Melanoma predilection for the lower limbs of women compared with men.

The lower limb is a common site for melanoma in women, but the reason for this is not fully understood. To investigate this phenomenon in more detail, we assessed the specific subsites of primary melanoma occurring on the lower limbs of females compared with males across age groups. In a records-based study at an oncology hospital in north-west of England, among an unselected sample of patients with primary invasive melanoma treated between 2002-2015, information was collected on patient age at diagnosis, sex, and co-morbidities, and the tumor thickness and anatomical subsite (thigh, lower leg, foot for lower limb). Of a total sample of 1,522 patients, 316 (227, 72% female) had lower limb melanoma. The most common subsite was lower leg (142 cases with F:M ratio =3.74), followed by thigh (55 cases with F:M = 1.83) and feet (30 cases with F:M = 1.15). At ages <40 years the odds of thigh to foot melanoma was 20 times higher in females than in males (OR 20.0, 95% CI 2.6-152.6) and 7.5 times higher on the lower limb (OR 7.5, 95% CI 1.1-49.2). For ages 40+ years, the odds of females developing thigh melanoma compared to foot melanoma was similar in males versus females (OR 0.8), while the corresponding odds of lower leg melanoma in females versus males remained significantly increased at ages 40-59 and 60+ (OR 4.2 and 2.8 respectively). Our study demonstrates the female predilection for lower limb melanoma persists over most but not all subsites.However, there is heterogeneity in the female to male occurence of lower limb melanoma across subsites and at different ages, which may be linked to relative influence of genetic and environmental risk factors.

Prediction and monitoring of relapse in stage III melanoma using circulating tumor DNA.

BACKGROUND: The advent of effective adjuvant therapies for patients with resected melanoma has highlighted the need to stratify patients based on risk of relapse given the cost and toxicities associated with treatment. Here we assessed circulating tumor DNA (ctDNA) to predict and monitor relapse in resected stage III melanoma. PATIENTS AND METHODS: Somatic mutations were identified in 99/133 (74%) patients through tumor tissue sequencing. Personalized droplet digital PCR (ddPCR) assays were used to detect known mutations in 315 prospectively collected plasma samples from mutation-positive patients. External validation was performed in a prospective independent cohort (n = 29). RESULTS: ctDNA was detected in 37 of 99 (37%) individuals. In 81 patients who did not receive adjuvant therapy, 90% of patients with ctDNA detected at baseline and 100% of patients with ctDNA detected at the postoperative timepoint relapsed at a median follow up of 20 months. ctDNA detection predicted patients at high risk of relapse at baseline [relapse-free survival (RFS) hazard ratio (HR) 2.9; 95% confidence interval (CI) 1.5-5.6; P = 0.002] and postoperatively (HR 10; 95% CI 4.3-24; P < 0.001). ctDNA detection at baseline [HR 2.9; 95% CI 1.3-5.7; P = 0.003 and postoperatively (HR 11; 95% CI 4.3-27; P < 0.001] was also associated with inferior distant metastasis-free survival (DMFS). These findings were validated in the independent cohort. ctDNA detection remained an independent predictor of RFS and DMFS in multivariate analyses after adjustment for disease stage and BRAF mutation status. CONCLUSION: Baseline and postoperative ctDNA detection in two independent prospective cohorts identified stage III melanoma patients at highest risk of relapse and has potential to inform adjuvant therapy decisions.

Prophylactic venous cannulation of the pedicled TRAM flap in breast reconstruction.

Since its inception nearly 30 years ago, the pedicled TRAM flap has remained a reliable technique of breast reconstruction. However, venous congestion of the flap in the early postoperative period is well recognised and may lead to partial or total flap loss. This study describes a simple technique routinely employed by the senior author over 15 years involving intraoperative cannulation of the deep inferior epigastric vein and externalisation into an ileostomy bag, in order to facilitate drainage and reduce the likelihood of venous congestion. In addition to its role in breast reconstruction, this technique may be a useful adjunct to any form of free or pedicled tissue transfer.

