E-cigarette explosions: patient profiles, injury patterns, clinical management, and outcome.

Background: E-cigarette abuse, also known as vaping, is a widespread habit. Recently, there have been increasing reports of explosions of these devices resulting in serious burn injuries, especially to the groin, hand, and face. Overheating rechargeable lithium-ion batteries are supposed to be the responsible mechanism, especially in low quality fabrications. Methods: In this single-center retrospective study, data of 46 patients are presented and analyzed. In addition to information on demographics, injury patterns, and treatment options, this is the first study investigating outcome after an average of 13 months via a standardized telephone interview of 31 patients (67%). Patients were specifically asked regarding their outcome, vaping habits, technical modifications to their devices and supply source. Results: Patients were mainly male (98.2%) with a median age of 36 years. Typical injury patterns included the groin region (n = 32; 69%), hands (n = 12; 25%) and face (n = 3; 7%). All patients underwent debridement, in nine cases hydrotherapeutically. 61% (n = 28) underwent consecutive tangential necrectomy and subsequent split thickness skin graft transplantation. Wound infection was observed in 18 patients (39%), with burn depth as a significant risk factor (p < 0.001). 91% of the followed-up patients were satisfied. Surprisingly, 38% were still using e-cigarettes. 42% (n = 13) reported manual modifications of their devices to prolong battery life or increasing smoke production. Conclusions: Injuries from exploding e-cigarettes can be serious and should be treated in a specialized burn center. E-cigarette explosions lead to characteristic injury patterns and often need surgical treatment. This should be made more public to reduce their use and keep people from modifying the devices. The counterintuitive and irrational observation of a high rate of abuse even after the injury underlines their addiction potential.

Proposal of a Multivariable Prediction Model for Graded Morbidity after Liver Resection for Colorectal Metastases.

BACKGROUND: Prognostic models to predict individual early postoperative morbidity after liver resection for colorectal liver metastases (CLM) are not available but could enable optimized preoperative patient selection and postoperative surveillance for patients at greater risk of complications. The aim of this study was to establish a prognostic model for the prediction of morbidity after liver resection graded according to Dindo. METHODS: N = 679 cases of primary liver resection for CLM were retrospectively analyzed using univariable and multivariable ordinal regression analyses. Receiver operating characteristics curve (ROC) analysis was utilised to assess the sensitivity and specificity of predictions and their potential usefulness as prognostic models. Internal validation of the score was performed using data derived from 129 patients. RESULTS: The final multivariable regression model revealed lower preoperative levels, a greater number of units of intraoperatively transfused packed red blood cells (pRBCs), longer duration of surgery, and larger metastases to independently influence postoperatively graded morbidity. ROC curve analysis demonstrated that the multivariable regression model is able to predict each individual grade of postoperative morbidity with high sensitivity and specificity. The areas under the receiver operating curves (AUROC) for all of these predictions of individual grades of morbidity were > 0.700, indicating potential usefulness as a predictive model. Moreover, a consistent concordance in Grades I, II, IV, and V according to the classification proposed by Dindo et al. was observed in the internal validation. CONCLUSION: This study proposes a prognostic model for the prediction of each grade of postoperative morbidity after liver resection for CLM with high sensitivity and specificity using pre- and intraoperatively available variables.

Superficial Temporal Recipient Vessels for Craniofacial Microvascular Free-Flaps.

The selection of recipient vessels for microvascular free-flaps is critical in craniofacial reconstruction. Especially the suitability of the superficial temporal vessels is questioned conflictingly in the literature. The aim of this study was to share our experience with microvascular craniofacial free-flap reconstruction and to evaluate a set of factors that are related to the recipient vessels and to determine how these factors influence flap survival. We conducted a retrospective analysis of 39 free-flaps for craniofacial reconstruction that were performed from 2006 until 2020 and evaluated the indication for microvascular reconstruction, recipient vessels, various factors related to the recipient vessels and complications. The most utilized recipient artery was the facial artery, selected in 20 patients followed by the superficial temporal artery selected in 12 patients. The most commonly used recipient vein was the facial vein used in 16 patients, followed by the superficial temporal vein selected in 10 patients and the external jugular vein in 6 patients. Total flap necrosis occurred in one patient. There was no statistically significant association between the selected recipient vessels and patient comorbidities, major and minor complications, revision of anastomosis or flap loss. The results of our study have demonstrated that the superficial temporal artery and vein show similar results when used for face and scalp reconstruction. Considering their technical and aesthetic advantages they may be the first choice recipient vessels in established free-flap treatment algorithms for craniofacial reconstruction.

