Effectiveness of Single vs Multiple Doses of Prophylactic Intravenous Antibiotics in Implant-Based Breast Reconstruction: A Randomized Clinical Trial.

Importance: Multiple-dose antibiotic prophylaxis is widely used to prevent infection after implant-based breast reconstruction despite the lack of high-level evidence regarding its clinical benefit. Objective: To determine whether multiple-dose antibiotic prophylaxis is superior to single-dose antibiotic prophylaxis in preventing surgical site infection (SSI) after implant-based breast reconstruction. Design, Setting, and Participants: This prospective, multicenter, randomized clinical superiority trial was conducted at 7 hospitals (8 departments) in Sweden from April 25, 2013, to October 31, 2018. Eligible participants were women aged 18 years or older who were planned to undergo immediate or delayed implant-based breast reconstruction. Follow-up time was 12 months. Data analysis was performed from May to October 2021. Interventions: Multiple-dose intravenous antibiotic prophylaxis extending over 24 hours following surgery, compared with single-dose intravenous antibiotic. The first-choice drug was cloxacillin (2 g per dose). Clindamycin was used (600 mg per dose) for patients with penicillin allergy. Main Outcomes and Measures: The primary outcome was SSI leading to surgical removal of the implant within 6 months after surgery. Secondary outcomes were the rate of SSIs necessitating readmission and administration of intravenous antibiotics, and clinically suspected SSIs not necessitating readmission but oral antibiotics. Results: A total of 711 women were assessed for eligibility, and 698 were randomized (345 to single-dose and 353 to multiple-dose antibiotics). The median (range) age was 47 (19-78) years for those in the multiple-dose group and 46 (25-76) years for those in the single-dose group. The median (range) body mass index was 23 (18-38) for the single-dose group and 23 (17-37) for the multiple-dose group. Within 6 months of follow-up, 30 patients (4.3%) had their implant removed because of SSI. Readmission for intravenous antibiotics because of SSI occurred in 47 patients (7.0%), and 190 women (27.7%) received oral antibiotics because of clinically suspected SSI. There was no significant difference between the randomization groups for the primary outcome implant removal (odds ratio [OR], 1.26; 95% CI, 0.69-2.65; P = .53), or for the secondary outcomes readmission for intravenous antibiotics (OR, 1.18; 95% CI, 0.65-2.15; P = .58) and prescription of oral antibiotics (OR, 0.72; 95% CI, 0.51-1.02; P = .07). Adverse events associated with antibiotic treatment were more common in the multiple-dose group than in the single-dose group (16.4% [58 patients] vs 10.7% [37 patients]; OR, 1.64; 95% CI, 1.05-2.55; P = .03). Conclusions and Relevance: The findings of this randomized clinical trial suggest that multiple-dose antibiotic prophylaxis is not superior to a single-dose regimen in preventing SSI and implant removal after implant-based breast reconstruction but comes with a higher risk of adverse events associated with antibiotic treatment. Trial Registration: EudraCT 2012-004878-26.

Long-term outcomes of implant-based immediate breast reconstruction with and without radiotherapy: a population-based study.

BACKGROUND: Radiotherapy (RT) is a risk factor for impaired outcomes after implant-based immediate breast reconstruction (IBR). Large studies including long-term follow-up are relatively scarce. The purpose of this analysis was to assess long-term effects of RT in implant-based IBR, distinguishing between implant removal because of postoperative complications versus patient preference. METHODS: This population-based cohort study included all patients with breast cancer who underwent implant-based IBR in Stockholm between 2005 and 2015. Data were collected through national registers and medical charts. The main endpoint was implant removal owing to postoperative complications (wound breakdown, infection, bleeding) or patient preference (dissatisfaction, pain, capsular contracture), with or without conversion to autologous reconstruction. RESULTS: Some 1749 implant-based IBRs in 1687 women were included. Median follow-up was 72 (range 1-198) months. Reconstructions were divided according to receipt of RT: No RT (n = 856, 48.9 per cent), adjuvant RT (n = 749, 42.8 per cent), and previous RT (n = 144, 8.2 per cent). Implant removal occurred after 266 reconstructions (15.2 per cent); 68 (7.9 per cent) in the no RT, 158 (21.1 per cent) in the adjuvant RT, and 40 (27.8 per cent) in the previous RT group. Implant removal was because of postoperative complications in 152 instances (57.1 per cent) and was most common in the first 3 years. This was especially observed in the previous RT group, where 15 of 23 implant removals occurred during the first 6 months. Implant removal owing to patient preference (114 of 266, 42.9 per cent) became more common with increasing follow-up. CONCLUSION: Implant removal after implant-based IBR is significantly associated with RT. The reason for implant removal shifts over time from postoperative complications to patient preference.

Irradiation of the chest wall after breast removal and implant placement (reconstruction) increases the risk of complications. These may lead to removal of the implant. Some women then choose a new breast reconstruction without an implant. The aim of this project was to find out how much irradiation affects complications after breast reconstruction using implants. This work used information on women who had a breast reconstruction with implants in Stockholm, Sweden, from 2005 to 2015. The main focus was on removal of the implant. This could be due to complications or patient preference. Implant removal could be with or without a new breast reconstruction. Of 1749 reconstructed breasts in 1687 women, 266 implants were removed. This was most often because of a complication, especially in the first years after surgery, but nearly as often due to patient wish. Implant removal owing to patient wish occurred later. Irradiation was a major factor increasing the risk of implant removal, together with, for example, smoking and obesity.

Correction to: Effect of periodic abstinence from dairy products for approximately half of the year on bone health in adults following the Christian Orthodox Church fasting rules for decades.

