5.0-10.9 [RR: 3.40; p &lt; 0.001]) and one male stratum (5.0-11.9 [RR: 2.02; p &lt; 0.001]). Increased risk of 2-year deep infection was associated with one female (5.0-10.9 [RR: 3.67; p &lt; 0.001]) and one male stratum (5.0-11.9 [RR: 2.11; p = 0.005]). CONCLUSIONS: SSLR analysis established single-level lumbar fusion-specific hemoglobin strata that maximize the likelihood of 90-day blood transfusions and predict the risk of 90-day major complication and 2-year deep infection. We recommend using these thresholds during preoperative optimization, noting the sequential increase in risk of complications starting with a hemoglobin of less than 13.5 in males and 12.5 in females.

Racial and Ethnic Minority Patients Have Increased Complication Risks When Undergoing Surgery While Not Meeting Clinical Guidelines.

Clinical guidelines for performing total joint arthroplasty (TJA) have not been uniformly adopted in practice because research has suggested that they may foster inequities in surgical access, potentially disadvantaging minority sociodemographic groups. The aim of this study was to assess whether undergoing TJA without meeting clinical guidelines affects complication risk and leads to disparities in postoperative outcomes. This retrospective cohort study evaluated the records of 11,611 adult patients who underwent primary TJA from January 1, 2010, to December 31, 2020, at an academic hospital network. Based on self-reported race and ethnicity, 89.5% of patients were White, 3.5% were Black, 2.9% were Hispanic, 1.3% were Asian, and 2.8% were classified as other. Patients met institutional guidelines for undergoing TJA if they had a hemoglobin A1c of <8.0% and a body mass index of <40 kg/m 2 and were not currently smoking. A logistic regression model was utilized to identify factors associated with complications, and a mixed-effects model was utilized to identify factors associated with not meeting guidelines for undergoing TJA. During the study period, 11% (1,274) of the 11,611 adults who underwent primary TJA did not meet clinical guidelines. Compared with the group who met guidelines, the group who did not had higher proportions of Black patients (3.2% versus 6.0%; p < 0.001) and Hispanic patients (2.7% versus 4.6%; p < 0.001). An increased risk of not meeting guidelines at the time of surgery was demonstrated among Black patients (odds ratio [OR], 1.60 [95% confidence interval (CI), 1.22 to 2.10]; p = 0.001) and patients insured by Medicaid (OR, 1.75 [95% CI, 1.26 to 2.44]; p = 0.001) or Medicare (OR, 1.22 [95% CI, 1.06 to 1.41]; p = 0.007). Patients who did not meet guidelines had a higher risk of reoperation than those who met guidelines (7.7% [98] versus 5.9% [615]; p = 0.017), including a higher risk of infection-related reoperation (3.1% [40] versus 1.4% [147]; p < 0.001). We found that patients who underwent TJA despite not meeting institutional preoperative criteria had a higher risk of postoperative complications. These patients were more likely to be from racial and ethnic minority groups, to have a lower socioeconomic status, and to have Medicare or Medicaid insurance. These findings underscore the need for surgery-related shared decision-making that is informed by evidence-based guidelines in order to reduce complication burden. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Fresh Osteochondral Allograft to Medial Femoral Condyle With Proximal Tibial Opening Wedge Osteotomy

Background: Contributors to knee degeneration include mechanical axis malalignment, patellar maltracking, meniscal deficiency, and tibiofemoral instability. Full-thickness osteochondral defects in young, active patients can lead to significant pain and instability. The gold standard treatment for large (&gt;2 cm2) osteochondral defects is an osteochondral allograft (OCA) which addresses the pathologic articular cartilage loss and underlying bone deficiency. While biologic failure of fresh OCAs is reported, the majority of early failures are attributed to unaddressed mechanical malalignment in the coronal plane. Proximal tibial osteotomy (PTO) corrects malalignment thereby unloading the affected medial compartment and the newly placed OCA, improving long-term survivability. Indications: OCAs are indicated for isolated osteochondral defects and lesions in active young patients. PTO is indicated for patients with varus malalignment who risk potential graft failure of the affected medial compartment. Technique Description: The articular cartilage defect is identified, and a guide pin is drilled in the center. The defect is templated and scored around the margins. A reamer is used to drill to a total depth of 7 to 8 mm. The recipient site is then dilated for graft insertion. On the donor graft, the harvest site is outlined and drilled to the proper diameter. Careful measurement is utilized to ensure graft depth measurements match the recipient site. Once sized, the graft is tapped into place obtaining an anatomic fit along its entire periphery. The osteotomy is performed by using guide pins to delineate the plane cutting the tibia. Fluoroscopy confirmed the osteotomy site and angle. A spacing plate was securely inserted with screws, with placement confirmed by fluoroscopy. Results: Fresh OCAs can restore osteochondral defects. PTO corrects malalignment and unloads the affected medial compartment, decreasing the risk of revision graft failure or total knee arthroplasty. Discussion: Clinical and biomechanical studies that compared isolated and concomitant procedures demonstrated that OCA with PTOs had significantly greater survival rates. Significant malalignment increases the risk of graft failure. It remains unclear whether concomitant osteotomy with osteoarticular allografts leads to increased complication risk; inherent risks remain associated with individual procedures. In adolescents, simultaneous corrective osteotomy along with fresh OCA may delay arthroplasty and associated ambulatory restrictions. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Growth Hormone Mediators and Glycemic Control in Youths With Type 2 Diabetes