Radiotherapy of Breast Cancer in Laterally Tilted Prone vs. Supine Position: What about the Internal Mammary Chain?

BACKGROUND: In the multimodal breast-conserving curative therapy of some high-risk breast cancer patients, extended external beam radiotherapy (EBRT) not only to the breast but also to the supraclavicular fossa and the internal mammary chain (parasternal region (PSR)) is indicated. We report a dosimetric study on the EBRT of the breast ("B") and the breast including PSR ("B + PSR"), comparing the supine and the laterally tilted prone patient positions in free breathing. METHODS: The planning CT scans of 20 left- and 20 right-sided patients were analyzed. EBRT plans were calculated with 3D conformal EBRT (3D) and with intensity-modulated EBRT (IMRT) for "B" and "B + PSR" in the prone and supine positions. The mean and threshold doses were computed. The quality of EBRT plans was compared with an overall plan assessment factor (OPAF), comprising three subfactors, homogeneity, conformity, and radiogenic exposure of OAR. RESULTS: In the EBRT of "B", prone positioning significantly reduced the exposure of the OARs "heart" and "ipsilateral lung" and "lymphatic regions". The OPAF was significantly better in the prone position, regardless of the planning technique or the treated breast side. In the EBRT of "B + PSR", supine positioning significantly reduced the OAR "heart" exposure but increased the dose to the OARs "ipsilateral lung" and "lymphatic regions". There were no significant differences for the OPAF, independent of the irradiated breast side. Only the IMRT planning technique increased the chance of a comparatively good EBRT plan. CONCLUSION: Free breathing prone positioning significantly improves plan quality in the EBRT of the breast but not in the EBRT of the breast + PSR.

Consequences and predisposing factors of self-discharge against medical advice in plastic and hand surgery.

PURPOSE: Therapeutic success of surgical interventions is significantly affected by patients' adherence. Patient autonomy can lead to unreasonable behavior. We analyzed the consequences and predisposing factors of patient self-discharge in a plastic and hand surgery cohort. STUDY DESIGN AND SETTING: Data was collected retrospectively in a case-control study with n = 73 patients who had self-discharged in a 10-year time period and n = 130 controls (discharge by the surgeon). Data was collected through the hospital information systems and a particular questionnaire. Statistical analyses were performed via chi-squared test and logistic regression analyses. RESULTS: Patients who self-discharged against medical advice had a significantly higher complication rate (p = 0.045) and a higher number of revision operations (p < 0.001). They were more often dissatisfied with the primary inpatient treatment (p < 0.05). Secondly, they lived more often in shared households (p = 0.002; OR 5.387 (1.734-16.732)) or had to take care of their children at home (p = 0.006; OR 1.481 (1.280-1.741)). There was a significantly lower pain score (NAS) on time of self-discharge (p = 0.002) as well as 24 h after self-discharge (p < 0.001) in self-discharged patients. CONCLUSION: Self-discharge was associated with predisposing factors and poorer outcomes. Patient autonomy can lead to health-compromising behavior and patients should be counseled accordingly.

Prospective Evaluation of Low-Dose External Beam Radiotherapy (LD-EBRT) for Painful Trapeziometacarpal Osteoarthritis (Rhizarthrosis) on Pain, Function, and Quality of Life to Calculate the Required Number of Patients for a Prospective Randomized Study.

