Reconstruction in Salvage Surgery for Head and Neck Cancers

Introduction

Salvage surgery is the treatment option in recurrences and second primary tumors. This paper aimed to study the options and outcomes of reconstruction and the predictors of poor reconstructive outcomes in salvage surgery for head and neck cancers.

Study Design

This is a retrospective study of all patients who underwent reconstructive flap surgery as part of salvage surgery for head and neck cancers between the years 2004 and 2017.

Methods

The initial treatment may be single modality radiotherapy or surgery or multimodality with combinations of surgery, radiotherapy, and chemotherapy. Any pathology that required surgical salvage was included. Any procedures done purely as reconstructive surgery were excluded. Predictor variables included demographical, clinical, and treatment factors. The outcome parameter was the occurrence of any flap-related complication or not. The complications and morbidity related to the procedures are reported.

Results

Ninety-three patients underwent loco-regional flaps (LRF group), and 100 had free flaps (FF group). Pectoralis major flap was the commonest flap used in 68 patients (73.1%). Anterolateral thigh (ALT) flap was the commonest free flap and comprised 41% of the FF group. Any skin-related complication was seen in 35 patients (37.6%) and 41 (41%), respectively, in LRF and FF subsets. Any flap-related complication was seen in 16 patients (17.2%) and 29 patients (29%), respectively, in LRF and FF subsets. A summary measure "any one of the complications" was seen in 46 (49.5%) and 57 (57%), respectively, in LRF and FF subsets. Univariate and multivariate analysis for any flap-related complication identified no statistically significant predictor.

Conclusions

Soft tissue flaps were preferred in salvage reconstruction, though the defects had a bony component. In the microvascular free flap reconstruction era, pectoralis major flap has shifted its role from a "workhorse flap" to a "salvage flap." About half of the patients develop some complications. Flap-related complications are also common. In salvage surgery, it is important that an appropriate flap is selected, suitable for the setting, according to the indications, neck, and patient conditions.

The injury patterns, management and outcomes of retroperitoneal haemorrhage caused by lumbar arterial bleeding at a Level-1 Trauma Centre: A 10-year retrospective review

PURPOSE

Haemorrhagic shock remains a leading preventable cause of death amongst trauma patients. Failure to identify retroperitoneal haemorrhage (RPH) can lead to irreversible haemorrhagic shock. The arteries of the middle retroperitoneal region (i.e., the 1st to 4th lumbar arteries) are complicit in haemorrhage into the retroperitoneal space. However, predictive injury patterns and subsequent management implications of haemorrhage secondary to bleeding of these arteries is lacking.

MATERIALS AND METHODS

We performed a retrospective cohort study of patients diagnosed with retroperitoneal haemorrhage who presented to our Level-1 Trauma Centre (2009-2019). We described the associated injuries, management and outcomes relating to haemorrhage of lumbar arteries (L1-4) from this cohort to assess risk and management priorities in non-cavitary haemorrhage compared to RPH due to other causes.

RESULTS

Haemorrhage of the lumbar arteries (LA) is associated with a higher proportion of lumbar transverse process (TP) fractures. Bleeding from branches of these vessels is associated with lower systolic blood pressure, increased incidence of massive transfusion, higher shock index, and a higher Injury Severity Score (ISS). A higher proportion of patients in the LA group underwent angioembolisation when compared to other causes of RPH.

CONCLUSION

This study highlights the injury patterns, particularly TP fractures, in the prediction, early detection and management of haemorrhage from the lumbar arteries (L1-4). Compared to other causes of RPH, bleeding of the LA responds to early, aggressive haemorrhage control through angioembolisation. These injuries are likely best treated in Level-1 or Level-2 trauma facilities that are equipped with angioembolisation facilities or hybrid theatres to facilitate early identification and management of thoracolumbar bleeds.

Management of “Large” Vascular Malformation: An Institutional Review

Background: Large vascular malformations (VM) are complex lesions anatomically, functionally or both. The criteria to define “Large” vascular malformations were unclear. This study aims to retrospectively identify Large VM based on clinical features and discussed about the method we adopted in management. Methods: This is retrospective study of analyzing all patients of vascular malformations treated by us since 2003. The criteria to categorize large vascular malformations were outlined after analyzing the anatomical area of involvement, functional disturbances by these lesions, operability of the lesions, morbidity associated with resection, and the requirement of reconstruction. All cases were managed by a multi-disciplinary team. Various methods utilized to control the bleeding varied from simple wound packing to cardiopulmonary bypass (CPB) assistance. The resection was either curative or palliative. Complete excision in the form of radical resection was carried out in all possible cases intended with curative aim. Vascularized tissue transfer was done to reduce the morbidity following surgical resection. Results: Out of 268 patients, 26 patients fulfilled the criteria for large vascular malformations. The predominant site of involvement is head and neck. 80% had more than one indication for surgery. Majority of the cases 54% were arterio-venous malformations (AVM) followed by 31% of capillary venous malformations (CVM). The commonest indication for surgery is bleeding in 73% followed by cosmetic disfigurement in 61.5%. Compressive wound packing with delayed wound closure and preoperative embolization were the commonly employed methods for bleeding control. CPB assisted resection was carried out in 5 cases. On analysing the recurrence, 7.7% had in complete excision, 36% in incomplete excision and 12% in cases of vascularized tissue transfer. Conclusion: The clinical criteria outlined in our study will be useful in identifying “Large” vascular malformations. Compression wound packing with delayed closure plays a major role in bleeding control immediately after resection. CPB assistance for aiding resection can be considered in selected cases. Complete resection in the form of radical excision will reduce the recurrence. Palliative resection provides symptom free disease when complete resection is not viable. The tissue transfer for the wound cover controls the residual disease in cases of incomplete resection.

