ENHANCED RECOVERY PROTOCOL FOLLOWING AUTOLOGOUS FREE TISSUE BREAST RECONSTRUCTION

BACKGROUND

Enhanced recovery after surgery (ERAS) aims to achieve earlier recovery, reduced hospital length of stay (LOS) and improved outcomes. Following the introduction of our ERAS protocol, we sought to review our ERAS experience. Our aims were to evaluate the LOS, post-operative complications, discharge analgesia, patient satisfaction and our ERAS protocol compared to the literature.

METHODS

This was a retrospective review of all our prospectively managed database between January 2016 and December 2016. Patient demographics, LOS, discharge analgesia and complications were collected. Patient satisfaction was determined using a 10-point Likert scale questionnaire.

RESULTS

A total of 70 patients underwent breast reconstruction using free deep inferior epigastric artery (DIEP) flaps. The mean age at surgery was 51 years (range 23-71). The mean LOS was 4.89 days (range 4-10). 61 patients (87%) were discharged within 5 days. 65 patients (93%) were discharged home on no controlled opioids. Major and minor complications were encountered in 3 patients (4%) and 5 (7%) patients respectively. There were no cases of complete or partial flap failure. 30-day patient satisfaction was high (>9/10) across all domains but patients complained of nausea & vomiting.

CONCLUSION

The adoption of our enhanced recovery protocol for autologous breast reconstruction has resulted in a mean LOS and opioid use reduction similar to contemporary literature. However, we have seen that there are further refinements that can be made to our ERAS protocol and there is still a need to develop a stronger evidence base to support our practices. This is in parallel with ongoing education and audit cycles to foster a culture of ERAS that can safely optimise patient outcomes.

Optical-Clock-Based Time Scale

A time scale is a procedure for accurately and continuously marking the passage of time. It is exemplified by Coordinated Universal Time (UTC) and provides the backbone for critical navigation tools such as the Global Positioning System. Present time scales employ microwave atomic clocks, whose attributes can be combined and averaged in a manner such that the composite is more stable, accurate, and reliable than the output of any individual clock. Over the past decade, clocks operating at optical frequencies have been introduced that are orders of magnitude more stable than any microwave clock. However, in spite of their great potential, these optical clocks cannot be operated continuously, which makes their use in a time scale problematic. We report the development of a hybrid microwave-optical time scale, which only requires the optical clock to run intermittently while relying upon the ensemble of microwave clocks to serve as the flywheel oscillator. The benefit of using a clock ensemble as the flywheel oscillator instead of a single clock can be understood by the Dick-effect limit. This time scale demonstrates for the first time subnanosecond accuracy over a few months, attaining a fractional frequency stability of 1.45 × 10-16 at 30 days and reaching the 10-17 decade at 50 days, with respect to UTC. This time scale significantly improves the accuracy in timekeeping and could change the existing time-scale architectures.

The effects of centralisation of vascular surgical services in the Bath, Bristol and Weston area on the carotid endarterectomy pathway

Introduction Patients who experience a transient ischaemic attack are at the highest risk of having a subsequent stroke immediately after their symptoms. A carotid endarterectomy should be performed on symptomatic, surgically suitable patients who present with a greater than 50% North American Symptomatic Carotid Endarterectomy Trial stenosis of the internal carotid artery within 2 weeks of their symptoms. This study aimed to determine whether the effectiveness of the carotid endarterectomy pathway has been impacted by the centralisation of vascular surgical services in the Bath, Bristol and Weston area. Materials and Methods From October 2013 to October 2015, critical steps in the patient carotid endarterectomy pathway that vascular surgeons from the Royal United Hospital Bath, Bristol Royal Infirmary and North Bristol NHS Trust input into the Royal College of Surgeons National Vascular Registry were collected. The dates of patient's symptoms, referral, first scan, surgical team review and surgery were analysed. Results Carotid endarterectomy data was collected for 261 patients. Overall, no significant difference in median time (days) from symptom to surgery from precentralisation data compared with post-centralisation data was seen (P = .175), with 65% patients meeting the national target of symptom to surgery in less than 14days. Discussion and Conclusion Centralisation has not significantly impacted the overall efficiency of the carotid endarterectomy pathway. This study highlights areas where improvement across the vascular network is required. This includes addressing the 35% patients that are not currently meeting the 14-day target and standardising the provision of care to outlying communities. Further follow-up is required to assess the longer term effects of centralisation.

