Impact and outcomes after lymphaticovenous anastomosis for 150 cases of lymphoedema followed up over 24 months.

BACKGROUND: Lymphoedema is a chronic condition affecting daily activities of life, causing significant alterations and adjustments. Since 2015, lymphaticovenous anastomosis (LVA) has been available on the National Health Service for people with lymphoedema in Wales, United Kingdom. This study aimed to explore the impact and outcomes after LVA over a 24-month follow-up. METHODS: Data were prospectively captured before and after LVA surgery on 150 patients with unilateral upper or lower limb lymphoedema. The same team (three lymphoedema specialists and two plastic surgeons) assessed/operated on all patients. Data captured included a quality of life tool (EQ5D5L), circumferential measurements (tape measure/perometer), compression garment usage, occurrence of cellulitis and a range of patient-reported outcome measures. RESULTS: People who underwent LVA surgery had predominantly cancer-related lymphoedema (n = 118). Reviewing baseline data and 24-months after LVA, quality of life statistically improved (p = <0.005), as well as pain, heaviness, anxiety, impact on hobbies, work, purchasing clothes and intimacy/desirability. Mean perometer and circumferential measurements did not reduce over the 24 months. Number of days per week and hours that the patient wore compression garments did lessen and was statistically significant (p = <0.001). The quantity of cellulitis episodes captured from two years before and two years after LVA decreased from 4.22 to 0.10 (p = <0.001). Significant results (p = <0.001) were also found in a reduction in patients taking days off work due to cellulitis (5.81 to 0.16). CONCLUSION: LVA resulted in significant improvements in patient-reported outcome measures, cellulitis episodes and reduced need for compression garments. Limb circumference via tape measure/perometer did not alter, yet the patient's quality of life considerably improved.

Linking Patient-Centered Outcomes to Neuropsychological Practice: A Conceptual Framework and Opportunities for Research.

In the current healthcare climate, reimbursement for services is increasingly linked to the ability to demonstrate beneficial patient outcomes. Neuropsychology faces some unique challenges in outcomes research, namely, that neuropsychologists often do not follow patients over time and the effect of neuropsychological services on patient outcomes may not be fully realized until under another provider's care. Yet there is an urgent need for empirical evidence linking neuropsychological practice to positive patient outcomes. To provide a framework for this research, we define a core set of patient-centered outcomes and neuropsychological processes that apply across practice settings and patient populations. Within each area, we review the available existing literature on neuropsychological outcomes, identifying substantial gaps in the literature for future research. This work will be critical for the field to demonstrate the benefit of neuropsychological services, to continue to advocate effectively for reimbursement, and to ensure high-quality patient care.

A 5-year follow-up study of 633 cutaneous SCC excisions: Rates of local recurrence and lymph node metastasis.

BACKGROUND: A 5-year follow-up study of 633 cutaneous squamous cell cancer (SCC) excisions was performed by collecting data on rates of local recurrence (LR) and lymph node (LN) metastasis. METHODS: A retrospective analysis of patients was performed across four regional plastic surgery centres (Stoke Mandeville Hospital, Aylesbury; John Radcliffe Hospital, Oxford; Salisbury District Hospital, Salisbury and Queen Alexandra Hospital, Portsmouth) assessing rates of LR and LN metastasis. RESULTS: We report 5-year outcomes from 598 SCCs (95% follow-up rate). The total recurrence rate (LR and LN metastasis) was 6.7% (n = 40) at 5 years, with 96% of these occurring within 2 years. Median time to LR was 9 months (1-57), with 76.9% (n = 20) undergoing further wide local excision. Median time to LN metastasis was 5.5 months (1-18 months). There were two cases of disease-related death. Only 15% (n = 6) of incomplete excisions recurred. Interestingly, 19.1% (n = 9) of 47 SCCs with perineural invasion on original histopathology recurred versus only 5.6% (n = 31) of the 551 SCCs without perineural invasion (p = 0.005). CONCLUSIONS: This study is one of the largest studies to date following up 598 SCC excisions at 5 years with total recurrence rates comparable to those in current published literature. We report perineural invasion as a significant predictor of recurrence and that 96% of total recurrence occurred within 2 years. This is in contrast to current UK guidelines (75% at 2 years, 95% at 5 years), thus suggesting that shorter length of hospital follow-up may be reasonable.

Sibling recurrence risk in Dupuytren's disease.

Dupuytren's disease is a complex condition, with both genetic and environmental factors contributing to its aetiology. We aimed to quantify the extent to which genetic factors predispose to the disease, through the calculation of sibling recurrence risk (ls), and to calculate the proportion of heritability accounted for by currently known genetic loci. From 174 siblings of patients with surgically confirmed disease, 100 were randomly selected. Controls were recruited from patients attending an ophthalmology outpatient clinic for eye conditions unrelated to diabetes. There were no statistically significant differences in baseline characteristics between the case and control groups. In siblings, 47% had Dupuytren's disease, compared with 10% of controls, giving a ls of 4.5. Currently known loci that predispose to Dupuytren's disease account for 12.1% of the total heritability of the disease. Dupuytren's disease was significantly more common in siblings than in controls. These results accurately quantify the magnitude of the genetic predisposition to Dupuytren's disease.