Background: Retrospective studies have described the effectiveness of low-dose radiotherapy (LD-EBRT) in painful arthrosis of small finger joints, but two recent prospective studies have yielded ambiguous results. To generate accurate data for the planning of a trial, we conducted a prospective, monocentric, observational study to describe the effects of LD-EBRT as precisely as possible. Methods: Twenty-five consecutive patients with symptomatic trapeziometacarpal (TMC) arthrosis were irradiated with 6 × 0.5 Gy. Before, 3, and 12 months after LD-EBRT, we assessed subjective endpoints (modified "von-Pannewitz score", 10-point visual analogue scale (VAS), "patient-rated wrist evaluation" (PRWE)), and objective measurements ("active range of motion" (AROM), Kapandji index, grip strength, pinch grip). Results: At 3/12 months, 80%/57% reported partial and 4%/18% complete remission according to the "von-Pannewitz" score. VAS "overall pain" significantly decreased from a median of seven (IQR 4) at baseline to three (IQR 6; p = 0.046) and to two (IQR 2; p = 0.013). Similar results were obtained for VAS "pain during exercise", VAS "pain during daytime", and VAS "function". "PRWE overall score" was reduced from 0.5 at baseline (SD 0.19) to 0.36 (SD 0.24, p = 0.05) and to 0.27 (SD 0.18, p = 0.0009). We found no improvements of the objective endpoints (AROM, Kapandji, grip strength) except for flexion, which increased from 64° (SD 12°) at baseline to 73° (SD 9.7°, p = 0.046) at 12 months. Conclusions: We recommend the PRWE score as a useful endpoint for further studies for this indication. To prove a 15% superiority over sham irradiation, we calculated that 750 patients need to be prospectively randomized.

Chemotherapy and Hepatic Steatosis: Impact on Postoperative Morbidity and Survival after Liver Resection for Colorectal Liver Metastases.

BACKGROUND: Hepatic steatosis and chemotherapy in the treatment of colorectal liver metastases (CLM) are often linked to increased mortality and morbidity after liver resection. This study evaluates the influence of macrovesicular hepatic steatosis and chemotherapeutic regimes on graded morbidity and mortality after liver resection for CLM. METHODS: A total of 323 cases of liver resection for CLM were retrospectively analysed using univariable and multivariable linear, ordinal and Cox regression analyses. The resected liver tissue was re-evaluated by a single observer to determine the grade and type of hepatic steatosis. RESULTS: Macrovesicular steatosis did not influence postoperative morbidity and survival, as evidenced by risk-adjusted multivariable Cox regression analysis (p = 0.521). Conversion chemotherapy containing oxaliplatin was an independent and significant risk factor for mortality in risk-adjusted multivariable Cox regression analysis (p = 0.005). Identified independently, significant risk factors for postoperative morbidity were neoadjuvant treatment of metastases of the primary tumour with irinotecan (p = 0.003), the duration of surgery in minutes (p = 0.001) and the number of intraoperatively transfused packed red blood cells (p ≤ 0.001). Surprisingly, macrovesicular hepatic steatosis was not a risk factor for postoperative morbidity and was even associated with lower rates of complications (p = 0.006). CONCLUSION: The results emphasize the multifactorial influence of preoperative liver damage and chemotherapy on the severity of postoperative morbidity, as well as the significant impact of conversion chemotherapy containing oxaliplatin on survival.

The surgical approach to Pyoderma gangrenosum: A retrospective monocenter study.

Pyoderma gangrenosum is a diagnosis of exclusion. It occurs rarely and is frequently misdiagnosed. It can result in severe tissue loss, particularly in surgical units with little experience. Nevertheless, surgical treatment might be necessary for reconstruction, once the progression of these wounds is controlled. We aimed to characterize medical findings in Pyoderma patients with extensive defects to assess the surgical procedures and their outcome. A retrospective study was conducted at our centre over an 18-year period. Inclusion criteria were the diagnosis of Pyoderma gangrenosum and at least one surgical intervention. Descriptive statistics were used to analyse the data. Sixteen patients were included. The mean size of the lesions was noted with 12 × 8 cm. Surgical procedures comprised debridements/necrectomies, allograft conditioning, negative pressure wound therapy, skin grafts, and microvascular free flaps. Seven patients were discharged with healed wounds, six with minor wound healing disturbances. Three patients succumbed to their underlying diseases. Drug-based therapy can stop the progress of Pyoderma, but severe tissue loss can be a persistent problem. According to our data, reconstructive-surgical treatments (debridement, autologous and allogenous skin transplantation and microvascular free flaps) act as an integral component of the therapy and can be safe options for selected patients. Furthermore, we provide an algorithm that we follow at our department in severe cases.