Gluteal fold flaps for perineal reconstruction.

Defects of the perineum are created during ablative procedures for gynaecological, urological and colorectal malignancies. The gluteal fold flap is a reliable means of reconstructing these defects. We retrospectively reviewed case notes of gluteal fold flaps performed for perineal reconstruction over four years (2007-2010) in our institution. 77 perineal defects were reconstructed using unilateral or bilateral gluteal fold flaps (127 flaps in total). 50% of all patients are discharged before 11 days, and 90% were discharged within one month. Mean time to discharge was 13.2 days. 70% of all patients were completely healed at 2 months, and 85% completely healed at three months. Pre-operative radiotherapy was found to have a prolonging effect on the time to discharge (P<0.05) but did not reach statistical significance when considering the eventual time to healing. The number of co-morbidities that each patient had at the time of surgery had a prolonging effect on both time to discharge and time to healing (P<0.03). The type of resected areas that required reconstruction did not have a statistically significant effect on the time to discharge, but defects where the anus had been resected did eventually take longer to heal than those were the anus was not resected (P<0.01). 124 flaps were successful (97.6%) with total or partial flap loss occurring in three. Complications were seen in 34 of the 77 patients (44%), with simple wound breakdown resulting in delayed healing seen most frequently (30%). The gluteal fold fasciocutaneous flap is a versatile option for reconstructing a wide range of pelvic and perineal defects. Patients with multiple co-morbidities, cases with radiotherapy and instances where the anus has been resected are more likely to experience longer healing times. We present our algorithm for management for perineal defects after tumour resection.

The pain of surgery: pain experienced by surgeons while operating.

INTRODUCTION: The operating theatre can be a dreaded experience not only for the patient but also occasionally for the surgeon. We sought to investigate the prevalence of pain experienced by surgeons while operating. METHODS: One hundred and thirty anonymous questionnaires were sent to surgical consultants in the Britain. RESULTS: The response rate was 60% and 63 experienced pain while operating. The back and neck were the most common areas of pain (36 & 30 consultants respectively), followed by the hand (24 consultants). Nearly 80% described pains on a regular basis. Table height was the most common cause of pain (35%), followed by the use of microscopes (27%) and standing (22%). Nearly 43% of the consultants will take a break from surgery because of their symptoms, and 4 took sick leave in direct relation to pain experienced as a result of operating. However only 27% took measures to reduce their symptoms and 65% never sought any help or advice and only one consultant informed the occupational health department. CONCLUSION: Many surgeons will experience pain while operating due to positioning or the instruments they use, however there are no guidelines from occupational health departments or training courses to help minimise these symptoms.

Patterns of sensory and autonomic reinnervation of long-standing myocutaneous microvascular flaps and split-skin grafts applied to fascial beds.

BACKGROUND: There is a paucity of reports in the literature examining the pattern of sensory and autonomic neural recovery of myocutaneous microvascular flaps and skin grafts to the lower limbs after a prolonged period of time. OBJECTIVES: To investigate the recovery of sensation and autonomic nerve activity in long-standing split-skin grafts applied to fascial beds and in myocutaneous microvascular flaps. METHODS: THE PATIENTS WERE DIVIDED INTO TWO GROUPS: group A consisted of patients with a split-skin graft applied to a fascial bed (n=11) and group B consisted of patients with free microvascular flaps (n=4). Patients in both groups underwent various clinical subjective and objective tests, including the measurement of electrical resistance and thermal sensory analysis. Laser Doppler flowmetry was used to investigate the blood flow patterns. RESULTS: Patients in both groups showed significantly reduced sensory modalities. However, the findings of both the electrical resistance and laser Doppler flowmetry were significantly different among the patients in group A compared with controls. In contrast, electrical resistance and laser Doppler flowmetry test results were similar in group B and controls. CONCLUSIONS: Both split-skin grafts applied to fascial beds and microvascular flaps on the lower limb had poor sensory recovery. However, after 15 years, the microvascular flaps regained the ability to sweat and some degree of thermoregulatory function. This may imply that the long-standing myocutaneous free flaps regained some aspects of their autonomic innervation, whereas the split-skin grafts had not.