Enhancing Wheat Disease Diagnosis in a Greenhouse Using Image Deep Features and Parallel Feature Fusion

Since the assessment of wheat diseases (e.g., leaf rust and tan spot) via visual observation is subjective and inefficient, this study focused on developing an automatic, objective, and efficient diagnosis approach. For each plant, color, and color-infrared (CIR) images were collected in a paired mode. An automatic approach based on the image processing technique was developed to crop the paired images to have the same region, after which a developed semiautomatic webtool was used to expedite the dataset creation. The webtool generated the dataset from either image and automatically built the corresponding dataset from the other image. Each image was manually categorized into one of the three groups: control (disease-free), disease light, and disease severity. After the image segmentation, handcrafted features (HFs) were extracted from each format of images, and disease diagnosis results demonstrated that the parallel feature fusion had higher accuracy over features from either type of image. Performance of deep features (DFs) extracted through different deep learning (DL) models (e.g., AlexNet, VGG16, ResNet101, GoogLeNet, and Xception) on wheat disease detection was compared, and those extracted by ResNet101 resulted in the highest accuracy, perhaps because deep layers extracted finer features. In addition, parallel deep feature fusion generated a higher accuracy over DFs from a single-source image. DFs outperformed HFs in wheat disease detection, and the DFs coupled with parallel feature fusion resulted in diagnosis accuracies of 75, 84, and 71% for leaf rust, tan spot, and leaf rust + tan spot, respectively. The methodology developed directly for greenhouse applications, to be used by plant pathologists, breeders, and other users, can be extended to field applications with future tests on field data and model fine-tuning.

Characteristics of the leachate produced during nutrient recycling of food and poultry slaughter wastes by fly larvae

Biowaste management is a pertinent problem and nutrient recycling utilizing fly larvae is an emerging solution. The leachate produced during biowaste management has potential implications for the environment but studies on this issue are scanty. This study was conducted to assess the characteristics of leachate produced during the bioconversion of food (BW-I) and poultry slaughter waste (BW-II) by natural fly larval activity. The results showed that total volumes of 2.2 L and 1.1 L leachate were produced for BW-I and II respectively. The highest pH in BW-I leachate was 7.43 ± 0.01 and the lowest pH in BW-II was 3.30 ± 0.12. The highest levels of BOD in BW-I and II were 36733.33 ± 430.63 mg/l and 2800.000 ± 999.50 mg/l. The highest level of COD in BW-I was 52575.000 ± 1076.86mg/l while in BW-II it was 4316.67 ± 790.45 mg/l. The high BOD and COD values of the leachate indicated that they needed to be pretreated before being released into the environment.

Comparison of health state utility measures and disabilities of arm, shoulder and hand questionnaire scores in bilateral hand amputees

Bilateral hand amputation (BHA) is a life-changing event that can result in a great degree of loss of function. Prosthetic limb replacement and composite tissue allotransplantation are the treatment options. Understanding the BHA in terms of economic utility will help direct future research and upgrading in healthcare delivery. This is a cross-sectional study in 32 BHA who have completed a minimum of six months after wound healing. The primary objective was to assess the convergent validity of three different health utility (HU) derivation methods, namely the time trade-off (TTO), EuroQol questionnaire (EQ-5D-5L), and EuroQol visual analog scale (EQ-VAS) among BHA. The secondary objective was to correlate the disabilities of arm, shoulder and hand (DASH) scores with the HU scores and see whether the DASH score predicts the HU scores derived by different methods. The mean (SD) HU scores for TTO, VAS, and EQ-5D-5L were 0.34 (0.25), 0.61 (0.25), and 0.46 (0.20), respectively. HU derived by the TTO method displayed a weak correlation with EuroQol-based derivatives (EQ-VAS & EQ-5D-5L). But there was a moderate correlation between values by EQ-VAS & EQ-5D-5L. Hence, the EuroQol HU derivative is preferable to TTO. The mean (SD) of the DASH score was 48.4 (22.9). There was a strong correlation between the DASH scores and HU derived by different methods. Also, the DASH score is seen to be a good predictor of HU scores. This study is the first to derive HU and correlate the DASH with HU scores in the BHA scenario .

Outcomes of Re-exploration Procedures After Head and Neck Free Flap Reconstruction

This study was conducted to evaluate the outcomes of re-exploration procedures done after head and neck microvascular flap reconstructions. This is a retrospective review of 109 flaps in 106 patients (three patients had two flaps each) that underwent re-exploration procedures in 1001 consecutive free flap surgeries. The outcome was analysed in terms of the type of the flaps, re-exploration rate, flap salvage rate and overall flap success rate. Free radial forearm (RFF) was the commonest flap done (354, 35.3%). One hundred nine flaps underwent re-exploration procedures in 106 patients. Out of this, 79 flaps could be salvaged, and 30 flaps failed. There were also another ten flaps, which failed without any re-exploration. The overall re-exploration rate was 10.8%. The flap salvage rate was 72.4%. The overall flap success rate was 96.1%. Nearly three-fourths of the flaps with vascular compromise can be successfully salvaged with appropriate and timely intervention.

