Complications and Risks Associated with the Different Types of Abdominoplasties: An Analysis of 55,956 Patients

BACKGROUND

Different types of abdominoplasties have been developed to address individual patient characteristics. However, complication rates and risk factors for complications between different types of abdominoplasties has yet to be reported.

OBJECTIVES

The aim of this study was to evaluate the complication rates and risks associated with each type of abdominoplasty.

METHODS

Using the CosmetAssure database, patients undergoing an abdominoplasty from 2015 to 2022 were identified. Demographic factors and major complications were recorded and analyzed using a chi-square test or ANOVA. A logistic regression was performed to identify the risk associated with each type of abdominoplasty for developing complications.

RESULTS

A total of 55,596 patients underwent an abdominoplasty procedure by any method. The overall complication rate was 2.1%. There was a significant difference in the overall complication rate between all seven types of abdominoplasties (p<0.05), with Fleur-de-lis abdominoplasty having the highest complication rate. The year of surgery, being underweight or morbidly obese, diabetes, and being male placed patients at a significantly higher risk for developing a post-operative complication. Over 15,000 patients (27.2%) had concurrent procedures related to breast surgery, other body contouring, liposuction, or facial surgery. When accounting for various risk factors in a regression model, there was no significant added risk for major complications after a combination procedure with an abdominoplasty compared to abdominoplasty alone.

CONCLUSIONS

Among the different types of abdominoplasties, a Fleur-de-lis abdominoplasty has the highest complication rate. Concurrent cosmetic procedures in addition to an abdominoplasty showed no added risk for major complications compared to abdominoplasty alone.

Pearls for Starting a Headache Surgery Practice in Academic and Private Practice

There has been a growing body of evidence indicative of the effectiveness of headache surgery in treating patients with refractory headache disorders. The American Society of Plastic Surgeons issued a Policy Statement in 2018 stating that peripheral nerve decompression surgery for the treatment of refractory chronic headache disorders in select patients is considered a standard of care treatment. This endorsement sparked the interest of numerous plastic surgeons into initiating their own headache surgery practices. However, establishing a headache surgery clinic introduces challenges and considerations. This report outlines the key pillars for launching a successful headache surgery practice in academic and private practice environments.

Assessment of x-ray efficacy for intraoperative microneedle retrieval using a cadaveric model

INTRODUCTION

Institutional protocols often mandate the use of x-rays when a microneedle is lost intraoperatively. Although x-rays can reliably show a macroneedle, the benefit of x-rays in detecting microneedles in human tissues has not been established as available data on this topic are investigated in anthropometric models. The current study aims to evaluate whether x-rays can reliably detect retained microneedles in a human cadaveric model. We hypothesize that microneedles would be detected at a significantly lower rate than macroneedles by x-ray in human tissues.

MATERIALS AND METHODS

Needles ranging from 4-0 to 10-0 were placed randomly throughout a cadaveric hand and foot. Each tissue sample was x-rayed using a Fexitron X-Ray machine, taking both anteroposterior and lateral views. A total of six x-ray images were then evaluated by 11 radiologists, independently. The radiologists circled over the area where they visualized a needle. The accuracy of detecting macroneedles (size 4-0 to 7-0) was compared with that of microneedles (size 8-0 to 10-0) using a chi-square test.

RESULTS

The overall detection rate for the microneedles was significantly lower than the detection rate for macroneedles (13.5% vs 88.8%, p < .01). When subcategorized between the hand and the foot, the detection rate for microneedles was also significantly lower than the rate for macroneedles (hand: 7.6% for microneedles, 93.2% for macroneedles, p < .01; foot: 19.5% for microneedles, 84.4% for macroneedles, p < .01). The detection rate, in general, significantly decreased as the sizes of needles became smaller (7-0:70.5%, 8-0:18.2%, 9-0:16.7%, 10-0:2.3%, p < .01).

CONCLUSION

X-rays, while useful in detecting macroneedles, had a significantly lower rate of detecting microneedles in a cadaveric model. The routine use of x-rays for a lost microneedle may not be beneficial. Further investigation with fresh tissue and similar intraoperative x-ray systems is warranted to corroborate and support these findings.

Addressing Current Deficits in Patient Education Materials Through Crowdsourcing

BACKGROUND

Patient education materials are commonly reported to be difficult to understand.

OBJECTIVES

We aimed to use crowdsourcing to improve patient education materials at our institution.

METHODS

This was a department-wide quality improvement project to increase organizational health literacy. There are 6 phases of this pilot study: (1) evaluating preexisting patient education materials, (2) evaluating online patient education materials at the society (the American Society of Plastic Surgeon) and government level (Medline Plus), (3) redesigning our patient education material and reevaluating the education material, (4) crowdsourcing to evaluate understandability of the new patient education material, (5) data analysis, and (6) incorporating crowdsourcing suggestions to the patient education material.

RESULTS

Breast-related patient education materials are not easy to read at the institution level, the society level, and the government level. Our new implant-based breast reconstruction patient education material is easy to read as demonstrated by the crowdsourcing evaluation. More than 90% of the participants reported our material is "very easy to understand" or "easy to understand." The crowdsourcing process took 1.5 days, with 700 workers responding to the survey. The total cost was $9. After incorporating participants' feedback into the finalized material, the readability of the material is at the recommended reading level. The material also had the recommended length (between 400 and 800 words).

DISCUSSION

Our study demonstrated a pathway for clinicians to efficiently obtain a large amount of feedback to improve patient education materials. Crowdsourcing is an effective tool to improve organizational health literacy.

Unraveling the effect of Cu doping on the structural and morphological properties and photocatalytic activity of ZrO2

Pristine ZrO2 and doped with different concentrations of Copper (0-7 %) were synthesized using a sol-gel combustion route. Several advanced techniques like XRD, EDX, TEM, XPS, P.L., and UV-vis spectrophotometer have characterized the compositions. The XRD proved that all peaks matched with a tetragonal phase of ZrO2 without any impurities of other phases. An average crystallite size rises from 20 to 55 nm by increasing the concentrations of Copper. The elemental analysis was examined by EDX and confirmed the presence of Cooper, Zirconium, and Oxygen. The red shift was observed due to a decrease in the bandgap (5.5-4.01 eV) with increasing the Cu concentrations. From the analysis of photocatalysis of pure ZrO2 and different concentrations of Cu-doped ZrO2 for M.B., RHB, and mix of them. The increase in doping of Cu led to enhancing the performance of the removing MB from 35 to 80 %, however, the RHB degradation was from 42 to 81 % while the mix of M.B. and RHB reached 85 % with 7 % Cu-doping ZrO2.

