The Case for Offering Paid Leave: Benefits to the Employer, Employee, and Society.

The COVID-19 pandemic has highlighted numerous problems in the labor market in the U.S., including high and low unemployment rates, burnout of employees in many industries, and inadequate time off for caregiving and medical issues. In this manuscript, we propose that employer-sponsored paid leave is increasingly important given that the U.S. lags behind most other nations in its leave policies, and many employees, particularly those in lower-wage, part-time, or front-line occupations do not have paid leave from their employers. We first discuss the common types of paid leave. Then, we make the case that paid leave is advantageous for both employees and employers, as well as society. We conclude with specific recommendations on how to implement paid leave in organizations.

Safe mobilisation of transverse upper gracilis flap in patients with hip replacements.

BACKGROUND: The transverse upper gracilis (TUG) flap is easily harvested to recruit a fair volume of tissue from the inner upper thigh region, making it the second choice of certain authors. Hip replacement is deemed prohibitive due to positional requirements that predispose to anterior dislocation of prosthetic femoral heads. In this report, we describe a simple and safe way to raise TUG flap in patients with existing hip prostheses, detailing patient assessments, and technical variations in a limited case series. MATERIAL AND METHODS: A retrospective single cohort study was conducted on patient who underwent TUG flap-based reconstruction after hip replacement. Hip joint instability was assessed clinically and with CT. Flap harvesting was performed to prevent the extra-rotation of the femoral head by the thigh flex or dissecting the pedicle keeping the thigh straight. RESULT: Eleven patients were qualified for the study, and the flap raising time was superimposable to the conventional technique. Six flaps were elevated, while the thigh was kept in the flexed position without any extra-rotation, and the pedicle dissection was completed in 5 cases by keeping the thigh in the straight position. No intra- or postoperative hip dislocations resulted. All patients ambulated on mornings after surgery, returning to daily activities within 4 weeks. CONCLUSION: TUG flap is a viable alternative that is not necessarily prohibited by existing prosthetic hips. Careful patient assessment and positioning during surgery are key considerations for safe and successful procedures.

Transverse Upper Gracilis Flap Breast Reconstruction: A 5-Year Consecutive Case Series of Patient-Reported Outcomes.

BACKGROUND: The transverse upper gracilis flap is an important reconstructive option for patients who desire autologous reconstruction after mastectomy but in whom a deep inferior epigastric perforator flap is unavailable or undesirable. The authors present an analysis of outcomes and patient satisfaction results, from a consecutive series in a single institution. METHODS: Using a prospectively populated free flap database, all patients undergoing transverse upper gracilis flap breast reconstruction for a mastectomy defect between January of 2013 and December of 2017 were identified. Retrospective review of clinical notes, admissions, and discharge information was conducted to identify outcomes, secondary operations, and complications. All patients were contacted by letter and invited to take part in a patient satisfaction survey a minimum of 12 months after free-flap surgery. RESULTS: Seventy-eight patients underwent transverse upper gracilis flap breast reconstruction using a total of 103 transverse upper gracilis flaps to reconstruct 99 breast mounds in the 5-year period studied. Patient satisfaction is evidenced by BREAST-Q scores showing 81 ± 19 percent Satisfaction with Breasts, 80 ± 20 percent Psychosocial Well-Being, and 84 ± 19 percent Physical Well-Being of the chest. Forty-six of 53 (87 percent) report satisfaction with the postoperative appearance of their thigh unclothed and 51 of 53 (96 percent) report satisfaction clothed. CONCLUSIONS: This is the first consecutive series of transverse upper gracilis flap breast reconstruction outcomes that presents BREAST-Q scores for multiple, postoperative reconstruction modules and details complications stratified by Clavien-Dindo score. The methodology can be easily replicated and benchmarked against. Our donor-site complication rates are lower than previous publications and patient satisfaction data reveal that this is a well-accepted option for patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Minimally invasive pelvic exenteration for gynaecological malignancy: A single-centre case series and review of the literature.