AB0360 A DECADE OF SUSPECTED GIANT CELL ARTERITIS: CLINICAL FEATURES OF A HIGHLY HETEROGENEOUS DISEASE

Background:

Giant cell arteritis is the most common chronic systemic vasculitis in older adults. Permanent visual loss is the most concerning complication can occur in up to 20% of patients (1). Diagnosis is based on a combination of clinical findings, laboratory evidence of inflammatory markers, and temporal artery biopsy (TAB) confirming histologic evidence of inflammation. There are no definitive markers of the disease when TAB is negative.

Objectives:

The objective of this study was to illustrate the clinical features of subjects suspected with GCA evaluated at the Dallas Veterans Affairs Medical Center (VAMC) and identify those features that would differentiate between TAB positive GCA, TAB negative GCA and non-GCA patients.

Methods:

This retrospective study searched the Dallas VAMC database for subjects between January of 2010 until December 2019 with ICD-9 and ICD-10 entry code for GCA. Based on the 1990 ACR clinical classification criteria for GCA, suspected patients were classified as TAB positive GCA, TAB negative GCA and non-GCA. Subjects with incomplete data needed for classification were excluded. Group comparisons were performed with Fisher’s exact test for categorical variables and the Mann-Whitney test for continuous variables.

Results:

One-hundred and sixty-nine subjects had ICD-9/10 entry code for GCA. Ophthalmology was the specialty who did the initial evaluation in 46% of the suspected cases. Seventy-one patients were excluded due to incomplete data. Of the remaining 98 patients, 42 (42.9%) were diagnosed with GCA out of which 10 patients had a positive TAB. Seventy-six percent of patients diagnosed with GCA had negative temporal artery biopsies. In 56 (57.1%) patients GCA was ruled out (Figure 1). New-onset headache was the predominant symptom suggestive of GCA affecting 88.9% TAB positive and 100% of TAB negative cases compared to 56.6% of non-GCA patients (p< 0.001), followed by scalp tenderness in 33.3%, 58.1% and 10.9%, respectively (p< 0.001), jaw claudication in 57.1%, 34.5% and 14.9% (p=0.021), and elevated sedimentation rate in 33%, 65.6% and 33% (p=0.013) (Table 1). Polymyalgia rheumatica was present in 28.6% and 21.7% of patients diagnosed with GCA compared to zero percent in non-GCA cases (p=0.017). More than 30% of patients with GCA had normal acute phase reactants in this cohort.

Table 1.

Comparison of demographics and clinical features of patients with suspected GCA

GCA TAB Positive (n=10)GCA - TAB Negative (n=32)non-GCA (n=56)n%n%n%pAge (mean/sd)71.3 (7.8)67.3 (8.1)67.3 (8.9)0.367Male99030/3293.851/5691.10.885Clinical findingsNew onset headache8/988.932/3210030/5356.6<0.001Visual symptoms9/109022/3268.842/5477.80.351Jaw claudication4/757.110/2934.57/4714.90.021PMR2/728.65/2321.70/3000.017Scalp tenderness2/633.318/3158.15/4610.9<0.001Fever0/505/2321.72/355.70.117ESR > 501/333.321/3265.618/5433.30.013CRP > 101/333.35/3016.76/5411.10.473Anemia (hemoglobin < 12 g/ dl)2/728.615/3246.921/5240.40.642Thrombocytosis (platelets >400)2/728.63/329.44/517.80.228

Conclusion:

There is clinical heterogeneity within the patients diagnosed with GCA regardless of TAB. A high index of clinical suspicion needs to be the cornerstone of diagnosis. There is need for new classification criteria to include patients with negative TAB.

References:

[1]Soriano A, et al. Nat Rev Rheumatol. 2017 Aug;13(8):476-484.

Disclosure of Interests:

Adela Castro: None declared, Jiby Mathew: None declared, Ola Azzouqah: None declared, Jesus Diaz: None declared, Andreas Reimold Consultant of: Lilly, Grant/research support from: Abbvie

Pfizer

Gilead, Kyawt Shwin: None declared

Evaluation of Anti-quorum Sensing Potential of Saraca asoca (Family Caesalpiniaceae) against Chromobacterium violaceum and Pseudomonas aeruginosa PA01