Patient satisfaction with receiving skin cancer diagnosis by letter: comparison with face-to-face consultation.

Providing patients with clear and concise information is central to modern medical practice. Patients diagnosed with skin cancer are traditionally told their result by face-to-face consultation in the outpatient clinic. Previous studies have shown poor patient satisfaction with the traditional outpatient consultation. The skin oncology service at Kingston Hospital uses two different methods to inform selected patients of their skin cancer diagnosis. Those diagnosed with thin melanoma (MM) or squamous cell carcinoma (<2 cm) (SCC) are informed by letter (with an accompanying information leaflet), or seen in outpatient clinic for a face-to-face consultation. However, it is unclear which of these methods patients prefer. We performed a retrospective postal questionnaire survey to elicit the views of patients that had been informed of their skin cancer by these two methods. Patients had been diagnosed with either MM or SCC between February 2005 and March 2006. Demographic details and patient satisfaction using five-point Likert scales were determined. Of the eligible 118 patients, 90 (76%) completed the questionnaire. Questionnaires from five respondents were incorrectly completed and excluded from further analysis. Of the final 85 patients, 41 (48%) were told their diagnosis via face-to-face consultation (clinic) and 44 (52%) by letter. The demographic profile of both groups was similar (P>0.05). Patients of both groups had a similar expectation of being told a skin cancer diagnosis (P>0.05). A high level of satisfaction was expressed for both methods of communication, with no difference between the groups (P>0.05). In the letter group, patients placed more value on convenience than preference to seeing a doctor (P<0.001). The option of contacting a support nurse was also cited as a reassuring feature. The findings of this study suggest disclosure of skin cancer diagnosis by letter has high satisfaction, for selected patients. Using this method of communication may ultimately lessen the burden on outpatient service.

Patient satisfaction following abdominoplasty: an NHS experience.

Abdominoplasty is one of the few cosmetic procedures performed in the UK on the National Health Service (NHS). In the current climate of tight resource rationing many primary care trusts (PCTs) are refusing to fund such operations, resulting in a number being carried out in the independent sector. There are very few studies in the literature on patient satisfaction following abdominoplasty, with none from the UK. Our study aimed to look at the patient satisfaction rate following abdominoplasty in the NHS and study further the areas of dissatisfaction. A questionnaire survey was sent to 153 patients who underwent the procedure over a 5-year period. Replies were received from 118 (78%) patients, revealing a 77% satisfaction rate amongst responders. Further analysis of the dissatisfied patients revealed particular dissatisfaction with dog-ears, residual abdominal overhang and issues relating to the scar. The dissatisfied group was exclusively female from across the age spectrum, although analysis showed an increase in dissatisfaction with time, with the highest levels seen at 4-6 years post-abdominoplasty. This study has identified a number of areas of patient dissatisfaction, even in carefully selected patients.

Ulnar nerve compression in Guyon's canal in the presence of a tortuous ulnar artery.

A case of ulnar nerve compression in Guyon's canal occurring in the presence of a tortuous ulnar artery in the canal is presented and the pathology and classification of ulnar nerve compression in Guyon's canal discussed.

EEG as a measure of developmental changes in the chicken brain.

Scalp-applied recording electrodes were used to monitor changes in basal EEG patterns in chickens during posthatch development. Frequency spectra produced by Fast Fourier Transform show a biphasic morphology in all chickens with one peak at about 6 Hz and another at 26 Hz. Changes in the lower frequency band show progressive development and provide a possible index of brain development. Both amplitude and dominant frequency of the spectra decrease between Weeks 3 and 8 posthatch, reaching adult levels between Weeks 5 and 7. These results suggest that modifications of basal EEG reflect the widespread functional changes in neuronal circuits occurring in chicken during the "synapse maturation" period between 3 and 8 weeks' posthatch.

K-ras mutation and loss of heterozygosity of chromosome 17p and survival in colorectal cancer.

BACKGROUND: The development of colorectal cancer (CRC) is thought to be a multistage process involving alterations to several types of genes, including oncogenes and tumour suppressor genes. This study examined the associations between allelic deletions of chromosome 17p in the region of the p53 gene and K-ras gene mutation and survival among CRC patients. METHODS: Resected specimens from 233 patients were examined. Point mutation of codon 12 of K-ras was assessed using a modified polymerase chain reaction method. Allelic deletion of 17p was demonstrated by loss of heterozygosity (LOH) with the marker Mfd144. RESULTS: Fifty-seven tumours (24%) showed somatic point mutation of codon 12 of K-ras and 86 tumours (37%) showed LOH of Mfd144. There were 107 tumours (46%) with either K-ras mutation or LOH and 18 tumours (8%) with both. Compared with patients with neither alteration, significantly poorer survival was experienced only by those with both alterations (P = 0.015). However, when this variable was introduced into a multivariate analysis controlling for the patient's age and tumour stage, it failed to show a statistically significant independent effect on survival. CONCLUSIONS: Point mutation of K-ras and LOH of Mfd144 in CRC does not add to the prognostic information already available from clinicopathological staging.