Youth-onset type 2 diabetes (T2D) has a more aggressive phenotype than adult-onset T2D, including rapid loss of glycemic control and increased complication risk. To identify associations of growth hormone mediators with glycemic failure, beta cell function, and insulin sensitivity in youth-onset T2D. This post hoc secondary analysis of the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) randomized clinical trial, which enrolled participants from July 2004 to February 2009, included 398 participants from 15 university-affiliated medical centers with available plasma samples from baseline and 36 months. Participants were youths aged 10 to 17 years with a duration of T2D of less than 2 years who were randomized to metformin, metformin plus lifestyle intervention, or metformin plus rosiglitazone. Participants were followed up for a mean (SD) of 3.9 (1.5) years during the trial, ending in 2011. Statistical analysis was performed from August 2022 to November 2023. Plasma insulin-like growth factor-1 (IGF-1), growth hormone receptor (GHR), and insulin-like growth factor binding protein 1 (IGFBP-1). Main outcomes were (1) loss of glycemic control during the TODAY study, defined as hemoglobin A1c (HbA1c) level of 8% or more for 6 months or inability to wean from insulin therapy, and (2) baseline and 36-month measures of glycemia (fasting glucose, HbA1c), insulin sensitivity (1/fasting C-peptide), high-molecular-weight adiponectin, and beta cell function (C-peptide index, C-peptide oral disposition index). This analysis included 398 participants (mean [SD] age, 13.9 [2.0] years; 248 girls [62%]; 166 Hispanic participants [42%]; 134 non-Hispanic Black participants [34%], and 84 non-Hispanic White participants [21%]). A greater increase in IGF-1 level between baseline and 36 months was associated with lower odds of glycemic failure (odds ratio [OR], 0.995 [95% CI, 0.991-0.997]; P < .001) and higher C-peptide index per 100-ng/mL increase in IGF-1 (β [SE], 0.015 [0.003]; P < .001). A greater increase in log2 GHR level between baseline and 36 months was associated with higher odds of glycemic failure (OR, 1.75 [95% CI, 1.05-2.99]; P = .04) and lower C-peptide index (β [SE], -0.02 [0.006]; P < .001). A greater increase in log2 IGFBP-1 level between baseline and 36 months was associated with higher odds of glycemic failure (OR, 1.37 [95% CI, 1.09-1.74]; P = .007) and higher high-molecular-weight adiponectin (β [SE], 431 [156]; P = .007). This study suggests that changes in plasma growth hormone mediators are associated with loss of glycemic control in youth-onset T2D, with IGF-1 associated with lower risk and GHR and IGFBP-1 associated with increased risk. ClinicalTrials.gov Identifier: NCT00081328.

BMI influence on total ankle arthroplasty outcomes: A systematic review

Total ankle arthroplasty has become an increasingly popular surgical treatment option for ankle arthritis. Patient selection for this procedure is a debated topic. Traditionally, total ankle arthroplasty is chosen for patients who perform only low-demand activities, those who are elderly, and those who are not overweight. More recently, foot and ankle surgeons have been expanding this selection criteria. The goal of the present study is to perform a systematic review on the impact of body mass index on total ankle survivorship and complications. 18 articles were included in the present systematic review. Five studies were analyzed for complications and indicated a potential increase in the odds of complications in patients with higher body mass index values, but this did not reach statistical significance (p > 0.05). There was not sufficient information to estimate a pooled effect of body mass index on total ankle arthroplasty survivorship. Due to the limited number of studies that met the review's inclusion and exclusion criteria, a statistical analysis was only performed on complication rates. In addition to a slight increase in complication risk for individuals with higher body mass index values, the results of this review also highlight the need for further studies that investigate the impact of body mass index on total ankle arthroplasty outcomes.

