3-Dimensional fasciectomy: A highly efficacious common ground approach to Dupuytren's surgery

BACKGROUND: Numerous Dupuytren’s fasciectomy techniques have been described, each associated with unique surgical challenges, complications and recurrence rates. We describe a common ground surgical approach to Dupuytren’s disease; 3-dimensional fasciectomy (3DF). 3DF aims to address the potential contributors to the high recurrence rate of Dupuytren’s disease and unite current limited fasciectomy practice that varies considerably between surgeons. METHODS: We describe the 3DF principles; raising thin skin flaps (addressing dermal involvement), excising diseased palmar fascia with a 3−5 mm clearance margin (treating highly locally recurrent conditions) and excising the vertical septae of Legueu and Juvara (providing deep clearance, hence addressing all potentially involved pathological tissue). The surgical outcomes between traditional limited fasciectomy (LF) and 3DF are compared. RESULTS: From the 786 operations included (n=585), postoperative recurrence rates were significantly lower for the 3DF group (2/145, 1.4%) than the LF group (72/641, 11.2%) (P=0.001), and the time to recurrence was significantly longer (5.0±0 years vs. 4.0±0.2 years; P < 0.0001). With recurrence excluded, there were no differences between the postoperative complication rates for 3DF (5/145, 3.5%) and LF (41/641, 6.4%) (P=0.4). CONCLUSIONS: Our results suggest that 3DF leads to lower recurrence rates and a longer disease-free period for patients, without increasing complications. 3DF provides a safe, efficacious, common ground surgical approach in the treatment of Dupuytren’s flexion deformity.

Erratum: Scar Revision Surgery: The Patient's Perspective

This erratum is being published to correct the printing errors on page 730, 732, and 733.

Scar Revision Surgery: The Patient's Perspective

BACKGROUND: Insufficient satisfaction outcome literature exists to assist consultations for scar revision surgery; such outcomes should reflect the patient's perspective. The aim of this study was to prospectively investigate scar revision patient satisfaction outcomes, according to specified patient-selection criteria. METHODS: Patients (250) were randomly selected for telephone contacting regarding scar revisions undertaken between 2007-2011. Visual analogue scores were obtained for scars pre- and post-revision surgery. Surgery selection criteria were; 'presence' of sufficient time for scar maturation prior to revision, technical issues during or wound complications from the initial procedure that contributed to poor scarring, and 'absence' of site-specific or patient factors that negatively influence outcomes. Patient demographics, scar pathogenesis (elective vs. trauma), underlying issue (functional/symptomatic vs. cosmetic) and revision surgery details were also collected with the added use of a real-time, hospital database. RESULTS: Telephone contacting was achieved for 211 patients (214 scar revisions). Satisfaction outcomes were '2% worse, 16% no change, and 82% better'; a distribution maintained between body sites and despite whether surgery was functional/symptomatic vs. cosmetic. Better outcomes were reported by patients who sustained traumatic scars vs. those who sustained scars by elective procedures (91.80% vs. 77.78%, P=0.016) and by females vs. males (85.52% vs. 75.36%, P<0.05), particularly in the elective group where males (36.17%) were more likely to report no change or worse outcomes versus females (16.04%) (P<0.01). CONCLUSIONS: Successful scar revision outcomes may be achieved using careful patient selection. This study provides useful information for referring general practitioners, and patient-surgeon consultations, when planning scar revision.

Pre-operative Serum Albumin and Neutrophil- Lymphocyte Ratio are Associated with Prolonged Hospital Stay Following Colorectal Cancer Surgery.

Aims: Colorectal cancer is the third most common cancer in European populations. It has been shown previously that neutrophil-lymphocyte ratio (NLR), pre-operative albumin, and haemoglobin are useful prognostic indicators. The aim of this study was to assess how these factors influence the length of postoperative stay (LOS) following colorectal cancer surgery. Methodology: All patients undergoing elective colorectal resections for malignancy between 2010 and 2011 in Pilgrim Hospital, Boston, U.K. were considered for the study. Hospital archive systems were used to ascertain pre-operative NLR, albumin and haemoglobin levels. LOS was calculated from electronic discharge documents with day 1 being the day after surgery. Unifactorial and multifactorial analyses were performed to identify independent predictors of prolonged stay. Results: 196 patients were included in the study. Pre-operative haemoglobin was not associated with prolonged hospital stay. On univariate analysis, pre-operative serum albumin and pre-operative NLR were associated with prolonged hospital stay. On multivariate analysis, pre-operative serum albumin >34.5 g/dl (odds ratio, 0.47; 95% confidence interval, 0.24 – 0.92; p = 0.027) retained independent association for prolonged hospital stay .However, pre-operative NLR failed to reach statistical significance on multivariate analysis. Conclusions: Patients with low albumin and elevated NLR are more likely to have an increased hospital stay following colorectal cancer surgery. This may be useful for surgeons in terms of identifying the ‘high-risk’ patient post-operatively and allow for early intervention.