Aim: The present study was performed to evaluate the anti-quorum sensing (QS) potential of traditional medicinal herb Saracaasoca (family Caesalpiniaceae) stem bark extract against Chromobacterium violaceum and Pseudomonas aeruginosa PA01. Study Design: First, the test sample (bark extract) was screened for anti-QS activity. Then systematic in-vitro and biochemical tests were performed to evaluate the effect of the test sample on the QS mediated virulence factors. Place and Duration of Study: All the experimental works were performed in Lab 311, pharmacology division, CSIR-NBRI Lucknow from June 2019 to October 2019. Methodology: The samples of Saraca asoca stem bark were washed, dried and extracted using 70% methanol. The minimum inhibitory concentration (MIC) of the prepared Sarca asoca bark extract was determined using the Alamar blue assay, and the anti-QS activity was screened using standard agar overlay method against CV 12472 at subinhibitory concentrations 100, 200 and 300 µg (< MIC value). SAE effect on biofilms formation was assessed by growing biofilms on glass slides in a static culture of PA01. Anti-virulence effect of SAE on the production of QS-regulated virulence factors such as Pyocyanin, proteases, elastases, rhamnolipid and alginate in Pseudomonas aeruginosa was determined using the supernatant of a 24 hours old broth culture of PA01 supplemented with SAE. Using the agar plate technique, the swimming and swarming motility assays were conducted on 0.3% and 0.5% agar plates respectively. One-way ANOVA was used to analyze the data, presented as mean ± SD (standard deviation) of three independent experiments. Results: Preliminary screening results showed significant QS inhibition against CV 12472 in an agar overlay disk diffusion assay in a concentration-dependent manner. Data from the biofilm assay showed loose, distorted, irregular PA01 biofilm formation at 200 µg (48%) and 300 µg (65%). SAE caused a significant drop in virulence factor production, with maximum reduction in pyocyanin (58%), proteases (67%), elastases (52%), rhamnolipid (53%), and alginate (44%) observed at 300 µg concentration. At SAE sub-lethal concentrations (200 and 300 µg), both the swimming and swarming motility of PA01 were significantly inhibited. Conclusions: The present study demonstrates the broad-spectrum anti-QS potential of SAE, reported for the first time, suggesting that SAE could be considered as an alternative herbal source to develop antimicrobial agents which can be either solitary or synergistically with conventional antimicrobial drugs.

40 Improving Urinary Catheter Documentation and Care in Geriatric Wards

Introduction

NICE guidelines state that urinary catheter insertion, changes and care should be documented. Duration of catheterization is directly linked to the risk of developing a catheter-associated UTI. Furthermore, Public Health England has announced a national aim to reduce the incidence of Gram-negative bacteraemia by 50% by March 2021, and targeting catheters is one of the first steps.

Local problem

These issues are relevant to the elderly population at Princess Royal University Hospital, where documentation surrounding catheters was found to be inadequate. Despite there being an Electronic Patient Record (EPR) order for catheter insertion and monitoring available, this was not being used. Our primary aim was for all patients to have this order. We also hoped to reduce the weekly rate of catheter days (catheter days per 100 bed days), and improve documentation in clinical notes.

Methods

We focused on two medical wards and sampled all patients admitted over a period of 4 months who had a catheter at the time of data collection. We identified catheterized patients and whether they had an EPR catheter order on a daily basis. Additional parameters such as indication, insertion date, inserter, and documentation standards were extracted from EPR on a weekly basis. Patients were kept “live” and contributing to catheter day calculations until they were no longer on the ward or if the catheter was removed.

Interventions

We implemented changes over 2 PDSA cycles. Interventions included the addition of catheter columns to boards and education sessions for doctors and nurses (cycle 1), as well as catheter posters, alert cards, and circulation of emails with guidance to doctors and nursing staff (cycle 2).

Results

A total of 87 patients were analysed during the project. There was an increase in EPR orders being used, with the 100% target being reached on the final data collection point, and with data showing a significant shift above baseline. Furthermore, there was a decrease in the weekly rate of catheter days, but changes were difficult to sustain. We also saw a general improvement in documentation standards.

Conclusion

By improving documentation and reducing unnecessary catheterization, we hope to have reduced the overall risk of infection whilst improving patient comfort and experience. Lessons may be transferrable to other trusts.

Penile fracture associated with complete urethra and bilateral corpora cavernosa transection

Penile fracture is a rare urological emergency caused by blunt trauma to the erect penis. It occurs due to the forcible bending of the turgid erect penis against resistance leading to tunica albuginea tear. The rupture of tunica albuginea surrounding the corpora cavernosa leads to hematoma formation and classical 'aubergine' deformity. Timely intervention is essential to improve sexual function. Urethral injury may occur concomitantly in case of severe trauma. Blood at the meatus, inability to void and haematuria are distinctive features. We describe a case of 36-year-old man who presented to the emergency department with penile fracture during sexual intercourse associated with blood at the meatus and voiding difficulty. On surgical exploration, complete bilateral corpora cavernosa tear and penile urethral transection was noted. The patient was successfully managed with timely repair. This case highlights the need for suspicion of an associated urethral injury in patients of penile fracture with blood at the meatus.

Shape-modified radial forearm free tissue transfer in oral cavity reconstruction: Technique and a prospective comparison with the conventional technique

BACKGROUND

Donor site morbidity is a significant drawback of the radial forearm flap. The purpose of this study is to describe a new shape-modified technique. The donor site morbidity was compared to that of the conventional technique, in terms of the esthetic, functional outcomes, and quality of life (QOL).

METHODS

This is a prospective study of 30 patients with oral cancer who underwent reconstruction using radial forearm flaps, in two groups.

RESULTS

Regarding the donor site characteristics, the differences in the time for healing (P = .006), the scar score (P < .0001), and the QOL score (P < .0001) were significant. The number of patients with sensory deficit was 11 in the conventional group and 3 in the shape-modified group (P = .009).

CONCLUSIONS

The functional and esthetic outcomes of the donor site were better for the shape-modified technique. It is best suited for small defects. Compromise of the pedicle length is a limitation.

AB0596 PREDICTORS, LONG TERM CLINICAL AND TREATMENT OUTCOMES IN SOUTH ASIAN PATIENTS WITH IDIOPATHIC INFLAMMATORY MYOSITIS: A SINGLE CENTER STUDY

Background:

Idiopathic inflammatory myositis (IIM) are a heterogeneous group of immune-mediated disorders with varied presentations and multiple organ involvement. Data on long term outcome among South Asian patients with IIM is sparse.