Deep Neck Contouring: Indications and Techniques.

A deep comprehension of key anatomical issues, along with the targeted application of suitable therapies, is vital for attaining exceptional neck contours. Traditional surgical approaches often focus solely on modifying subcutaneous fat and, occasionally, the platysma muscle, neglecting subplatysmal structures. This narrow focus may yield less-than-ideal results and potentially exacerbate existing issues, leading to additional contour abnormalities that prove challenging to correct. In fact, in most cases, there are additional factors deep to the platysma-such as subplatysmal fat, the anterior bellies of the digastric muscles, perihyoid fascia, and the submandibular glands-that contribute to obtuse neck contours. For these patients, accessing the neck through a submental incision allows for precise management of these deep neck structures as required. Unfamiliarity with deep anatomical structures can deter surgeons from performing subplatysmal procedures due to unwarranted concerns about increased complication risks. However, both published clinical series and our clinical experience indicate favorable long-term outcomes with natural, refined, harmonious neck contours and a minimal rate of complications. This article serves as a comprehensive guide, describing indications, strategies, and providing a step-by-step description of the senior author's techniques for mastering deep neck contouring.

Surfacing undiagnosed disease: consideration, counting and coding.

The diagnostic odyssey for people living with rare diseases (PLWRD) is often prolonged for myriad reasons including an initial failure to consider rare disease and challenges to systemically and systematically identifying and tracking undiagnosed diseases across the diagnostic journey. This often results in isolation, uncertainty, a delay to targeted treatments and increase in risk of complications with significant consequences for patient and family wellbeing. This article aims to highlight key time points to consider a rare disease diagnosis along with elements to consider in the potential operational classification for undiagnosed rare diseases during the diagnostic odyssey. We discuss the need to create a coding framework that traverses all stages of the diagnostic odyssey for PLWRD along with the potential benefits this will have to PLWRD and the wider community.

Surgical treatment of sacral pressure injury in ambulating patients during the COVID-19 pandemic: A prospective cohort with complications analysis and elaboration of a surgical treatment protocol

The sudden increase of intensive care unit patients during the coronavirus pandemic led to an increase in the incidence of sacral pressure lesions. Despite being ambulating patients, in many cases the lesions were deep (Grade III and IV), mainly due to the long-term intubation and being bedridden during the pandemic. Most of these wounds necessitated surgical repair. To measure the success and the rate of complications in reconstructions of grade III and IV hospital acquired sacral pressure lesions in ambulating patients after hospitalization for COVID-19. Developing a well-established protocol for surgical treatment of hospital acquired sacral pressure lesions during the COVID-19 pandemic. Prospective cohort involving ambulating patients with grades III and IV sacral pressure lesions developed after hospitalization for COVID-19 from May 2020 to August 2020 (4 months). All of them were submitted to reconstruction with fasciocutaneous flaps. Demographics, comorbidities, and preoperative laboratory tests were compared and multivariable-adjusted logistic regression was made in order to identify risk factors for complications. Thirty-eight patients were submitted to fasciocutaneous flaps to repair sacral pressure lesions with a total complication rate of 36.0%. Hemoglobin levels lower than 9.0mg/dl (p=0,01), leukocyte levels higher than 11.000/mm3 (p=0,1), and C Reactive protein levels higher than 142mg/dl (p=0,06) at the time of reconstruction and bilateral flaps were independent factors for complications. Specific preoperative laboratory tests and surgical techniques were associated with a statistically significant increased complication risk. It was established a protocol for surgical treatment of hospital-acquired sacral pressure lesions to diminish these risks, focusing on ambulating patients during the COVID-19 pandemic.