Independent Risk Factors for Impaired Early Outcome after Isolated Ankle Fracture - A Multivariate Analysis and Prognostic Models. / Unabhängige Risikofaktoren für komplizierte Frühverläufe nach isolierter Sprunggelenksfraktur ­ eine multivariate Analyse und prognostische Modellierung.

BACKGROUND: Ankle fractures are common operative indications in orthopedic surgery. Their incidence is increasing. OBJECTIVES: To identify independent risk factors and to develop prognostic models for the prediction of prolonged length of hospital stay (LOS) and the onset of postoperative complications. MATERIALS AND METHODS: This is a single-center, retrospective, observational study analyzing data of 154 consecutive, isolated, surgically treated ankle fractures. Multivariate binary logistic regression analysis was applied to identify significant independent risk factors. The validity and clinical applicability of the developed prognostic models was assessed with ROC-curve analysis (ROC: Receiver Operating Characteristic). Internal validation of prognostic models was performed with randomized backwards bootstrapping. RESULTS: The median LOS was 7 days. 50 patients (33%) had a longer LOS. 13% of operated patients had a postoperative complication (n = 20). Independent preoperative risk factors for prolonged length of stay were leukocytosis (p = 0.020; OR: 1.211), an increased CRP-level (p = 0.005; OR: 1.901), as well as a bi- (p = 0.002; OR: 15.197) or trimalleolar (p = 0.001; OR: 10.678) fracture type. Immediate operative therapy was an independent beneficial factor (p < 0.001; OR: 0.070). The onset of complications was associated significantly with diabetes mellitus (p = 0.004; OR: 9.903) and an elevated ASA score (p = 0,004; OR: 3.574). The developed prognostic models for the prediction of prolonged LOS (AUROC: 0.736) and postoperative complications (AUROC: 0.724) had a good clinical validity and were internally validated. CONCLUSION: The current data pronounce the importance of preoperative laboratory works. Furthermore, co-morbidities play a major role in the prognosis of outcome. The developed prognostic models are able to reliably predict the outcome and enable the preoperative identification of high-risk patients.

Expected Reduction of The Nipple-Areolar Complex Over Time After Treatment of Gynecomastia with Ultrasound-Assisted Liposuction Mastectomy Compared to Subcutaneous Mastectomy Alone.

BACKGROUND: The enlarged nipple-areola-complex (NAC) is a characterizing aspect of gynecomastia. OBJECTIVE: The purpose of this study was to multidimensionally quantify the reduction of the NAC after a subcutaneous mastectomy (SCM) with or without ultrasound-assisted liposuction (UAL). MATERIALS AND METHODS: A retrospective assessment of patients who underwent SCM +/- UAL due to gynecomastia over a period of 11 years was conducted. The NAC diameters were measured before and after surgery. In addition, a survey (including the BREAST-Q) regarding patient-oriented outcome was performed. RESULTS: The study cohort consisted of 55 men and resulting 105 NACs (SCM n=63, SCM+UAL n=42). It could be shown that the reduction of the NAC considering all parameters (horizontal and vertical diameter and the area) was significantly larger (p=<0.001) in the SCM+UAL compared to the SCM only cohort. The mean reduction of the area in the SCM cohort was 1.60cm2 (SD 1.48) or 23.37% (SD 9.78) after 5.82 years and in the SCM+UAL cohort 2.60cm2 (SD 1.60) or 35.85% (SD 6,86) after 7.43 years. As independent significant factors for reduction of the NAC, the resection weight and SCM+UAL combination were identified. There were no significant differences regarding the patients' satisfaction measured with the BODY-Q (p=0.222) and the ordinal scale (p=0.445) between the two cohorts. CONCLUSIONS: The SCM with UAL showed a larger reduction over time of the NAC compared to the SCM independent from the stage of gynecomastia. When planning the surgical treatment of gynecomastia, a technique and resection weight dependent reduction of the NAC over time must be considered. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Spread of Hand Infection According to the Site of Entry and Its Impact on Treatment Decisions.