Burn Injury-related Growth Factor Expressions and Their Potential Roles in Burn-related Neuropathies

In the context of burn injury, growth factors (GFs) play a significant role in mediating the complex local and systematic processes that occur. Among the many systemic complications that arise following a burn injury, peripheral neuropathy remains one of the most common. Despite the broad understanding of the effects GFs have on multiple tissues, their potential implications in both wound healing and neuropathy remain largely unexplored. Therefore, this review aims to investigate the expression patterns of GFs prominent during the burn wound healing process and explore the potential contributions these GFs have on the development of burn-related peripheral neuropathy.

Easing the Burden on Caregivers- Applications of Artificial Intelligence for Physicians and Caregivers of Children with Cleft Lip and Palate

OBJECTIVE

Many caregivers of children with cleft lip and palate experience a high level of anxiety throughout their child's medical and surgical care. We aim to evaluate artificial intelligence (AI) as a tool to mitigate these feelings and can aid clinicians in the development of robust pediatric educational materials for caregivers and families.

DESIGN

Thirteen of the most common postoperative questions following cleft lip and/or palate repair were developed by an expert panel of senior Pediatric Plastic Surgeons and were posed to ChatGPT. Professional answers from the expert panel were provided and compared to responses from ChatGPT. A literature review was also conducted to generate a new support model for caregivers with children undergoing a surgical procedure.

SETTING

Department of Pediatric Plastic Surgery at a metropolitan Children's Hospital.

PARTICIPANTS

Senior Pediatric Plastic Surgeons at a metropolitan Children's Hospital.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

The primary outcome was to determine the ability of ChatGPT to respond to common postoperative questions and to develop a model for AI assistance in family-centered perioperative care.

RESULTS

ChatGPT had a postoperative question response accuracy rate of 69% when compared with subject matter expert responses, with its greatest errors being information errors. An extensive literature search revealed that AI can assist in multiple traditional perioperative strategies to reduce caregivers and patient anxiety.

CONCLUSIONS

Artificial Intelligence can help to reduce the burden of generating patient education materials as well as support caregivers in multiple aspects and perioperative care.

Association study between genetic polymorphisms in MTHFR and stroke susceptibility in Egyptian population: a case-control study

Stroke is a major global disability cause, and genetic variables for multifactorial illnesses like stroke are crucial for precision medicine. The purpose of this study is to see if genetic variants in the MTHFR gene are associated with a higher risk of ischemic stroke among the Egyptian population. A case-control study was conducted at Mansoura University Hospital, involving 100 stroke patients and 150 healthy volunteers as the control group. Peripheral blood genomic DNA was isolated and single-nucleotide polymorphisms were genotyped using ARMS-PCR. The CT and TT genotypes of the C677T gene polymorphism exhibited substantial risks for having stroke disease [(OR 3.856; P ≤ 0.001); (OR 4.026; P ≤ 0.001), respectively]. The T allele was significantly more prevalent among patients compared to controls. (OR 2.517; (P = 0.001)). The over-dominant and dominant models demonstrated a substantial relationship between stroke groups at risk of developing stroke but not the Recessive model. An extensive connection was found between the MTHFR A1298C and stroke danger in three different inheritance models: dominant (CC + CA vs. AA), over-dominant (AA + CC vs AC), and allelic (C allele) (P < 0.001). A highly significant difference in blood pressure, total cholesterol, and triglycerides levels was found between patients and control. While there was no meaningful link discovered between genetic polymorphism with SBP, DBP, TG, LDL, VLDL among stroke group (P > 0.05 for each) except the CC genotype that was significantly associated with lower levels of TC and HDL when compared to CT + TT genotypes. The study evaluates a strong link among MTHFR mutations in genes and the probability to get stroke. The research significantly supports the use of MTHFR ((rs1801133) and (rs1801131) variations in stroke prediction.

Systematic Review and Meta-Analysis of Global Neuroma Incidence in Upper Extremity Amputees

BACKGROUND

Neuromas substantially decrease a patient's quality of life and obstruct the use of prosthetics. This systematic review and meta-analysis aimed to determine the global incidence of neuroma formation in upper extremity amputees.

METHODS

A literature search was performed using 3 databases: Web of Science, MEDLINE, and Cochrane. Inclusion criteria for the systematic review were those studies investigating only upper extremity amputees and reported postamputation neuroma. A random-effects, inverse-variance analysis was conducted to determine the pooled proportion of neuromas within the upper extremity amputation population. Critical appraisal using the JBI Checklist for Studies Reporting Prevalence Data of each individual article were performed for the systematic review.

RESULTS

Eleven studies met the inclusion criteria collating a total of 1931 patients across 8 countries. More than three-fourth of patients are young men (77%; age range, 19-54 years) and had an amputation due to trauma. The random-effects analysis found the pooled combined proportion of neuromas to be 13% (95% confidence interval, 8%-18%). The treatment of neuroma is highly variable, with some patients receiving no treatment.

CONCLUSIONS

The pooled proportion of neuroma incidence in the 1931 patients was 13%. With the known global prevalence of upper extremity amputees, this translates to nearly 3 million amputees suffering from a neuroma globally. Increasing training in preventative surgical methods could contribute to lowering this incidence and improving the outcomes of this patient population.

Comparison of Complication Rates Between Subpectoral vs Prepectoral Techniques in Prosthetic Breast Reconstruction

BACKGROUND

The location of tissue expanders in implant-based breast reconstruction remains controversial due to variation in surgical techniques and devices.

OBJECTIVES

The aim of this study was to provide a comprehensive assessment of early and late complication rates between prepectoral and subpectoral placement of tissue expanders.

