Can we reduce excision margins for head and neck melanoma? A 12-year retrospective study.

Although wide local excision is the standard treatment for primary melanoma, the surgical margin remains controversial. Melanomas of the head and neck exhibit higher recurrence rates and worse prognosis than lesions in other body locations, and their close proximity to critical anatomical and functional structures means that wide excision margins are often not feasible. Surgeons must therefore achieve a balance of oncological safety and functional and aesthetic needs. The aim of this study was to retrospectively analyse melanoma data over a 12-year period at a large skin surgery unit to identify potential differences in outcomes in patients who had reduced wide local excision margins for primary head and neck melanoma. The study would provide further evidence for the need for large randomised prospective trials to reduce excision margins for head and neck melanoma. Local cancer network data were retrospectively analysed over a period of 12 years (2008-2019). Data included site, initial stage, multidisciplinary team (MDT) meeting recommendations for excision margins and the actual wide local excision margin taken, recurrence rate, and disease-specific and absolute survival. A total of 222/305 patients (73%) had the recommended excision margin, while in 27% margins were reduced due to anatomical or functional considerations. Recurrence rates were similar (recommended 11.7% vs narrow 13.3% excision margins) (p = 0.64). The mean follow-up time for all patients was 48.5 months. In aesthetically and functionally sensitive areas of the head and neck, wide local excision margins need to be carefully considered after MDT discussion and discussion with the patient. This study suggests the need for further multicentre trials to address the uniqueness of head and neck melanoma.

Cataract extraction and patient vision-related quality of life: a cohort study.

AIMS: Cataract surgery is one of the most common surgeries performed, but its overuse has been reported. The threshold for cataract surgery has become increasingly lenient; therefore, the selection process and surgical need has been questioned. The aim of this study was to evaluate the changes associated with cataract surgery in patient-reported vision-related quality of life (VR-QoL). METHODS: A prospective cohort study was conducted. Consecutive patients referred to cataract clinics in an NHS unit in Scotland were identified. Those listed for surgery were invited to complete a validated questionnaire (TyPE) to measure VR-QoL pre- and post-operatively. TyPE has five different domains (near vision, distance vision, daytime driving, night-time driving, and glare) and a global score of vision. The influence of pre-operative visual acuity (VA) levels, vision, and lens status of the fellow eye on changes in VR-QoL were explored. RESULTS: A total of 320 listed patients were approached, of whom 36 were excluded. Among the 284 enrolled patients, 229 (81%) returned the questionnaire after surgery. Results revealed that the mean overall vision improved, as reported by patients. Improvements were also seen in all sub-domains of the questionnaire. CONCLUSION: The majority of patients appear to have improvement in patient-reported VR-QoL, including those with good pre-operative VA and previous surgery to the fellow eye. VA thresholds may not capture the effects of the quality of life on patients. This information can assist clinicians to make more informed decisions when debating over the benefits of listing a patient for cataract extraction.

Management of maxillofacial wounds sustained by British service personnel in Afghanistan.

UK service personnel sustaining maxillofacial wounds in Afghanistan are stabilised in a field hospital prior to evacuation for definitive treatment at the Royal Centre for Defence Medicine (RCDM). Descriptive injury data were gathered from the Joint Theatre Trauma Registry (JTTR) between 1 January 2008 and 31 December 2009 and matched to hospital clinical records. The mean Abbreviated Injury Severity (AIS) scores in service personnel sustaining maxillofacial wounds alone were compared with those with injuries to all body areas. Maxillofacial wounds were present in 21% of British servicemen sustaining battle injuries, but 30% of all evacuations despite the similar mean AIS of each group. This probably reflects the complex care these injuries often require that is not possible in the field. In the field hospital, maxillofacial wounds were predominantly debrided and definitive repair was deferred until evacuated to RCDM. AIS codes are an excellent predictor of mortality from face and eye wounds but they reflect morbidity poorly. The authors propose that instead of a single AIS code, each military face and eye injury should be ascribed a second separate Occulo-Facial Functional and Aesthetic (OFFA) outcome score that more accurately predicts the aesthetic and functional parameters of these wounds.

Clinical strategies in the management of complex maxillofacial injuries sustained by British military personnel.