Objectives:

To study the long term clinical outcome, treatment responses and factors predicting outcome among adult patients with IIM

Methods:

Patients diagnosed as ‘Idiopathic Inflammatory Myositis’ under the department of Clinical Immunology and Rheumatology at CMC, Vellore, India were screened retrospectively. Patients aged 18 years and above, satisfying Bohan and Peter criteria, having follow up of one year or more with atleast two outpatient or inpatient visits between January 2010 and April 2019 were included in this study. Those patients with connective tissue disease associated myositis were not included. Details on muscle weakness, extramuscular involvement, muscle enzymes and treatment administered were recorded at baseline, 3, 6, 12, 18, 24 months and yearly thereafter. After assessing their cumulative response, categorization of patients into complete and partial responders was done. Complete responders were defined as patients with persistent muscle power of more than 4/5 and/or MMT 8 more than 76/80, complete resolution of skin, articular and lung involvement (if any) as well as muscle enzymes less than twice the upper limit of normal without any documented flares during the entire follow up period. Patients not satisfying the said criterias were grouped as Partial responders. Disease free survival duration was also analyzed.

Results:

Out of 310 patients of IIM identified, 187 (60.3%) patients satisfied the inclusion criteria. Women were 2.2 times more than men and mean age at symptom onset was 35.7±12.6 years. Dermatomyositis was the predominant myositis subtype seen. All patients were put on steroids with the mean dose being 45.9 ± 18.6 mg/day. At baseline, the key immunosuppressants used were methotrexate in 44.9% and mycophenolate in 37.6% patients. The median follow up duration was 48 (25-80) months. An associated malignancy was diagnosed in 3.2% after a median duration of 24.5 months. Five patients expired after a median duration of 80 months from diagnosis. Normal muscle power was attained in 76.1% patients and 88.6% were vocational by the last follow up visit. Steroids were discontinued in 56.7% patients after a median duration of 24 months (p=0.0002). Discontinuation of the immunosuppressant was feasible in 10.2% patients after a median duration of 44 months. Assessment of the cumulative responses revealed a relapsing and remitting course in 45.9%. Outcome predictors in univariate analysis were Jo-1 status, presence of arthritis, interstitial lung disease and pericardial effusion at baseline. On multivariate analysis, absence of pericardial effusion (p=0.011) and interstitial lung disease (p=0.067) at baseline were found to be predictors of complete response. Disease free survival probability estimated at 5 years and 10 years was 91.6% and 72.4% respectively. Estimating the probability gender wise, males achieved disease free status earlier than females.

Conclusion:

A favorable clinical and functional outcome was seen in a significant proportion of these patients with IIM on long term follow up. Pericardial effusion and ILD were identified as predictors of poor clinical outcome.

References:

[1]Taborda AL, Azevedo P, Isenberg DA. Retrospective analysis of the outcome of patients with idiopathic inflammatory myopathy: a long-term follow-up study. Clin Exp Rheumatol. 2014 Apr; 32(2):188–93.

Acknowledgments:

Nil

Disclosure of Interests:

None declared

THU0523 CLINICAL UTILITY OF TESTING CONVENTIONAL AND NON-CONVENTIONAL ANTI-PHOSPHOLIPID ANTIBODIES IN SUSPECTED OBSTETRIC ANTI-PHOSPHOLIPID SYNDROME

Background:

Anti-phospholipid syndrome (APS) is an important cause for recurrent pregnancy losses (RPL). Conventional APS antibodies (aPLs) like lupus anti-coagulant (LA), anti-cardiolipin(ACL) and anti-beta 2 glycoprotein I (anti-β2 GP I) are not present in significant number of obstetric APS(OAPS) patients, leading to a state described as “ sero-negative” OAPS (SNOAPS). Recent literature shows non-conventional aPLs like Anti phosphatidylserine-prothrombin complex (Anti-PSPT) and Anti-Annexin V (Anti-Ann V) can be positive in up to 50% of SNOAPS patients

Objectives:

Testing the performance of conventional and non-conventional aPLs in suspected OAPS patients (obstetric events as defined in the Sydney classification criteria for APS)

Methods:

We performed a retrospective chart review of 101 patients who underwent combined testing for non-conventional aPLs for suspected OAPS from May 2016 to November 2019 at our department. Patients were categorized into OAPS cases (n=50, median age 31 years) and controls (n=51, median age 30 years) based on their fulfillment of clinical definition of OAPS events defined by Sydney criteria. Conventional aPLs were tested by methods adapted in Sydney criteria and Anti PSPT /Anti Ann V were tested by commercial ELISA. The sample size(n=101) has 95% confidence interval with a margin of error of 10% for the objective of the study.

Results:

36 cases (72%) were ‘sero-positive’ & 14 cases (28%) were truly ‘sero-negative’ for conventional aPLs. 5 (35.7%) of the SNOAPS patients were positive for Ant-PSPT and/or Anti AnnV antibodies. Performance of the various aPLs in suspected OAPS is displayed in Table 1 & Figure 1.