METHODS

A retrospective cohort study was conducted of all adult female patients who had undergone 2-stage implant-based breast reconstruction between 2013 and 2019 in our institution. Early complication was defined as complications that occurred within 30 days after surgery. Time-to-event analyses were performed and Cox proportional hazard models were used to adjust for confounders.

RESULTS

In total, 854 patients were included; 76% of patients underwent a subpectoral tissue expander placement. After the first-stage procedure, the early complication rate was 34% and the late complication rate was 36.4%. After the second-stage procedure, the early complication rate was 16.3% and the late complication rate was 16.1%. Location of the tissue expander did not predict either overall early or late complication rates, regardless of the stages of reconstruction, after adjusting for confounders. Tissue expanders placed in prepectoral plane were associated with a higher hazard ratio (HR) for developing early and late infection after the first stage of reconstruction (HR, 2.1 and 2.4, respectively) as well as late infection after the second stage of reconstruction (HR, 5.3; all P < .05).

CONCLUSIONS

Location of tissue expanders did not predict risk of complication. However, the prepectoral group was associated with an increased risk of developing infection.

LEVEL OF EVIDENCE: 4

Comparison of Patient Education Materials Generated by Chat Generative Pre-Trained Transformer Versus Experts: An Innovative Way to Increase Readability of Patient Education Materials

INTRODUCTION

Improving patient education materials may improve patient outcomes. This study aims to explore the possibility of generating patient education materials with the assistance of a large language model, Chat Generative Pre-Trained Transformer (ChatGPT). In addition, we compare the accuracy and readability of ChatGPT-generated materials versus expert-generated materials.

METHODS

Patient education materials in implant-based breast reconstruction were generated by experts and ChatGPT independently. Readability and accuracy of the materials are the main outcomes. Readability of the materials was compared using Flesch-Kincaid score. Accuracy of the materials generated by ChatGPT was evaluated by 2 independent reviewers. Content errors are categorized into information errors, statistical errors, and multiple errors (errors more than 2 types).

RESULTS

The content generated by experts had higher readability. The Flesch-Kincaid score is at the 7.5 grade for expert-generated materials, whereas the content generated by ChatGPT is at the 10.5 grade (despite ChatGPT being asked to generate content at the seventh grade level). The accuracy of ChatGPT-generated content is 50%, with most errors being information errors. ChatGPT often provides information about breast reduction or breast augmentation, despite being asked specifically about breast reconstruction. Despite its limitation, ChatGPT significantly reduced the time required to generate patient education materials. Although it takes experts 1 month to generate patient education materials, ChatGPT generates materials within 30 minutes.

CONCLUSIONS

ChatGPT can be a powerful starting tool to generate patient education materials. However, its readability and accuracy still require improvements.

Niraparib plus abiraterone acetate with prednisone in patients with metastatic castration-resistant prostate cancer and homologous recombination repair gene alterations: second interim analysis of the randomized phase III MAGNITUDE trial

BACKGROUND

Patients with metastatic castration-resistant prostate cancer (mCRPC) and BRCA alterations have poor outcomes. MAGNITUDE found patients with homologous recombination repair gene alterations (HRR+), particularly BRCA1/2, benefit from first-line therapy with niraparib plus abiraterone acetate and prednisone (AAP). Here we report longer follow-up from the second prespecified interim analysis (IA2).

PATIENTS AND METHODS

Patients with mCRPC were prospectively identified as HRR+ with/without BRCA1/2 alterations and randomized 1 : 1 to niraparib (200 mg orally) plus AAP (1000 mg/10 mg orally) or placebo plus AAP. At IA2, secondary endpoints [time to symptomatic progression, time to initiation of cytotoxic chemotherapy, overall survival (OS)] were assessed.

RESULTS

Overall, 212 HRR+ patients received niraparib plus AAP (BRCA1/2 subgroup, n = 113). At IA2 with 24.8 months of median follow-up in the BRCA1/2 subgroup, niraparib plus AAP significantly prolonged radiographic progression-free survival {rPFS; blinded independent central review; median rPFS 19.5 versus 10.9 months; hazard ratio (HR) = 0.55 [95% confidence interval (CI) 0.39-0.78]; nominal P = 0.0007} consistent with the first prespecified interim analysis. rPFS was also prolonged in the total HRR+ population [HR = 0.76 (95% CI 0.60-0.97); nominal P = 0.0280; median follow-up 26.8 months]. Improvements in time to symptomatic progression and time to initiation of cytotoxic chemotherapy were observed with niraparib plus AAP. In the BRCA1/2 subgroup, the analysis of OS with niraparib plus AAP demonstrated an HR of 0.88 (95% CI 0.58-1.34; nominal P = 0.5505); the prespecified inverse probability censoring weighting analysis of OS, accounting for imbalances in subsequent use of poly adenosine diphosphate-ribose polymerase inhibitors and other life-prolonging therapies, demonstrated an HR of 0.54 (95% CI 0.33-0.90; nominal P = 0.0181). No new safety signals were observed.

CONCLUSIONS

MAGNITUDE, enrolling the largest BRCA1/2 cohort in first-line mCRPC to date, demonstrated improved rPFS and other clinically relevant outcomes with niraparib plus AAP in patients with BRCA1/2-altered mCRPC, emphasizing the importance of identifying this molecular subset of patients.

Clinical updates in neoadjuvant immunotherapy for melanoma before surgery

INTRODUCTION

Locoregionally advanced melanoma represents a large group of high-risk melanoma patients at presentation and poses major challenges in relation to management and the risks of relapse and death.

AREAS COVERED

Melanoma systemic therapy has undergone substantial advancements with the advent of immune checkpoint inhibitors and molecularly targeted therapies, which have been translated to the neoadjuvant setting for the management of locoregionally advanced disease. Notably, PD1 blockade as monotherapy, in combination with CTLA4 blockade or LAG3 inhibition, has demonstrated significant progress in reducing the risk of relapse and mortality, attributed to high pathologic response rates. Likewise, BRAF-MEK inhibition for BRAF mutant melanoma has yielded comparable outcomes, albeit with lower response durability than immunotherapy. Localized intralesional therapies such as Talimogene laherparepvec (T-VEC) and Tavokinogene Telseplasmid (TAVO) electro-gene-transfer combined with anti-PD1 have demonstrated favorable pathologic responses and increased immune activation. Most importantly, the S1801 randomized trial has demonstrated for the first time the advantage of the neoadjuvant approach over standard surgery followed by adjuvant therapy.

