Moderate Complications Research Articles

Comparative Evaluation of Three Different Techniques for Open Reduction and Fixation of Anterior MandibulComparative Evaluation of Three Different Techniques for Open Reduction and Fixation of Anterior Mandibular Fracturesar Fractures

Aim of the study: To compare the safety and efficacy of three different fixation techniques for anterior mandibular fractures,namely two lag screws, 3D miniplate, and two miniplates.Methods: In randomized, controlled, trial, we enrolled patients with anterior mandibular fractures. Patients were randomlyallocated to one of the following fixation techniques: group (1): two lag screws, group (2): 3D miniplate and group (3): twominiplates. All patients were followed-up for six months.Results: Thirty patients were included. The miniplates group had statistically significant longer time for hardware fixationthan patients in the other two groups (p 0.05). The overall rate of moderate postoperative complications wassignificantly higher in miniplates group than lag screw and 3D plate groups at the 1st postoperative week (p = 0.01). On the1st postoperative months, the overall rate of mild complications was significantly higher in miniplates group than lag screwand 3D plate groups at the 1st postoperative week and month (p < 0.001).Conclusion: Fixation with lag screws and 3D plates lead to less frequency and severity of postoperative complications thanfixation with miniplates for anterior mandibular fractures.

A Single-Center Review of Cerebrospinal Fluid Drainage Complications After Open and Complex Endovascular Thoracoabdominal Aortic Repair

Use of cerebrospinal fluid drainage (CSFD) has become common practice for prevention and treatment of spinal cord ischemia/infarction (SCI) during thoracoabdominal aortic (TAAA) repair at most centers. However, CSFD has inherent risks that can contribute to morbidity and mortality in these patients. Here we present a contemporary single-center review of CSF drain-related complications at a tertiary medical center. Retrospective single-center review of all open and endovascular TAAA repairs who had a CSFD placed at our institution from 2017 to 2019. We included all indications including elective and emergent aneurysm, dissection, penetrating atherosclerotic ulcer, and IMH. CSFD complications were graded as mild (did not require intervention of prolong length of stay), moderate (did not require intervention but prolonged length of stay) and severe (required intervention, resulted in significant morbidity or mortality). A total of 97 patients who had 118 CSF drains placed were included in this analysis. Of the 118 drains, 102 (86%) were placed for endovascular repairs (TEVAR and complex EVAR), 17 of the 118 (14%) were placed for open TAAA and pararenal aortic repairs. The majority of drains (107/118; 90.6%) were preoperative prophylactic drains as our site utilizes a preoperative prophylactic CSFD policy, 11 of 118 (9.3%) were placed emergently as SCI postoperative therapeutic drains. In patients who had CSFD, our overall SCI rate was 5.1% with a temporary SCI (complete resolution) rate of 7.2% (7/97) and a permanent SCI (permanent paralysis) rate of 3.1% (3/97). Of those with permanent paralysis, 2 of 3 (66%) had a preoperative prophylactic drain and 1 of 3 (33%) had a postoperative therapeutic drain placed. CSFD-related minor complications (including headache [6/97] and epidural hematoma at entry site not requiring intervention [2/97]) incidence was 8.2% (8/97). Moderate CSFD related complications (including any neuroaxial bleeding not requiring intervention) was 4 of 97 (4.1%) with 3 patients having subarachnoid hemorrhage (SAH) and 1 patient with cerebellar hemorrhage. Severe CSFD-related complications (including major bleeding and lumbar drain damage requiring intervention) incidence was 5/97 (5.1%); with 2.1% (2/97) related to subdural hemorrhage (SDH) and 3.1% (3/97) related to retained lumbar drains. Both major SDH events were in patients who had preoperative prophylactic drains placed and both developed symptoms of SDH >48 hours after removal of CSF drain. We had no CSFD-related mortalities. Rates of major CSFD-related complications at our institution parallel that of previously published data. CSFD-related complications are not insignificant and should be taken into consideration when determining the need for a prophylactic CSF drain.

Microwave Ablation of Adrenal Tumors in Patients With Continuous Intra-Arterial Blood Pressure Monitoring Without Prior Alpha-Adrenergic Blockade: Safety and Efficacy.