Background: Hand infections can spread quickly and destroy functional structures. Early diagnosis and adequate therapy can prevent severe morbidities. The aim of this study was to evaluate systematically the spread of hand infections according to injury mechanism, pathogens, and entry site. Methods: The data and medical records of 425 patients were collected and analyzed retrospectively. Results: The entry site had a significant influence on the severity of hand infections. Especially finger lesions led to severe infections. Furthermore, a high C-reactive protein (CRP) concentration correlated with more involved compartments of the hand. Bacterial counts also correlated with the number of compartments involved. Conclusions: Compared with known factors for the severity of hand infections finger lesions lead to especially severe infections and should not be underestimated. If there is a higher CRP concentration or more than one bacterial species isolated, compartments adjacent to the site of injury should be checked intra-operatively.

Hand injuries in sports - a retrospective analysis of 364 cases.

BACKGROUND: Hand injuries are common in sports and associated with high dropout rates and costs. Hence, efforts should strive for further risk prevention measures in order to increase safety in sports. This implies knowledge of sports injury risk profiles. So far, major surveillance programs exist mainly in Anglo-American countries, reflecting the specific concerns of sports in this part of the world. Data on sports injuries within Europe are scarce. As sports behaviour appears to vary demographically, we hypothesised that risk injury profiles differ as well. METHODS: To assess whether the described sports injuries of the hand are applicable to the German population, we performed a five-year retrospective, single-centre analysis of sports-related hand injuries, using data from the Enterprise Clinical Research Data Warehouse of the Hannover Medical School. RESULTS: Notable differences in comparison to other data were observed. Ball sports, cycling and equestrian sports caused most of the recorded hand injuries, which were predominantly fractures of the wrist and hand. Hand injuries in equestrian sports were associated with significantly higher operation and hospitalisation rates as well as a significantly longer inpatient treatment. CONCLUSION: Risk profiles for sports-related hand injuries appear to differ not only in terms of age- and sex, but also geographically. Nation- and Europe-wide hand trauma registries as well as a broad registry participation are necessary in order to accurately assess the risk patterns in Europe; henceforth reducing hand injuries and their sequelae.

Multivisceral resection for adenocarcinoma of the pancreatic body and tail-a retrospective single-center analysis.

BACKGROUND: Adenocarcinoma of the pancreatic body and tail is associated with a dismal prognosis. As patients frequently present themselves with locally advanced tumors, extended surgery including multivisceral resection is often necessary in order to achieve tumor-free resection margins. The aim of this study was to identify prognostic factors for postoperative morbidity and mortality and to evaluate the influence of multivisceral resections on patient outcome. METHODS: This is a retrospective analysis of 94 patients undergoing resection of adenocarcinoma located in the pancreatic body and/or tail between April 1995 and December 2016 at our institution. Uni- and multivariable Cox regression analysis was conducted to identify independent prognostic factors for postoperative survival. RESULTS: Multivisceral resections, including partial resections of the liver, the large and small intestines, the stomach, the left kidney and adrenal gland, and major vessels, were carried out in 47 patients (50.0%). The median postoperative follow-up time was 12.90 (0.16-220.92) months. Median Kaplan-Meier survival after resection was 12.78 months with 1-, 3-, and 5-year survival rates of 53.2%, 15.8%, and 9.0%. Multivariable Cox regression identified coeliac trunk resection (p = 0.027), portal vein resection (p = 0.010), intraoperative blood transfusions (p = 0.005), and lymph node ratio in percentage (p = 0.001) as independent risk factors for survival. Although postoperative complications requiring surgical revision were observed more frequently after multivisceral resections (14.9 versus 2.1%; p = 0.029), postoperative survival was not significantly inferior when compared to patients undergoing standard distal or subtotal pancreatectomy (12.35 versus 13.87 months; p = 0.377). CONCLUSIONS: Our data indicates that multivisceral resection in cases of locally advanced pancreatic carcinoma of the body and/or tail is justified, as it is not associated with increased mortality and can even facilitate long-term survival, albeit with an increase in postoperative morbidity. Simultaneous resections of major vessels, however, should be considered carefully, as they are associated with inferior survival.