1273 Ethical Considerations in Paediatric Bariatric Surgery: A Systematic Review

Abstract Aim With childhood obesity prevalence increasing rapidly, bariatric surgery is being given greater consideration in the paediatric population. Paucity of long-term evidence, physical and emotional risks, and reliance on parental decision-making are factors constituting this subject’s moral complexity, forming debate around the eligibility and timing of offering the procedure. Consequently, a systematic review was conducted to evaluate ethical considerations. Method All relevant synonyms of “Paediatric”, “Bariatric Surgery” and “Ethics” were used to identify papers for inclusion in the systematic review and reference lists were also scanned. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were adhered to. Results 10 papers were included. A key ethical dilemma frequently explored was the issue of consent, and ensuring the child is at the forefront of the decision. Paediatric bariatric surgery causes controversy as children are exposed to surgical risk early in life, and thus prolonged preventative measures are encouraged with the aim to mitigate obesity by adulthood causing unnecessary harm. Children without a strong support network have additional obesity risk, whereby withholding surgery may be viewed as inequitable and non-beneficent. There is also conflict between delaying surgery until the child is Fraser-competent versus increased complication risk. Conclusions Further evidence to guide assessment criteria are needed to facilitate informed consent. Post-operative support should be audited, with inclusive care and sustained health outcomes monitored. Although preventative methods are important in the paediatric population, clinicians must not discriminate against those for whom it proves ineffective, with bariatric surgery being a last resort for high-risk obese patients.

Safety and medium-term outcome of redo laparoscopic sacrocolpopexy: a matched case-control study.

In the case of recurrent apical prolapse following laparoscopic sacrocolpopexy (LSCP), one may consider a "redo" procedure. We hypothesized that redo LSCP may carry an increased complication risk and less favorable outcomes when compared with primary procedures. This is a single-center, matched case-control (1:4) study, comparing all 39 women who had a redo LSCP and 156 women who had a primary LSCP for symptomatic apical prolapse between 2002 and 2020 with a minimum follow-up of 12 months. Matching was based on proximity to the operation date. The primary outcome was the occurrence of intraoperative and early postoperative complications within 3 months. Secondary outcomes included subjective (Patient Global Impression of Change [PGIC] ≥4) and objective (Pelvic Organ Prolapse Quantification [POP-Q] stage <2) success rates, surgical variables, graft-related complications and reinterventions. There was no difference in the rate of intraoperative and early postoperative complications (redo: 21.1% vs control: 29.8%, OR: 0.63, 95% CI 0.27-1.48). The conversion rate was higher in redo patients (redo: 10.3% vs control: 0.6, OR: 17.71, 95% CI 1.92-163.39). Early postoperative complications were comparable: they were mainly infectious and managed by antibiotics. At a comparable follow-up (redo: 81 months (IQR: 54) vs control: 71.5 months (IQR: 42); p=0.37), there were no differences in graft-related complications (redo: 17.9% vs control: 9.6%, p=0.14) and reinterventions for complications (redo: 12.8% vs control: 5.1%, p=0.14) or prolapse (redo: 15.4% vs control: 8.3%, p=0.18). Subjective (redo: 88.5% vs control: 80.2%, p=0.41) and objective (redo: 31.8% vs control: 24.7%, p=0.50) success rates were also comparable. In our experience, redo LSCP is as safe and effective as a primary LSCP, but there is a higher risk of conversion.

FTP5.4 Ethical Considerations Within Paediatric Bariatric Surgery: A Systematic Review

Abstract Aims With childhood obesity prevalence increasing rapidly, bariatric surgery is being given greater consideration in the paediatric population. Paucity of long-term evidence, physical and emotional risks, and reliance on parental decision-making are factors constituting this moral complexity, forming debate around eligibility and timing of offering the procedure. To evaluate these ethical considerations, a systematic review was conducted. Methods All relevant synonyms of “Ethics”, “Bariatric Surgery” and “Paediatric” were used to identify papers for inclusion in the systematic review and reference lists were also scanned. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Results 10 papers were included. A key ethical dilemma frequently explored was the issue of consent, and ensuring the child is at the forefront of the decision. Paediatric bariatric surgery causes controversy as children are exposed to surgical risk early in life, and thus prolonged preventative measures are encouraged with the aim to mitigate obesity by adulthood causing unnecessary harm. Children without a strong support network have additional obesity risk, whereby withholding surgery may be viewed as inequitable and non-beneficent. There is also conflict between delaying surgery until the child is Fraser-competent versus increased complication risk. Conclusions Further evidence to guide assessment criteria are needed to facilitate informed consent. Post-operative support should be audited, with sustained health outcomes and inclusive care monitored. Although preventative methods are important in the paediatric population, clinicians must not discriminate against those for whom it proves ineffective, with bariatric surgery being a last resort for high-risk obese patients.