Table 1

showing the performance of the various conventional and non-conventional APLs in suspected obstetric APS cases

AntibodySensitivitySpecificityLikelihood Ratio(+)Likelihood Ratio (-)Positive Predictive ValueNegative Predictive ValueAccuracyYouden’s IndexLA50%94.1 %8.50.589.3%65.7%72.3%44.1%ACL32%98%16.30.794.1%59.5 %65.3%30 %anti β2 GP I IgM38.4%91.4 %4.50.783.3%57.1 %63.5%29.8%anti β2 GP I IgG24%96.1 %6.10.885.7%56.3%60.4%20.1%Anti PSPT28%96.1 %7.10.787.5%57.6 %62.4%24.1%Anti AnnV28%98 %14.30.793.3%58.1%63.4%26%Conventional APLs72%88.2%6.10.385.7%76.3 %79.8%60.2%Non-conventional APLS38%94.1%6.40.786.4%60.7 %66.3%32.1%All APLs82%86.3%6.000.2085.4%83 %84.2%68.3%Figure 1

showing the comparative diagnostic performance of Conventional aPL testing vs Combined testing along with non-conventional aPLs in suspected obstetric APS scenario

Conclusion:

In a delicate situation like RPL, performance of non-conventional aPLs on their own, though not as sensitive as conventional aPLs, still demonstrate better specificity. Non-conventional APLs can newly identify 1/3rd of SNOAPS as APS. The real value of testing Anti PSPT & Anti Ann V in RPL, is combined testing with conventional aPLs wherein they improve the sensitivity and accuracy of diagnosis of OAPS by 10% & 4.4 % respectively, with only 1.9% drop in specificity. Non-conventional aPLs should be tested in SNOAPS.

Disclosure of Interests:

None declared

Indian Subcontinent's First Bilateral Supracondylar Level Upper Limb Transplantation

Introduction This is the first case of supracondylar level transplant from the Indian subcontinent, performed for a bilateral below elbow amputee. It has a completely different set of challenges for the transplant team, with a relatively shorter ischemia time window.

The technical considerations for the same have been discussed in detail in this article.

Materials and Methods The patient was a 19-year-old female who lost her both upper limbs at proximal forearm level due to severe crush injury following a road traffic accident. Insufficient bone length on either side necessitated a supracondylar level transplant. The preoperative workup included detailed clinical evaluation, biochemical, and psychological evaluation.

The donor was a young brain-dead, male patient from a hospital, 30 minutes away. The donor and recipient preparations in this case were unique. The recipient’s own elbow flexors and extensors were used while the elbow joint was from the donor. The specific challenges we faced during this procedure have been described in detail.

Results The transplantation has been a complete technical success, with the patient rehabilitated back to her independent life style. This article describes only the technical considerations. The functional recovery aspect is part of an another soon to be published manuscript.

Conclusion Supracondylar level arm-transplant requires a highly coordinated team effort with precise preoperative planning, along with meticulous attention to detail to achieve a successful outcome. In properly selected patients, it could be a life-changing procedure, worth all the effort.

A checklist for trauma quality improvement meetings: A process improvement study

BACKGROUND

Each year approximately five million people die from injuries. In countries where systems of trauma care have been introduced, death and disability have decreased. A major component of developed trauma systems is a trauma quality improvement (TQI) program and trauma quality improvement meeting (TQIM). Effective TQIMs improve trauma care by identifying and fixing problems. But globally, TQIMs are absent or unstructured in most hospitals providing trauma care. The aim of this study was to implement and evaluate a checklist for a structured TQIM.

METHODS

This project was conducted as a prospective before-and-after study in four major trauma centres in India. The intervention was the introduction of a structured TQIM using a checklist, introduced with a workshop. This workshop was based on the World Health Organization (WHO) TQI Programs short course and resources, plus the developed TQIM checklist. Pre- and post-intervention data collection occurred at all meetings in which cases of trauma death were discussed. The primary outcome was TQIM Checklist compliance, defined by the discussion of, and agreement upon each of the following: preventability of death, identification of opportunities to improve care and corrective actions and a plan for closing the loop.

RESULTS

There were 34 meetings in each phase, with 99 cases brought to the pre-intervention phase and 125 cases brought to the post-intervention phase. There was an increase in the proportion of cases brought to the meeting for which preventability of death was discussed (from 94% to 100%, p = 0.007) and agreed (from 7 to 19%, OR 3.7; 95% CI:1.4-9.4, p = 0.004) and for which a plan for closing the loop was discussed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001) and agreed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001).

CONCLUSION

This study developed, implemented and evaluated a TQIM Checklist for improving TQIM processes. The introduction of a TQIM Checklist, with training, into four Indian trauma centres, led to more structured TQIMs, including increased discussion and agreement on preventability of death and plans for loop closure. A TQIM Checklist should be considered for all centres managing trauma patients.

Effect of external volume expansion on the survival of fat grafts

Introduction:

External volume expansion (EVE) is one method, which has been utilised for increasing the survival of adipose tissue grafts. EVE releases positive pressure from the graft and also induces intense levels of edema that decreases diffusion of metabolites essential for graft survival initially. The ideal timing of external volume expansion in relation to the injection of the fat to facilitate survival is not yet clear.

Aims and Objectives:

This study was undertaken to evaluate and compare the efficacy of external volume expansion applied at variable time points in relation to the injection of the fat.

Materials and Methods:

Athymic mouse was the animal model and human lipo-aspirate mixed with PRP was used as graft. An indigenous dome shaped silicone device was fabricated to deliver a negative pressure of -30 mm of Hg. The EVE was applied at variable time intervals. At the end of 4 weeks visual, histological and radiological features of the injected fat were compared. The adipose tissue was stained with human vimentin to ascertain the origin of the retained fat.