The maxillofacial injuries sustained by British troops requiring aeromedical evacuation to the United Kingdom are almost exclusively treated at The Royal Centre for Defence Medicine in Birmingham. As a result the Maxillofacial Department has collectively gained extensive experience in the management of ballistic injuries. In many cases the most successful outcomes have been achieved by using traditional strategies combined with contemporary techniques. This paper will highlight the types of injuries sustained and discuss some cases that typify those the department has managed.

The use of autologous blood and adjunctive 'face lift' bandage in the management of recurrent TMJ dislocation.

The use of a sclerosant in the management of recurrent dislocation of the temporomandibular joint has lost popularity in recent years, though it can, in selected cases, be valuable. We describe the technique of intra-articular injection of autologous blood, together with support from an elastic bandage of a type designed for use after a face lift, in a medically unfit 83-year-old woman.

Advantages of not using the intensive care unit after operations for oropharyngeal cancer: an audit at Worcester Royal Hospital.

We reviewed 68 cases of oral and oropharyngeal cancer that were managed without the routine use of intensive care units (ICU), to establish success rates for flaps, complications including nosocomial infections, cancellations, and length of stay. More than 98% of flaps survived and over half the patients had no complications. Low rates of perioperative infection were recorded with a median length of stay of 12 days (range 2-63), and there were no cancellations. We conclude that the routine use of a specialist head and neck ward is more appropriate than ICU for selected cases; it fulfils current guidelines for cancer services, and is an effective use of resources.

Bronchoscopic instillation of surfactant in acute respiratory distress syndrome.

Abnormalities of surfactant action in acute respiratory distress syndrome (ARDS) result in decreased lung compliance and significant hypoxemia. Several case reports and small studies suggest that there is an improvement in patients with ARDS following the administration of surfactant. However, there is no clear-cut ideal method for surfactant administration. The bronchoscopic administration of surfactant may represent an effective method of surfactant delivery in ARDS. Bronchoscopic instillation offers the theoretical advantages that the surfactant may be distributed directly to the desired regions of the lung, a more economical use of surfactant, and the opportunity to lavage leaked serum proteins prior to instillation. Surfactant has been administered in adults with success. We present a case of initial improvement in oxygenation index, ventilation index, and mechanical ventilatory support in a pediatric patient with ARDS following the bronchoscopic administration of surfactant.

Age-related differences in adolescent smokers' and nonsmokers' assessments of the relative addictiveness and health harmfulness of cigarettes, alcohol, and marijuana.

The present work was undertaken to determine how general beliefs about various substances and substance use behaviors change during adolescence. Secondary analyses were carried out on the telephone interview responses of 1,200 adolescent smokers and nonsmokers between the ages of 12 and 17. The specific beliefs regarding which substances were hardest to stop using and which were the most harmful to one's health by smoking status and age were compared using Chi-squared analyses for univariate comparisons, and polytomous logistic regression for multivariate analyses. Results revealed that the youngest cohort believed that marijuana was the substance most difficult to stop using while the oldest cohort believed that cigarettes were the hardest to stop using. A similar pattern was observed regarding which substance was the most harmful to one's health. While smokers believed that cigarettes were both the hardest to stop using and the most harmful, nonsmokers were divided between cigarettes and marijuana as the hardest to stop using, and indicated that marijuana, rather than cigarettes, were most harmful. Results are discussed in terms of their implications for substance abuse prevention and the development of relative risk assessments.

Murine chromosome 16 telomeric region, homologous with human chromosome 21q22, contains the osmoregulatory Na(+)/myo-inositol cotransporter (SLC5A3) gene.

The murine Na(+)/myo-inositol cotransporter (SLC5A3) gene (Slc5a3) was cloned, the restriction sites mapped, and the coding region sequenced. Similar to other mammalian counterparts, including human, the gene has a single coding exon, with an open reading frame of 2.2 kb. The predicted protein of 718 amino acids is also highly conserved, compared to other mammalian homologs. Using fluorescence in situ hybridization, Slc5a3 was localized to the telomeric region of mouse chromosome 16, which is syntenic to human chromosome 21q22. An increased Slc5a3 copy number may explain the increased levels of myo-inositol in the brains of trisomy 16 mice and the increased rate of transport of myo-inositol into cultured neurons derived from trisomy 16 mice.