EXPERT OPINION

Current evidence supports neoadjuvant therapy as a standard of care for locoregionally advanced melanoma. Ongoing research will define the optimal regimens and the biomarkers of therapeutic predictive and prognostic value.

Detection of dengue virus serotype 4 in Sudan

Background

Dengue virus infection is spreading globally and most parts of Sudan have witnessed repeated dengue outbreaks, with the detection of DENV-1, DENV-2 and DENV-3 serotypes.

Aims

In this report we describe the dengue fever outbreaks that occurred in eastern Sudan (Kassala and Port Sudan cities) from August to November 2019.

Methods

We enrolled 79 (29.8%) suspected cases from Kassala and 186 (70.2%) from Port Sudan who presented with fever. The participants were medically examined and their clinical signs recorded. Blood samples were collected for complete blood count, detection of anti-dengue virus IgM, detection of NS1 dengue antigen and identification of the virus serotype using RT-PCR.

Results

The main clinical presentations were fever, abdominal pain, joint pain and vomiting, and thrombocytopenia was the main laboratory finding. One hundred and twenty-five blood samples tested positive for the anti-dengue IgM antibody, and 145 were positive for the NS1 antigen. Using RT-PCR, we identified 35 (24%) infections with DENV-2, 100 (69%) with DENV-3 and 10 (7%) with DENV-4 serotypes.

Conclusions

We identified multiple serotypes - DENV-2, DENV-3 and DENV-4 - as the causes of the outbreak. The presence of DENV-4 serotype was documented for the first time in Sudan.

Examination of Outcome Disparities in Reports of Prepectoral and Subpectoral Direct-to-Implant Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

There are mixed results in surgical complications regarding the usage of prepectoral versus subpectoral implant placement in direct-to-implant breast reconstruction. This study aimed to provide a comprehensive synthesis of surgical complications between the subpectoral and prepectoral reconstructive method.

METHODS

PubMed, Embase, and Cochrane were searched for literature published up until December 2022. Studies that compared subpectoral and prepectoral breast reconstruction and reported at least one postoperative complication were included. The following 8 major outcomes were included: revision and reoperation, capsular contracture, explantation, seroma, hematoma, infection, skin necrosis, and animation deformity. Systematic review and meta-analysis were performed to compare outcomes of the 2 techniques. Subgroup analysis was performed to compare whether practice differences in different countries may have an impact on outcomes.

RESULTS

A total of 18 studies were identified in our literature search. Two thousand three hundred sixty patients were included, representing a total of 3135 breasts. Our analysis demonstrated that prepectoral reconstruction had significantly lower odds of developing postoperative hematoma [odds ratio (OR), 0.62; P = 0.05], seroma (OR, 0.67; P = 0.01), infection (OR, 0.64; P = 0.03), revision and reoperation (OR, 0.44; P < 0.00001), and animation deformity (OR, 0.01; P < 0.00001), compared with the subpectoral method. Subgroup analysis showed that differences between 3 countries (United States, Korea, Italy) are low (all subgroup heterogeneity test P > 0.1).

CONCLUSIONS

While both subpectoral and prepectoral are safe methods for breast reconstruction, the prepectoral technique may lead to lower odds of developing multiple major postoperative complications.

Three siblings with variable degrees of neuromuscular involvement and congenital sideroblastic anemia: A peculiar phenotype and a surprise genotypic explanation

INTRODUCTION

Congenital sideroblastic anemias (CSAs) are a group of inherited bone-marrow disorders manifesting with erythroid hyperplasia and ineffective erythropoiesis.

METHODS

We describe a detailed clinical and genetic characterization of three siblings with CSA.

RESULTS

Two of them had limb-girdle myopathy and global developmental delay. The two elder siblings performed allogenic hematopoietic stem-cell transplantation 5 and 3 years prior with stabilization of the hematological features. Exome sequencing in the non-transplanted sibling revealed a novel homozygous nonsense variant in SLC25A38 gene NM_017875.2:c.559C > T; p.(Arg187*) causing autosomal-recessive sideroblastic anemia type-2, and a second homozygous pathogenic previously reported variant in GMPPB gene NM_013334.3:c.458C > T; p.(Thr153Ile) causing autosomal-recessive muscular dystrophy-dystroglycanopathy type B14. With the established diagnosis, hematopoietic stem cell transplantation is now being scheduled for the youngest sibling, and a trial therapy with acetylcholine esterase inhibitors was started for the two neurologically affected patients with partial clinical improvement.

CONCLUSION

This family emphasizes the importance of whole-exome sequencing for familial cases with complex phenotypes and vague neurological manifestations.

Oxidative stress and viral Infections: rationale, experiences, and perspectives on N-acetylcysteine

This article explores current evidence on the role of oxidative stress in viral infections, and on the use of antioxidant drugs as adjunctive treatment. MEDLINE/PubMed was searched for appropriate keywords, and preclinical and clinical studies with reviews were retrieved and examined by authors. Old and current evidence shows that GSH content reduction is the main mechanism of redox imbalance in viral-infected cells. Clinical studies found that GSH levels are depleted in patients with viral infections such as HIV and SARS-CoV. Viral infections activate inflammation through different pathways, and several of these mechanisms are related to oxidative stress. NAC is a precursor of GSH, and many of its intracellular effects are mediated by GSH replenishment, but it also activates some anti-inflammatory mechanisms. NAC has an excellent safety profile and better oral and topical bioavailability than GSH. These characteristics make NAC a suitable option as a repurposed drug. Adjunctive antioxidant treatment may improve the outcomes of antiviral therapies. Current evidence supports the rationale for this practice and some clinical experience showed encouraging results.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Increased cannabis intake during the COVID-19 pandemic is associated with worsening of depression symptoms in people with PTSD

BACKGROUND

Some evidence suggests substance use affects clinical outcomes in people with posttraumatic stress disorder (PTSD). However, more work is required to examine links between mental health and cannabis use in PTSD during exposure to external stressors such as the COVID-19 pandemic. This study assessed mental health factors in individuals with self-reported PTSD to: (a) determine whether stress, anxiety, and depression symptoms were associated with changes in cannabis consumption across the pandemic, and (b) to contrast the degree to which clinically significant perceived symptom worsening was associated with changes in cannabis intake.