Ex vivo limb perfusion for traumatic amputation in military medicine.

BACKGROUND: Limb loss has a drastic impact on a patient's life. Severe trauma to the extremities is common in current military conflicts. Among other aspects, "life before limb" damage control surgery hinders immediate replantation within the short post-traumatic timeframe, which is limited in part by the ischemic time for successful replantation. Ex vivo limb perfusion is currently being researched in animal models and shows promising results for its application in human limb replantation and allotransplantation. PRESENTATION OF THE HYPOTHESIS: The current lack of replantation possibilities in military operations with high rates of amputation can be addressed with the development of a portable ex vivo limb perfusion device, as there are several opportunities present with the introduction of this technique on the horizon. We hypothesize that ex vivo limb perfusion will enable overcoming the critical ischemic time, provide surgical opportunities such as preparation of the stump and limb, allow for spare-part surgery, enable rigorous antibiotic treatment of the limb, reduce ischemia-reperfusion injuries, enable a tissue function assessment before replantation, and enable the development of large limb transplant programs. TESTING THE HYPOTHESIS: Data from in vivo studies in porcine models are limited by the relatively short perfusion time of 24 h. In the military setting, notably longer perfusion times need to be realized. Therefore, future animal studies must focus especially on long-term perfusion, since this represents the military setting, considering the time for stabilization of the patient until evacuation to a tertiary treatment center. IMPLICATIONS OF THE HYPOTHESIS: The development and clinical introduction of ex vivo limb perfusion in the military setting could lead to a drastic reduction in the number of limb amputations among service members. Ex vivo limb perfusion enables replantation surgery in Role 4 facilities and changes the clinical setting from a highly urgent, life-threatening situation to a highly methodical, well-prepared starting point for optimal treatment of the wounded service member. With its introduction, the principle of "life before limb" will change to "life before limb before elective replantation/allotransplantation after ex vivo limb perfusion".

Optimizing Organ Donation: Expert Opinion from Austria, Germany, Spain and the U.K.

BACKGROUND Organ donation-rates using deceased donors and organizational approaches to organ donation differ drastically between countries at a similar level of health care as measured by the Euro Health Consumer Index (EHCI). MATERIAL AND METHODS Expert opinions from intensive care nurses, physicians, transplant coordinators and transplant surgeons from Austria, Germany, Spain, and the U.K. were obtained in semi-structured interviews followed by qualitative content analysis. Results were reported back to all interview partners to identify potential controversies and consensus recommendations. RESULTS No controversies could be detected. On a variety of beneficial factors an interprofessional consensus between interview partners could be reached: A) The relevance of standardization of the screening for potential donors, the family approach and training; B) standards and best-practice procedures should be regulated and supervised by state authorities; C) full transparency and the prevention of scandals is essential; D) overburdened intensive care unit (ICU) doctors need to be supported by full-time in-house special nurses who organize donor evaluation, transport logistics and pastoral care, if required; E) public awareness campaigns are helpful; F) a broad public consensus on the concept of donation after brain and cardiac death is essential; G) incentives for the reporting of potential organ donors are inappropriate; H) an opt-out system alone is not sufficient. CONCLUSIONS Expert opinions from different professional backgrounds from different European health care systems reach a broad consensus on the most relevant issues for the improvement of organ donation.

