Breast reconstruction with tissue expanders: implementation of a standardized best-practices protocol to reduce infection rates.

BACKGROUND: Periprosthetic infection remains a frustrating and costly complication of breast reconstruction with tissue expanders. Although some specific steps have been previously shown to reduce periprosthetic infections, no comprehensive protocol addressing all aspects of preoperative, intraoperative, and postoperative patient management has been evaluated in the literature. The authors' goal was to evaluate the effectiveness of their protocol at reducing periprosthetic infections. METHODS: A comprehensive, best-practices protocol was introduced and implemented in November of 2010. All patients undergoing breast reconstruction using tissue expanders at the authors' institution in the 5 years before the protocol, and in the 2 years after, were analyzed. RESULTS: Three hundred five patients underwent 456 tissue expander reconstructions in the 5 years before the protocol, and 198 patients underwent 313 reconstructions in the 2 years after. Significantly fewer patients developed periprosthetic infection after protocol (11.6 percent versus 18.4 percent; p=0.042), and the number of infected tissue expanders trended toward a decrease (9.3 percent versus 13.2 percent; p=0.097). On multivariate analysis, the protocol significantly reduced the odds of periprosthetic infection (OR, 0.45; p=0.022). Predictors of infection included obesity (OR, 2.01; p=0.045) and preoperative breast size larger than C cup (OR, 2.83; p=0.006). CONCLUSIONS: The authors' comprehensive, best-practices protocol allowed them to reduce the odds of tissue expander infections by 55 percent (OR, 0.45; p=0.022). The authors were able to identify several potential areas of improvement that may help them lower the rate of infection further in the future. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Mechanical Leeching with Venocutaneous Fistula and Monitoring with Near-infrared Spectroscopy.

SUMMARY: The report herein describes the use of a venocutaneous fistula with angiocatheter attachment and near-infrared spectroscopy device to correct venous congestion of a vertical upper gracilis free flap used for breast reconstruction. This method of mechanical leeching was precisely controlled through monitoring trends in the tissue oxygen saturation levels of the flap, allowing venous congestion to be relieved before it became clinically apparent.

Use of a routine, self-report outcome measure (HoNOSCA-SR) in two adolescent mental health services. Health of the Nation Outcome Scale for Children and Adolescents.

BACKGROUND: The Health of the Nation Outcome Scale for Children and Adolescents (HoNOSCA) is an established outcome measure for child and adolescent mental health. Little is known of adolescent views on outcome. AIMS: To develop and test the properties of an adolescent, self-rated version of the scale (HoNOSCA-SR) against the established clinician-rated version. METHOD: A comparison was made of 6-weekly clinician-rated and self-rated assessments of adolescents attending two services, using HoNOSCA and other mental health measures. RESULTS: Adolescents found HoNOSCA-SR acceptable and easy to rate. They rated fewer difficulties than the clinicians and these difficulties were felt to improve less during treatment, although this varied with diagnosis and length of treatment. Although HoNOSCA-SR showed satisfactory reliability and validity, agreement between clinicians and users in individual cases was poor. CONCLUSIONS: Routine outcome measurement can include adolescent self-rating with modest additional resources. The discrepancy between staff and adolescent views requires further evaluation.