METHOD

Data were obtained as part of a larger web-based population survey from April 3rd to June 24th 2020 (i.e., first wave of the pandemic in Canada). Participants (N = 462) with self-reported PTSD completed questionnaires to assess mental health symptoms and answered questions pertaining to their cannabis intake. Participants were categorized according to whether they were using cannabis or not, and if using, whether their use frequency increased, decreased, or remained unchanged during the pandemic.

RESULTS

Findings indicated an overall perceived worsening of stress, anxiety, and depression symptoms across all groups. A higher-than-expected proportion of individuals who increased their cannabis consumption reached threshold for minimal clinically important worsening of depression, X²(3) = 10.795, p = 0.013 (Cramer's V = 0.166).

CONCLUSION

Overall, those who increased cannabis use during the pandemic were more prone to undergo meaningful perceived worsening of depression symptoms. Prospective investigations will be critical next steps to determine the directionality of the relationship between cannabis and depressive symptoms.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with prostate cancer

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of prostate cancer was published in 2020. It was therefore decided, by both the ESMO and the Singapore Society of Oncology (SSO), to convene a special, virtual guidelines meeting in November 2021 to adapt the ESMO 2020 guidelines to take into account the differences associated with the treatment of prostate cancer in Asia. These guidelines represent the consensus opinions reached by experts in the treatment of patients with prostate cancer representing the oncological societies of China (CSCO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), Singapore (SSO) and Taiwan (TOS). The voting was based on scientific evidence and was independent of the current treatment practices and drug access restrictions in the different Asian countries. The latter were discussed when appropriate. The aim is to provide guidance for the optimisation and harmonisation of the management of patients with prostate cancer across the different regions of Asia.

Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

Background

Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.

Methods

This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.

Results

Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.

Conclusion

The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.

Enhanced immune activation within the tumor microenvironment and circulation of female high-risk melanoma patients and improved survival with adjuvant CTLA4 blockade compared to males

BACKGROUND

We hypothesized that a gender difference in clinical response may exist to adjuvant CTLA4 blockade with ipilimumab versus high-dose IFNα (HDI). We investigated differences in candidate immune biomarkers in the circulation and tumor microenvironment (TME).

PATIENTS AND METHODS

This gender-based analysis was nested within the E1609 trial that tested adjuvant therapy with ipilimumab 3 mg/kg (ipi3) and 10 mg/kg (ipi10) versus HDI in high risk resected melanoma. We investigated gender differences in treatment efficacy with ipi3 and ipi10 versus HDI while adjusting for age, stage, ECOG performance (PS), ulceration, primary tumor status and lymph node number. Forest plots were created to compare overall survival (OS) and relapse free survival (RFS) between ipi and HDI. Gene expression profiling (GEP) was performed on tumors of 718 (454 male, 264 female) patients. Similarly, serum and peripheral blood mononuclear cells (PBMC) samples were tested for soluble and cellular biomarkers (N = 321 patients; 109 female and 212 male).

RESULTS

The subgroups of female, stage IIIC, PS = 1, ulcerated primary, in-transit metastasis demonstrated significant improvement in RFS and/or OS with ipi3 versus HDI. Female gender was significant for both OS and RFS and was further explored. In the RFS comparison, a multivariate Cox regression model including significant variables indicated a significant interaction between gender and treatment (P = 0.024). In peripheral blood, percentages of CD3+ T cells (P = 0.024) and CD3+ CD4+ helper T cells (P = 0.0001) were higher in females compared to males. Trends toward higher circulating levels of IL1β (P = 0.07) and IL6 (P = 0.06) were also found in females. Males had higher percentages of monocytes (P = 0.03) with trends toward higher percentages of regulatory T cells (T-reg). Tumor GEP analysis supported enhanced infiltration with immune cells including gammadelta T cells (P = 0.005), NK cells (P = 0.01), dendritic cells (P = 0.01), CD4+ T cells (P = 0.03), CD8+ T cells (P = 0.03) and T-reg (P = 0.008) in the tumors of females compared to males and a higher T-effector and IFNγ gene signature score (P = 0.0244).

CONCLUSION

Female gender was associated with adjuvant CTLA4 blockade clinical benefits and female patients were more likely to have evidence of type1 immune activation within the TME and the circulation. Trial registration ClinicalTrials.gov NCT01274338. Registered 11 January 2011, https://www.

CLINICALTRIALS

gov/ct2/show/NCT01274338.

Racial disparities in surgical outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) undergoing pancreas surgery

e16255

Background: Previous studies have suggested disparity in PDAC survival in African American (AA) compared to non-AA patients. Pancreas surgery is associated with significant morbidity, and technical outcomes are known to impact survival; however, there is little reported data on surgical outcomes by race. We sought to evaluate the effect of race on surgical outcomes and survival in an urban tertiary care center for patients with PDAC undergoing pancreas surgery. Methods: A retrospective single-center analysis of PDAC patients undergoing pancreas resection between January 2013 and September 2021 was performed. Patient demographics, Clavien-Dindo (CD) complications, readmission, and mortality in the 30- and 90- day period were collected and stratified by race. Univariate and multivariate analyses were performed. Results: Among 180 patients, 145 (81%) were non-AA and 35 (19%) were AA. Demographic and pre-operative characteristics were found to be similar between the two groups. 30-day ED visits, postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), and intra-abdominal abscess (IAA) were found to be significant on univariate analysis in the AA cohort. On multivariate analysis, 30-day ED visit (OR 4.5; 95% CI 1.3-15.8; p = 0.02), POPF (OR 4.5; 95% CI 1.3-14.8; p = 0.015), and IAA (OR 4.4; 95% CI 1.12-17.3; p = 0.033) were still significantly higher in the AA cohort while DGE lost its significance. Median overall survival and disease-free survival showed no significant difference on Kaplan-Meier curves. There was no statistical difference in local, regional, or metastatic recurrence patterns between the two groups (distant metastasis 36% in non-AA and 37% in AA). Conclusions: AA undergoing pancreas surgery for PDAC were noted to have higher incidence of POPF and IAA as well as ED visits compared to non-AA patients. However, no significant difference was seen in reoperation rates, major CD complications, recurrences, or survival. Exploring tumor biology, and preoperative treatment algorithms may shed additional insight on the differences in surgical outcomes in this patient cohort.[Table: see text]