The Risk of Complications after Carpal Tunnel Release in Patients Taking Acetylsalicylic Acid as Platelet Inhibition: A Multicenter Propensity Score-Matched Study.

BACKGROUND: Carpal tunnel release is one of the most common procedures in hand surgery. There is only scarce evidence regarding whether platelet inhibitors increase the risk of developing postoperative hemorrhage in carpal tunnel release. METHODS: This is a multicenter, propensity score-matched study including 635 carpal tunnel releases in 497 patients. Multivariate regression models were adjusted with the propensity score, which was developed to mitigate differences in patients with and without platelet inhibition with acetylsalicylic acid. Propensity score matching provides results close to the statistical quality of randomized controlled trials. The primary study endpoint was postoperative bleeding complication, defined as acute bleeding leading to reoperation or hematoma leading to physician visit. Patient satisfaction, functional outcome measured with the Boston Carpal Tunnel Questionnaire, and onset of surgical-site infection were also analyzed. RESULTS: Bleeding complications were observed in 56 procedures (8.8 percent). After propensity score matching, there was no significant difference between the patients with and without acetylsalicylic acid treatment (p = 0.997). History of thyroid disease (p = 0.035) and of rheumatoid arthritis (p = 0.026) were independent risk factors, whereas higher body mass index might have a beneficial effect (p = 0.006). Patients with postoperative bleeding had significantly impaired functional outcome as measured with the Boston Carpal Tunnel Questionnaire (p = 0.026). Median satisfaction in the investigated study population was 10 of 10 points and did not differ significantly between the antiplatelet and the non-antiplatelet cohorts (p = 0.072) CONCLUSION:: Carpal tunnel release under platelet inhibition with acetylsalicylic acid is safe and can be performed without interruption of such medication. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Prediction of survival after left-sided pancreatic resection for adenocarcinoma: Introduction of a new prognostic score.

BACKGROUND: Due to the clinically unapparent course the entity of left-sided pancreatic adenocarcinoma is often diagnosed at advanced stages, resulting in small numbers of patients qualifying for pancreatectomy. This study strives to develop a prognostic model for survival after left-sided pancreatic resection. METHODS: A total of 54 patients were analyzed. Pre- and intra-operative predictive factors for 18-month mortality were identified with multivariable binary logistic regression analysis and compiled into a prognostic model. The applicability was evaluated by assessment of the area under the receiver operating characteristic curve (AUROC). The model was internally validated applying a randomized backwards bootstrapping analysis. RESULTS: The 18-month mortality rate was 74.1% (n = 40). Mean survival was 19.1 months. A prognostic model for 18-month mortality after left sided-pancreatectomy showed an AUROC >0.800: 18-month mortality risk in% = Exp(Y) / (1 + Exp(Y)) with y= -0.927 + (1.724, if CA 19-9 elevated, otherwise 0) + (1.212 × number of intra-operative transfused packed red blood cells) + (2.771, if prior abdominal surgery, otherwise 0) - (3.612, if gastric resection, otherwise 0) This model was internally validated in 40 randomized backwards bootstrapping steps with AUROCs ranging from 0.757 to 0.971. CONCLUSIONS: The 18-month mortality risk for patients after left-sided pancreatectomy for adenocarcinoma of the pancreatic body can be assessed with the number of intra-operatively transfused packed red blood cells, elevated CA 19-9 levels, additional gastric resection and prior abdominal surgeries in the patient's history.

Prediction of Three-Year Mortality After Deceased Donor Kidney Transplantation in Adults with Pre-Transplant Donor and Recipient Variables.