When Are Circular Lesions Square? A National Clinical Education Skin Lesion Audit and Study

BACKGROUND: Skin cancer is the most prevalent cancer by organ type and referral accuracy is vital for diagnosis and management. The British Association of Dermatologists (BAD) and literature highlight the importance of accurate skin lesion examination, diagnosis and educationally-relevant studies. METHODS: We undertook a review of the relevant literature, a national audit of skin lesion description standards and a study of speciality training influences on these descriptions. Questionnaires (n=200), with pictures of a circular and an oval lesion, were distributed to UK dermatology/plastic surgery consultants and speciality trainees (ST), general practitioners (GP), and medical students (MS). The following variables were analysed against a pre-defined 95% inclusion accuracy standard: site, shape, size, skin/colour, and presence of associated scars. RESULTS: There were 250 lesion descriptions provided by 125 consultants, STs, GPs, and MSs. Inclusion accuracy was greatest for consultants over STs (80% vs. 68%; P<0.001), GPs (57%) and MSs (46%) (P<0.0001), for STs over GPs (P<0.010) and MSs (P<0.0001) and for GPs over MSs (P<0.010), all falling below audit standard. Size description accuracy sub-analysis according to circular/oval dimensions was as follows: consultants (94%), GPs (80%), STs (73%), MSs (37%), with the most common error implying a quadrilateral shape (66%). Addressing BAD guidelines and published requirements for more empirical performance data to improve teaching methods, we performed a national audit and studied skin lesion descriptions. To improve diagnostic and referral accuracy for patients, healthcare professionals must strive towards accuracy (a circle is not a square). CONCLUSIONS: We provide supportive evidence that increased speciality training improves this process and propose that greater focus is placed on such training early on during medical training, and maintained throughout clinical practice.

A Preoperative Marking Template for Deep Inferior Epigastric Artery Perforator Flap Perforators in Breast Reconstruction

Preoperative perforator marking for deep inferior epigastric artery perforator flaps is vital to the success of the procedure in breast reconstruction. Advances in imaging have facilitated accurate identification and preselection of potentially useful perforators. However, the reported imaging accuracy may be lost when preoperatively marking the patient, due to 'mapping errors', as this relies on the use of 2 reported vectors from a landmark such as the umbilicus. Observation errors have been encountered where inaccurate perforator vector measurements have been reported in relation to the umbilicus. Transcription errors have been noted where confusing and wordy reports have been typed or where incorrect units have been given (millimetres vs. centimetres). Interpretation errors have also occurred when using the report for preoperative marking. Furthermore, the marking process may be unnecessarily time-consuming. We describe a bespoke template, created using an individual computed tomography angiography image, that increases the efficiency and accuracy of preoperative marking. The template is created to scale, is individually tailored to the patient, and is particularly useful in cases where multiple potential suitable perforators exist.

Trends in All-Cause Mortality during the Scale-Up of an Antiretroviral Therapy Programme: a Cross-Sectional Study in Lusaka; Zambia

Objective To follow the trends in all-cause mortality in Lusaka; Zambia; during the scale-up of a national programme of antiretroviral therapy (ART). Methods Between November 2004 and September 2011; we conducted 12 survey rounds as part of a cross-sectional study in Lusaka; with independent sampling in each round. In each survey; we asked the heads of 3600 households to state the number of deaths in their households in the previous 12 months and the number of orphans aged less than 16 years in their households and investigated the heads' knowledge; attitudes and practices related to human immunodeficiency virus (HIV). Findings The number of deaths we recorded - per 100 person-years - in each survey ranged from 0.92 (95confidence interval; CI: 0.78-1.09) in September 2011; to 1.94 (95CI: 1.60-2.35) in March 2007. We found that mortality decreased only modestly each year (mortality rate ratio: 0.98; 95CI: 0.95-1.00; P = 0.093). The proportion of households with orphans under the age of 16 years decreased from 17 in 2004 to 7 in 2011. The proportions of respondents who had ever been tested for HIV; had a comprehensive knowledge of HIV; knew where to obtain free ART and reported that a non-pregnant household member was receiving ART gradually increased. Conclusion :The expansion of ART services in Lusaka was not associated with a reduction in all-cause mortality. Coverage; patient adherence and retention may all have to be increased if ART is to have a robust and lasting impact at population level in Lusaka

Universal Combination Antiretroviral Regimens to Prevent Mother-to-Child Transmission of HIV in Rural Zambia: a Two-Round Cross-Sectional Study