HISTORIQUE: La documentation scientifique fait état de peu de comptes rendus sur le motif de rétablissement neuronal sensoriel et neurovégétatif de lambeaux microvasculaires myocutanés et de greffes cutanées dans les membres inférieurs après une période prolongée. OBJECTIFS: Étudier le rétablissement de l'activité nerveuse sensorielle et neurovégétative dans des greffes dermo-épidermiques aponévrotiques de longue date et dans des lambeaux microvasculaires myocutanés. MÉTHODOLOGIE: Les patients ont été séparés en deux groupes : le groupe A se composait de patients ayant une greffe dermo-épidermique aponévrotique (n=11) et le groupe B, de patients présentant des lambeaux microvasculaires libres (n=4). Les patients des deux groupes ont subi divers tests cliniques subjectifs et objectifs, y compris une mesure de la résistance électrique et une analyse sensorielle thermique. Une débitmétrie Doppler à laser a permis d'examiner les motifs de débit sanguin. RÉSULTATS: Les patients des deux groupes ont affiché une diminution considérable des modalités sensorielles. Cependant, les observations tant de la résistance électrique que de la débitmétrie Doppler à laser différaient de manière significative entre les patients du groupe A et ceux du groupe témoin. Par contre, ces résultats étaient similaires entre les patients du groupe B et ceux du groupe témoin. CONCLUSIONS: Tant les greffes dermo-épidermiques aponévrotiques que les lambeaux microvasculaires des membres inférieurs comportaient une faible récupération sensorielle. Cependant, au bout de quinze ans, les lambeaux microvasculaires avaient recouvré la capacité de sudation et un certain degré de fonction thermorégulatoire. D'après ce phénomène, les lambeaux libres myocutanés de longue date pourraient retrouver certains aspects de leur innervation neurovégétative, contrairement aux greffes dermo-épidermiques.

Patterns of reinnervation and blood flow in split-skin grafts.

One of the most important functions of skin is thermoregulation. The alterations in the patterns of blood flow in skin is one of the main physiological processes responsible for thermoregulatory control. The mechanisms governing the thermoregulatory control of cutaneous blood flow are mainly neural and chemical in nature. At present, there is a lack of studies in the literature looking at the relationship between reinnervation and the blood flow pattern of skin grafts. The present study uses Laser Doppler flowmetry and the immunohistochemical stains protein gene product 9.5, calcitonin gene-related peptide and substance P to identify nerve fibres, and antibodies to CD31 and von Willebrand factor to identify endothelial tissues. The aim of the present study was to investigate the patterns of blood flow and nerve tissue regeneration in split-skin grafts up to 15 years following the original procedure. Thirty-two split-skin grafts were studied and these were placed into two groups based on the nature of the bed of excision: group I consisted of patients who underwent tangential excision and split-skin grafting (n=17), and group II consisted of patients with split-skin grafts placed onto fascial beds (n=15). Each subpopulation of patients was further divided into three groups based on the length of time following grafting: one to three years, four to six years and seven to 15 years. These divisions were arbitrarily chosen and called A1, A2 and A3, respectively. In the Laser Doppler flowmetry arm of the study, the grafts were assessed at various stages after heating, cooling and further reheating. The Laser Doppler flowmetry studies showed that, on subjecting the skin grafts in both groups I and II to heating and cooling followed by reheating, the overall response of the blood flow to changes in the temperature was slower. The immunohistochemical analysis showed that in all graft types and graft ages, protein gene product 9.5, calcitonin gene-related peptide and substance P stains demonstrated a relative lack of the presence of nerve fibres in the split-skin grafts compared with the control ('normal' skin). However, von Willebrand factor and CD31 immunological staining demonstrated that vessels were present in the split-skin grafts, with no significant difference in size or quantity from the control samples. It was found that the blood flow in the split-skin graft in response to thermal challenge, although present, was slower than that of normal skin, a finding which was independent of the age of the skin graft. It is thought that this was related to a lack of regeneration of nerve fibres and, hence, a deficiency in the neurally mediated reflexes of the blood vessels within the split-skin grafts.