Abstract P4-17-03: Towards the standardisation of outcome reporting in reconstructive breast surgery: Initial results of the BRAVO (Breast Reconstruction and Valid Outcome) Study–A multicentre consensus process to develop a core outcome set for reconstructive breast surgery

Introduction: Appropriate outcome selection is essential if research is to guide decision-making for patients, professionals and policy makers. Systematic reviews evaluating the clinical, cosmetic and patient-reported outcomes of breast reconstruction, however, have demonstrated marked heterogeneity of outcome reporting such that results from individual studies cannot be compared or combined. Standardising end-points by developing and using core outcome sets - an agreed minimum set of outcomes that should be measured and reported in all research and audit studies – is one way by which outcome reporting may be improved. We therefore report the initial results of the BRAVO (Breast Reconstruction and Valid Outcomes) Study which aims to use a scientifically rigorous Delphi consensus process to develop a core outcome set for reconstructive breast surgery.

Methods: The Delphi process involves the sequential completion of questionnaires to allow stakeholder opinions to be synthesised using item responses to prioritise outcome domains.

The questionnaire was developed from a long list of 148 outcomes generated from literature reviews and qualitative work with stakeholders. The outcomes were categorised into 34 domains in six categories (short-term complications; late complications; symptoms; psychosocial issues; practical issues and cosmesis) and each domain operationalised.

Key stakeholders were identified as patients, surgeons, specialist nurses and psychologists and participants were sampled purposively to ensure a breadth of perspectives. Each participant was sent a questionnaire and asked to prioritise the outcomes on a nine-point likert scale from 1(not important) to 9(extremely important).

The number of respondents in each group rating each outcome as not important(scores 1–3); equivocal(scores 4–6) or very important(score 7–9) were calculated for each item and compared between groups. The proportions of respondents rating each item as very important(score 7–9) was used to rank the items.

Results: 213 of the 430 questionnaires were returned(126/274 patients and 87/156 professionals) giving a response rate of 49.5%.

Patient participants had a median age of 53.4 years(range 34–76) and had undergone a full range of reconstructive procedures. The professional group included 39 breast surgeons, 20 plastic surgeons and 18 clinical nurse specialists.

There was agreement between 7 of the 10 outcomes that each group rated most highly. Items with consensus included patient-reported cosmesis, cosmetic satisfaction and early complications. Patients, but not professionals, considered generic complications such as bleeding to be important while professionals valued psychosocial issues such as self-esteem more highly than patients.

Conclusions: Patients and professionals prioritise similar outcomes, but areas of discrepancy with regard to complications and psychosocial outcomes remain. A further Delphi round asking participants to re-prioritise outcomes and a consensus meeting to ratify the final decisions will be necessary to determine a final core outcome set for reconstructive breast surgery.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-17-03.

Circulating endothelial progenitor cells, endothelial function, carotid intima-media thickness and circulating markers of endothelial dysfunction in people with type 1 diabetes without macrovascular disease or microalbuminuria

AIMS/HYPOTHESIS

Type 1 diabetes is associated with premature arterial disease. Bone-marrow derived, circulating endothelial progenitor cells (EPCs) are believed to contribute to endothelial repair. The hypothesis tested was that circulating EPCs are reduced in young people with type 1 diabetes without vascular injury and that this is associated with impaired endothelial function and increased carotid intima-media thickness (CIMT).

METHODS

We compared 74 people with type 1 diabetes with 80 healthy controls. CD34, CD133, vascular endothelial (VE) growth factor receptor-2 (VEGFR-2) and VE-cadherin antibodies were used to quantify EPCs and progenitor cell subtypes using flow-cytometry. Ultrasound assessment of endothelial function by brachial artery flow-mediated dilatation (FMD) and CIMT was made. Circulating endothelial markers, inflammatory markers and plasma plasminogen activator inhibitor-1 (PAI-1) levels were measured.

RESULTS

CD34+VE-cadherin+, CD133+VE-cadherin+ and CD133+VEGFR-2+ EPC counts were significantly lower in people with diabetes (46-69%; p = 0.004-0.043). In people with type 1 diabetes, FMD was reduced by 45% (p < 0.001) and CIMT increased by 25% (p < 0.001), these being correlated (r = -0.25, p = 0.033). There was a significant relationship between FMD and CD34+VE-cadherin+ (r = 0.39, p = 0.001), CD133+VEGFR-2+ (r = 0.25, p = 0.037) and CD34+ (r = 0.34, p = 0.003) counts. Circulating high-sensitivity C-reactive protein, PAI-1, interleukin-6 and E-selectin were significantly higher in the diabetes group (p < 0.001 to p = 0.049), the last two of these correlating with FMD (r = -0.27, p = 0.028 and r = -0.24, p = 0.048, respectively).

CONCLUSIONS/INTERPRETATION

These findings suggest that abnormalities of endothelial function in addition to pro-inflammatory and pro-thrombotic states are already common in people with type 1 diabetes before development of clinically evident arterial damage. Low EPC counts confirm risk of macrovascular complications and may account for impaired endothelial function and predict future cardiovascular events.