To evaluate if a pilot programme to prevent mother-to-child transmission (PMTCT) of the human immunodeficiency virus (HIV) was associated with changes in early childhood survival at the population level in rural Zambia.Methods Combination antiretroviral regimens were offered to pregnant and breastfeeding; HIV-infected women; irrespective of immunological status; at four rural health facilities. Twenty-four-month HIV-free survival among children born to HIV-infected mothers was determined before and after PMTCT programme implementation using community surveys. Households were randomly selected and women who had given birth in the previous 24 months were asked to participate. Mothers were tested for HIV antibodies and children born to HIV-infected mothers were tested for viral deoxyribonucleic acid. Multivariable models were used to determine factors associated with child HIV infection or death. Findings In the first survey (2008-2009); 335 of 1778 women (18.8) tested positive for HIV. In the second (2011); 390 of 2386 (16.3) tested positive. The 24-month HIV-free survival in HIV-exposed children was 0.66 (95 confidence interval; CI: 0.63-0.76) in the first survey and 0.89 (95 CI: 0.83-0.94) in the second. Combination antiretroviral regimen use was associated with a lower risk of HIV infection or death in children (adjusted hazard ratio: 0.33; 95 CI: 0.15-0.73). Maternal knowledge of HIV status; use of HIV tests and use of combination regimens during pregnancy increased between the surveys. Conclusion The PMTCT programme was associated with an increased HIV-free survival in children born to HIV-infected mothers. Maternal utilization of HIV testing and treatment in the community also increased

High risk bladder cancer: current management and survival

PURPOSE: To evaluate the pattern of care in patients with high risk non muscle invasive bladder cancer (NMIBC) in the Comprehensive Cancer Center North-Netherlands (CCCN) and to assess factors associated with the choice of treatment, recurrence and progression free survival rates. MATERIALS AND METHODS: Retrospective analysis of 412 patients with newly diagnosed high risk NMIBC. Clinical, demographic and follow-up data were obtained from the CCCN Cancer Registry and a detailed medical record review. Uni and multivariate analysis was performed to identify factors related to choice of treatment and 5 year recurrence and progression free survival. RESULTS: 74/412 (18 percent) patients with high risk NMIBC underwent a transurethral resection (TUR) as single treatment. Adjuvant treatment after TUR was performed in 90.7 percent of the patients treated in teaching hospitals versus 71.8 percent in non-teaching hospitals (p < 0.001). In multivariate analysis, age (60-79 years OR 0.40 and > 80 years OR 0.1 p = 0.001) and treatment in non-teaching hospitals (OR 0.25; p < 0.001) were associated with less adjuvant treatment after TUR. Tumor recurrence occurred in 191/392 (49 percent) and progression in 84 /392 (21.4 percent) patients. The mean 5-years progression free survival was 71.6 percent (95 percent CI 65.5-76.8). CONCLUSION: In this pattern of care study in high risk NMIBC, 18 percent of the patients were treated with TUR as single treatment. Age and treatment in non-teaching hospitals were associated with less adjuvant treatment after TUR. None of the variables sex, age, comorbidity, hospital type, stage and year of treatment was associated with 5 year recurrence or progression rates.

Pre-osteoblastic MC3T3-E1 cells promote breast cancer growth in bone in a murine xenograft model / 癌症

The bones are the most common sites of breast cancer metastasis. Upon arrival within the bone microenvironment, breast cancer cells coordinate the activities of stromal cells, resulting in an increase in osteoclast activity and bone matrix degradation. In late stages of bone metastasis, breast cancer cells induce apoptosis in osteoblasts, which further exacerbates bone loss. However, in early stages, breast cancer cells induce osteoblasts to secrete inflammatory cytokines purported to drive tumor progression. To more thoroughly evaluate the role of osteoblasts in early stages of breast cancer metastasis to the bones, we used green fluorescent protein-labeled human breast cancer cell lines MDA-MB-231 and MDA-MB-435, which both induce osteolysis after intra-femoral injection in athymic mice, and the murine pre-osteoblastic cell line MC3T3-E1 to modulate osteoblast populations at the sites of breast cancer metastasis. Breast cancer cells were injected directly into the femur with or without equal numbers of MC3T3-E1 cells. Tumors grew significantly larger when co-injected with breast cancer cells and MC3T3-E1 cells than injected with breast cancer cells alone. Osteolysis was induced in both groups, indicating that MC3T3-E1 cells did not block the ability of breast cancer cells to cause bone destruction. MC3T3-E1 cells promoted tumor growth out of the bone into the extraosseous stroma. These data suggest that breast cancer cells and osteoblasts communicate during early stages of bone metastasis and promote tumor growth.

Chroriocarcinoma presenting as a ruptured tubal ectopic pregnancy

A case of a choriocarcinoma of the fallopian tube presenting as a ruptured tubal ectopicpregnancy is described. The patient's satisfaactory clinical course over a twelve-month period is docimented, and factors that govern the prognosis of this once rapidly fatal disease are discussed