Evaluate the safety and efficacy of adrenal microwave ablation performed with continuous intra-arterial blood pressure monitoring (IABPM) and without alpha-adrenergic blockade (AAB) as pretreatment. A single-center, retrospective review of all percutaneous adrenal microwave ablation performed between 2011 and 2018. Microwave ablation was completed on 11 patients, with a total of 15 adrenal tumors with a mean size of 3.3cm (1.4-6.9cm) treated metastatic RCC, HCC, esophageal carcinoma, adrenal adenoma. Cases were performed without prior AAB, but with continuous IABPM and rapid intervention using short-acting antihypertensive medications. There were no post-procedural episodes of hypertension, no neurological or cardiovascular complications, and no SIR moderate or worse adverse event complications. Mean intraprocedural maximum systolic blood pressure (SBP) was 211mmHg (range: 132-288), with an average increase in SBP of 100mmHg (range: 23-180). A hypertensive crisis (SBP ≥ 180 and/or DBP ≥ 120) occurred in 9 of the 15 procedures (60%) with a mean length of 3.0min (range: 1-12). The technical success rate was 100% (15/15 procedures). The mean follow-up time was 2.4years (range: 0.9-7.7years), with primary and secondary efficacy rates of 77% and 87%, respectively, and an overall survival of 82%. In this single-center retrospective study, microwave ablation of adrenal tumors without AAB was safe and effective when performed with continuous arterial line monitoring of vital signs and the use of short-acting, rapid-onset antihypertensive medications. Level 4, Case Series.

Re-challenge with High Dose Methotrexate vs. Reduced Dose After Methotrexate Toxicity in Pediatric Osteosarcoma:Case Report

Introduction: Methotrexate (MTX), a classic antifolate, is one of the most widely used and well-studied anticancer agents. High-dose methotrexate (HD-MTX) with folinic acid (leucovorin) rescue is one of the standard therapies for osteosarcoma. High-dose methotrexate (HDMTX) can exert significant toxicity and requires complex pharmacokinetic monitoring and leucovorin rescue. The side effect profile of MTX varies markedly according to the dose. Regimens containing MTX are classified as high, intermediate, or low-dose. High-dose methotrexate (HD-MTX; 12 g/m2) is a part of the golden standard therapy for pediatric osteosarcoma (OS). Risk factors associated with MTX toxicity in children with OS are not well defined. Case Presentation: We report here a case of pediatric osteosarcoma with nephrotoxicity associated with delayed MTX excretion who was successfully managed using supportive measures that encouraged us to re-challenge with a full dose of MTX then we reduced the dose to 50% to attain the final critical decision about continuation or changing the regimen of treatment for the patient. Our patient developed moderate renal complications during therapy that improved with supportive care, so we challenged with more cycles of a high dose MTX, but the patient developed serious renal complications. A reduced dose of MTX with 50% was given successfully without any renal impairment. Conclusion: Methotrexate toxicity that might not occur during the initial courses of high-dose MTX is not a predictive of the tolerability of further courses and re-challenging with HDMTX is risky, but reduced dose methotrexate is a good option rather than changing the regimen, with good tolerability and rapid clearance of HDMTX. HDMTX-induced renal impairment occurs in a low percentage of patients with osteosarcoma and can be managed successfully by maximum supportive care. MTX clearance can be affected by gender and age.

Large Craniotomy Increases the Risk of Minor Perioperative Complications in Revascularization Surgery for Moyamoya Disease

Larger craniotomy is expected to increase blood flow over a wider range after indirect revascularization. However, the optimal size of craniotomy has not been established. In this study perioperative complications in revascularization surgery for moyamoya disease are evaluated, focusing on craniotomy size. We retrospectively analyzed 87 hemispheres in 65 patients with moyamoya disease who had undergone revascularization surgery. Areas and types of craniotomy were classified as 1-piece craniotomy in the middle cerebral artery (MCA) territory (1-piece group) in 54 hemispheres (mean area of craniotomy, 40.6 ± 13.5 cm2); 2-piece craniotomy in the MCA territory with anterior cerebral artery (ACA) territory (2-piece group) in 16 hemispheres (mean area of craniotomy, 55.4 ± 12.0 cm2); and 1-piece craniotomy in both MCA and ACA territories (large group) in 17 hemispheres (mean area of craniotomy, 84.2 ± 11.0 cm2). Perioperative complication rates in each craniotomy group were analyzed. Perioperative complications occurred in 45 hemispheres (52%). Transient, moderate, and severe complications occurred in 38 hemispheres, 3 hemispheres, and 4 hemispheres, respectively. Complication rates in the 1-piece, 2-piece, and large groups were 41%, 63%, and 76%, respectively. Large craniotomy was associated with a significantly higher frequency of complications (P= 0.01). However, no significant difference was found among groups when limiting analysis to moderate and severe complications. Multivariate analysis showed large craniotomy as the only factor independently related to complications (odds ratio, 2.93; 95% confidence interval, 1.08-7.92; P= 0.034). Large craniotomy is associated with more frequent perioperative complications, especially transient symptoms.

Efficacy and complications of cavo-tricuspid isthmus-dependent atrial flutter ablation in patients with and without structural heart disease: results from the German Ablation Registry.