The original version of this article, published on 27 June 2019, unfortunately contained a mistake.

Effect of periodic abstinence from dairy products for approximately half of the year on bone health in adults following the Christian Orthodox Church fasting rules for decades.

Christian Orthodox Church (COC) fasting is characterized by periodic abstinence from animal foods (including dairy products). We found that, despite this, older individuals adhering to COC fasting for decades did not differ in bone mineral density, bone mineral content, or prevalence of osteoporosis at five sites from non-fasting controls. PURPOSE: The present observational study investigated whether adherence to COC fasting, characterized by periodic abstinence from animal foods (including dairy products), affects bone health and the prevalence of osteoporosis in older individuals. METHODS: Participants were 200 men and women, of whom 100 had been following the fasting rules of the COC for a median of 31 years and 100 were non-fasters, all aged 50 to 78 years. Participants underwent measurements of bone mineral density (BMD) and bone mineral content (BMC) at the lumbar spine, right hip, left hip, right femoral neck, and left femoral neck; completed a 3-day food intake record and food frequency questionnaire; and provided blood samples for biochemical measurements. RESULTS: Fasters did not differ from non-fasters in demographic characteristics, anthropometric measures, BMD, BMC, or prevalence of osteopenia or osteoporosis at any of the five sites measured (P > 0.05). Fasters had lower daily calcium intake than non-fasters (median 532 vs 659 mg, P = 0.010), daily protein intake (0.67 vs 0.71 g/kg, P = 0.028), and consumption of dairy and soy products (10.3 vs 15.3 servings per week, P < 0.001). Groups did not differ in serum calcium, vitamin D, or urea concentrations. CONCLUSIONS: Despite lower calcium intake and lower consumption of dairy and soy products, older individuals adhering to COC fasting did not differ in BMD, BMC, or prevalence of osteoporosis from controls. Thus, periodic abstinence from dairy and, generally, animal products does not seem to compromise bone health in older individuals.

Informal Caregivers in Greek Hospitals: a Unique Phenomenon of a Health System in Financial Crisis.

BACKGROUND: In Greece it is quite common for family members to provide informal unpaid care for another family member during hospitalization, alongside healthcare professionals. Understaffing and lack of nursing personnel, due to austerity measures implemented in Greece during the last eight years, force families to provide informal care during hospitalization. The aim of the research was to study the role of informal caregivers (IC) during a family's member hospitalization, factors affecting their presence and patient's needs that were met by them. MATERIAL AND METHODS: This cross-sectional study was conducted in five medical wards of a tertiary general hospital in big city of Northern Greece, during 14 weeks using a questionnaire with demographics, clinical data, and type and frequency of interventions performed by ICs. Patient/nurse ratio was also recorded. RESULTS: On the total, 210 ICs participated (63.42% response rate). The vast majority of ICs were females, married, close relatives and in their late forties. More than half of them (58.1%, n=122) stayed by their patient bedside for more than 17 hours per day, as it was found that 13.8 patients were allocated to each nurse. Less than one quarter of ICs reported that their patient's status was not serious at all and according to them, one third of the patients were totally dependent and one fifth were totally self-sufficient and able to take care of themselves. Nineteen out of the twenty three interventions performed by caregivers were interventions of basic nursing care. CONCLUSION: The GHS administration officials are called to consider nursing understaffing in order to provide adequate and safe care. As new personnel is very difficult to be hired, family members could be trained, through structured programs, in basic nursing skills and interventions, so that they could participate in their family member's care and provide continuity of care at home.

Early rupture of an ultralow duodenal stump after extended surgery for gastric cancer with duodenal invasion managed by tube duodenostomy and cholangiostomy.

When dealing with gastric cancer with duodenal invasion, gastrectomy with distal resection of the duodenum is necessary to achieve negative distal margin. However, rupture of an ultralow duodenal stump necessitates advanced surgical skills and close postoperative observation. The present study reports a case of an early duodenal stump rupture after subtotal gastrectomy with resection of the whole first part of the duodenum, complete omentectomy, bursectomy, and D2+ lymphadenectomy performed for a pT3pN2pM1 (+ number 13 lymph nodes) adenocarcinoma of the antrum. Duodenal stump rupture was managed successfully by end tube duodenostomy, without omental patching, and tube cholangiostomy. Close assessment of clinical, physical, and radiological signs, output volume, and enzyme concentration of the tube duodenostomy, T-tube, and closed suction drain, which was placed near the tube duodenostomy site to drain the leak around the catheter, dictated postoperative management of the external duodenal fistula.

Total Reconstruction of the Afferent Loop for Treatment of Radiation-Induced Afferent Loop Obstruction with Segmental Involvement after Pancreaticoduodenectomy with Roux-en-Y Reconstruction.

As the literature on afferent loop obstruction (ALO) after pancreaticoduodenectomy (PD) is very limited, standardized rules for its management do not exist. Herein, we report the case of a 65-year-old male patient with chronic ALO who had undergone PD with single Roux-en-Y limb reconstruction and adjuvant chemoradiation therapy for pancreatic head adenocarcinoma 2 years earlier. The patient was brought to the operating room with the diagnosis of radiation enteritis of the afferent loop with segmental involvement and concurrent hepaticojejunostomy (HJ) and pancreaticojejunostomy (PJ) stricture. Complete mobilization of the afferent loop, removal of the affected segment and reconstruction were performed. Reconstruction of the afferent loop was a one-way option for the surgeons because the Roux-en-Y reconstruction limited endoscopic access to the afferent loop, and the segmental radiation injury of the afferent loop ruled out bypass surgery. However, mobilization of the affected segment through a field of dense adhesions and revision of the HJ and PJ were technically demanding.