L'une des plus importantes fonctions de la peau est la thermorégulation. Les altérations de la circulation sanguine dans la peau demeurent parmi les principaux processus physiologiques à l'origine de la thermorégulation. Les mécanismes qui régissent la thermorégulation de la circulation sanguine cutanée sont principalement de nature neurale et chimique. Encore trop peu d'études ont été faites et publiées à propos du lien entre la réinnervation et la circulation sanguine dans les greffes cutanées. La présente étude repose sur l'utilisation de la débitmétrie Doppler à laser et sur des colorations immunohistochimiques avec le produit du gène de protéine 9.5, le peptide lié au gène de la calcitonine et la substance P dans le but d'identifier les fibres nerveuses et les anticorps dirigés contre le CD31 et contre le facteur de von Willebrand pour visualiser les tissus endothéliaux. Le but de la présente étude était d'explorer les modes de régénération de la circulation sanguine et des tissus nerveux dans des greffes de demi-épaisseur, jusqu'à 15 ans après l'intervention originale. Trente-deux greffes de demi-épaisseur ont été étudiées et elles ont été classées en deux groupes selon la nature du lit d'excision : groupe I, composé de patients ayant subi une excision tangentielle et une greffe de demi-épaisseur (n = 17) et groupe II, comportant des patients ayant subi des greffes de demi-épaisseur de fascias (n = 15). Chaque sous-groupe de patients a été de nouveau divisé en trois groupes selon la durée des greffons : 1 à 3 ans, 4 à 6 ans et 7 à 15 ans. Ces subdivisions ont été choisies arbitrairement et nommées A1, A2 et A3, respectivement. Dans le groupe de l'étude soumis à la débitmétrie Doppler à laser, les greffons ont été évalués à divers stades après application de chaleur, de froid et de chaleur à nouveau.Les analyses de débitmétrie Doppler à laser ont montré qu'en soumettant les greffons cutanés des groupes I et II à la chaleur puis au froid, suivi de chaleur à nouveau, la réponse globale de la circulation sanguine aux changements de température était plus lente.L'analyse immunohistochimique a montré que dans tous les types de greffe, la coloration par produit du gène de protéine 9.5, peptide lié au gène de la calcitonine et substance P a révélé une absence relative de fibres nerveuses dans les greffes de demi-épaisseur comparativement aux témoins (peau « normale ¼). Par contre, la coloration immunologique du facteur de von Willebrand et du CD31 a montré que les vaisseaux étaient absents des greffes de demi-épaisseur sans différence significative de taille ou de quantité comparativement aux échantillons témoins.On a découvert que la circulation sanguine dans le greffon de demi-épaisseur en réponse aux changements de température, bien que présente, est plus lente que dans la peau normale, un phénomène qui serait indépendant de l'âge du greffon et que l'on croit relié à l'absence de régénération des fibres nerveuses et donc à un déficit des réflexes neuraux des vaisseaux sanguins dans les greffons de demi-épaisseur.

Polymacron enzyme immunoassay system for detection of naturally contaminating Salmonella in foods, feeds, and environmental samples.

A simple dot blot enzyme immunoassay was developed to screen enrichment broth cultures for the presence of Salmonella. This unique system utilizes macroporous polyester cloth (Polymacron) with an inexpensive hemoglobin coating to provide a high-affinity adsorbent for lipopolysaccharide (LPS) antigens in test samples. Bound LPS antigens are then detected using a monoclonal antibody conjugate recognizing a core oligosaccharide epitope common to all salmonellae frequently found in foods and related samples. The entire test (not including enrichment culture) could be completed in less than 1 h. The performance of this assay was evaluated in the analysis of enrichment broth cultures from a variety of egg and dairy products, chicken carcasses, animal feeds, and food-processing plant environmental samples for the presence of Salmonella.