The impact of structural heart disease (SHD) on safety and efficacy of catheter ablation of cavo-tricuspid isthmus-dependent atrial flutter (AFLU) is unclear. In addition, recent data suggest a higher complication rate of AFLU ablation compared to the more complex atrial fibrillation (AF) ablation procedure. Within our prospective multicenter registry, 3526 consecutive patients underwent AFLU ablation at 49 German electrophysiological centers from 2007 to 2010. For the present analysis, the patients were divided into a group with SHD (n= 2164 [61.4%]; median age 69years; 78.5% male) and a group without SHD (n= 1362 [38.6%]; 65years; 70.3% male). In our study, SHD mainly encompasses coronary artery disease (52.6%), left ventricular ejection fraction ≤ 50% (47.6%), and hypertensive heart disease (28.0%). The primary ablation success (97%) and the incidence of major (0.2%) or moderate (1.2%) complications did not differ significantly between the two groups (P= 1.0 and 0.87, respectively). Vascular access site complications (0.6%), AV block III° (0.2%), and bleeding (≥ BARC II: 0.2%) were most common. After a median 562days of follow-up, we observed a 2.92-fold higher one-year mortality (P< 0.0001) in patients with SHD. Patients' satisfaction with the ablation therapy (72.0% satisfied) was close to the overall subjective tachyarrhythmia-free rate (70.7%). The present analysis demonstrates that ablation of cavo-tricuspid isthmus dependent AFLU in patients with SHD has a comparable, excellent risk-benefit profile in our large "real-world" registry. Mortality rates expectedly are higher in patients with SHD and AFLU compared to patients without SHD. CLINICALTRIALS.GOV: NCT01197638, http://clinicaltrials.gov/ct2/show/NCT01197638.

Spinal cord injury after open and endovascular repair of descending thoracic and thoracoabdominal aortic aneurysms: A meta-analysis

ObjectiveAn inclusive contemporary analysis of spinal cord injury (SCI) rates in patients undergoing aneurysm repair and the factors associated with complications has not been performed. MethodsFollowing a systematic literature search, studies from 2008 to 2018 on repair of descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) were pooled in a meta-analysis performed using the generic inverse variance method. The primary outcome was permanent SCI. Secondary outcomes were temporary SCI, operative mortality, long-term mortality, postoperative stroke, and cerebrospinal fluid (CSF) drain-related complications. ResultsOne-hundred sixty-nine studies (22,634 patients) were included. The pooled rate of permanent SCI was 4.5% (95% confidence interval [CI], 3.8-5.4); 3.5% (95% CI, 1.8-6.7) for DTA and 7.6% (96% CI, 6.2-9.3) for TAAA repair (P for subgroups = .02), 5.7% (95% CI, 4.3-7.5) for open repair and 3.9% (95% CI, 3.1-4.8) for endovascular repair (P for subgroups = .03). Rates for Crawford extents I, II, III, IV, and V aneurysms were 4.0% (95% CI, 3.0-5.0), 15.0% (95% CI, 10.0-22.0), 7.0% (95% CI, 6.0-9.0), 2.0% (95% CI, 2.0-4.0), and 7.0% (95% CI, 2.0-23.0) respectively (P for subgroups <.001). The pooled rates for operative mortality, late mortality at a mean follow-up of 5.0 years, stroke, and temporary SCI were 7.4% (95% CI, 6.1-9.4), 1.0% (95% CI, 0.0-1.0), 4.2% (95% CI, 3.6-4.8), and 3.7% (95% CI, 3.0-4.6), respectively. The pooled rates for severe, moderate, and minor CSF-drain related complications were 5.1% (95% CI, 2.23-11.1), 4.1% (95% CI, 0.6-22.0), and 3.6% (95% CI, 1.2-8.0) respectively. ConclusionsDespite improvement, both open and endovascular aneurysm repair remain associated with a substantial risk of permanent SCI. The risk is greater for TAAA repair, especially extent II, III, and V.

Short- to Midterm Follow-up of Cemented Total Ankle Replacement Using the INBONE II: A Retrospective Chart Review.