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Frequency of musculoskeletal disorder of upper limb in Type 2 Diabetes patients

Diabetes is a frequently occurring chronic metabolic disease that is characterized by a high blood glucose levels. If left unchecked, it can lead to severe functional impairments such as blindness, renal failure, and coronary artery disease. Approximately 463 million adults (20-79 years) are living with diabetes; by 2045 this will rise to 700 million. Material and method: A cross-sectional survey was conducted in National Institute of Diabetes and Endocrinology, Dow University Hospital, Ojha campus. Patients who had T2DM, and were above 35 years of age were included in the study. Anthropometric measurements were recorded, and the remaining data was collected via a self-reporting questionnaire. Results and discussions: In this study n=55(36.2%) participants were male and n=97(63.8%) were female, with the average age of 52.9 years, and an average BMI of 29.5kg/m2. The mean HBA1C of those diabetic patients was 8.8, and average duration of diabetes of our sample was 6.7 years. Prevalence of MSK disorders was 55.3%. Conclusions: There is a high prevalence of musculoskeletal disorders among diabetic pa-tients. There was poor knowledge that upper limb musculoskeletal problems could occur due to diabetes, and a small percentage of patients sought physical therapy treatment for these disor-ders. Keywords: diabetes mellitus, musuculoskeletal diseases, upper extremity

257 Comparing Practice Testing to Restudying in the Dissecting Room: An Experimental Study

Aim

Medical students employ many strategies for learning, most commonly restudying. However, evidence suggests that restudying is not as effective as other strategies, namely practice testing. Different studies have compared restudying to practice testing on a variety of subjects. Few studies have assessed the effect of practice testing in anatomy courses. To the best of the authors' knowledge, no studies have investigated practice testing in the dissecting room (DR). In this study, we aim to measure the effect of practice testing in a DR setting, as compared to restudying.

Method

Second-year medical students learning the cardiovascular system were included in the study. Two groups were randomly selected to participate in practice tests taken at the end of DR sessions. The other two groups were asked to restudy the material. At the end of the four-week course, all students took a 15 points multiple-choice exam on learned material. Authors of practice tests were blind to the final exam content and vice versa.

Results

One hundred eight students participated in the study. Fifty-three students were in the practice testing group, and 55 were in the restudying group. The practice testing group performed significantly better than the restudying group (p = .008), with a mean of 8.57 +/- 2.3 for the practice testing group and 7.27 +/- 2.6 for the restudying group.

Conclusions

Practice testing significantly improved retention of Anatomy. We recommend that practice testing is implemented regularly at the end of DR sessions to enhance the learning experience.

206 Longevity of Deep Brain Stimulation Batteries at a Tertiary Neurosurgical Centre

Introduction

Deep brain stimulation (DBS) is a surgery used in the treatment of movement disorders. It involves surgical placement of electrodes in the brain that are connected to a battery-powered stimulator to regulate brain activity. DBS has been used successfully in the management of Parkinson's disease (PD). It has improved patients' movement and quality of life. However, one inconvenience is the limited battery life and the need for battery change to prevent deterioration in function. In this audit, we measured the longevity of DBS batteries in PD at a tertiary neurosurgical centre.

Method

A retrospective audit on the longevity of DBS batteries in 86 Patients with PD. We collected data on; date and position of device implant, type of battery used (rechargeable vs non-rechargeable), and the two most recent battery changes. We excluded battery changes that were due to infection.

Results

86 patients had DBS batteries. 21 patients had rechargeable batteries (Abbot Brio, Medtronic Activa RC and Boston Gevia), and 65 had non-rechargeable batteries (Abbot Infinity, Abbot Libra XP, Medtronic Activa PC). 53 patients have undergone a battery change, 49 of those were non-rechargeable batteries. Average battery life of non-rechargeable batteries was 3.06 ± .55 years in Infinity (n = 16), 4.0 ± 1.7 years in Libra XP(n = 22), and 4.6± .9 years in Activa PC (n = 11).

Conclusions

All three types of non-rechargeable batteries are lasting less than five years. Activa PC batteries had the lengthiest battery life of 4.6± .9 years, while infinity had the shortest battery life of 3.06± .55 years.

A single-center analysis of 30- and 90-day post-pancreatectomy complications in patients undergoing neoadjuvant radiation with EBRT versus MRI-guided SBRT

572

Background: Stereotactic MRI -guided adaptive radiation therapy (SMART) is being investigated for enhanced efficacy in locally advanced, borderline resectable and medically inoperable pancreatic cancer. Traditionally, conventionally fractioned chemoradiation (EBRT) has been used for operable patients. We sought to evaluate whether there would be differences in surgical complications and outcomes in the 30- and 90- day postoperative period in patients who received either neoadjuvant EBRT or SMART followed by definitive surgery. Methods: A retrospective single-center analysis of patients with either resectable, borderline resectable or locally advanced tumors of the pancreas or duodenum, treated with neoadjuvant radiation and surgical management between 2014 and 2021 was performed. Patient demographics and post-surgical complications were collected and stratified according to both treatment arms. The International Study Group of Pancreatic Surgery (ISGPS) classifications were used to define and grade postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE) and postpancreatectomy hemorrhage (PPH). A univariate analysis was done followed by a multivariate analysis. Results: Among the 65 patients (mean age 62.6 years, 46% female) who underwent definitive surgical intervention, 44 (67.7%) received EBRT, and 21 (32.3%) received SMART. Baseline characteristics including age, sex, race, ASA, and Charlson comorbidity index (CCI) scores were found to be similar. On univariate analysis, PPH was significantly higher in SMART (OR, 6.6; 95% CI, 1.2 to 37.3; p = 0.034). After adjusting for confounders on multivariate analysis, it appears there is a trend towards higher PPH in the SMART cohort ( p = 0.052). Conclusions: Neoadjuvant SMART followed by definitive surgery is not associated with worse outcomes in the 30- and 90- day postoperative period vs. neoadjuvant EBRT. Although there was a trend towards PPH on multivariate analysis, further discussion is warranted involving vascular resection, vascular stents and anticoagulation.[Table: see text]