Results:

All the grafts, which had EVE, had significantly better volume retention and vascularity. The groups which underwent a delayed EVE or prior expansion followed by concomitant graft injection and expansion showed the most optimal vascularity and graft retention.

Conclusions:

A delayed EVE or prior expansion followed by concomitant graft injection and expansion may be the most ideal combinations to optimize graft take. However, on account of the relatively small sample size, there was a limitation in drawing statistically significant conclusions for certain variables.

Administration of tranexamic acid for victims of severe trauma within pre-hospital care ambulance services (PHCAS) in Malaysia

INTRODUCTION

Trauma is a Global threat and the 5th highest cause of all-cause mortality in Malaysia caused predominantly due to road traffic accidents. Majority of trauma victims are young adults aged between 21-40 years old. In Malaysia, 24 out of 100,000 population die annually due to trauma, rating us amongst the highest in South East Asia. These alarming figures justify aggressive preventive and mitigation strategies. The aim of this paper is to promote the implementation of evidence-based interventions that will reduce the rate of preventable death because of trauma. Tranexamic acid is one of the few interventions in the early management of severe trauma with level-one evidence. Tranexamic acid has been proven to reduce all causes of mortality and mortality due to bleeding. Evidence proves that it is most effective when administered early, particularly within the 1st hour of trauma. This proposed guideline is formulated based upon quality evidence from multicentre studies, clinical practices in other countries and consideration of the local demographic factors with the intent of enabling an easy and simple pathway to administer tranexamic acid early in the care of the severely injured.

CONCLUSION

The guideline highlights select pre-hospital criteria's and the methods for drug administration. The authors recognise that some variants may be present amongst certain institutions necessitating minor adaptations, nevertheless the core principles of advocating tranexamic acid early in the course of pre-hospital trauma should be adhered to.

Outcomes following pharyngeal reconstruction in total laryngectomy - Institutional experience and review of literature

Background:

Pharyngeal reconstruction is a challenging aspect of reconstruction after resections for head-and-neck cancer. The goals of reconstruction are to restore the continuity of the pharyngeal passage to enable oral alimentation and rehabilitation of speech wherever possible. This study was performed to determine the outcomes following pharyngeal reconstruction in total laryngectomy (TL) using different reconstructive options and to determine the predictors of pharyngocutaneous fistula (PCF) and swallowing dysfunction.

Materials and Methods:

Retrospective analysis of patient data between 2003 and 2010 of patients undergoing TL with partial or total pharyngectomy. Demographic and treatment details were collected and analysed. Univariate analysis was performed to determine predictors of PCF and swallowing dysfunction.

Results:

Fifty-seven patients underwent pharyngeal reconstruction following TL, 31 of whom had received prior treatment. Following tumour resection, 31 patients had circumferential defects and 26 patients had partial pharyngeal defects. The flaps used include pectoralis major myocutaneous flap (n = 29), anterolateral thigh flap (n = 8), gastric pull-up (n = 13) and free jejunal flap (n = 7). PCF was seen in 20 patients, of which 15 (75%) were managed conservatively and 5 required another surgery. At last follow-up, 99 patients (68%) were on full oral alimentation. Tracheo-oesophageal puncture and prosthesis insertion was done in 20 patients, of whom 17 (85%) developed satisfactory speech. Partial pharyngeal defects were associated with a higher risk of PCF on univariate analysis (P = 0.006) but were not significant on multivariate analysis. Post-operative swallowing dysfunction was significantly higher with hypopharyngeal involvement by tumour (P = 0.003).

Conclusion:

Pharyngeal reconstruction in TL is feasible with good results. Majority of the patients swallow and regain acceptable swallowing function within 3 months.

First two bilateral hand transplantations in India (Part 2): Technical details

Introduction:

This article deals with two patients who underwent bilateral hand transplantation following amputation of both upper limbs at the distal third of the foream.

Materials and Methods:

The first patient had a history of loss of hands in a train accident , with possiblity of a run over element during the injury. The second patient lost his both hands in a mine blast. The preoperative work up included detailed clinical and psychological evaluation. The donor retrieval was similar in both the cases and the donors were housed in our own instittution. The donor preparation, recipient preparation and the transplant procedure was similar except for the need of primary tendon transfers in the left hand of the first patient.

Results:

The first patient needed a free flap transfer to cover compromised skin flap on the left hand on the second day. The second hand transplant was uneventful. Both the recipients are now back to their normal daily routines.

Conclusions:

Hand transplantation is a potentially life altering procedure, but to optimise the results, it is imperative that there is a meticulous planning and diligent execution with utmost importance to the detail coupled with a synchronised team effort.

First two bilateral hand transplantations in India (Part 4): Immediate post-operative care, immunosuppression protocol and monitoring

Introduction:

Being able to counter immune-mediated rejection has for decades been the single largest obstacle for the progress of vascular composite allotransplantation (VCA). The human immune system performs the key role of differentiating the 'self ' from the 'non-self '. This, although is quintessential to eliminate or resist infections, also resists the acceptance of an allograft which it promptly recognises as 'non-self'.

Materials and Methods:

Pre-operative evaluation of the recipient evaluation included immunological assessment in the form of panel reactive antibodies (PRA), human leucocyte antigen (HLA) typing, donor-specific antibody detection assays (DSA) and complement-dependent cytotoxicity assays (CDC). Induction immunosuppression was by thymoglobulin and the maintenance by the standard triple-drug therapy.