Background: Total ankle arthroplasty is a viable option for the treatment of end stage ankle arthritis. The purpose of this study is to report on the mid-term results with a cemented total ankle prosthesis, the Inbone™ II implant over a 5 year period. Methods: A retrospective, single-center chart and radiographic review of all patients with end stage ankle arthritis treated with Inbone™ II TAR) as the primary index procedure from 12/1/2012 to 3/1/2017. Clinical data were evaluated at 3 month, 6 month, 1 year and subsequent intervals for the study period. Preoperative diagnosis, pertinent patient demographics adjunctive procedures, implant associated complications, subsequent surgeries, and revisions were recorded. Results: 121 total ankles met our inclusion criteria. Patients had an INBONE™ II TAR implant placed with bone cement with a minimum of a 12 months follow up. Average age was 62.88 (range, 32-87) years, average body mass index was 32.74 (range, 21.8-56.04) kg/m2 and average follow up was 28.51(range, 12-69) months. Using the COFAS complication classification there were 14 minor, 11 moderate, and 5 major complications. 6/121 (5.0%) revisions which included: polyethylene exchange, device explant/fusion, and antibiotic spacer in situ. No complications over the course of this study ended in amputation. Conclusion: Total Ankle Arthroplasty utilizing the cemented INBONE™ II yielded good midterm results with regards to minor, moderate, and major complications. Rate of revision 6/121 (5.0%) was within the reported range with only 5 patients converted to fusion during the study period resulting in a 95% survivability at mid-term follow up.Levels of Evidence: Level IV: Retrospective case series.

Acute Mesenteric Ischemia Remains a Highly Morbid Diagnosis after Initial Hospitalization Survival.

Acute mesenteric ischemia (AMI) remains a vascular emergency. Our aim was to explore readmission for AMI. We identified all patients admitted for AMI from the state of California through the Healthcare and Utilization Project from 2005 to 2011. Our primary end point was the rate and etiology for readmission. Our secondary end points were the length of hospitalization and in-hospital mortality. Cox proportional hazard regression was utilized to assess risk of 30-day readmission. There were 534 (9.9%) readmissions at 30 days. The mean age was 67 ± 17 years and 209 (39.1%) were male. The five most common etiologies for readmission were AMI (7.6%), cardiac events (5.3%), severe sepsis (1.2%), dehydration (1.1%), and acute kidney failure (1.1%). Once readmitted, these patients were most likely to experience cardiac catheterizations (25.4%), red blood cell transfusions (23.6%), intubation and mechanical ventilation (17.6%), biopsy of the large intestine (13.9%), reoperation for small bowel resection (10.9%), administration of total parenteral nutrition (10.5%), and transfusion of other blood products (6.9%). This hospitalization was 8.8 ± 12.7 days long. In-hospital mortality was 36 patients (6.7%). On multivariable Cox-regression analysis, severe (hazard ratio [HR]: 2.1 [1.4-3.2], p = 0.0005) and moderate (HR: 1.5 [1.03-2.13], p = 0.04) Elixhauser Comorbidity Group, complications (HR: 1.5 [1.2-1.9], p = 0.0007), and longer index hospitalization (HR: 1.02 [1.01-1.02], p < 0.0001) were predictors of readmission. Conclusion AMI remains a vascular emergency. Readmissions have a significant rate of morbid invasive procedures and can lead to an in-hospital mortality of 6.7%. The adoption of guidelines similar to the European Society for Trauma and Emergency Surgery should be considered.

High level of unmet needs and anxiety are associated with delayed initiation of adjuvant chemotherapy for colorectal cancer patients

AimsAdjuvant chemotherapy is recommended for patients with curatively resected colorectal cancer. The aim of this study is to evaluate the impact of unmet supportive care needs and anxiety on the initiation of postoperative adjuvant chemotherapy in colorectal cancer patients.MethodsThis is a retrospective study from a single tertiary referral hospital. Patients diagnosed with colorectal cancer who met the inclusion criteria were included. The Hospital Anxiety and Depression Scale (HADS) and modified 34-item Supportive Care Needs Survey (SCNS-SF34) were applied to assess patient’s anxiety level and unmet needs. The time intervals between initiation of adjuvant chemotherapy and operation were recorded. Factors associated with delayed initiation of chemotherapy were investigated in univariate and multivariate analysis.ResultsA total of 135 patients with colorectal cancer were included. In total, 16.3% (22/135) and 5.2% (7/135) reported symptoms of anxiety and depression. In multivariate analysis, low to moderate income status, postoperative complications, anxiety, and high level of unmet needs are independent risk factors for late initiation of chemotherapy.ConclusionsOur findings showed that psychological problems such as anxiety and high unmet supportive needs are correlated with delayed initiation of adjuvant chemotherapy in colorectal cancer patients.