An ergonomics program for the health care setting.

The basic elements needed to establish a formal ergonomics program are addressed: work site analysis, hazard prevention, training and education and medical management. Occupational risk factors, both environmental and workplace, also are identified.

Skeletal muscle pyruvate dehydrogenase activity during maximal exercise in humans.

The regulation of the active form of pyruvate dehydrogenase (PDHa) and related metabolic events were examined in human skeletal muscle during repeated bouts of maximum exercise. Seven subjects completed three consecutive 30-s bouts of maximum isokinetic cycling, separated by 4 min of recovery. Biopsies of the vastus lateralis were taken before and immediately after each bout. PDHa increased from 0.45 +/- 0.15 to 2.96 +/- 0.38, 1.10 +/- 0.11 to 2.91 +/- 0.11, and 1.28 +/- 0.18 to 2.82 +/- 0.32 mmol.min-1.kg wet wt-1 during bouts 1, 2, and 3, respectively. Glycolytic flux was 13-fold greater than PDHa in bouts 1 and 2 and 4-fold greater during bout 3. This discrepancy between the rate of pyruvate production and oxidation resulted in substantial lactate accumulation to 89.5 +/- 11.6 in bout 1, 130.8 +/- 13.8 in bout 2, and 106.6 +/- 10.1 mmol/kg dry wt in bout 3. These events coincided with an increase in the mitochondrial oxidation state, as reflected by a fall in mitochondrial NADH/NAD, indicating that muscle lactate production during exercise was not an O2-dependent process in our subjects. During exercise the primary factor regulating PDHa transformation was probably intracellular Ca2+. In contrast, the primary regulatory factors causing greater PDHa during recovery were lower ATP/ADP and NADH/NAD and increased concentrations of pyruvate and H+. Greater PDHa during recovery facilitated continued oxidation of the lactate load between exercise bouts.

A frame shift mutation in the PMP22 gene in hereditary neuropathy with liability to pressure palsies.

Hereditary neuropathy with liability to pressure palsies (HNPP) has been a associated with a deletion of 1.5 megabases of chromosome 17p. One of four biopsy proven HNPP families that we have studied did not possess this deletion. As the deleted DNA region includes the coding region for a peripheral myelin gene (PMP22), we used single strand conformation analysis to examine this gene for mutations in the non-deleted HNPP family. An abnormal fragment in exon 1 was identified, and sequencing revealed a two base pair deletion in all affected family members. The deletion results in a frame shift, providing strong evidence that this gene has an important role in the pathogenesis of the disease.

Thirty-one new RFLP systems detected by twenty-four DNA markers on human chromosome 10.

Thirty-one new RFLP systems corresponding to 24 loci have been identified from a chromosome 10-specific cosmid library. Twelve of the markers on the proximal long arm (cen-q11.2) of this chromosome, including four RFLP systems for the RET locus, will be especially useful in efforts to identify the gene responsible for multiple endocrine neoplasia type 2A (MEN2A). The new panel of markers also may contribute to fine-scale mapping of tumor suppressor genes associated with glioblastoma multiforme or renal cell carcinoma, because allelic deletions in these tumors have implied the presence of a tumor suppressor gene(s) on chromosome 10.

Nucleotide sequence and analysis of the lethal factor gene (lef) from Bacillus anthracis.

The nucleotide sequence of the Bacillus anthracis lethal factor (LF) gene (lef) has been determined. LF is part of the tripartite protein exotoxin of B. anthracis along with protective antigen (PA) and edema factor (EF). The apparent ATG start codon, which is located immediately upstream from codons which specify the first 16 amino acids (aa) of the mature secreted LF, is preceded by an AAAGGAG sequence, which is its probable ribosome-binding site. This ATG codon begins a continuous 2427-bp open reading frame which encodes the 809-aa LF-precursor protein with an Mr of 93,798. The mature secreted protein (776 aa; Mr 90,237) was preceded by a 33-aa signal peptide which has characteristics in common with leader peptides for other secreted proteins of the Bacillus species. The codon usage of the LF gene reflects its high (70%) A + T content. The N-terminus of LF (first 300 aa) shared extensive homology with the N-terminus of the anthrax EF protein. Since LF and EF each bind PA at the same site, these homologous regions probably represent their common PA-binding domains.

Linked markers flanking the gene for multiple endocrine neoplasia type 2A.

The inherited cancer syndrome multiple endocrine neoplasia type 2A (MEN2A) has recently been mapped to chromosome 10. We have typed 29 families with this disorder with DNA markers from the pericentromeric region of chromosome 10. Two markers, RBP3 and MCK2, were tightly linked to the MEN2A gene at recombination fractions of less than 3%. Multipoint analysis of the linkage data suggests that the gene is located within a 3-cM interval defined by the markers RBP3/MCK2 on one side and TB14.34 on the other. No evidence for locus heterogeneity was detected in any of the 27 families from 14 countries who were informative for the markers tested. The data confirm and refine the original assignment and provide the basis for presymptomatic screening for this disorder.