Clinical results with nonthoracotomy ICD systems.

The results of two separate US Food and Drug Administration clinical trials that involved endocardial and epicardial leads were compared with regard to patient demographics, detection and conversion characteristics, and subsequent clinical course including long-term survival experience. The patient groups, although not strictly contemporaneous, were sufficiently similar to allow meaningful comparisons. There were no significant differences in detection of induced arrhythmias and ability to convert them. The surgical mortality, infection rate, and incidence of other morbid complications were lower in patients who had received endocardial leads; however, the differences did not reach statistical significance. Survivals through 1 year of follow-up were uniformly high. These results suggest that the performance of the endocardial lead system is comparable to existing epicardial leads in similar patient populations.

Clinical efficacy of low energy cardioversion in automatic implantable cardioverter defibrillator patients.

The inclusion of low energy cardioversion capability into modern implantable antiarrhythmic devices, although an appealing idea, is nevertheless unproven with regard to its potential benefits. Moreover, since occasional reports have surfaced suggesting that ineffective application of low energy shocks may prejudice subsequent arrhythmia reversion, we examined the effectiveness and risks of this feature in a large series of patients performed as part of a US Food and Drug Administration clinical trial performed under an investigational device exemption. A total of 813 induced monomorphic ventricular tachycardias were studied in 244 patients. We found that many of the arrhythmias could be reverted to sinus rhythm with small amounts of energy. Cardioversion energy was less than or equal to 6 joules (J) for 84 (53.2%) and less than or equal to 14 joules in 105 (66.4%) of the 158 patients tested at implant and subsequently remained unchanged through greater than 4 months follow up. The incidence of noncardioversion, acceleration or both occurred in 12.7%, 5.7%, and 13.1%, respectively on a per patient basis. On a per episode basis, nonconversion occurred in 51 (6.3%) and acceleration in 61 (7.5%) of the 813 inductions. There was no correlation between the occurrence of nonconversions and accelerations. The devices were allowed to recycle in the event the arrhythmia was not reverted. The subsequent shock was almost always effective, and in any event, no patient failed to be reverted by the second 30-J rescue shock. Over the entire follow-up period as long as 17 months, there were 17 deaths. Neither the incidence nor the mode of death was correlated with nonconversion or acceleration.(ABSTRACT TRUNCATED AT 250 WORDS)

Reduced mononuclear leukocyte ascorbic acid content in adults with insulin-dependent diabetes mellitus consuming adequate dietary vitamin C.

Several recent studies suggest that vitamin C (ascorbic acid [AA]) status may be altered in insulin-dependent diabetes mellitus (IDDM). We measured the AA content of mononuclear leukocytes (MN-AA) as an indicator of tissue vitamin C status in adults with IDDM and nondiabetic adults matched for age and sex. Dietary vitamin C intake and plasma AA were analyzed to ensure that vitamin C availability was adequate. Dietary vitamin C intakes were above recommendations and were not different between the groups. MN-AA was reduced by 33% on average (P less than .05) in adults with IDDM (1.75 microgram/mg total protein [TP]) when compared with nondiabetics (2.60 micrograms/mg TP). When MN-AA is indexed to the dietary vitamin C intake (MN-AA/100 mg diet C), the storage deficit in adults with IDDM averages 50% (P less than .05). This observation suggests an impaired tissue AA storage in adults with IDDM and supports the theory that intracellular scurvy contributes to the chronic degenerative complications of the disease.

A demonstration of a strain related restriction effect in the formation of experimental metastases.

In view of the role of histocompatibility proteins in mediating many types of cell interaction it was decided to investigate their role in the formation of experimental metastatic deposits using the B16 mouse melanoma cell line. The expression of both major histocompatibility complex (MHC) Class I and Class II proteins was studied in vitro. Expression of both MHC Class I and Class II proteins was greater in the highly metastatic F10 cell line as compared with the poorly metastatic F1 line. Intravenous injection of cells into syngeneic and semi-allogeneic animals revealed a strain related restriction effect on tumour growth following intravenous injection. However, this was mediated by a locus other than H-2. No restriction of lung trapping of radiolabelled cells or local growth following intraperitoneal injection was found. It is suggested that non-H-2 Class I proteins may mediate some of the stages of metastatic tumour growth independent of the immune system.