A144 A MULTIDISCIPLINARY TEAM APPROACH REDUCES PEG SITE COMPLICATIONS

Abstract Background Education provided to patients and their family on how to care for the percutaneous enteroscopic gastrotomy (PEG) tube is limited and varies widely. This can result in site and tube complications, patient discomfort and increased health care utilization. In addition, a lack of practitioner expertise and variability in practice can affect timely treatment of PEG site complications. Continuous Levodopa/Carbidopa Intestinal Gel (LCIG) has become a standard of treatment option for patients with advanced Parkinson Disease. This medication is delivered by a jejunal tube through a PEG tube (PEG-J). Previous studies in this population reported up to 40% of adverse events related to the PEG site. At Toronto Western Hospital, we developed a multidisciplinary team (MDT), involving a gastroenterologist, a clinical nurse specialist (CNS) with expertise in wound and stoma care and the movement disorder clinical nurse to care for the PEG-J in this patient population. Aims To evaluate the effectiveness of our MDT in reducing PEG site complications and health care utilization. Methods Consecutive PEG-J patients (n=33) assessed by the MDT between October 2018 and September 2019 were provided standard education on the routine care and maintenance of PEG site complications. The CNS uses a systematic approach to prevent, assess and treat PEG site complications. Before and after the MDT approach, patients were seen the day after the PEG insertion (POD 1), 2 weeks after (titration) and then ad hoc determined by incidence of mild, moderate and severe complications. Post implementation of a MDT approach, patients are seen POD 1, at titration and every 3–6 months during routine visits to the Movement Disorder Clinic. Table 1 outlines classification and suggested treatment based on severity for mild, moderate and severe PEG site complications. Results The systematic MDT approach completely eliminated all unscheduled, urgent contact to the health care providers by patients who have been assessed and provided education by the MDT (n=33), including new PEG-J (n=7) and previously inserted PEG-J (n=26). 28.5% of new PEG-J patients had moderate or severe site complication rate, 71.5% had mild or no complications. In the group of patients with previously inserted PEG-J tubes, 58% had moderate or severe site complications, 42% had mild or no complications. Conclusions An interprofessional MDT systematic approach drastically reduces PEG site complications and urgent health care utilization. Patients who receive standardized education pre- and post-insertion have a lower incidence of moderate or severe classification of PEG site complications and unscheduled clinic visits. Funding Agencies None

3:36 PM Abstract No. 203 Safety and efficacy of percutaneous computed tomography–guided transplant pancreas biopsy

Percutaneous computed tomographic (CT)-guided biopsy is a minimally invasive alternative to open biopsy, not frequently described in the literature. The purpose is to describe and assess technique, complications, and diagnostic yield of CT-guided percutaneous transplant pancreas biopsy. This is a single institution retrospective review of 75 patients (47 women, 28 men, mean age 47) who underwent CT-guided transplant pancreas biopsy (n = 149) between April 2005 and October 2018.Three cases (2%) were aborted due to inadequate safe percutaneous approach. Biopsy results were classified based on final pathology as diagnostic (with the subcategory partially diagnostic used if the sample was adequate for the diagnosis of cell mediated rejection, but not humoral rejection) and nondiagnostic. Diagnostic yield and complication rates were evaluated. 149 percutaneous CT-guided biopsies of transplant pancreas were performed. 98% (n =143) of the biopsies used 17/18 Gauge coaxial core biopsy system, and 2% (n = 3) used a 19/20 Gauge coaxial device. On-site pathologic touch prep assessment was utilized for 91% of biopsies. Diagnostic tissue was obtained 94% of the time, of which 9% were considered partially diagnostic. 6% of the samples were deemed non-diagnostic. Of the diagnostic biopsies, 7 (51%) were positive for rejection (24% grade I, 16% grade II, 4% grade III, and 7% chronic) and 49% were negative for rejection. On-site pathologic touch prep did not appear to have an effect on sample adequacy (P = 0.9) nor did the number of cores (P =.28) or graft location (P = 1.0). The most common complication was minor bleeding (9%), pancreatitis (1%) and sedation related adverse events (1%); there was 1 moderate complication (hemorrhage requiring overnight observation), and no major complications. No significant difference in the INR (P = 0.68) or platelet count (P = 0.07) between patients who had bleeding complications and those who did not have bleeding complications. Image-guided percutaneous CT-guided transplant pancreas biopsies have high diagnostic yield with low complication rates.

Analysis of age influence on oncological results and toxicity of BCG immunotherapy in non-muscle invasive bladder cancer.

The aim of this study was to analyse the influence of age on the treatment outcome and toxicity in patients with T1HG non-muscle invasive bladder cancers treated with BCG immunotherapy. Data from 637 patients with primary T1HG bladder cancer who were treated between 1986 and 2016 in two academic centres were retrospectively reviewed. Median follow-up was 57months. Patients were divided into two groups: younger (< 70years old) and older (≥ 70years old). Additional analyses in subgroups of older (> 75 and > 80) patients were performed. Log-rank test, Cox regression analysis, and propensity score matching were performed to compare the groups. There were 389 patients below and 248 patients above or equal 70years old. Recurrence-free, progression-free, and cancer-specific survival rates did not differ significantly between younger and older patients. Recurrence-free survival for younger and older patients were 55.4% vs 52.9%, progression-free survival 75.9% vs 76.6%, and cancer-specific survival were 87.5% vs 89.9% (all p > 0.05). Differences in the oldest subgroups also did not reach statistical significance. In both regression analysis and propensity score matching, no statistically significant associations of age with any of analysed end-points were found. Finally, there were no statistically significant differences between younger and older group in terms of moderate and severe complications occurrence (47.6% vs. 44.5%; p > 0.05) CONCLUSIONS: It was shown that increasing age was not associated with BCG immunotherapy oncological outcomes, or with BCG toxicity in T1HG non-muscle invasive bladder cancer.