Effectiveness of Decision Aid in Men with Localized Prostate Cancer: a Multicenter Randomized Controlled Trial at Tertiary Referral Hospitals in an Asia Pacific Country

There are several treatment options for localized prostate cancer with very similar outcome but vary in terms of technique and side effect profiles and risks. Considering the potential difficulty in choosing the best treatment, a patient decision aid (PDA) is used to help patients in their decision-making process. However, the use and applicability of PDA in a country in Asia Pacific region like Malaysia is still unknown. This study aims to evaluate the effectiveness of a PDA modified to the local context in improving patients' knowledge, decisional conflict, and preparation for decision making among men with localized prostate cancer. Sixty patients with localized prostate cancer were randomly assigned to control and intervention groups. A self-administered questionnaire, which evaluate the knowledge on prostate cancer (23 items), decisional conflict (10 items) and preparation for decision-making (10 items), was given to all participants at pre- and post-intervention. Data were analyzed using independent T test and paired T test. The intervention group showed significant improvement in knowledge (p = 0.02) and decisional conflict (p = 0.01) from baseline. However, when compared between the control and intervention groups, there were no significant differences at baseline and post-intervention on knowledge, decisional conflict and preparation for decision-making. A PDA on treatment options of localized prostate cancer modified to the local context in an Asia Pacific country improved patients' knowledge and decisional conflict but did not have significant impact on the preparation for decision-making. The study was also registered under the Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12614000668606 registered on 25/06/2014.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with renal cell carcinoma

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of renal cell carcinoma was published in 2019 with an update planned for 2021. It was therefore decided by both the ESMO and the Singapore Society of Oncology (SSO) to convene a special, virtual guidelines meeting in May 2021 to adapt the ESMO 2019 guidelines to take into account the ethnic differences associated with the treatment of renal cell carcinomas in Asian patients. These guidelines represent the consensus opinions reached by experts in the treatment of patients with renal cell carcinoma representing the oncological societies of China (CSCO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), Singapore (SSO) and Taiwan (TOS). The voting was based on scientific evidence and was independent of the current treatment practices and drug access restrictions in the different Asian countries. The latter were discussed when appropriate.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

88 Evidence of enhanced immune activation within the tumor microenvironment and the circulation of female patients with high-risk melanoma compared to males

Background

Sex differences in tumor immunity and response to immunotherapy were shown in murine models and descriptive analyses from recent clinical trials. We recently reported that female gender is a favorable prognostic marker for survival benefit following ipilimumab and high dose interferon-alfa (HDI) adjuvant therapy of high-risk melanoma in the ECOG-ACRIN E1609 trial (N=1670). Therefore, we investigated differences in candidate immune biomarkers in the circulation and tumor microenvironment (TME) of female and male patients.

Methods

Gene expression profiling (GEP) was performed on the tumor biopsies of 718 (454 male, 264 female) patients. The primary endpoint was mRNA expression profiling using U133A 2.0 Affymetrix gene chips. Raw microarray data sets were normalized by using the Robust Multi-array Average (RMA) method using Affymetrix Power Tools (APT) as previously published. Multiple probe sets representing the same genes were collapsed by using the probe with maximum gene expression. Gene set enrichment analysis (GSEA) was performed by comparing the female and male tumor samples, and gene sets with FDR q-value <0.1 were deemed as significant. Similarly, peripheral blood (serum and PBMC) samples were tested for soluble (Luminex) and cellular (multicolor flow cytometry) prognostic biomarkers in a subset of patients (N=321; 109 female and 212 male). All patients provided an IRB-approved written informed consent.

Results

Among the subset of patients tested for circulating biomarkers, females were significantly younger than males (P=0.03). Testing PBMCs, the percentages of CD3+ T cells (P=0.04) and CD3+CD4+ helper T cells (P=0.0005) were significantly higher in female patients compared to males. Also, there were trends toward higher levels of proinflammatory cytokines IL1beta (P=0.07) and IL6 (P=0.06) in females. On the other hand, males had significantly higher percentages of monocytes (P=0.03). Further, there were trends toward higher percentages of CD3+/CD4+/CD25hi+/Foxp3+ (P=0.1) and CD3+/CD4+/CD25+/CD127low+ (P=0.1) T-reg in male patients compared to females. Among the cohort of patients (N=718) with tumor GEP data, females were significantly younger than males (P=0.0009). GEP identified pathways and genes related to immune cell infiltration and activation that were significantly enriched in the tumors of females compared to males (table 1).

Abstract 88 Table 1

Immune pathways significantly enriched in tumors of females

Conclusions

Female gender was associated with adjuvant immunotherapeutic benefits and female patients were more likely to have evidence of immune activation within the TME and the circulation, supporting a potentially important role for female related factors in the immune response against melanoma, and these require further investigation.

Acknowledgements

We are grateful to the patients and family members who participated in the E1609 trial and the E1609 trial investigators. This study was conducted by the ECOG-ACRIN Cancer Research Group (Peter J. O’Dwyer, MD and Mitchell D. Schnall, MD, PhD, Group Co-Chairs) and supported by the National Cancer Institute of the National Institutes of Health under the following award numbers: U10CA180794, U10CA180820, U10CA180888, UG1CA233180, UG1CA233184. Biomarkers studies were supported under the following award number: P50CA12197310 (Tarhini and Kirkwood). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Trial Registration

NCT01274338

Ethics Approval

The E1609 study protocol was approved by the institutional review board of each participating institution and conducted in accordance with Good Clinical Practice guidelines as defined by the International Conference on Harmonization. All patients provided an IRB-approved written informed consent.