For those with certain recurrent gynaecological cancers where primary management such as chemo-radiotherapy has failed, or in cases of recurrence following primary surgery, pelvic exenteration (PE) is considered the only curative option. Whilst initially considered a morbid procedure, improved surgical techniques, advancing technology, and nuanced reconstructive options have facilitated more radical resections and improved morbidity and mortality. Open PE remains the gold standard approach, however, minimally invasive techniques for PE may lessen morbidity whilst achieving the same oncological outcomes. The objective of this study was to assess the feasibility and safety of minimally invasive PE with a laparoscopic or robot-assisted approach. We also performed a review of the literature on robot-assisted PE which has not been widely reported for cases of recurrent gynaecological malignancy. Between 2015 and 2021six minimally invasive PE were performed. All patients underwent extensive multi-disciplinary assessment and counselling pre-operatively. Patient characteristics, treatment indication, perioperative data, short-term complications, and histological outcomes were recorded. There were two anterior exenterations, three posterior exenterations and one total exenteration performed. The primary cancer stage varied from stage 1a-3b. Five out of six patients had pre-operative chemo-radiotherapy. The average operative time (including surgical docking) was 600 min. Mean blood loss was 400 mL and the average length of stay was eight days. Enhanced recovery practices were used where possible. There were no intraoperative complications and one major post-operative complicationwhich was breakdown of an inferior gluteal artery perforator flap perineal reconstruction. All patients had negative margins at post-operative histopathology. All patients are alive and recurrence free at follow-up, but long-term outcome data is needed. This initial case series suggest that minimally invasive pelvic exenterationcan feasibly be performed in place of open pelvic exenteration. Furthermore, our findings suggest this may be a safe alternative as we report similar findings to the existing literature, however no firm conclusions can be drawn at such an early stage. Long term follow-up data and a larger cohort study will be needed to establish non-inferiority to open PE.

Preoperative volume estimation in transverse upper gracilis flap surgery: A pilot study.

BACKGROUND: The transverse upper gracilis (TUG) flap provides a good alternative to the gold standard DIEP in breast reconstruction. However, flap volume estimates are subjective, making preoperative planning potentially challenging. STUDY AIM: To derive a reliable, accurate, and reproducible mathematical algorithm for the preoperative calculation of TUG flap volumes. MATERIALS AND METHODS: Nineteen consecutive patients with 30 TUG flaps were prospectively included. On the assumption that the TUG flap resembles two isosceles prisms, the formula of the volume of a prism was used to calculate their preoperative flap weights. These were then intraoperatively compared to the actual flap weights. A regression equation was calculated from the correlation analysis of 10 random flaps. This was then applied to the remaining 20 flaps to assess for improved reliability and weight prediction accuracy. RESULTS: The prism volume equation used to clinically calculate flap volumes was: Geometric flap weight = (h1bT)/2+ (h2bT)/2, (h = height, b = base, T = flap thickness); all in centimetres. Geometric and actual flap weights were found to be significantly correlated (r2 = 0.977) generating the following regression formula: predicted TUG weight = 0.924 × geometric weight + 26.601. When this was applied to the remaining 20 flaps, no significant difference was found (p = 0.625) between predicted and actual flap weights, demonstrating an increased accuracy of predicting flap volume. CONCLUSION: The proposed formula provides the clinician with a more accurate and reliable estimation of available TUG flap volume and may potentially aid with preoperative planning and patient consultations.

Monitoring Breast Reconstruction Flaps Using Near-Infrared Spectroscopy Tissue Oximetry.

Free flap reconstruction is a common procedure with success rates greater than 99%. However, vascular complications may occur, resulting in flap failure. For this reason, early detection of vascular compromise is crucial for flap salvage. Vascular complications may be detected early by monitoring tissue oximetry parameter changes using near-infrared spectroscopy (NIRS). This method of noninvasive monitoring can evaluate changes in flap oxygenation levels caused by arterial and venous thrombosis before surgical reexploration. The goal of this study was to assess the validity of using NIRS oximetry for monitoring free flaps. We conducted a prospective cohort observational study of 10 patients undergoing breast reconstruction. We used the INVOS 7100 cerebral oximetry monitoring system (Medtronic, Dublin, Ireland) to provide 24-hr continuous postoperative monitoring of flap perfusion and compared the data with clinical assessment findings. The median patient age was 57 years (range = 41-61 years). Patients underwent immediate breast reconstruction with deep inferior epigastric perforator (DIEP) flap surgery (n = 4), delayed reconstruction with DIEP flap surgery (n = 4), transverse upper gracilis flap surgery (n = 1), and latissimus dorsi flap with lipofilling (n = 1). We successfully monitored all 10 flaps for 24 hr postoperatively. The overall flap survival rate was 100%. Findings of clinical examination, Doppler studies, and surgical outcome were consistent with NIRS monitoring. In conclusion, NIRS tissue oximetry could potentially provide a noninvasive method for effective postoperative monitoring of free flaps.