Abstract P6-14-06: Prepectoral direct to implant reconstruction following nipple sparing mastectomy using the TiLOOP bra pocket

Abstract Aim: Evaluation of safety, cosmetic outcome and patients satisfaction following nipple sparing mastectomy with prepectoral direct to implant reconstruction using the TiLOOP® Bra Pocket. Background: TiLOOP® Bra Pocket is a new surgical tool consisting of a large-pore, non-absorbable synthetic mesh made from titanized monofilament polypropylene thread. It is used for immediate prepectoral implant reconstruction to fix the implant on the pectoralis major muscle and to avoid implant rotation. Material and methodes: Between October 2017 and February 2019, 57 patients underwent nipple sparing mastectomy in the certified breast cancer centre, at the AGAPLESION Markus Hospital, Frankfurt, Germany. Data was collected in a prospective registry. All of the patients underwent a prepectoral direct to implant reconstruction using the new TiLOOP® Bra Pocket. We present the first analysis of this prospective unicentric registry. To measure and to analyse the cosmetic outcome and patients’ satisfaction, the BREAST-Q questionnaire was used, an established modular questionnaire to assess patient reported outcome (PRO). Results: All of the 57 patients were available for postoperative analysis. In 35/57 (61%) of the cases a seroma occured and was worth to be punctured. The median number of punctures was 4. The volume was 70 ml in average. Seven patients had a postoperative hematoma and had to undergo another surgical procedure. Three patients developed a skin necrosis or severe wound healing problem due to bad quality of the soft tissue and skin mantle and had to undergo implant explantation. One patient suffered from implant infection but could be treated conservatively. The analysis of patients’ reported outcome via the BREAST-Q resulted in a high satifaction rate regarding the cosmetic outcome. Conclusion: Direct to implant reconstruction with prepectoral implant position by using the TiLOOP® Bra Pocket is a very promising surgical approach. In comparison to a subpectoral implant reconstruction it reduces the duration of surgery, avoids a jumping breast phenomenon and causes less postoperative pain, moreover, it leeds to a high patient satisfaction rate and shows a moderate complication rate. Follow up of our patients will continue. The next analysis will be done after 24 months. Citation Format: Marc Thill, Viviane van Haasteren, Katharina Kelling. Prepectoral direct to implant reconstruction following nipple sparing mastectomy using the TiLOOP bra pocket [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-14-06.

A Qualitative Research for Defining Meaningful Attributes for the Treatment of Inflammatory Bowel Disease from the Patient Perspective.

IntroductionCrohn’s disease (CD) and ulcerative colitis (UC) are chronic, inflammatory bowel diseases (IBD). Each class and type of medication available for the treatment of IBD has distinct characteristics and long-term effects that a patient may consider. We present the results of qualitative research that aimed to develop a descriptive framework that outlines the most relevant disease and/or treatment attributes for IBD treatment decisions and focuses on the patient perspective.MethodsThis research employed a three-step approach: a literature review to identify a broad list of attributes, a focus group meeting including patients and clinicians to assess the relevance of the attributes, and two rounds of voting to name and define each attribute. The literature review was used to develop the initial list of attributes. Although the same attributes were defined for both UC and CD, the relative importance of each attribute to UC or CD was considered. The list of attributes was discussed and evaluated in the focus group meeting, which included eight patient representatives and nine gastroenterologists. Using feedback elicited from the focus group meeting, the research team developed a draft of the descriptive framework that grouped the attributes into domain subsets. All members of the focus group participated in two subsequent rounds of structured, online voting, which was used to refine the wording to name and define each attribute. Additionally, participants ranked all the attributes included in the descriptive framework to suggest which attributes were less relevant and could be omitted.ResultsAmong 574 publications retrieved from the databases and registries, we identified 32 eligible publications, and an initial list of attributes was developed. This list was refined during the focus group meeting, resulting in a draft descriptive framework of attributes within subsets of domains. The final descriptive framework was developed based on structured rounds of online voting to further refine attribute names and definitions. In the final descriptive framework, a total of ten attributes were identified: abdominal pain, other disease-related pain, bowel urgency, fatigue, risk of cancer and serious infections within the next 10 years, risk of mild to moderate complications, aesthetic complications related to treatment, emotional status, sexual life, and social life and relationships. These attributes were distributed across three domains: efficacy, complications and risk, and health-related quality of life.ConclusionsThrough the identification of the ten most relevant attributes that influence patient decision making for IBD treatments, we developed a descriptive framework that should be considered by physicians when discussing IBD treatment options with their patients. The results of our qualitative research may also be helpful for the development of future IBD clinical studies and quantitative research.Electronic supplementary materialThe online version of this article (10.1007/s40271-019-00407-5) contains supplementary material, which is available to authorized users.