Consent

Not applicable.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Power-Assisted Liposculpture in Male Patients: A Spectrum of Definitions

BACKGROUND

Liposculpture procedures have gained popularity over the last 2 decades with the evolution of surgeons' skills and technological advancement. According to the 2018 The Aesthetic Society report, liposuction is the second-most popular aesthetic procedure in the United States.

OBJECTIVES

The authors aimed to demonstrate that a spectrum of liposculpture definitions can be achieved utilizing power-assisted liposuction (PAL). Also, the authors sought to describe the satisfaction and complication rates in mild-, moderate-, and high-definition groups utilizing the PAL technology.

METHODS

The authors designed a single-center retrospective study, including male patients who underwent PAL liposculpture of the chest, abdomen, back, and arms. Inclusion criteria were male patients >18 years of age and body mass index <30 kg/m2. Measured outcomes included extent of definition, complication rates, and levels of satisfaction.

RESULTS

Fifty male patients were included in this study between January 2018 and November 2019. The average age was 37.34 years (range = 25-56 years). The average body mass index was 26.4 kg/m2 (range = 24-30 years). A total of 54.3% of patients opted for high definition (HD), 36.4% for moderate definition, and 9.2% for mild definition. There were no major complications. The HD subgroup registered the highest incidence of minor complications (21%). Patient satisfaction levels were high in all 3 subgroups, with the highest scores in the HD subgroup (9.3/10).

CONCLUSIONS

A spectrum of definitions can be safely achieved utilizing the PAL technology, with high patient satisfaction in mild-, moderate-, and high-definition liposculpture subgroups and low complication rates.

LEVEL OF EVIDENCE: 4

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

The pedicled submental flap in facial reconstruction

Submental flap (SF) is a reconstructive technique that can be utilised for reconstruction of medium to large oral cavity defects, head and neck cancer, and pharyngocutaneous fistula. The submental artery island flap is pedicled on the submental artery and veins. The vascular pedicle has a length of up to 8cm. If it is further dissected to its origin from the facial artery, the pedicle can be lengthened by an additional 1-2cm to reach the lateral canthus and zygomatic arch. The use of SF for the reconstruction of head and neck defects has re-emerged over the past decade due to various reasons. We present a series of four case reports of head and neck cancers including a basal cell carcinoma, squamous cell carcinoma, and Merkel tumour, where the SF technique was used to successfully reconstruct the resultant facial defect. The advantages and disadvantages of the SF are discussed with a brief literature review.

Aptamers and Aptamer-Coupled Biosensors to Detect Water-Borne Pathogens

Aptamers can serve as efficient bioreceptors for the development of biosensing detection platforms. Aptamers are short DNA or RNA oligonucleotides that fold into specific structures, which enable them to selectively bind to target analytes. The method used to identify aptamers is Systematic Evolution of Ligands through Exponential Enrichment (SELEX). Target properties can have an impact on aptamer efficiencies. Therefore, characteristics of water-borne microbial targets must be carefully considered during SELEX for optimal aptamer development. Several aptamers have been described for key water-borne pathogens. Here, we provide an exhaustive overview of these aptamers and discuss important microbial aspects to consider when developing such aptamers.

Impact of morphine treatment with and without metoclopramide co-administration on myocardial and microvascular injury in acute myocardial infarction: insights from a randomized trial

Background

Intravenous morphine administration in patients with acute myocardial infarction (AMI) can adversely affect platelet inhibition induced by P2Y12 receptor antagonists, potentially resulting in an increased risk of adverse clinical events. In contrast, some evidence suggests that opioid agonists may have cardioprotective effects on the myocardium. Currently available data in this regard are, however, sparse, inconsistent, and methodologically limited.

Purpose

The aim of this study was to investigate the impact of morphine with or without metoclopramide (MCP) co-administration on myocardial and microvascular injury after AMI assessed by cardiac magnetic resonance (CMR).

Methods

This prospective, randomized, single-center study assigned 138 patients with AMI in a 1:1:1 ratio to (a) ticagrelor 180 mg plus intravenous morphine 5 mg (morphine group); (b) ticagrelor 180 mg plus intravenous morphine 5 mg and MCP 10 mg (morphine + MCP group); or (c) ticagrelor 180 mg plus intravenous placebo (control group). Study drugs were administered before primary percutaneous coronary intervention. CMR was performed in 101 patients on day 1–4 after the index event to assess infarct size, microvascular obstruction, and left ventricular ejection fraction.

Results

Infarct size was significantly smaller in the morphine only group as compared to controls (15.5%LV [IQR 5.0 to 21.4%LV] vs. 17.9%LV [IQR 12.3 to 32.9%LV]; p=0.047). Furthermore, the number of patients with microvascular obstruction was significantly lower after morphine administration (10/36 [28%] versus 21/39 [54%]; p=0.022) and the extent of microvascular obstruction was smaller (0%LV [0 to 1.40%LV] versus 0.74%LV [0 to 3.10%LV]; p=0.037). In multivariable regression analysis, morphine administration was independently associated with a reduced risk for the occurrence of microvascular obstruction (odds ratio 0.37; 95% confidence interval 0.14 to 0.93; p=0.035). Left ventricular ejection fraction did not differ significantly between the morphine and the control group (p=0.970) and there was no significant difference in left ventricular ejection fraction (p=0.790), infarct size (p=0.491), and extent (p=0.753) or presence (p=0.914) of microvascular obstruction when comparing the morphine + MCP group to the control group.

Conclusions

In this randomized study, intravenous administration of morphine prior to primary percutaneous coronary intervention resulted in a significant reduction of myocardial and microvascular damage following AMI. This potential cardioprotective effect of morphine requires further evaluation in well-designed future trials with clinical endpoints.

Funding Acknowledgement

Type of funding source: None