BACKGROUND Prognostic models for 3-year mortality after kidney transplantation based on pre-transplant donor and recipient variables may avoid futility and thus improve donor organ allocation. MATERIAL AND METHODS There were 1546 consecutive deceased-donor kidney transplants in adults (January 1, 2000 to December 31, 2012) used to identify pre-transplant donor and recipient variables with significant independent influence on long-term survival (Cox regression modelling). Detected factors were used to develop a prognostic model for 3-year mortality in 1289 patients with follow-up of >3 years (multivariable logistic regression). The sensitivity and specificity of this model's prognostic ability was assessed with the area under the receiver operating characteristic curve (AUROC). RESULTS Highly immunized recipients [hazard ratio (HR: 2.579, 95% CI: 1.272-4.631], high urgency recipients (HR: 3.062, 95% CI: 1.294-6.082), recipients with diabetic nephropathy (HR: 3.471, 95% CI: 2.476-4.751), as well as 0, 1, or 2 HLA DR mismatches (HR: 1.349, 95% CI: 1.160-1.569) were independent and significant risk factors for patient survival. Younger recipient age ≤42.1 years (HR: 0.137, 95% CI: 0.090-0.203), recipient age 42.2-52.8 years (HR: 0.374, 95% CI: 0.278-0.498), recipient age 52.9-62.8 years (HR: 0.553, 95% CI: 0.421-0.723), short cold ischemic times ≤11.8 hours (HR: 0.602, 95% CI: 0.438-0.814) and cold ischemic times 11.9-15.3 hours (HR: 0.736, 95% CI: 0.557-0.962) reduced this risk independently and significantly. The AUROC of the derived model for 3-year post-transplant mortality with these variables was 0.748 (95% CI: 0.689-0.788). CONCLUSIONS Older, highly immunized or high urgency transplant candidates with anticipated longer cold ischemic times, who were transplanted with the indication of diabetic nephropathy should receive donor organs with no HLA DR mismatches to improve their mortality risk.

Ventilation after pancreaticoduodenectomy increases perioperative mortality: Identification of risk factors and their relevance in Germany that do not apply in England.

BACKGROUND: Pre-operative risk factors for post-operative ventilation and their influence on survival after pancreaticoduodenectomy for malignancy are unknown. METHODS: Totally 391 patients operated in Hannover, Germany were investigated with multivariable logistic regression and Cox regression modeling to identify independent risk factors for post-operative ventilation ≥6 h, patient survival and 90-day mortality. And 84 patients operated in Birmingham, United Kingdom were analyzed to assess the external relevance of findings. RESULTS: Longer operations, history of thrombosis, intra-operative blood transfusion, lower estimated glomerular filtration rates (eGFR) and higher values of the age at operation divided by the Horovitz Quotient independently increased the risk of post-operative ventilation ≥ 6 h in German patients (n = 108; 27.6%) (P<0.050). Blood transfusion and lower pre-operative eGFR levels increased the risk of early death in German patients significantly and independently of established prognostic factors. A history of thrombosis and lower eGFR levels were also independent significant risk factors for 90-day mortality in German patients but not in English patients. None of the English patients received post-operative ventilation. Significantly more German patients were >75 years, had a history of thrombosis, received blood transfusions, and had significantly worse lung function parameters. pT4 tumors were detected in 18 German patients (4.6%), but not in the English patients. CONCLUSIONS: Identified risk factors for post-operative ventilation are clinically relevant in Germany but not in England and may be used to lower mortality risk. The German and the English cohorts displayed significant differences in the approach to patient selection and early post-operative extubation.

Decision modelling for economic evaluation of liver transplantation.

As the gap between a shortage of organs and the immense demand for liver grafts persists, every available donor liver needs to be optimized for utility, urgency and equity. To overcome this challenge, decision modelling might allow us to gather evidence from previous studies as well as compare the costs and consequences of alternative options. For public health policy and clinical intervention assessment, it is a potentially powerful tool. The most commonly used types of decision analytical models include decision trees, the Markov model, microsimulation, discrete event simulation and the system dynamic model. Analytic models could support decision makers in the field of liver transplantation when facing specific problems by synthesizing evidence, comprising all relevant options, generalizing results to other contexts, extending the time horizon and exploring the uncertainty. For modeling studies of economic evaluation for transplantation, understanding the current nature of the disease is crucial, as well as the selection of appropriate modelling techniques. The quality and availability of data is another key element for the selection and development of decision analytical models. In addition, good practice guidelines should be complied, which is important for standardization and comparability between economic outputs.