Complications of decompressive lumbar spine procedures without instrumentations – an institutional experience

Background Till now, there is insufficient documentation of operative complications in spine surgery, and the expected results are far less predictable if the actual indication for surgical intervention is not clear. Complication could be defined as 'a condition that directly or indirectly results from surgical intervention and disrupts the planned outcome of the surgery.' So, spine surgeons should be aware of these events and know how to deal with them. Aim To detect the number and percentage of moderate and/or major operation-related complications associated with the relatively repeated and popularized neurosurgical procedures performed at the Neurosurgical Department, Shebin Elkom Teaching Hospital, to analyze our work in relation to published literature that addresses this topic, so as to optimize the future practice. Patients and methods A retrospective study was conducted on documented operation-related complications of patients operated upon at the Neurosurgical Department, Shebin Elkom Teaching Hospital, between March 2011 and March 2019. This study involved patients who underwent decompressive lumbar spine procedures without instrumentation. The operations were performed by neurosurgeons with the same professional degree but with different number of operated cases. Any decompressive surgery with instrumentation techniques was excluded. Results A total number of 3496 patients were operated upon between March 2011 and March 2019, of whom 1087 fulfilled the inclusion criteria. Their medical records were reviewed for documentation of the existed complications related to surgery. The number of documented moderate and/or major operation-related complications was 124 (11.41%) cases from the total number of the studied group. Conclusion Till now, there is insufficient inclusive documentation of operative complications in spine surgery. In this study, the number and percentage of moderate and/or major complications related to different decompressive lumbar surgery techniques without instrumentations could be detected, and it was found that most of the identified complications lie within the reported incidence. With insightful understanding of these complications, surgeons could adequately analyze and evaluate risk factors in patients and procedure-related factors and then develop preventive measurements to reduce the rate of these complications.

Intraoperative haemodynamic optimisation therapy with venoarterial carbon dioxide difference and pulse pressure variation - does it work?

Current evidence suggests that intraoperative goal-directed haemodynamic therapy (GDT) should be considered for high-risk patients undergoing major gastrointestinal surgery. We aimed to evaluate if an algorithm using venoarterial carbon dioxide difference (CO2 gap) and pulse pressure variation (PPV) as therapeutic targets during GDT would decrease the major complications after gastrointestinal surgery. This was a before-and-after study (n = 204) performed in a tertiary hospital on patients who underwent elective open major gastrointestinal surgeries. The inclusion criteria were surgeries expected to last more than two hours, family and physician's agreement on total postoperative support, and survival expectancy of at least three months. The exclusion criteria were previous haemodynamic instability, presence of infection, cardiac arrhythmias, and emergency surgery. In the intervention group (IG), an algorithm was applied using fluids, dobutamine, and noradrenaline during the intraoperative period aiming at MAP > 65 mm Hg, SpO2 > 95%, CO2 gap < 6 mm Hg, and PPV < 13%. The control group (CG) comprised consecutive eligible patients who were operated by the same team before the institution of the algorithm. The rates of moderate and severe postoperative complications were lower in the IG (11% vs. 23%; IC: RR = 0.47, 95% CI: 0.246-0.929; P = 0.025). The respective 90- and 180-day mortality rates in the IG and CG were 9.8% vs. 22.5% (P = 0.014) and 12.6% vs. 25.5% (P = 0.020). An algorithm aiming to minimise the CO2 gap and normalise PPV was feasible and effective in decreasing rates of moderate and severe complications after surgery in high-risk patients.

Symptomatic Respiratory Physiotherapy Management Strategies for COVID-19 Patients

The role of physiotherapy while dealing with the current pandemic of COVID 19 is by using various methods included as an adjuvant therapy such as- Deep breathing exercises, Bronchial hygiene techniques Permissive hypercapnia Iontophoresis with zinc ion (Zn2+), Diaphragmatic pacing, Active movement of extremities (lower and upper) Mechanical airway clearance and oscillating devices such as positive pressure devices, high-frequency chest oscillation, oral high-frequency chest oscillation, flutter device and Cornet devices along with NIV, HNFC, and COT. The benefit of these techniques and devices is to loosen the adhesion of mucus, reducing the load from mechanical ventilation and facilitate its transport from smaller to higher airways respectively. So that the mucus gets easily removed, improves in systemic & peripheral airflow, exchange in oxygen, and for maintaining lung hygiene in mild, moderate, and severe complications.