A prospective patient observational study of the role of hyperhomocysteinemia in restenosis in patients undergoing infrainguinal angioplasty or bypass procedures

AIM

The aim of this study was to examine the correlation between elevated plasma homocysteine (HCy) and restenosis/occlusion in patients undergoing infrainguinal angioplasty or bypass grafting.

METHODS

Fifty-three patients presenting to the Northern Vascular Unit were sequentially recruited to the study and prospectively followed up for 12 months post-infrainguinal angioplasty or bypass surgery. Plasma HCy was measured preprocedure and at least 3 months postprocedure using the Abbott IMx system. Hyperhomocysteinemia (HHCy) was taken at a level >15 microM/L. All patients were serially duplex scanned at 6 weeks, and 3, 6, 9 and 12 months. Kaplan-Meier analysis was performed to assess the restenosis/occlusion rate in patients with HHCy versus controls. Analysis of correlation between risk factors for restenosis/occlusion was performed using the Pearson correlation coefficient. In addition, logistic regression analysis was performed.

RESULTS

Forty-eight percent of procedures was performed in patients with HHCy. There were 18 graft stenoses/occlusions, and 13 restenoses/occlusions postangioplasty. HHCy did not correlate with an increased risk of restenosis/occlusion (P=0.79). There was a significant correlation between HCy, age, folate and cholesterol levels. Logistic regression analysis revealed no factors that correlated with failure of therapeutic intervention.

CONCLUSIONS

This study does not support the hypothesis that HHCy is associated with an increased risk of restenosis after vascular intervention.

Optical frequency synthesis and comparison with uncertainty at the 10(-19) level

A femtosecond laser-based optical frequency synthesizer is referenced to an optical standard, and we use it to demonstrate the generation and control of the frequency of electromagnetic fields over 100 terahertz of bandwidth with fractional uncertainties approaching 1 part in 10(19). The reproducibility of this performance is verified by comparison of different types of femtosecond laser-based frequency synthesizers from three laboratories.

Lysozyme as a measure of cellular dynamics in the lesions of leprosy

The levels and distribution of lysozyme-positive cells and exudate were studied in leprosy lesions through the spectrum, in untreated and treated patients, in relapse and in reactions. Altogether 124 skin biopsies were examined by the immunoperoxidase technique. Monocytes, neutrophil-polymorphs and mast cells were the most conspicuous cells seen. Lysozyme proved to be a useful means of indexing renewal of these cells in the lesions. Peak numbers of monocytes were seen in lesions of active lepromatous leprosy (LL) and of tuberculoid leprosy (TT), at poles of opposite immunological performance. In TT the stimulus for recruitment was delayed hypersensitivity (DH). A decline in DH from TT towards the middle of the spectrum, mid-borderline, was accompanied by a fall in monocyte level. Furthermore, reacting lesions due to enhanced DH also had increased numbers of monocytes. On the other hand reactions associated with immunological deterioration were similar to active lepromatous leprosy (LL) and monocyte influx was raised in response to the stimulus of free multiplication of bacilli in both cases. In TT delayed hypersensitivity acted also to promote the rapid transformation of monocytes to epithelioid and giant cells all of which were strongly positive for lysozyme. This was in contrast to much lower levels in histologically similar macrophage-epithelioid cells of BT granulomas. Lysozyme synthesis was not seen in macrophages after ingestion of M. leprae. Early foamy change was made conspicuous by lysozyme deposited in phagocytic vacuoles, but old foam cells in regressing lepromas were negative. Lysozyme bound to dead extracellular M. leprae but not to viable or intracellular organisms. Dead bacilli or immune complexes appeared to be the stimulus for neutrophil-polymorph recruitment, mainly in reactions.

Stimulation of cell division in ectopic liver tissue following partial removal of the lung

Autografts of liver were implanted into the left lung (Xenopus laevis). Subsequent removal of the right lung stimulated increased mitotic activity in the lung and in the liver graft.

Stimulation of cell division in ectopic kidney grafts following unilateral removal of the lung

Small fragments of kidney tissue were grafted into the right lung (Xenopus laevis) and the left lung was subsequently removed. This stimulated compensatory hyperplasia (increased mitotic rate) in alveolar tissue of the right lung and in the kidney graft. This suggests that the stimulus to compensatory hyperplasia is location-specific rather than tissue- or organ-specific. After implantation into the lung the kidney grafts are revascularized by the surrounding pulmonary supply. Damage or functional impairment of an organ usually produces a localized increase in the rate of blood flow and we therefore propose that this may lead to an increased rate of cell division in one of two ways: by permitting an increased functional capacity in the tissue concerned, or by causing a more rapid local clearance of mitotic control factors.