Results:

Both the recipients were managed by the standard triple drug therapy and have had only minor episodes of rejections thus far which have been managed appropriately.

Discussion:

Induction immunosuppression was by thymoglobulin and the maintenance by the standard triple-drug therapy. Various groups have tried various other formulations and regimes as well.

Conclusion:

A comprehensive plan has to be drawn up for immunological screening, selection and the post-operative immunosuppressant usage. The ultimate goal of these immunosuppression modalities is to achieve a state of donor-specific tolerance.

First two bilateral hand transplantations in India (Part 1): From vision to reality

Introduction

Vascularized composite tissue allotransplantation is a relatively new concept, which was unavailable in the Indian subcontinent till a bilateral hand transplant was carried out successfully in January 2015.

Materials and Methods

The setting up of the transplant programme involved obtaining legal clearances, creating public awareness, harnessing the institutional facilities, drawing up protocols, assembling the surgical team, managing immunological issues, rehabilitation and preparing the ancillary services.

Results

Both, the first and second bilateral hand transplants were resounding successes with both the recipients getting back to their original daily routines.

Conclusions

The organisation of the hand transplant programme was a large task, which necessitated intensive planning, and cooperation from various teams within and outside the institution. Exemplary team-work was the key to the phenomenal success of these path breaking endeavors in the subcontinent.

Video-tube thoracostomy in trauma resuscitation: A pilot study

BACKGROUND

Complications related to incorrect positioning of tube thoracostomy (TT) have been reported to be as high as 30%. The aim of this study was to assess the feasibility of flexible videoscope guided placement of a pre-loaded chest tube, permitting direct intrapleural visualization and placement (Video-Tube Thoracostomy [V-TT]).

METHODS

A prospective, single centre, phase 1 pilot study with a parallel control group was undertaken. The population studied were adult thoracic trauma patients requiring emergency TT who were haemodynamically stable. The intervention performed was VTT. Patients in the control group underwent conventional TT. The primary outcome was tube position as defined by a consultant radiologist's interpretation of chest x-ray (CXR) or CT. The trial was registered with ANZCTR.org.au (ACTRN: 12,615,000,870,550).

RESULTS

There were 37 patients enrolled in the study - 12 patients allocated to the VTT intervention group and 25 patients allocated to conventional TT. Mean age of participants was 48 years (SD 15) in intervention group and 46 years (SD 15) years in the control group. In the VTT group all patients were male; the indications were pneumothorax (83%), haemothorax (8%) and haemopneumothorax (8%). The median injury severity score was 23 (16-28). There were 1 positional and 1 insertional complications. In the control group 72% of patients were male, the indications were pneumothorax (56%), haemothorax (4%) and haemopneumothorax (40%). The median injury severity score was 24 (14-36). There were 8 (32%) positional complications and no insertional complications.

CONCLUSION

V-TT was demonstrated to be a feasible alternative to conventional thoracostomy and merits further investigation.

Gastro-omental free flap for reconstruction of tongue defects

OBJECTIVES

The purpose of this paper is to report the technique and outcomes of the use of gastro-omental free flap reconstruction in glossectomy defects.

MATERIALS AND METHODS

This is a prospective case series of 9 patients of tongue squamous cell carcinoma, who underwent either subtotal or partial glossectomy and reconstruction with gastro-omental free flap. The flap anatomy, surgical technique and the outcomes including the swallowing and speech are presented.

RESULTS

Five patients underwent partial glossectomy and 4 had sub-total glossectomy. The median age was 43 years; and the median follow up was 11.4 months. Laparoscopic harvest was done in 8 patients. There was one flap loss. Seven patients underwent postoperative radiotherapy. Functional evaluation was done in 5 patients who were disease free. Four could tolerate soft diet orally, one patient was on liquid to pureed diet. Speech was intelligible in 4. None of the patients had any complications related to laparotomy or laparoscopy.

CONCLUSION

Gastro-omental flap provided a secretory mucosal surface and was beneficial in the saliva depleted patients post radiotherapy. The laparoscopic harvest of this flap has minimized donor site morbidity. One patient had a flap loss. Two patients reported superficial ulcerations on the surface, one of them had to undergo surgical debulking to correct it while the other healed with conservative measures. Speech and swallowing outcomes of the reconstructed tongue was good, especially in patients with partial glossectomy. The reconstructed gastric mucosal flaps tolerated the adjuvant radiation well.

First two bilateral hand transplantations in India (Part 3): Rehabilitation and immediate outcome

Introduction

This report covers the strategies adopted for rehabilitation for the first and second dual hand transplants performed in India.

Materials and Methods

The team, under a trained physiatrist, including physiotherapy and occupational therapy personnel, was involved in the management of both these patients. The management protocol was developed considering previous reports as well as our management strategies in the rehabilitation of the replanted hands. The involvement of the team with the patients started in the 1st week itself and continued on a daily basis for the entire year.

Results

Outcome analysis was performed at 6 months and 1 year using the disability of shoulder and hand evaluation and hand transplant scoring system. Functional magnetic resonance imaging was done at the end of 1 year to assess the cortical integration of the transplanted hand.

Conclusion

Despite more than 110 hands being transplanted worldwide, hand transplant remains an experimental procedure. It is still not considered the "standard of care" for hand amputees. Outcome analyses performed worldwide do indicate that the procedure can provide a substantial improvement in the quality of life for the hand amputee, especially the bilateral amputees.