Does graft choice influence the outcome of MPFL reconstruction in patients with patellofemoral instability and increased TT-TG distance?

A systematic review of the literature was conducted to determine the effect of graft choice on patient outcomes in patients undergoing a medial patellofemoral ligament (MPFL) reconstruction with concomitant tibial tubercle transfer (TTT). Utilizing the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and QUORUM (Quality of Reporting of Meta-Analyses) protocol, a systematic search identified and analyzed the published literature pertaining to MPFL reconstruction with TTT. The literature search yielded eight eligible studies with a total of 183 knees treated with a MPFL reconstruction with TTT procedure involving either a gracilis autograft, a semitendinosus autograft, or a medial retinaculum autograft. The eight studies varied on the outcome measures reported, but the outcome measures most consistently used and assessed in this systematic review included the complication rate, postoperative instability rate, Kujala score, Lysholm score, International Knee Documentation Committee functional evaluation form, and the Tegner activity scale. Our study found that patients undergoing MPFL reconstruction with TTT resulted in good overall patient outcomes. No statistical difference was found between the graft choices on any of the outcome measures. While MPFL reconstruction with TTT resulted in low to moderate complication rates and low postoperative patellofemoral instability rates, one potential explanation for the postoperative instability and knee stiffness observed may derive from graft choice. Future research may consider addressing the effect of graft choice on improperly tensioned grafts and overmedialized TTTs.

Validation of Siddha Diagnostic Procedure of Manikkadai nool for Gunmam Patients at Government Siddha Medical College &amp; Hospital, Palayamkottai

Introduction: Siddha Medicine is a system of traditional medicine originating in ancient Tamil Nadu in South India and Sri Lanka. Traditionally, it is taught that the siddhas laid the foundation for this system of medicine. Siddha system has a unique diagnostic method to identify the diseases and their causes. Manikkadai Nool is one of the diagnostic tool. It is explained in the Agasthiyar Soodamani Kajiru Soothiram by Saint Veadammamuni in Pathinen Siddhar Naadi Nool.&#x0D; Aim: The primary aim of this study was to validate the Siddha diagnostic procedure of Manikkadai nool for gunmam patients.&#x0D; Study Setting: Government Siddha Medical College, Palayamkottai from April to August 2019.&#x0D; Methodology: It is an observational study. After identifying the eligible subjects, Data will be collected by using the interview administrated questionnaire &amp; relevant data will be collected by measurement. Collected data were processed and statistically analysed by a simple statistical method using Microsoft Excel.&#x0D; Results and Discussion: Gunmam symptoms are included in 10, 9 ½, 8 ¾, 8, 7 ½, 7, 6 ½ &amp; 6 ¼ Manikkadai measurements according to the siddha literatures. Researcher has been divided the gunmam conditions as mild moderate and severe condition according to the evidence of literatures, Researcher has been included Premonitory symptoms as Mild Condition, Common signs and symptoms as Moderate Condition and complications as Severe condition. Mild condition is in 10-9 fbs Manikkadai measurements. Moderate condition is in 8 ¾-7 ¾ fbs Manikkadai measurements. Severe condition is in 7 ½-6 ½ &gt; Manikkadai measurements. 55% (11) of right hand Manikkadai measurements in male and 53% (16) of Right hand Manikkadai measurements in female have been correlated with the siddha literatures in the diagnosis of gunmam. Pearson correlation value implies that negative correlation between the chronicity of gunmam and Manikkadai measurement. This data showed the negative relationship between the severity of gunmam, &amp; manikkadai measurements.&#x0D; Conclusion: Majority of the gunmam subjects were females (60%). The maximum number of subjects was observed in Pitha Kaalam. Majority of the gunmam subjects had vali azhal naadi (38%) and azhal vali naadi (32%). Nei kuri was observed as vali azhal &amp; azhal vali in gunmam subjects. Siddha Physicians could be diagnosed the gunmam fifty percentage with the help of Manikkadai measurements. Pearson correlation value implies that negative correlation between the chronicity of gunmam and Manikkadai measurement. This data showed the negative relationship between the severity of gunmam &amp; manikkadai measurements. Out of 50 gunmam subjects, 45 were in the assumed assessment criteria range. So further study is essential to validate this assumed assessment of criteria of manikkadai measurement in diagnosis of gunmam.