Microsurgical Training Opportunities at the Queen Victoria Hospital: A Retrospective Review of 848 Free Flaps for Breast Reconstruction.

Becoming a competent microsurgeon requires training in a variety of skills and competences. However, instructing the next generation of microsurgeons seems to be a challenging task, considering the current trend to reduce training hours along with increased patient expectations. To evaluate the microsurgical training opportunities at the Queen Victoria Hospital, we conducted a retrospective review of the last 3 and a half years, to identify the opportunities given to trainees during breast reconstruction cases. We also surveyed the microsurgical fellows who worked in our unit during the same period. A total of 848 free flaps were performed between November 2015 and May 2019 for 699 patients undergoing breast reconstruction, with a flap failure rate of 0.47%. For unilateral cases, more than half of the flaps were raised by trainees: 39% by fellows and 12% by specialist registrars. For bilateral breast and bipedicled reconstructions, these figures were 44% and 2%, respectively. A total of 1835 microvascular anastomoses were performed, of which 33% were done by fellows and 17% by specialist registrars, with the remaining 50% being done by consultants. Six of 8 fellows who worked in our unit during the studied period replied to our survey. All of them were pleased with their training experience, and the majority of them progressed to a consultant post after their fellowship. We consider that a standardized surgical approach, along with a high-volume caseload, allows delivering an outstanding training experience while maintaining low complications rates.

Prevention of perioperative limb neuropathies in abdominal free flap breast reconstruction.

BACKGROUND AND AIMS: Perioperative peripheral neuropathies are a significant cause of post-operative morbidity in patients undergoing prolonged procedures. The aims of this study were to determine the incidence and possible causes of peripheral neuropathy in patients undergoing abdominal free flap breast reconstruction and to develop methods of ameliorating this problem. METHODS: A 4-year retrospective study of patients undergoing abdominal free flap breast reconstruction by a single surgeon and anaesthetist was undertaken to determine the incidence and potential causes of perioperative neuropathy. A new positioning protocol was introduced to minimise the stretch on the brachial plexus and to protect peripheral nerves from compression forces. In addition, regular intraoperative physiotherapy was introduced. A prospective study was then conducted on patients managed by the same team to evaluate the effect of this change in practice on the subsequent incidence of peripheral neuropathies. RESULTS: Over the 4-year retrospective period, 93 consecutive patients underwent abdominal free flap breast reconstruction, six of whom (6.5%) developed a peripheral neuropathy. Following the introduction of the new positioning protocol, prospective data collected on 65 consecutive patients showed no further occurrences of perioperative neuropathy (p = 0.04). There were no significant differences in the characteristics between the two cohorts. CONCLUSION: Perioperative peripheral neuropathy in abdominal free flap breast reconstruction is a preventable problem. This paper presents a peripheral neuropathy prevention protocol for managing these patients.

Sepsis in burns: a review of current practice and future therapies.

Sepsis is a major cause of death worldwide and remains the subject of much research and debate within the critical care community. Despite advances in burn prevention, treatment, and rehabilitation, sepsis remains a common cause of death in patients who have sustained a severe burn injury. The unique physical, metabolic, and physiologic changes seen after major thermal injury mean that the management of sepsis in burns poses a particular challenge and differs in many respects to the management of sepsis in the general critical care population. This article describes current issues in the prevention, diagnosis, and treatment of sepsis in burns with a review of the associated literature. In addition, we discuss possible future therapies for managing this condition.